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Megan and her husband were informed of the diagnosis by the haematologist who together with the obstetrician spent some time explaining the various options available to her. Also present at the consultation was a midwife and a haematology nurse specialist.
Although devastated by the news, Megan unequivocally expressed her desire to continue with her pregnancy. She asked for a list of all the treatments she could and could not have whilst pregnant, what harm the myeloma and the treatments could do to her baby and what her prognosis was if she declined treatment whilst pregnant.
At this point, unable to handle the discussion, Megan’s husband left the room. Her haematologist admitted this was the first time he had been presented with such a case but had known of a colleague who had a similar case a few years ago. He reassured her that continuing with the pregnancy was possible but some form of treatment was needed at this stage. More intensive treatment would be administered once the baby was born and various clinical trial options were also explored.
Megan agreed to only have treatment that was compatible with her pregnancy and would consider more intensive anti-myeloma treatment after delivery. Multidisciplinary follow-up (including members from haematology, oncology, orthopaedics, obstetrics, gynaecology and neonatology) was organised and psychological support and counselling was offered immediately to Megan and her husband. Megan and her baby were offered more frequent monitoring than usual, including ultrasound scans.
Q1: Based on the case what would you recommend for this pregnant newly diagnosed myeloma patient?CorrectIncorrect
Megan commenced treatment with prednisolone at 50mg every second day. She also received standard prophylactic antibiotic, antacid, low molecular weight heparin and allopurinol as supportive care together with weekly review by the haematologist and obstetrician.
Within a month, her k light-chains had reduced from 7229 mg/L to 3014 mg/L and her haemoglobin levels had improved to 101g/L.
However, her back pain was still severe and continued to restrict her mobility.
Q2: What would you do now?CorrectIncorrect
Throughout this time, Megan and her husband received continuous specialist psychological support. She was advised to deliver her baby before term so that she could receive the optimal treatment for her myeloma and all relevant supportive treatments currently contraindicated to her.
Following the last multidisciplinary review, assuming Megan remained clinically stable, the advice was for an early delivery at 34 weeks gestation. However, Megan strongly disagreed and was worried the premature delivery would have a detrimental impact on the long-term development of her child. She felt she was being rushed into making decisions and as she was doing well, wanted to continue with her pregnancy and as far as possible, deliver at term. Her counsellor advised she attend a premature baby parent support group to speak to people who had dealt with premature births.
However, in the 32nd week of pregnancy, Megan developed a sharp pain in her sternum. A serum free light chain test revealed that her light chain levels had risen to 5290 mg/L whilst haemoglobin levels had dropped to 77g/L, consistent with disease progression.
An ultrasound scan showed linear growth and umbilical artery Doppler scans were within normal levels but steadily increasing resistance.
Megan’s haematologist informed her that the prednisolone was no longer controlling her myeloma and further action was needed.
Q3: What would you do now?CorrectIncorrect
On the advice of the haematologist and gynaecologist, Megan agreed to have her baby delivered within the next week. A caesarean section under general anaesthetic was strongly recommended to avoid subjecting her spine and pelvis to the stress associated with a normal birth. After recovering from the birth, the plan was for Megan to begin intensive anti-myeloma treatment.
However, Megan’s pregnancy has been much longed for and before her diagnosis she had envisaged having a natural birth with as little intervention as possible. She was unable to accept the recommended caesarean section, becoming tearful and refusing to give consent.
Q4: What would you do now?CorrectIncorrect
With family support, Megan agreed to a caesarean section and at 33+2 weeks gestation, delivered a baby girl weighing 1.920kg, with an APGAR score of 9 and 10 (1 and 5 min respectively), normal physical examination and foetal cord blood gases. Neonatal blood and urine showed no abnormal proteins.
Megan had no operative complications and recovered well. Her estimated blood loss was 440ml and a blood transfusion was given as a precaution.
Her sternum and back were still causing considerable pain. A post-partum skeletal survey revealed numerous lytic lesions in the arm, pelvis and sternum and confirmed the presence of pathological fractures in the fourth and fifth lumbar vertebrae.
Q5: What would you do next?CorrectIncorrect