Background
Chronic myeloid leukaemia (CML) during pregnancy is rare and presents significant challenges in balancing maternal disease control with fetal safety. Management becomes particularly complex when patients decline recommended therapy, raising important clinical and ethical considerations regarding maternal autonomy and peripartum care.
Case
A 23-year-old G2P0 woman with chronic-phase CML presented following a late diagnosis of pregnancy at 16 weeks' gestation. She had previously discontinued tyrosine kinase inhibitor therapy because of adverse effects and declined recommencement of nilotinib during pregnancy, believing it reduced fetal movement despite repeated counselling. Progressive disease resulted in marked hyperleukocytosis (peak white cell count 295 × 10⁹/L), thrombocytosis, and worsening constitutional symptoms. Multidisciplinary management involved Haematology, Maternal-Fetal Medicine, Obstetric Medicine, Anaesthesia, Social Work, and Perinatal Mental Health, with serial maternal-fetal surveillance, counselling, assessment of decision-making capacity, advance care planning, and delivery planning. Neuraxial anaesthesia was avoided because of extreme leukocytosis. Induction of labour at 36+5 weeks resulted in a successful vaginal birth. The postpartum course was complicated by primary and secondary postpartum haemorrhage and endometritis. Postpartum, the patient commenced pegylated interferon therapy with subsequent haematological improvement and completed six weeks of therapeutic thromboprophylaxis.
Conclusion
Despite progressive untreated CML during pregnancy, favourable maternal and neonatal outcomes were achieved through coordinated multidisciplinary care, proactive risk mitigation, and preservation of a therapeutic alliance that enabled postpartum initiation of disease-modifying therapy. This case highlights that sustained therapeutic engagement, grounded in shared decision-making and respect for maternal autonomy, can achieve favourable outcomes despite refusal of recommended treatment.