Multiple myeloma is the second most common haematological malignancy. However it typically occurs in the sixth decade of life and the incidence therefore, in patients under the age of 40 is extremely rare.
A 39 year old woman presented at 16 weeks gestation in her second pregnancy with shortness of breath and extreme fatigue. A full blood count revealed a microcytic anaemia with an isolated markedly raised serum protein level. Subsequent serum electrophoresis identified a raised IgG paraprotein, and urine electrophoresis detected Bence Jones proteins. Bone marrow aspirate showed elevated plasma cells confirming the diagnosis of multiple myeloma.
Antenatally this woman was commenced on thromboprophylaxis (TEDS and LMWH) and managed expectantly with regular plasma exchange and blood transfusion. Rising levels of serum paraproteins necessitated treatment with high dose fluorinated corticosteroids at 31 weeks gestation. Chemotherapy was considered but declined by the patient because of concerns about her unborn child.
The pregnancy continued without event. Labour was induced at 35 weeks gestation, achieving vaginal delivery of a female infant weighing 3100g.
Worsening back pain, partly relieved by delivery was formally assessed within the puerperium. Lumbar x ray confirmed several vertebral crush fractures but no typical lytic lesions.
A full skeletal survey and active therapy will start imminently.
Whilst myeloma does not appear to be an indication for termination of pregnancy there is no doubt that given the paucity of literature available management presents a diagnostic and therapeutic challenge requiring a multidisciplinary approach.
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