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
Wow, Amanda, I had absolutely no idea this could occur. Thank you for your very helpful synopsis of the issue and current literature on the topic.
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