Introduction:

Multiple Myeloma (MM) is an incurable and rare cancer that starts in the plasma cells in the bone marrow. These cancerous plasma cells result in an overproduction of abnormal monoclonal proteins (M-protein), which can build up and cause a range of symptoms and complications.

According to the International Agency for Research on Cancer (IARC), as of 2020 the number of new cases were approximately 170000 globally and 6900 in South East Asia, of which only 2900 were women. 

According to literature, fewer than 50 cases of MM in pregnancy have been reported. The challenge would be to distinguish clinical features of MM from typical pregnancy-related disorders. 

 

Case Report: 

A 37 years old Gravida 3, Para 1+1 presented at 36 weeks gestation with unprovoked gum bleeding and back pain. Clinical examination revealed a cachexic patient and blood workup showed anemia, thrombocytopenia, renal injury, hyperuricemia and hypercalcemia. The patient was managed by a multidisciplinary team consisting of obstetricians, intensivists and hematologists.  

She underwent a lower segment caesarean section and bone marrow aspirate and trephine biopsy (BMAT) but was complicated with primary postpartum hemorrhage (PPH) secondary to uterine atony requiring Bakri balloon insertion. She developed secondary PPH on day3 postpartum which required Bakri balloon reinsertion and on day18 secondary to endometritis which was treated conservatively with antibiotics. 

Her peripheral blood film showed bicytopenia with leucoerythroblastic picture and presence of 19% abnormal lymphoplasmacytoid cells. The BMAT showed abnormal plasma cells which were positive to CD128, CD56 with Kappa light chain restriction. They were negative to CD20 and CD38 and other T-markers.

A diagnosis of MM was established and she was started on Bortezomib, Thalidomide and Dexamethasone for 6cycles.  

 

Discussion: 

According to the Malaysian National Cancer Registry Report from 2012-2016, only 347 female patients were reported most of which were above the age of 65.

Due to the low incidence of MM in young females, the patient’s presenting symptoms of bone pain and anemia was directed towards common pregnancy related disorders such as iron deficiency anemia, gestational thrombocytopenia and pregnancy related pelvic girdle pain. Not until she was at 36weeks gestation was she referred for tertiary medical care where further blood workup revealed bicytopenia and BMAT with suspicion of MM.  

 

Conclusion:

Despite its rarity, the possibility of MM in young pregnant patients should be considered as to not delay the diagnosis, decision about pregnancy continuation and initiation of appropriate and safe efficient therapy.