February 4, 2010
Amrita School of Medicine, Kochi
Amrita doctors continue winning top honors at conferences around the country. Recently Dr. Anupama, Assistant Professor in the Obstetrics and Gynecology Department at the Amrita School of Medicine, won the best paper prize in oncology at the Obstetrics and Gynecology Conference in Guwahati.
Subsequently, Dr. Anupama’s award-winning work on malignancies in pregnancy was profiled in major newspapers. “Amrita is probably one of the few centers to have separate data on pregnant women with cancer,” wrote the New Indian Express.
“Though there is a lot more to be done, the study is a ray of hope for many whose life is caught between the yearning for a healthy child and a cure from cancer.”
The paper described at length, the considerations in surgery, radiotherapy, chemotherapy and pre-term delivery.* Reproduced below are other extracts from the winning paper.
Cancer is a leading cause of death in women. As technology expands the reproductive capabilities of older women, the incidence of cancer complicating pregnancy is also on the rise.
Concurrence of pregnancy and malignancy raises therapeutic ethical dilemmas. The most appropriate and timely treatment for the mother may not be in the best interest of the fetus.
The treatment will depend upon 1) the gestational age at diagnosis, 2) mother’s desire to continue the pregnancy and 3) whether the treatment for the mother precludes a good outcome for the mother and the baby.
The mainstays of cancer treatment are surgery, radiotherapy and chemotherapy. We have to select the best possible treatment for the mother without compromising the well-being of the fetus, wherever possible.
The paper contains a study on cancer found among pregnant women, who were admitted to the Obstetrics and Gynecology Department from 2006 to 2009. During this time, we saw fourteen cases of malignancy complicating pregnancy.
Four women of the fourteen had breast cancer. Two underwent surgery and chemotherapy during pregnancy and went on to deliver healthy infants. Two patients had CNS tumors; one patient underwent surgery and radiotherapy during pregnancy and had a normal pregnancy outcome.
Four other patients had gastrointestinal cancers, of which two had a normal pregnancy outcome. Three patients suffered from lymphoma and one of these three had a normal pregnancy outcome after chemotherapy.
One case was that of a Ca larynx. The woman underwent surgery and chemotherapy during pregnancy and a preterm caesarean section was done at 35 weeks to deliver a healthy infant.
These examples show that even if malignancy coexists with pregnancy, it is possible to have a good obstetric outcome without compromising the mother’s life.
Diagnostic and staging operations have classically been deferred until the second trimester to minimize abortion risks. Therapeutic surgery should be performed regardless of gestational age if maternal well-being is imperiled. If indicated, the ovaries may be removed without affecting the pregnancy, after 8 weeks. Prophylactic tocolytics are shown to reduce uterine irritability but do not decrease the incidence of preterm labor. Sequential compression devices for lower extremities in the intrados and post op period can be given to reduce the chance of thrombosis.
Diagnostic radiographic procedures have very low exposure and should not be delayed. Exposure to less than 5 rad has not been associated with an increase in fetal anomalies or pregnancy loss. The risk of malformations is significantly increased above controls only at doses above 15 rad.
Therapeutic radiation can result in significant fetal exposure to ionizing radiation. Although the most susceptible period is during organogenesis, no gestational age is considered safe.
Characteristic adverse fetal effects are microcephaly and mental retardation. Late exposure can cause fetal growth restriction and brain damage. So therapeutic radiation should be given only after therapeutic abortion.
If abortion is refused, delay the initiation of treatment until mid II trimester. In some cases, such as head and neck cancers, radiotherapy to supra diaphragmatic areas can be given relatively safety with abdominal shielding.
The risk for adverse fetal effects is dependent primarily on gestational age during chemotherapy. First Trimester chemotherapy can cause fetal loss and morphologic abnormalities. In second and third trimester, it causes increased IUD, IUGR.
Ideally chemotherapy has to be withheld 3 weeks prior to delivery. In case of preterm delivery within 3 weeks of chemo, fetal bone marrow suppression can occur because of the limited ability of the preterm baby to metabolize the drug.
Safety not established during lactation, so breast feeding is not recommended. No late mutagenic effects have been reported for the child.