OB II: NEOPLASTIC DISORDERS LECTURER: DR.

DULNUAN

 Consider type and stage of malignancy,  0.06 Gy – threshold dose for intellectual
desire for pregnancy continuation, and disability at 8th-15th week; 0.25 at 16th-25th
inherent risks associated with modifying or week
delaying Ca tx  No gestational age is considered safe for
therapeutic radiation exposure
CANCER THERAPY IN PREGNANCY  Head and neck Ca – supradiaphragmatic
SURGERY area is allowed provided there is an
abdominal shield
 Should be performed regardless of
gestational age if maternal well-being is in CHEMOTHERAPY
danger
 Risks are dependent on fetal age at
 Include procedures indicated for dx,
exposure
staging, or therapy
 Most agents are potentially detrimental in
 Pregnancy and malignancy are risk for
the 1st trim during organogenesis
venous thromboembolism (VTE) – Myeloid
 After 1st trim, most antineoplastic drugs are
leukemia, Hodgkin disease, cervical Ca,
without immediate obvious adverse fetal
ovarian Ca
sequelae
 Use of prophylactic low-molecular-weight
 Some recommend that chemotherapy be
heparin + elastic stockings and/or
withheld in the 3 weeks before expected
intermittent pneumatic compression
delivery b/c neutropenia or pancytopenia
DIAGNOSTIC IMAGING might cause maternal infection or
haemorrhage
 UTZ is preferred in pregnancy  Most cytotoxic agents are C/I during BF
 MRI – withhold during the first trimester to
↓ potential risk MOLECULAR THERAPY
 Gadolinium – avoid during first trim; used
 RBC can be stimulated by erythropoietin
only in the later pregnancy when the
alfa (Procrit) – maternal hypotension is a
benefits outweigh the risks
potential risk
 CT – less often selected d/t ionizing
radiation; evaluate pulmonary embolism, TARGETED THERAPY
bowel or renal obstruction, acute
 2 main types are monoclonal Abs and small
neurological events
molecule inhibitors – block the actions of
 Oral and IV contrast – lacks known fetal
spec. enzymes, proteins, or other molecules
harm and BF need not be interrupted
involved in Ca cell growth
RADIATION THERAPY  Most are labelled by FDA as Class D
 Many of the drugs target tyrosine kinase – an
 A/E: fetal malformation, intellectual
enzyme that reg. signalling pathways
disability, growth restriction, sterility,
involved in cell division, differentiation,
carcinogenesis
and apoptosis
 2 weeks after fertilization exposure –
 1st trim use – teratogenicity
chromosomal damage and embryonic death
 Used only if benefits justify the potential
 Next most susceptible period: 2nd-8th week
risks to the fetus
(organogenesis) – malformation for dose
 Trastuzumab (Herceptin) – monoclonal Ab;
>0.1-0.2 Gy
inhibits human epidermal growth factor
 8th-25th week – CNS is vulnerable
receptor type 2 (HER2) for breast Ca; assoc.
with oligohydramnios in the 2nd and 3rd trim
1 | H.M.B.V
OB II: NEOPLASTIC DISORDERS
FERTILITY AND PREGNANCY AFTER CA
THERAPY
 ↓fertility after chemo and radio 
counselling
 Cryopreservation of embryos or oocytes
prior to therapy
 Surgical transposition of ovaries if pelvic
radiation is planned – ovaries and their
intact blood supply are fixed to the lateral
abdominal wall at a site 3-4 cm above the
level of the umbilicus
 For Ca survivors, exposure to radio and
chemo agents in childhood or adulthood
does not ↑ risk of congenital anomalies or
genetic disease in their offspring
 A/E of abdominopelvic radiation: ↑ rates of
abortion, LBW, stillbirth, preterm birth
 Radiation lowers reproductive potential by
causing ↓uterine volume, thinned
endometrium, and impaired uterine blood
flow
PLACENTAL METASTASES
 Tumor cells are usually confined within the
intervillous spaces  fetal metastases are
infrequent
REPRODUCTIVE TRACT NEOPLASMS
CERVIX
 Most common location of RT malignancy
 ENDOCERVICAL POLYP – overgrowth of
endocervical stroma covered by epithelium;
single, red, elongated fleshy masses that
extend outward from the cervical canal.
 Usually benign, can bleed, and a source of
Pap test results describing atypical glandular
cells of undetermined significance (AGUS)
 Small asymptomatic lesions are left alone to
slough during delivery or puerperal
remodelling
 Removal if (+) malignancy or bleeding is
troublesome
 (+) slender stalk – polyp is grasped with
ring forceps and twisted repeatedly about
its base to strangulate feeding vessels
2 | H.M.B.V
LECTURER: DR. DULNUAN
 Monsel paste – ferric subsulfate; applied with
pressure to the stalk stub for hemostasis
 Thick-pedicle polyp – ligation and excision
 CERVICAL INTRAEPITHELIAL
NEOPLASIA (CIN) – pregnancy status is
noted on Pap test requisition form  (+)
decidual cells hinder accurate interpretation
 Arias-Stella reaction – endocervical gland
hyperplasia; also hinders interpretation
 ↑risk for CIN – HIV, immunocompromised
state, in utero DES exposure
 Screening Guidelines:
1. No screening until age 21
2. Cytology alone every 3 years in those
aged 21-29 y/o
3. >30 y/o, HPV and cytology co-testing
every 5 years, or cytology alone every 3
years
 HPV – may promote benign, premalignant,
or cancerous neoplastic growth
 100 serotypes – several are assoc. with high-
grade intraepithelial lesions and invasive Ca
 most prominent are Types 16 & 18
 Co-testing – cytology + testing for high-risk
HPV serotype
 >25 y/o – primary HPV testing alone
 HPV 6 & 11 – benign maternal warts
 CS delivery do not ↓ risk of neonatal
laryngeal papillomatosis
 3 approved vaccines for HPV is C/I during
pregnancy but compatible with BF
 CYTOLOGY AND HISTOLOGY.
Unsatisfactory colposcopic exam is less
common during pregnancy because
transformation zone (SCJ) is better exposed
d/t cervical eversion
 Goal: Exclusion of invasive Ca
 Insufficient visualization  Repeat after 6-8
weeks
 CIN 1 – reevaluation postpartum
 CIN 2 or 3 – defer reevaluation until at least
6 weeks postpartum; Alternative: Repeat
colposcopy and cytology at intervals no
more frequent than 12 weeks
 Regression of CIN lesion is common during
pregnancy or postpartum
OB II: NEOPLASTIC DISORDERS
 Adenocarcinoma-in-situ (AIS) – treatment is
not recommended until 6 weeks postpartum
 CONIZATION – for suspected invasive
epithelial lesions; thru loop electrosurgical
excisional procedure (LEEP) or cold-knife
conization.
 Extensive excision is linked with ↑ risk of
membrane rupture, abortion, haemorrhage,
preterm delivery
 Complications of CIN treatment before
pregnancy: CONGLUTINATED CERVIX –
complete effacement without dilation, and
presenting part is separated from the vagina
by only a thin layer of cervical tissue 
spontaneous dilation by a firm pressure
with a fingertip
 INVASIVE CANCER. Mostly Squamous
cell carcinoma, others are adenocarcinoma.
 Abnormal tumor vessels may cause heavier
than expected biopsy-site bleeding,
controlled by Montel paste and firm
pressure
 Physiological pregnancy changes impede
accurate staging
 MRI without gadolinium contrast –
ascertain urinary tract and LN involvement
Management Of Pap Test Abnormalities In
Pregnancy
3 | H.M.B.V
LECTURER: DR. DULNUAN
 Stage IA1 – microinvasive disease; lesions
with deepest invasion ≤3 mm and widest
lateral extension of ≤7 mm  cont. of
pregnancy and vaginal delivery is safe and
definitive therapy is reserved until 6 weeks
postpartum
 Invasive Ca – immediate tx during the 1st
half of pregnancy; latter half of pregnancy
can be continued until fetal lung maturity is
attained
 Laparoscopic lymphadenectomy – staging
in order to delay tx if metastases are
excluded
 Neoadjuvant therapy with platinum
derivatives prior to surgery
 Young women with stage I and early stage
IIA: Radical hysterectomy + Pelvic
Lymphadenectomy
 Radiotherapy – destroy ovarian and
possibly sexual function; causes intestinal
and urinary tract injury
 Surgery before 20th week AOG for Stage IB
 Radical hysterectomy
 External beam radiation in early pregnancy
leads to spontaneous abortion.
 5-year survival rate for pregnancy-
associated cervical Ca
 Most favour CESAREAN DELIVERY.
OB II: NEOPLASTIC DISORDERS
 Significant haemorrhage from bulky or
friable tumors complicate vaginal delivery.
 ↑recurrence from episiotomy scar b/c of
tumor cells “seeding” the episiotomy
 Fertility-sparing Radical Trachelectomy –
cervix is amputated at the level of internal
os  a permanent-suture cerclage is placed
around the isthmus for support in future
pregnancies  uterine isthmus is
reconstructed to the vagina  d/t
permanent cerclage, a classical CS incision
is required
UTERUS
 LEIOMYOMAS – benign smooth-muscle
tumors; submucosal, subserosal, or
intramural
 Some become parasitic and derive their
blood supply from adjacent structures such
as the omentum.
 Leiomyomatosis peritonealis disseminata –
numerous, small, benign subperitoneal
smooth-muscle tumors that appear similar
to carcinomatosis; likely caused by Es
stimulation of multicentric subcoelomic
mesenchymal cells to become smooth-
muscle cells  regress after pregnancy
 Do not require surveillance with serial UTZ
unless assoc. complications are anticipated.
 Most are asymptomatic; acute or chronic
pain may develop
 Nonnarcotic analgesic – chronic pain 2 to
large tumor size
 Red or carneous degeneration – myomas
outgrow their blood supply and
hemorrhagic infarction follows; acute focal
abdominal pain, fever, and leucocytosis
 DDX: appendicitis, placental abruption,
ureteral stone, pyelonephritis; preterm labor
d/t by inflammation
 Tx of degenerated myoma: Analgesic,
symptoms usually abate within a few days;
WOF septic cause; myomectomy in selected
cases
 Intramural myoma in contact with
implantation site  CS
4 | H.M.B.V
LECTURER: DR. DULNUAN
 Pedunculated subserosal myoma with
subsequent painful necrosis  Laparoscopy
or laparotomy to ligate the stalk and resect
the necrotic tumor
 Complications: preterm labor, placental
abruption, fetal malpresentation, obstructed
labor, CS, postpartum haemorrhage
 Factors in det. Morbidity – number, size,
location
 Placenta is adjacent or implanted over a
myoma  preterm labor, placenta
abruption, abortion, PP haemorrhage
 Retroplacental  growth-restriction
 Cervix/LUS  obstruction of labor
 Trial of labor first unless the mass clearly
obstruct the birth canal
 R/O uterine malrotation before CS
 Myomas are generally left alone
 CS hysterectomy is difficult d/t lateral
ureteral displacement by the mass
 (+) heavy or persistent bleeding  stalk is
ligated vaginally near term to avoid tumor
avulsion during delivery
 Myomas rarely become infected – usually
postpartum, d/t septic abortion, and
myoma perforation by a sound, dilator, or
curette.
 Pritts (2001) – submucous myoma affects
fertility; hysteroscopic myomectomy
improved infertility and early miscarriage
rates
 Uterine artery embolization is C/I in
women who plan future pregnancies
 ENDOMETRIAL LESIONS. Endometriosis
develop after delivery from endometrial
tissue implanted within CS delivery or
episiotomy scars
 Adenomyosis r/t disruption of the
endometrial-myometrial border during
sharp curettage for abortion; ↑ risk of 2nd-
trim abortion, preeclampsia, fetal
malposition, and preterm delivery
 Endometrial carcinoma – an Es-dependent
neoplasia usually found in women >40 y/o;
early-stage, well-differentiated
adenocarcinomas; tx consists of TAHBSO
OB II: NEOPLASTIC DISORDERS
 Curettage with or without postprocedural
progestational therapy – to preserve future
fertility
OVARY
 Most frequent types – corpus luteum cysts,
endometriomas, benign cystadenomas,
mature cystic teratoma
 Malignant tumors and those of low
malignant potential are uncommon b/c
pregnant women are usually young
 Most are aymptomatic; some cause pressure
or chronic pain, and acute abdominal pain
d/t torsion, rupture, or haemorrhage
 Dx during routine prenatal UTZ
 CA 125 – tumor marker; concentrations in
early pregnancy and early puerperium are
normally elevated possibly d/t decidua
 Preeclampsia – CA 125 are abnormally ↑
 2 most common complications: torsion and
haemorrhage
 Torsion – causes acute constant or episodic
lower abdominal pain with N/V
 Color Doppler – ovarian mass with absent
flow strongly correlates with torsion 
Laparoscopy/Laparotomy
 Management: Untwisting attempt 
relieves congestion, ↓ ovarian volume and
cyanosis
 Don’t perform adnexectomy to avoid clot
release
 Rupture of a corpus luteum cyst – most
common cause of ovarian haemorrhage
 Progestational support – if corpus luteum is
removed before 10th week
 Cystic benign mass <5 cm – no additional
antepartum surveillance  CORPUS
LUTEUM CYST that resolves by early 2nd
trim
VULVA AND VAGINA
 ≥10 cm – surgery d/t risk of malignancy,
torsion, or labor obstruction
 Endometrioma or teratoma – resected
postpartum or during CS
 Cancer – thick septa, nodules, papillary
excrescences, or solid components 
immediate resection
5 | H.M.B.V
LECTURER: DR. DULNUAN
 PREGNANCY LUTEOMA – benign,
ovarian cells and causes ↑ testosterone
levels
 Does not require surgical intervention
unless there is torsion, rupture, or
haemorrhage
 Resolves during the first few months PP
 Lactation is delayed for a week
 HYPERREACTIO LUTEINALIS –
multiple, large theca-lutein cysts, typically
after 1st trim
 Cysts are caused by luteinization of the
follicular theca interna layer, or in response
to stimulation by ↑ hCG levels
 Common with gestational trophoblastic
disease, twins, fetal hydrops, and other
conditions with ↑ placental mass
 UTZ – “spokewheel” pattern; these masses
resolve after delivery
 OVARIAN HYPERSTIMULATION
SYNDROME – multiple ovarian follicular
cysts accompanied by ↑ capillary
permeability;
 Most often a complication of ovulation-
induction therapy for infertility
 hCG stimulation of VEGF expression in
granulosa lutein cells  ↑ vascular
permeability  ascites, pleural or
pericardial effusion, hypovolemia with AKI,
and hypercoagulability
 OVARIAN CANCER – leading cause of
death from genital-tract cancers in all
women
 Surgical staging is done with careful
inspection of all accessible peritoneal and
visceral surfaces
 Bilateral adnexectomy and omentectomy ↓
most tumor burden
 Vulvar intraepithelial neoplasia (VIN) and
vaginal intraepithelial neoplasia (VAIN) –
are commonly assoc. with HPV infection
 Generally a malignancy of older women,
and thus, rarely assoc. with pregnancy
OB II: NEOPLASTIC DISORDERS LECTURER: DR. DULNUAN

BREAST CARCINOMA - Node (+)  Multiagent chemo is begun if

delivery is not anticipated within several
- Common in younger women; most frequent
weeks – CYCLOPHOSPHAMIDE,
Ca in gravidas
DOXORUBICIN, CISPLATIN
- Postponed childbearing – partially
- Trastuzumab (Herceptin) – monoclonal Ab
responsible for ↑ in pregnancy-associated
to the HER2/neu receptor; not
Ca
recommended in pregnancy b/c HER2/neu
- >40 y/o parous women with BRCA1 and
is strongly expressed in fetal renal
BRCA2 mutations have ↓ Ca risk
epithelium and it causes miscarriage, fetal
- (+) BRCA mutation induced abortion or BF
RF,preterm birth and oligohydramnios
have no ↑ risk
- LATER DISEASE STAGES ARE MORE
- BF has a protective Ca effect in (+) BRCA1
COMMON IN PREGNANT WOMEN
but not BRCA2 mutation
- Chemo render some women infertile
- Dx in pregnancy is delayed b/c pregnancy-
- Delay conception for 2-3 years after
induced breast tissue obscures masses.
treatment b/c of recurrence risk  can use
- Palpable discrete mass can be biopsied or
IUD
excised
- Tamoxifen – has an extremely long half-life
- UTZ to differentiate whether solid or cystic
 delay conception for at least 2 months
mass has high sensitivity and specificity
after completion d/t risk of congenital
- Cystic breast lesions:
anomalies to the NB
o Simple – no special mgt; maybe
aspirated if asymptomatic THYROID CANCER
o Complicated – internal echoes
- Nodules are evaluated by UTZ and serum
during UTZ; aspirated; core-needle
TSH and free thyroxine det.
biopsy if it does not resolve
- PREGNANCY TERMINATION is not
completely
necessary
o Complex – (+) septa or intracystic on
- THYROIDECTOMY DURING 2ND TRIM
UTZ; excision
- Post-op: THYROXINE can be given
- Solid breast mass – evaluation with TRIPLE
- Radioiodine is C/I in pregnancy and
TEST: clinical exam, imaging, core-needle
lactation
biopsy
o Transplacental I is trapped by the
o Malignancy – Excision
fetal thyroid gland to cause
- After dx  limited search for the most
hypothyroidism
common metastatic sites thru CXR, liver
o Lactation - ↑ concentration of I in the
UTZ, skeletal MRI
breast
- Multidisciplinary tx – OB, breast surgeon,
o 3 months delay bet. Lactation and
medical oncologist
thyroid ablation to ensure complete
- CHEMO and SURGERY are postponed to
breast involution
the 2nd trim; ADJUVANT RADIOTHERAPY
o Delay pregnancy for 6 months-1
IS WITHHELD UNTIL DELIVERY
year
- Absent metastasis – Excision or modified or
total mastectomy with axillary node staging LYMPHOMAS
- Staging by SENTINEL LYMPH NODE
A. Hodgkin disease
BIOPSY and LYMPHOSCINTIGRAPHY
o B-cell derived; Reed-Sternberg cells
with TECHNETIUM-99 is safe
o More frequent in pregnancy
- Breast reconstruction is delayed until
delivery
6 | H.M.B.V
OB II: NEOPLASTIC DISORDERS
Symptoms: fever, night sweats,
o
malaise, weight loss, pruritus
o Early stage in the 1st trim:
observation until after 12 weeks
gestation, single-agent
VINBLASTINE at 2nd trim,
pregnancy termination followed by
Chemo or radio for isolated neck or
axillary sites
o Advanced stage: CHEMO regardless
of AOG; Therapeutic abortion before
20 weeks
o Remission – pregnancy does not
stimulate a relapse
B. Non-Hodgkin
o Can be B-cell, T-cell, or NK cell
o Assoc. with viral infections – HIV,
EBV, Hepa-C, HHV-8
o Dx in 1st trim – pregnancy
termination followed by multiagent
chemo
o Dx after 1st trim – Chemo and
immunotherapy with Rituximab
o Burkitt Lymphoma – aggressive B-
cell tumor assoc. with EBV; poor
prognosis; Tx is MULTIAGENT
CHEMO
C. Leukemia
o Lymphoid tissues (lymphoblastic or
lymphocytic) or from bone marrow
(myeloid)
o Dx: Bone marrow biopsy
o Abortion in early pregnancy to
avoid potential chemo teratogenesis
– trans-retinoic acid and tyrosine
kinase inhibitors
o AML – Chemo followed by stem-cell
transplant to prevent relapse
o Stem-cell transplant – EARLY
DELIVERY
o Complications: infection and
haemorrhage
MALIGNANT MELANOMA
7 | H.M.B.V
LECTURER: DR. DULNUAN
- Pre-existing skin nevus and its melanocytes
- Changes in contour, surface elevation,
discoloration, bleeding, or ulceration 
biopsy
- Frequent in whites and women of child-
bearing age
- One of the tumors known to metastasize to
the placenta and fetus
- Staging
o I – no palpable LN
o II – palpable LN
o III – distant metastasis
- Tx: resection of the primary tumor under
local anesthesia and postpone sentinel LN
biopsy until after delivery
- Distant metastatic melanoma –
PALLIATIVE
- Deep cutaneous invasion or regional LN
involvement have the worst prognosis
- Therapeutic abortion does not improve
maternal survival rates
- Avoid pregnancy for 3-5 years after surgical
resection
GIT CANCER
- Colorectal tumors are uncommon before
age 40
- Most frequent symptoms: abdominal pain,
distention, nausea, constipation, rectal
bleeding
- DRE, Occult blood test, sigmoidoscopy, and
colonoscopy
- Some malignancies are discovered b/c of
metastasis to the ovary
- (-) metastasis – Resection
- 1st half of pregnancy – therapeutic abortion
not necessary
- Late pregnancy  therapy delayed until
fetal maturation; bowel haemorrhage,
obstruction, and perforation may force
surgery
- Endoscopy – dx for persistent unexplained
upper GI symptoms