Chemotherapy in Pregnancy

Spending the day with a perinatologist I can across an unusual and sad case that I wanted to share. S.T. is a 33 year old, gravid 3 para 2. She is pregnant with her third child and is currently 19 weeks and 6 days. S.T. is married and has a 10 year old and 5 year old child at home. Three months ago S.T. found a mass in her left breast. The mass was diagnosed as breast cancer with lymphnode involvement in the axillary region. One week after being diagnosed with breast cancer S.T. found out she was 8 weeks pregnant with her third child. S.T. underwent a mastectomy of her left breast and removal lymphnodes in her axilla shortly after being diagnosed with breast cancer and pregnancy. One week ago she had a port surgically implanted to receive chemotherapy. Four days ago S.T. began her first round of chemotherapy, which she will receive every three weeks until the end of December. Early delivery is planned by the perinatologist at the end of January 2013.

The reason I wanted to share this case was because I was completely unaware that chemotherapy can be given during pregnancy. I thought that the mother would have to choose between ending the pregnancy and receiving treatment or not receiving treatment and putting her life at extreme risk. Although there are significant risks to receiving chemotherapy during pregnancy I was surprised at the results. According to Gzirl et al. (2012), chemotherapy needs to be avoided during the first trimester of pregnancy due to teratogenic risks. Chemotherapy in the second and third trimester may be associated with intrauterine growth restriction, preterm delivery, and rarely cardiotoxic fetal effects. In the majority of patients the cardiotoxic effects were transient. Fetal and maternal monitoring for cardiotoxicity is recommended (Gzirl et al., 2012). In a study by Mir et al. (2008), twenty five pregnant patients received chemotherapy after the first trimester once organogenesis was complete. All the neonates showed a normal physical exam at delivery except for two who had respiratory distress due to prematurity. Of the 25 pregnancies, four patients received chemotherapy within three weeks of delivery, leading to two babies with mild anemia and four babies with neutopenia. It is recommended to stop chemotherapy four weeks prior to delivery due to late transplacental transfer of chemotherapy drugs which lead to neutropenia in the neonate (Mir et al., 2008). Another study conducted by Abdel-Hady et al. (2012), included 118 patients diagnosed with malignancy during pregnancy who were followed over an 8 year period. In the study 61 women received chemotherapy during the second and third trimester. Infant survival, preterm birth, small for gestational age, and malformations were not significantly different between the chemotherapy group and the control group. The conclusion states that exposure to chemotherapy in the second and third trimester carry minimal morbidity to an unborn fetus (Abdel-Hady et al., 2012).

References

Abdel-Hady, E., Hemida, R. A., Gamal, A., El-Zafarany, M., Toson, E., & El-Bayoumi, M. A. (2012). Cancer during pregnancy: Perinatal outcome exposure to chemotherapy. Maternal-Fetal Medicine, 286, 283-286. doi: 10.1007/s00404-01202287-5

Gzirl, M. M., Amant, F., Debieve, F., Calsteren, K. V.,  Catte, L. D., & Martens, L. (2012). Effects of chemotherapy during pregnancy on the maternal and fetal heart. Prenatal Diagnosis 32, 614-619. doi: 10.1002/pd.3847

Mir, O., Berveiller, P., Ropert, S., Goffinet, F., Pons, G., Treluyer, J. M., & Goldwasser, F. (2008) Emerging therapeutic options for breast cancer chemotherapy during pregnancy. Annals of Oncology, 19, 607-613. doi: 10.1093/annonc/mdm460