Navigating acute leukemia in pregnancy: A case series and clinical insights

Acute leukemia during pregnancy is exceedingly rare, occurring in fewer than 1 in 100,000 pregnancies. Pregnancy coexisting with malignancy complicates management due to gestational-age–dependent fetal sensitivity to cytotoxic agents and the lack of standardized treatment protocols. We report a series of four pregnant patients diagnosed with acute leukemia at different trimesters. The first-trimester case (12 weeks) elected medical termination prior to induction chemotherapy (3 + 7 daunorubicin/cytarabine → HiDAC consolidation). Three patients in the second and third trimesters (22–29 weeks) received tailored induction and consolidation regimens with biweekly Doppler monitoring, achieving complete maternal remission and favorable neonatal outcomes (deliveries at 31–34 weeks). These cases illustrate trimester-specific decision-making: in the first trimester, termination is generally advised before initiating chemotherapy; in later trimesters, anthracycline-based regimens may be safely administered with vigilant fetal surveillance. Risk stratification (WHO criteria, cytogenetics, FLT3-ITD status) and multidisciplinary collaboration are critical to optimize both maternal and fetal prognoses. A structured, trimester-adapted approach to acute leukemia in pregnancy can yield positive outcomes for mother and child. Further prospective studies are needed to refine treatment algorithms, assess novel targeted therapies, and evaluate long-term effects of in utero chemotherapy exposure. • Rarity and Complexity: Acute leukemia in pregnancy is extremely rare (<1 in 100,000) and requires careful diagnostic evaluation, considering trimester-specific fetal sensitivity to chemotherapy. • Individualized Management: Our case series demonstrates that tailored, multidisciplinary approaches are essential—one first-trimester case required termination, while second/third trimester cases achieved favorable outcomes. • Practice and Research Implications: Effective management can yield positive results for both mother and fetus, underscoring the need for ongoing case reporting and research to develop safer, standardized treatment protocols.