Pregnancy in a Jehovah's witness with cervical cancer and anemia

Emergency Presentation of Invasive Cervical Cancer in Late Pregnancy: A Case Report and Literature Review

Antepartum hemorrhage (APH) often prompts consideration of the presence of obstetric disorders. Here, we describe a case with active APH in which invasive cervical cancer was the cause. A 41-year-old woman, fifth gravida, fourth para (G5, P4), presented to the emergency department at 38 weeks of gestation with an acute severe attack of vaginal bleeding, which occurred immediately after a per-vaginal examination at another local institute. Despite initial stabilization measures and investigations to exclude common causes of APH, a protruding cervical mass was discovered during a Cusco speculum examination. The patient underwent an emergent cesarean section (CS). Postoperatively, the patient was referred to the gynecological oncology unit for further evaluation and management. Magnetic resonance imaging (MRI) confirmed the presence of a large cervical mass. A punch biopsy revealed squamous cell carcinoma (SCC) of the cervix. All these confirmed the condition as cervical carcinoma stage IB3. This case and literature review highlight the obstacles that might delay the diagnosis of cervical cancer and the importance of continuing the screening program strategies even during pregnancy to avoid complications of invasive cervical cancer. In addition, bleeding due to cervical cancer should always be considered one of the important differential diagnoses of APH even in full-term pregnancy.

Individual management of cervical cancer in pregnancy

Purpose

The management of cervical cancer in pregnancy persists to be challenging. Therefore, identification of factors that influence the choice of therapeutic management is pivotal for an adequate patient counseling.

Methods

We present a literature review of 26 studies reporting 121 pregnancies affected by cervical cancer. Additionally, we add a retrospective case series of five patients with pregnancy-associated cervical cancer diagnosed and treated in our clinic between 2006 and 2013.

Results

The literature review revealed that the therapeutic management during pregnancy varies according to the gestational age at diagnosis, while in the postpartum period no influence on the treatment choice could be detected. Also in our case series the choice of oncologic therapy was influenced by the gestational age, the wish to continue the pregnancy and the risks of delaying definitive treatment.

Conclusions

There are no standardized procedures concerning the treatment of cervical cancer in pregnancy. Therefore, in consultation with the patient and a multidisciplinary team, an adequate individualized treatment plan should be determined.

Electronic supplementary material

The online version of this article (doi:10.1007/s00404-015-3980-y) contains supplementary material, which is available to authorized users.

Impact and treatment of cancer during pregnancy

Cancer is the second most common cause of death in the reproductive years and complicates up to one in 1000 pregnancies. When cancer is diagnosed during pregnancy, the management strategy must take into account both the mother and developing fetus. In this article, the four most common malignancies diagnosed in pregnant patients--cervical and breast cancer, malignant melanoma and lymphoma--will be reviewed, with an emphasis on the impact of the diagnosis and management on the pregnant patient and the developing fetus.