Healthy Pregnancy Is ‘Definitely’ Possible for Women With MPNs

Despite the challenges for women with myeloproliferative neoplasms (MPNs), safe and healthy pregnancy is possible, but communicating with their health care team and planning are crucial to the process, according to an expert.

“We hope that women are reassured from the data (that are) out there in the literature that a safe and healthy pregnancy is possible and (that) definitely planning aheadhelps making the pregnancy safer,” Dr. Naseema Gangat, an associate professor of medicine in the division of hematology at Mayo Clinic College of Medicine in Rochester, Minnesota, said in an interview with CURE®. “Even if the pregnancy ... and the MPN (are) diagnosed concurrently ... the pregnancy (still) can be made safer by optimizing risk factors — by addressing the MPN, the blood counts — and hopefully ameliorate any complications that may occur.”

Gangat discusses further about the complications women with polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis may face when being pregnant, and the importance of individualizing treatment for them.

Challenges and Complications

MPNs increase a patient’s risk for clotting and bleeding; pregnancy can also increase the risk of clotting. Gangat noted the combination of MPNs and pregnancy can create a dilemma, escalating complication risks for the mother and the fetus.

Additionally, treatments for MPNs can pose problems in pregnancies. For example, the chemotherapy medication Hydrea (hydroxyurea) and the blood thinner Coumadin (warfarin), which are commonly used in MPN patients, may be harmful for the fetus, she explained.

Gangat has performed multiple studies evaluating pregnancy in patients with MPNs and observed that the risk of first trimester fetal loss in patients with essential thrombocythemia (ET), the most common MPN type that pregnancy is observed in — due to the younger age—, is 30%; however, this is not much higher than the general population.

Study results have demonstrated that a previous fetal loss increases the risk of subsequent fetal loss in women with ET. Prior obstetric and medical history including cardiovascular risk factors (smoking, diabetes mellitus, hypertension, hyperlipidemia), prior clotting or bleeding is important when making treatment decisions during the pregnancy.

The risk of clotting and bleeding is highest in PV and theoretically complication rates might be higher in pregnancy in a patient who has received a diagnosis of PV compared with ET—— but more data is needed for clarification, Gangat added. However, rate of fetal loss are similar in PV as in ET.

In myelofibrosis, data is limited because pregnancy is not very common because the average age for a woman to receive a diagnosis is much higher. These patients also might not be medically well enough to carry a pregnancy due to an enlarged spleen. However, one study, she noted, demonstrated that patients with myelofibrosis who are pregnant have similar outcomes as those with ET

“It’s a very important area, and we do have a subset of women who are (younger than) 40 years of age when they’re diagnosed with (an) MPN,” Gangat said. “The pregnancy and the MPN (intersect), especially now with better diagnostics for MPN. Diagnosis of MPN occurs earlier through molecular mutation analysis, and pregnancies are occurring later in life, according to statistical data. So there’s more of an ... intersection between the two entities.”

Individualized Treatment

Gangat explained that for a woman who is pregnant and has received an MPN diagnosis, treatment should be individualized based on prior obstetric/medical history.

Gangat said that aspirin is “the cornerstone of treatment” in this setting. Since aspirin has shown to be the most beneficial in protecting against fetal loss.

The chemotherapeutic medication interferon is recommended for patients who have had prior blood clots, fetal losses or a high-risk pregnancy, Gangat said.

Gangat noted that if a patient has had blood clots, a blood thinner should be continued during pregnancy. She added that blood thinners are available that are safe for women who are pregnant, such as Lovenox (enoxaparin).

“There is definitely a treatment menu to choose from,” she said. “We don’t want to prescribe extra treatments, but definitely each of the treatments needs to be discussed as to why it’s being considered and why not. Aspirin alone, especially in the absence of high risk features, might be sufficient.”

Gangat emphasized that these treatments can be beneficial options only if there is open communication between patient and physician. For women with MPNs, especially those younger than 40, who are contemplating pregnancy, a conversation with their health care team about their obstetrics and medical history is important to optimize treatment.

Gangat emphasized that women with MPNs should know that a healthy pregnancy is “definitely” possible and that they should not avoid pregnancy due to the potential for increased risks of complications.

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