British Journal of Obstetrics and Gynaecology October 1977. Vol 84. pp 791-792

HODGKIN’S DISEASE DIAGNOSED IN PREGNANCY CASE REPORT BY

I. R. JOHNSON* AND

G . M. FILSHIE Department of Obstetrics and Gynaecology, The Women’s Hospital Peel Street, Nottingham

Summary A patient is described in whom Hodgkin’s disease was diagnosed and treated during the antenatal period, and who was delivered of a premature, but otherwise normal, infant.

HODGKIN’Sdisease is a primary malignant condition of lymphoreticular tissue. It is more common in men than women and has a bimodal age distribution with peaks at 25 and 70 years. The patient usually presents with painless enlargement of the lymph nodes, but may have systemic symptoms such as fever, weakness, weight loss and an anaemia which does not respond to iron therapy. A patient is presented in whom pregnancy was complicated by severe systemic symptoms and treatment with cytotoxic agents.

and her general practitioner, she had conceived some two weeks prior to the first consultation. The patient had been pregnant twice before, both pregnancies being complicated by hypertension necessitating induction shortly before term, with delivery of a normal infant each time. When 18 weeks pregnant she was referred to an obstetrician. She complained of tiredness and losing weight. Examination revealed that she weighed 36 kg, a weight loss of 13 kg since her last pregnancy four years earlier. There was a firm, smooth goitre present and a fine tremor of the hands. Other findings were normal. The haemoglobin was 10.2 g/dl and her thyroid function tests were abnormal with a thyroxine level of 350 nmol/l, a T3 uptake of 91 and a free thyroxine index of 385. The fetal biparietal diameter was compatible with dates. The patient was seen at two-weekly intervals initially. The fetus continued to grow, and the weight increased slightly, but the haemoglobin continued to fall despite iron therapy. The physicians were undecided about the diagnosis of thyrotoxicosis in view of the pregnancy. At 26 weeks gestation the haemoglobin was 6. 7 dljl and the patient looked very ill. A new finding at this stage was generalized lymphadenopathy and hepatosplenomegaly. She was

CASEREPORT A 37-year-old Pakistani patient presented to her general practitioner with complaints of weakness and lassitude. She was found to have erythema nodosum and a chest X-ray demonstrated right paratracheal lymphadenopathy. The Heaf reaction was strongly positive and a presumptive diagnosis of tuberculosis was made, although no bacterial confirmation was ever obtained. She was started on a course of rifampicin and isoniazid. Unknown to her

* Present

address: Department of Physiology and Pharmacology, University Hospital and Medical School, Nottingham NG7 2UH. 79 1

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admitted, transfused and an axillary node biopsy was taken, which showed Hodgkin’s disease of the lymphocyte depleted variety. When the patient was 28 weeks pregnant, quadruple chemotherapy (mustine, vinblastine, procarbazine and prednisolone) was begun, along with carbimazole for thyrotoxicosis. The antituberculous therapy was stopped. The patient’s general condition improved rapidly and her lymphoid tissue reduced in size. When 31 weeks pregnant she was allowed home by the physicians, but was readmitted two days later in the second stage of labour and within 20 minutes of arrival was delivered of a live infant weighing 1.42 kg. The baby had a mild anaemia, which responded to oral iron, but otherwise thrived. Apart from a urinary tract infection, which was treated successfully, the mother had an uneventful puerperium and was discharged to continue her cytotoxic therapy. DISCUSSION Successful evaluation of this patient’s severe systemic symptoms was complicated by evidence of thyrotoxicosis and a previous diagnosis of tuberculosis, Hodgkin’s disease being diagnosed only after the appearance of generalized lymphadenopathy and hepatosplenomegaly. It is unusual for Hodgkin’s disease to complicate pregnancy, and even more uncommon for the disease to present during a pregnancy. Morgan et al (1976) could find only three cases in 16 000 deliveries; however Barry et al (1962) reported a series of

84 pregnancies associated with Hodgkin’s disease. No infants showed evidence of the disease and no adverse effects of pregnancy on the disease were noted. During pregnancy fewer exacerbations were seen, although more occurred in the puerperium and the net effect was th:: same as in non-pregnant patients over the same period. They concluded that if the mother was fit enough to survive pregnancy and the systemic symptoms were not too pronounced, a successful outcome could be expected. Nicholson (1968) reported 185 cases in which cytotoxic drugs had been used in pregnancy, including 27 cases of Hodgkin’s disease. The normality of the fetus was related to the timing of the therapy, and after the first trimester there was no increase in the risks to the fetus except for a tendency to low birth weight. In our patient the systemic symptoms were pronounced and the patient was very ill, necessitating immediate treatment. The evidence suggests that cytotoxic therapy at this stage of pregnancy is unlikely to harm the fetus. The patient had stage 4b lymphocyte depleted Hodgkin’s disease and her own prognosis remains poor; however, she was well and in remission one year after delivery. REFERENCES Barry, R. M., Diamond, H. D., and Craver, L. F. (1962): American Journal of Obstetrics and Gynecology, 84, 445. Morgan, 0. S., Hall, J. St. E., and Gibbs, W. N. (1976): West Indian Medical Journal, 25, 121. Nicholson, H. 0. (1968): Journal of Obstetrics and Gynaecology of the British Commonwealth, 75, 307.

Hodgkin's disease diagnosed in pregnancy, case report.

British Journal of Obstetrics and Gynaecology October 1977. Vol 84. pp 791-792 HODGKIN’S DISEASE DIAGNOSED IN PREGNANCY CASE REPORT BY I. R. JOHNSON...
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