Diagnostic Workup

If there is any suspicion of marrow dysfunction based on the blood counts, peripheral blood smear, or presence of circulating leukemic blasts, then a bone marrow biopsy and aspirate should be performed. Bone marrow evaluation at any gestational age is safe; only local anesthesia is used and the patients can maintain a lateral decubitus position for an estimated 20-minute procedure. If a pregnant woman is diagnosed with acute leukemia, a multilumen central venous catheter is often required due to frequent blood draws, transfusions, chemotherapy infusions, and antibiotic use. Catheter placement can be safely performed by a general surgeon or interventional radiologist. Fluoroscopy is often used for guidance during placement, but can be avoided or used sparingly with pelvic shielding. Measurement of left ventricular ejection fraction is recommended prior to initiation of therapy, as anthra-cyclines are cardiotoxic. Multigated acquisition scans are often used, but in pregnant patients an echocar-diogram can be performed to avoid radiation exposure. Computed tomography (CT) scans of the abdomen and pelvis are not critical for treatment or prognosis, and therefore are not required in the work-up of a pregnant leukemic patient. In summary, there is minimal fetal risk in the maternal diagnostic work-up for acute leukemias and in preparation for therapy.

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