Pregnancy following treatment for malignancy

Important studies:

North American Childhood Cancers Survivors Study(CCSS)

The British Childhood Cancer Survivor Study

Impact on maternal health

Cardiovascular

In general:

Congestive heart failure

Myocardial infarction

Pericardial disease

Valvular abnormalities

Specific:

Anthracyclines

Cause:

a dose-dependent decline in ejection fraction  dilated cardiomyopathy

Potentiated by:

mediastinal radiotherapy

other chemotherapy agents.

Other chemotherapy agents

Cause:

Myocarditis

Coronary artery disease,

Pericarditis

Prolonged QT interval and other arrhythmias.

Radiotherapy:

Cause:

Pericardial disease

Coronary artery disease

Valvular disease

Cardiomyopathy.

Effect of pregnancy:

In cardiac patient in general :

can cause decompensation in women with established heart disease.

In patients receiving therapy for cancer :

Some studies reported dilated cardiomyopathy in pregnancy and peripartum cardiomyopathy in women previously treated with doxorubicin.

Management:

In general:

SIGN recommendations

Modality:

Regular Echo screening

Candidates:

Anthracyclines

Radiation to a ﬁeld that includes the heart.

In pregnancy:

RCOG Green-top Guideline Pregnancy and Breast

Modality:

should have an echocardiogram to assess ejection fraction and fractional shortening in pregnancy

Candidates:

Cancer advises that women whose breast cancer was treated with adjuvant chemotherapy with anthracyclines

Endocrine

Hypothalamus

Causative agent:

Radiation

Survivors of	childhood cancers are more likely to develop endocrine consequences of treatment compared with those treated for cancer as an adult.

Thyroid dysfunction

Causative agent:

Radiotherapy to the neck or the cranium

Management:

In general

SIGN recommendations:

Modality:

Annual thyroid function tests

Candidates:

radiotherapy to the neck, spine or brain

In pregnancy:

No formal guideline exist (authors opinion)

Modality:

Antenatal screening for thyroid dysfunction

Candidates:

history of neck or cranial irradiation

diabetes and the metabolic syndrome

In pregnancy:

No formal guidelines (authors opinion)

Modality:

Glucose tolerance tests

Candidates:

Irradiation cranial, abdomen or total body

Alkylating agents.

Other endocrinal deficiencies:

Hypopituitarism

Growth hormone deficiency

Syndrome of inappropriate anti-diuretic hormone deficiency.

Effects on bone mineral density

Respiratory

Causative agent:

Bleomycin

Radiotherapy to the chest and total body irradiation

Effect:

Pneumonitis

Recurrent pneumonia

Pulmonary ﬁbrosis

Management:

In pregnancy:

No formal guidelines (authors opinion)

Modality:

Pulmonary functions test

Candidates:

bleomycin

Thrombotic risks

Causative agent:

association between venous thrombosis and malignancy

Management:

In pregnancy:

Routine VTE risk assessment

Recurrence in pregnancy

Management:

Defer pregnancy until after the highest risk of recurrence, for example, with breast cancer a wait of 2 years after treatment is recommended

Secondary malignancy

Causative agent:

as a result of the treatment they have received (chemotherapy and radiotherapy)

Management:

Low Threshold for reporting new symptoms

Other effects

Poor peripheral vasculature:

Causative agent:

cancer treatment

Management:

An assessment of peripheral veins

Anesthesia consultation (if poor vasculature)

Blood-borne viruses and Red cell antibodies.

Causative agent:

Blood and blood products transfusion

Management:

All women are routinely screened for red cell antibodies and blood-borne infections in pregnancy;

Anesthesia consultation (if RBCs alloimmunization)

Chronic graft versus host disease (cGVHD)

Causative agent:

allogeneic bone marrow transplantation

immunoregulatory disorder that shares features of autoimmunity and immunodeﬁciency

Impact on fetal outcomes

Congenital anomalies

No association

Background:

Both chemotherapy and radiotherapy are potentially mutagenic to somatic cells.

Concerns regarding transmission of genetic damage (via a mutated germ cell)

Miscarriage

++

Risk factor:

Pelvic radiotherapy

Cranial radiotherapy Interfering with hypothalamo-pituitary axis.

Intrauterine growth restriction

++

Risk factor:

highest dose of radiotherapy to the uterus (>500 cGy)

Abdomino-pelvic radiotherapy

Management

Growth scan

Prematurity:

++

Risk factor:

Abdomino-pelvic radiotherapy.

Stillbirth

++

Risk factor:

High-dose radiotherapy + pelvic organ + before menarche

Management:

Antenatal surveillance at 32 weeks

Continuous fetal monitoring

Heritable cancer conditions

Example:

BRCA

Management:

Genetic counselling

Management during pregnancy

See all the above management

Preconception:

Genetic counselling

Defer pregnancy until after the highest risk of recurrence, for example, with breast cancer a wait of 2 years after treatment is recommended

Antenatal:

Cardiac issues

RCOG Green-top Guideline Pregnancy and Breast

Modality:

should have an echocardiogram to assess ejection fraction and fractional shortening in pregnancy

Candidates:

Cancer advises that women whose breast cancer was treated with adjuvant chemotherapy with anthracyclines

Thyroid issues

No formal guideline exist (authors opinion)

Modality:

Antenatal screening for thyroid dysfunction

Candidates:

history of neck or cranial irradiation

Diabetes mellitus

No formal guidelines (authors opinion)

Modality:

Glucose tolerance tests

Candidates:

Irradiation cranial, abdomen or total body

Alkylating agents.

Pulmonary issues

No formal guidelines (authors opinion)

Modality:

Pulmonary functions test

Candidates:

Bleomycin

VTE risk:

Routine VTE risk assessment

Anesthesia consultation (if poor vasculature)

Fetal Stillbirth

Antenatal surveillance at 32 weeks

SGA issues

Growth scan

Anesthesia consultation (if RBCs alloimmunization)

Anesthesia consultation (if poor vasculature)

Intrapartum:

Continuous fetal monitoring