Abdominal Radiology (2023) 48:1679–1693

https://doi.org/10.1007/s00261-023-03836-x

SPECIAL SECTION: CANCER IN PREGNANCY

Cervical cancer in the pregnant population

Trinh Nguyen1   · Stephanie Nougaret2 · Patricia Castillo3 · RajMohan Paspulati4 · Priya Bhosale5

Received: 24 October 2022 / Revised: 24 January 2023 / Accepted: 26 January 2023 / Published online: 18 April 2023
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023

Abstract
Cervical cancer is the second most encountered cancer in pregnant patients. The 2018 International Federation of Gynecology
and Obstetrics (FIGO) staging system for cervical cancer updated the staging of primary cervical carcinoma and disease pro-
cess, with formal incorporation of imaging as a vital source of information in the management process to improve accuracy.
Diagnosis and treatment of the pregnant population is a complex interplay of achieving adequate diagnostic information
and optimal treatment while minimizing toxicity and risks to the mother and fetus. While novel imaging techniques and
anticancer therapies are rapidly developed, much information on the safety and feasibility of different therapies is not yet
available in the pregnant population. Therefore, managing pregnant patients with cervical cancer is complex and requires a
multidisciplinary approach.

Keywords  Cervical cancer · Pregnant · FIGO 2018 · Magnetic resonance imaging · Ultrasound · Computed tomography

Introduction associated with pregnancy or within 12 months postpartum

status [2]. Fortunately, most patients are diagnosed early
Cervical cancer is the second most frequently encountered due to increased routine prenatal screening [3]. To date, no
cancer during pregnancy, following breast cancer [1]. It data are available from large, randomized trial studies on
is estimated that up to 1–3% of cervical cancer cases are the efficacy of therapy in the pregnant population. Much
management relies on evidence from observational studies
tailored to individualized patient conditions and preferences.
* Trinh Nguyen However, when stratified by stage, the prognosis of preg-
nguyent2@billingsclinic.org; tnguy090@gmail.com nant patients with cervical cancer is similar to the nonpreg-
Stephanie Nougaret nant cohort when appropriate therapy and management are
Stephanie.Nougaret@icm.unicancer.fr employed. Imaging plays a crucial role in the diagnosis and
Patricia Castillo management of cervical cancer patients and was formally
castillo3@med.miami.edu incorporated in the updated FIGO 2018 staging system.
RajMohan Paspulati However, diagnostic and surveillance imaging of the subset
RajMohan.Paspulati@uhhospitals.org; pregnant population remains challenging due to a lack of
prajmohan@hotmail.com
standardization and available information. This article aims
Priya Bhosale to provide an updated overview of the diagnosis and man-
Priya.Bhosale@mdanderson.org
agement of pregnant cervical cancer patients, including the
1
Billings Clinic Hospital, 2800 10th Ave N, Billings, latest imaging protocol and considerations.
MT 95106, USA
2
Institute Regional du Cancer Montpellier, EU Euromedicine
Park, 208 Av. des Apothicaires, 34090 Montpellier, France Epidemiology
3
Sylvester Comprehensive Cancer Center, 1475 NW 12th Ave,
Miami, FL 33136, USA Cervical cancer is a leading cause of death by cancer in
4
Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, women worldwide. In the United States, approximately
FL 33612, USA 14,000 new cases are identified each year, with a death
5
MD Anderson Cancer Center, 1515 Holcombe Blvd, rate of 5000 per year. While there is a bimodal distribution
Houston, TX 77030, USA

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with peak incidence occurring between 35–39 years and
60–65 years old in the normal population, the average age
of pregnant women with cervical cancer ranges from 30 to
35 years old [4]. Approximately 1.6 to 10.6 cases of mater-
nal cervical cancer are identified per 10,000 births [2].
The risk factors of cervical cancer include human papil-
lomavirus (HPV) infection, multiple sexual partners, early
intercourse experience, multiparity, smoking, low socio-
economic status, and lack of cervical cancer preventative
screening [5]. The overall incidence of invasive cervical
cancer has decreased in recent years from increased screen-
ing with Papanicolaou (Pap) smear and HPV vaccination.
The routine Pap smear with regular obstetric examination
facilitates early detection in the pregnant population. Preg-
nant women are three times more likely to be diagnosed with
stage 1 disease than the nonpregnant cohort [6]. Addition-
ally, with an increasing number of women delaying preg-
nancy to later years, it is expected that cervical cancer in the
pregnant population will be more frequently encountered.
Clinical presentation
The symptoms of cervical cancer depend on the tumor's
stage and size. Studies have found that all patients with
stage 1A and about 50% of patients with stage 1B reported
no symptoms at the time of diagnosis, with cervical can-
cer detected at routine screening [4, 7]. The most com-
mon symptoms reported are abnormal vaginal bleeding or
discharge. In cases of advanced disease, other symptoms
include pelvic and flank pain, sciatica, anemia, and shortness
of breath. Some cervical cancer manifestations overlap with
pregnancy symptoms, posing a challenge in early disease
recognition. The average duration of symptoms before a for-
mal diagnosis of cervical cancer is 4.5 months [8].
Diagnostic evaluation
Physical and cytological examination
Cervical cancer is often detected at routine screening exami-
nation from an abnormal screening Papanicolaou exam. The
rate of abnormal pap smears is about 5–8% [3]. Patients of
age 21–29 years old may undergo interval screening every
3 years. Patients aged 30–65 may undergo a Papanicolaou
test every 3 years if normal, primary HPV testing every 5
years, or co-testing with both exams every 5 years. Preg-
nant patients undergo a more complete physical and sono-
graphic examination with evaluation of the vaginal vault,
cervix, uterus, and adnexa. The standard prenatal visit panel
also includes cervical cancer screening, which consists of a
Papanicolaou test and primary HPV testing [9, 10].
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Abdominal Radiology (2023) 48:1679–1693
Patients with abnormal cytology on Pap smear are
referred for further evaluation with colposcopy. In general,
colposcopy examination of pregnant women requires exper-
tise and experience as pregnancy-related cervical changes
such as stromal edema, cervical ripening, and ectropion limit
the ability to detect neoplasia on colposcopy exams. In addi-
tion, the normal decidual reaction of the cervix stimulated
by pregnancy hormones can mimic the appearance of cervi-
cal cancer. Conversely, neoplastic lesions may be mistaken
for regular early pregnancy-related changes.
There are critical differences in the diagnostic workup
of pregnant women and nonpregnant cohorts. One is the
preferential deferral of diagnostic conization until postpar-
tum to avoid pregnancy disruption. Conization should only
be performed during pregnancy if confirmation of invasive
cancer will alter the pregnancy management, including tim-
ing and route of delivery. Some complications of conization
include hemorrhage, miscarriage, premature rupture of the
membrane, infection, and preterm labor [11].
TNM Staging and 2018 FIGO system
Staging of cervical cancer is unique in that it encompasses
both imaging and physical evaluation, which includes a pel-
vic examination under anesthesia with colposcopy and blad-
der cystoscopy. Imaging is required in staging patients with
invasive tumors greater than or equal to 5 mm.
There is a large degree of overlap between the 8th edition
TNM staging system and the revised 2018 FIGO classifica-
tion system, outlined in Table 1.[12, 13] The revised 2018
FIGO staging system includes significant changes compared
to the 2014 version, which transitioned from clinical staging
of cervical cancer to incorporation of imaging and pathology
findings when available.
Similar to FIGO 2014, in FIGO 2018 stage I disease is
defined as carcinoma confined to the cervix, regardless of
extension to the uterine corpus, Fig. 1.
One of the changes of FIGO 2018 was the incorporation
of a new size cut-off value of 2 cm, which distinguishes the
stages IB1 and IB2. Patients with IB1, i.e., tumors less than
2 cm, have a much lower risk of cervical cancer-related death
than those with stage IB2 and above, i.e., tumors greater than
2 cm, and are eligible for radical vaginal trachelectomy, a
fertility-sparing surgical technique which preserves the uter-
ine isthmus competence for future pregnancy, Fig. 2 [14].
FIGO stage II disease is defined as carcinoma invading
beyond the uterus but not yet extended into the lower third
of the vagina or to the pelvic wall.
FIGO stage IIB disease includes parametrial involvement
but not up to the pelvic side wall. Parametrial involvement
is defined as a breach of the low signal intensity cervi-
cal stroma on the oblique axial high-resolution imaging,
unchanged from FIGO 2014. The preservation of the T2
Abdominal Radiology (2023) 48:1679–1693 1681

Table 1  TNM (8th edition) and revised FIGO (2018) classification of cervical cancer
TNM FIGO Description

Tx Primary tumor cannot be assessed

T0 No evidence of primary tumor
Tis Preinvasive carcinoma
T1 I The carcinoma is strictly confined to the cervix (extension to the uterine corpus should be disregarded)
T1a IA Invasive carcinoma that can be diagnosed only by microscopy, with maximum depth of invasion < 5 mm
T1a1 IA1 Measured stromal invasion depth of < 3 mm
T1a2 IA2 Measured stromal invasion depth ≥ 3 mm and < 5 mm
T1b IB Invasive carcinoma with measured deepest invasion of ≥ 5 mm (greater than Stage IA), lesion limited to the cervix uteri
T1b1 IB1 Invasive carcinoma with measured deepest stromal invasion of ≥ 5 mm, and greatest dimension of < 2 cm
T1b2 IB2 Invasive carcinoma with greatest dimension of ≥ 2 cm and < 4 cm
IB3 Invasive carcinoma with greatest dimension of > 4 cm
T2 II The carcinoma invades beyond the uterus, but has not extended into the lower third of the vagina or to the pelvic wall
T2a IIA Involvement limited to the upper two-thirds of the vagina without parametrial invasion
T2a1 IIA1 Invasive carcinoma with greatest dimension of < 4 cm
T2a2 IIA2 Invasive carcinoma with greatest dimension of ≥ 4 cm
T2b IIB Presence of parametrial involvement but not up to the pelvic wall
T3 III The carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or non-
functioning kidney and/or involves pelvic and/or para-aortic lymph nodes
T3a IIIA The carcinoma involves the lower third of the vagina, with no extension to the pelvic wall
T3b IIIB Extension to the pelvic wall and/or hydronephrosis or nonfunctioning kidney (unless known to be due to another cause)
N IIIC Involvement of pelvic and/or para-aortic lymph nodes, irrespective of tumor size and extent, with r (radiological) and p (patho-
logical) notations
IIIC1 Pelvic lymph node metastasis only
IIIC2 Para-aortic lymph nodes metastasis
T4 IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum (the
presence of bullous edema is not sufficient to classify a case as Stage IV)
IVA Spread to adjacent pelvic organs
M1 IVB Spread to distant organs

Fig. 1  A patient undergoes MRI

staging for a small endocervical
mass. Stage I disease, the mass
is confined to the cervical canal,
demonstrating T2 hypointense
signal (a), with diffusion restric-
tion (b, c). No evidence of
stromal invasion or parametrial
invasion

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Fig. 2  A pregnant patient underwent a staging MRI for a newly diag-
nosed cervical cancer (arrows). Stage IB, the mass demonstrates T1
hypointense (a), T2 hypointense (b, c) signal, with diffusion restric-
hypointense cervical stromal ring excludes parametrial
involvement, with a negative predictive value of 94–100%
[15].
In FIGO stage III disease, the carcinoma invades the
lower third of the vagina, and/or extends to the pelvic side
wall, and/or causes hydronephrosis, and/or involves the pel-
vic or para-aortic lymph node.
The integration of abdominopelvic retroperitoneal lymph
node status in the staging of cervical cancer is an additional
change in the 2018 FIGO staging system, previously not
included in the 2014 version. The presence of nodal metas-
tases is a significant indicator of poor prognosis and survival
[16]. The risk of pelvic nodal involvement increases with
larger tumors, specifically 6% for tumors smaller than 2 cm
and 36% for tumors larger than 4 cm [17]. The 5-year sur-
vival rate for node-positive patients is 39–54%, in contrast
to 67–92% in patients without nodal disease [18, 19]. The
added identification of lymphadenopathy precludes curative
surgery and allows upstaging patients at higher risk and bet-
ter targeting of radiation and neoadjuvant chemotherapy in
those eligible. In high-stage tumors, identification of nodal
disease is also helpful in radiotherapy planning, though
radiation is contraindicated if pregnancy is preserved, Fig. 3.
In general, cervical cancer metastasizes to parametrial
nodes, obturator nodes, then iliac nodes. Size is the main cri-
terion to identify nodal metastasis; typically, a 10 mm short
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Abdominal Radiology (2023) 48:1679–1693
tion (d, e). The tumor margin extends to the posterior left cervical
stroma without stromal breaching or evidence of parametrial invasion
axis is considered the threshold. However, the size criterion
alone is inaccurate, with sensitivity ranging from 29 to 86%
for MRI [15]. Additional features, including round shape
regardless of nodal size, central necrosis, soft tissue or tumor
signal intensity, or extracapsular tumor extension beyond the
nodal capsule, are used to identify nodal involvement. The
presence of necrosis within the lymph node has a positive
predictive value of 100% for nodal disease detection [20].
In FIGO stage IV, the carcinoma involves adjacent organs,
including the bladder or rectum, or extends beyond the true
pelvis with metastasis to distant organs.
Imaging modalities
Magnetic resonance imaging (MRI)
MRI is not used in evaluating stage IA disease as small
tumors (< 5 mm) cannot be reliably detected with imag-
ing. However, in tumors over 10 mm in size, MRI imag-
ing is indicated and is considered the optimal modality for
locoregional staging of cervical cancer, complementary
to the clinical examination. Studies have shown that the
MRI assessment of locoregional disease does not depend
on administering a Gadolinium-based contrast agent [21,
22]. Using T2 weighted and diffusion-weighted (DWI)
Abdominal Radiology (2023) 48:1679–1693 1683
Fig. 3  A pregnant patient undergoes pelvic MRI to stage a newly diagnosed cervical cancer stage IIIC. The mass demonstrates T2 hypointense
signal (a, b), diffusion restriction (c, d, e), with parametrial invasion (white arrows) and pelvic nodal metastases (f, black arrow)
sequences, readers can accurately assess the disease extent,
including evaluation of tumor size, parametrial and pelvic
wall invasion, involvement of adjacent organs, and iden-
tification of nodal and organ metastases [21]. The combi-
nation of T2/DWI can improve specificity for parametrial
invasion (96.5–99%) compared to T2 weighted imaging
alone (85.2–88.7%), with similar sensitivity (67–75%) [23].
Additionally, in a meta-analysis comparing MRI, PET/CT,
and CT, DWI-MRI has the highest sensitivity for detecting
nodal metastases with an area under the curve of 0.92, while
FDG- PET/CT is 0.9 and CT 0.83 [24].
DWI relies on the principle of random motion of water
molecules within tissues. Information regarding cellularity,
microcirculation, and cellular membrane integrity can be
inferred based on DWI. In conjunction with the apparent
diffusion coefficient (ADC), DWI improves the detection
and characterization of abnormal tissue. Cervical cancer
generally demonstrates higher signal than adjacent normal
cervical tissue, particularly with higher b- values, while the
corresponding mean ADC is significantly lower than normal
cervical tissue.
MRI protocol
Patient preparation and imaging technique are crucial to
achieving high-quality images. The patient should fast for
4 h prior to the examination in order to limit artifacts asso-
ciated with small bowel peristalsis. An antiperistaltic agent
is also needed to further suspend bowel movements. The
bladder should also be partially full at the time of the scan;
therefore, patients are encouraged to empty their bladder 1 h
before the exam. A surface array coil rather than a body coil
is used to achieve higher signal-to-noise, spatial resolution,
and shorter imaging time [15, 25]. An anterior presaturation
band can be applied to reduce breathing motion artifacts.
Presaturation pulses above and below the area of interest
may also help reduce intravascular pelvic vessels signal. The
use of vaginal gel to distend the canal has been shown to
improve the detection of vaginal involvement and is cur-
rently utilized at many institutions [26, 27].
To achieve the highest accuracy for staging, pelvic MRI
should include the following key sequences: large field-of-
view (FOV) axial T2 and T2 weighted imaging of the pel-
vis, sagittal T2 weighted imaging of the pelvis, axial small
FOV oblique T2 and T1 weighted imaging perpendicular to
the long axis of the cervix, coronal small FOV oblique T2
weighted imaging parallel to the long axis of the cervix, and
axial T2 weighted imaging or SSFP in the upper abdomen
[21]. Multiplanar acquisition perpendicular and parallel to
the plane of the cervix is crucial for tumor delineation and
assessment of local extension. DWI can accurately detect
tumor extension and identify nodal and peritoneal metasta-
ses. Additional use of axial oblique DWI perpendicular to
the plane of the cervix is also crucial for tumor delineation
and increases specificity and accuracy. Large FOV T1 and
T2 weighted imaging of the pelvis help assess the integrity
of local organs and skeletal structures. T2 imaging of the
upper abdomen can delineate the extent of retroperitoneal
nodal disease and survey the liver for metastases. The sug-
gested sequences are outlined in Table 2.
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1684 Abdominal Radiology (2023) 48:1679–1693

Table 2  Suggested MRI sequences in cervical cancer evaluation

MRI sequences
Key sequence Purpose

Large field-of-view (FOV) axial T2 weighted imaging of the pelvis Assess local organs and skeletal structures
Sagittal T2 weighted imaging of the pelvis Tumor delineation
Axial small FOV oblique T2 and T1 weighted imaging perpendicular to major axis of cervix Tumor delineation and local extension
Coronal small FOV oblique T2 weighted imaging parallel to the major axis of the cervix Tumor delineation and local extension
Axial oblique DWI perpendicular to major axis of the cervix and pelvic DWI Tumor extension, nodal and peritoneal metastases
Axial T2 weighted imaging of SSFP of the upper abdomen Extent of retroperitoneal nodal disease and survey
the liver for metastases

3  T MRI demonstrates superior signal-to-noise ratio
and contrast resolution compared to 1.5 T MRI, providing
excellent anatomical details of pelvic viscera, allowing for
more accurate cervical cancer staging [28, 29]. 3 T MRI,
therefore, may be preferred for staging pelvic malignan-
cies. However, its use in pregnancy is currently debated
given the fetal exposure to the high static magnetic field,
high radiofrequency absorption (SAR), high tissue heating
and acoustic noise, and the theoretical risk of intrauterine
growth retardation and fetal hearing loss, though currently
there is no documented risk on humans in the literature. The
Society of Pediatric Radiology and the American College of
Radiology (ACR) recommend that the radiologist assess the
risk–benefit of using 3 T MRI in pregnant women and keep
SAR within the permitted limit [30, 31].
MR imaging findings and pitfalls
The tumor typically appears as intermediate signal on T2
weighted imaging, lower than fat but higher than myome-
trium and cervical stroma, and with diffusion restriction
on DWI. However, in pregnant patients, the cervix may
appear more hyperintense on T2 weighted imaging, making
the tumor more isointense to the adjacent cervical stroma
[21, 32]. This presents a challenge in delineating the tumor.
Being aware of this physiologic change can negate the ten-
dency to overestimate the degree of tumor involvement.
Patients in late-stage pregnancy may experience physi-
ologic hydronephrosis from compression of the ureter by the
enlarged gravid uterus, estimated to be present in up to 80%
of pregnant patients [33]. This phenomenon more commonly
occurs on the right side, thought to be related to dextrorota-
tion of the uterus by the left-sided sigmoid colon [33]. It is
essential to distinguish this from tumor involving the ureter,
a marker of stage III disease. In physiologic hydronephro-
sis, it is often difficult to delineate the ureter to the point of
obstruction. Conversely, in pathologic hydronephrosis, the
source of obstruction may be more apparent and identifi-
able. Careful evaluation of the tumor and clear identifica-
tion of tumor signal intensity extending to the pelvic wall
is required. In ureteral cancer involvement, hydronephrosis
occurs ipsilateral to the side of the tumor [34].
Other pitfalls in imaging pregnant patients include dilata-
tion of pelvic parametrial vessels during pregnancy that may
mimic nodal disease on the axial plane, Fig. 4. Multiplanar
and diffusion-weighted imaging helps delineate the primary
tumor, identify nodal disease and avoid this pitfall. Addi-
tionally, recognizing flow voids on T2 weighted imaging
or blood pool signals on steady-state free precession-based
sequences can negate this pitfall.

Fig. 4  T2 weighted (a, b), T2 fat-saturated (c), and ADC (d) images of a pregnant patient with cervical cancer demonstrate dilated parametrial
vessels mimicking pathologic pelvic nodal disease (d), a pitfall to be aware of, especially in pregnant patients (white arrows)

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Abdominal Radiology (2023) 48:1679–1693 1685
Artifacts from fetal movement may compromise imag-
ing of the cervix, Fig. 5. Techniques such as T2 weighted
FSE and SSFSE are fast acquisitions allowing for great
detail anatomic delineation while minimizing fetal artifacts.
Steady-state free precession-based sequences have a high
signal-to-noise ratio, are motion insensitive, and may help
outline the vasculature and detect nodal and peritoneal dis-
ease [21].
MRI is a highly reproducible imaging technique and is
increasingly used to assess response to neoadjuvant chemo-
therapy. The treated tumor typically decreases in size with
decreased hypercellularity or a higher ADC value. However,
there are technical limitations to MRI, including a lack of
standardization of protocols, varying ADC values across
different MRI scanners, and a lack of an established ADC
value that allows for precise differentiation of tumor aggres-
siveness [35]. It is therefore recommended that the study be
performed on the same scanner with the same sequences
and parameters for more reliable use of ADC values pre-and
post-treatment in assessing treatment response.
Gadolinium‑based contrast agents (GBCAs)
The American College of Radiology (ACR) advises that
GBCAs not be routinely administered to pregnant patients.
GBCAs can pass through the placental barrier, enter the
fetal circulation, subsequently be excreted via the fetal kid-
neys, and excreted into the amniotic fluid. It may remain
in the amniotic fluid for a long time, increasing the risk of
dissociating toxic-free-Gadolinium from the chelate. Stud-
ies of nonhuman primates have found the persistence of
Gadolinium concentrations in amniotic fluid up to 50 days
after contrast administration, although no human data are
available [36]. Although no cases of teratogenicity from
intrauterine GBCA exposure have been reported, there are
Fig. 5  Motion artifacts are prevalent in MR imaging of pregnant
patients due to fetal motion, as demonstrated in this sagittal T2
(a) weighted image. The tumor is only conspicuous on diffusion-
no well-controlled studies on the effect of Gadolinium on
fetuses [36–38]. Also, there are no known cases of nephro-
genic systemic fibrosis (NSF) in fetal exposure to GBCAs
[36]. However, a macrocyclic agent with lower NSF associa-
tion should be used if Gadolinium contrast is required in a
pregnant patient.
In the primary staging of cervical cancer, GBCA helps
detect small tumors, which may enhance more avidly in the
early dynamic phase compared with the cervical stroma. It is
estimated that post-contrast images can result in an improved
sensitivity of 92% for small tumors with a depth of stro-
mal invasion ranging between 3.1 and 5 mm, compared to
23% sensitivity using only T2-weight images [15]. Using
dynamic multiphase contrast MRI, a study has established
that the peak differential enhancement of tumor and cervi-
cal stroma is between 45 and 90 s, Fig. 6. [39] Additionally,
in patients treated with chemoradiotherapy, the addition of
post-contrast imaging helps distinguish radiation fibrosis
from disease recurrence, and improves detection of other
complications such as necrosis and fistula [15, 40].
With an appropriate clinical indication, there may be a
role of GBCA in pregnant cervical cancer patients. How-
ever, as the fetal risk from GBCA exposure remains largely
unknown, it is recommended that there be a thorough discus-
sion between the radiologist, referring physician, and patient
with well-documented informed consent before Gadolinium
contrast administration.
Ultrasound
Transvaginal or transrectal ultrasound can assess the pri-
mary tumor and locoregional disease process in patients
with early-stage disease, stage IIB or lower [41]. The tumor
typically appears as an intrinsically vascular hypoechoic
mass relative to the adjacent cervical stroma, Fig. 7 [41].
weighted images (b, c, arrows). Fast acquisitions such as T2-FSE,
SSFSE, and HASTE are more resistant to motion and may improve
the visibility of the lesion
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1686 Abdominal Radiology (2023) 48:1679–1693

Fig. 6  Staging MRI of the cervical mass on prior ultrasound demon- (d, e) image confirms the findings. Of note, GBCM is not absolutely
strates a T1 hypointense (a), T2 hypointense (b), diffusion restrict- contraindicated during pregnancy and can be given in appropriate
ing (c) mass (arrow), stage IB1 limited to the external cervix with- clinical settings as deemed appropriate by the provider with careful
out stromal invasion or pelvic metastases. Post Gadolinium contrast weighing of risks and benefits and patient consent

Fig. 7  Greyscale (a) and Dop-

pler (b) ultrasound of the cervix
demonstrates a heterogenous
vascular cervical mass (arrow)
and a partially visualized intrau-
terine pregnancy

Ultrasound can also detect hydronephrosis, which can be
seen in stage IIIB, and evaluate for liver metastases, stage
IVB. The utility of ultrasound is even more crucial in preg-
nant patients as computed tomography is generally avoided
in this population due to the risk of ionizing radiation. How-
ever, ultrasound lacks specificity as hydronephrosis is often
seen in late gestation. Additionally, ultrasound is not as
accurate for evaluating higher-stage disease or larger stage
IB tumors as it is operator-dependent, and cross-sectional
imaging is preferred.
Computed tomography (CT)
Abdominal/pelvic CT is typically performed for the detec-
tion of retroperitoneal lymphadenopathy (stage IIIC) and
other intra-abdominal/pelvic metastases (stage IV), typically

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as part of the PET/CT examination in the nonpregnant popu-
lation, Fig. 8. However, PET/CT is generally not recom-
mended in the pregnant population due to the high radia-
tion dose. Moreover, abdominal/pelvic CT in the pregnant
population is typically avoided as direct pelvic radiation of
the fetus can have a significant adverse effect depending on
the fetal age. A typical CT of the abdomen/pelvis can have
a fetal radiation dose of 8–25 mGy [42]. CT is also inferior
to MRI for the locoregional staging of cervical cancer due to
its suboptimal tissue contrast. The tumor typically appears
homogeneously enhancing, similar to the normal cervical
tissue on CT [7]. However, if pelvic magnetic resonance
imaging (MRI) is unavailable or contraindicated, contrast
CT can be used as an alternative modality for staging, with
careful weighing of risks and benefits to the mother and
fetus. Direct pelvic radiation imaging in the pregnant popu-
lation should be avoided, especially in the first trimester.
A contrast chest CT alone has a low fetal dose of
0.01–0.66 mGy and can be utilized to assess for thoracic
metastases [42]. Studies have shown that indirect fetal expo-
sure from internal scatter is considered negligible, and chest
CT should not be withheld when necessary [43].
Other imaging considerations in the pregnant
population
Imaging the abdomen and pelvis of pregnant patients can
be challenging, partly due to fetal and intestinal artifacts
Fig. 8  A patient with early pregnancy undergoes staging MRI for a
recently diagnosed cervical cancer. The mass (white arrow) demon-
strates a T1 isointense signal (a) and T2 mildly hypointense signal (b,
c), with post-contrast avid enhancement (d, e). In addition, there is
evidence of parametrial extension and involvement of the lower uter-
that may limit the imaging quality and analysis. Some
authors have advocated for pregnant patients to fast for 4 h
before an MRI examination to reduce maternal peristal-
sis and fetal movements [44]. In the nonpregnant cohort,
spasmolytic agents such as hyoscine butylbromide can be
used to decrease intestinal peristalsis. However, its use in
pregnant patients is controversial due to the side effect of
dilatation of the cervical canal [45].
Additionally, the classic supine position in cross-
sectional imaging may induce discomfort in patients in
the late stages of pregnancy. The large gravid uterus may
compress the inferior vena cava, compromising venous
return and precipitating syncope. Alternative imaging in
the left lateral decubitus position may be performed in
these patients [44].
The duration of the MRI exam should also be kept as
short as possible to reduce patient discomfort while main-
taining a low specific absorption rate (SAR), limited to
2W/kg [43]. Short sequences such as T2 weighted fast-
spin-echo (FSE) and single-shot-fast-spin-echo (SSFSE)
can be used in pregnant patients to achieve good anatomic
details while minimizing artifacts related to fetal motion.
In addition, alternating these high SAR sequences with
low SAR sequences, such as T1 weighted gradient echo
(GRE) and steady-state free precession (SSFP) sequences,
can minimize fetal heat deposition.
ine segment (black arrow). After counseling on risks and benefits,
the patient undergoes termination of pregnancy to expedite treat-
ment. Her staging PET/CT (f) demonstrates an FDG avid mass (white
arrow) and pelvic nodal metastases (grey arrow), Stage IIIC
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1688 Abdominal Radiology (2023) 48:1679–1693

Management common in the United States. However, when possible, early

delivery is encouraged to avoid nonlethal fetal exposure to
Preinvasive disease teratogens [48, 49].

Treatment of preinvasive disease, or carcinoma-in-situ, Pregnancy is preserved

should be delayed until postpartum. One study found that
the rate of tumor regression is as high as 34.2% of patients
[46]. The risk of progression to invasive carcinoma during
pregnancy is as low as 0 to 0.4% [47].
Invasive disease
Management of pregnant patients with invasive cervical
cancer is outlined in Fig. 9 algorithm. In general, patient
counseling regarding the preservation of pregnancy should
happen at the diagnosis of invasive cervical cancer. Subse-
quent management is based on the patient's desire to pre-
serve pregnancy and the gestational age.
Pregnancy termination
Termination of pregnancy is complex and subject to local
statutes and clinical scenarios. However, if the patient elects
to terminate the pregnancy, definitive treatment will be
administered as in nonpregnant patients along with preg-
nancy termination. A radical hysterectomy with the fetus
in situ can be performed in early pregnancy. Second-trimes-
ter termination is more complex and may include medical
and/or surgical abortion. Third-trimester termination is not
If the patient elects to continue the pregnancy, management
requires multidisciplinary collaboration and is based on
the disease stage and gestational age. Radiation therapy is
contraindicated during pregnancy as the typical therapeutic
radiation doses can lead to fetal demise or severe harm.
In gestational age less than 22–25 weeks at diagnosis,
lymphadenectomy is an option given the relatively small size
of the gravid uterus and the feasibility and safety of surgery.
Therefore, management depends on the disease stage and the
presence of pelvic nodal involvement in lymphadenectomy,
outlined in Fig. 9 algorithm.
In gestational age later than 22–25 weeks, lymphadenec-
tomy is less of an option due to the increased risk asso-
ciated with surgery and technical challenges due to the
enlarged gravid uterus. Treatment is mainly based on the
clinical stage of the disease at diagnosis, outlined in Fig. 9
algorithm.
Systemic therapy in pregnancy
Systemic neoadjuvant chemotherapy may be required in
stage IB2 (i.e., tumor greater than or equal to 2 cm) or higher
regardless of gestational age or stage IA2 to IB1 (i.e., tumor

Does the paent want to

preserve the pregnancy?
Yes No

Terminate
Is the gestaonal age > 22 to 25 weeks? pregnancy
and
Yes No management
as in
Tumor Tumor nonpregnant
stage stage paent
IA1 to IB1 Stage IB2 (size >/= Stage IA2 to IB1
Stage IA1
(<2cm) 2cm) or higher (size <2cm)

Definive Pelvic
Delay Neoadjuvant treatment lymphadenopathy?
treatment chemotherapy
unl aer with
Stage IB2 (size Yes No
delivery conizaon
>/= 2 cm)
Neoadjuvant
therapy Definive
Pelvic lymphadenopathy if treatment
size >/= 4 cm? (conizaon or
trachelectomy)
No Yes

Neoadjuvant Neoadjuvant therapy. *Note

therapy high risk of disease
progression and should be
offered terminaon of
pregnancy and definive
therapy as an alternave
opon.

Fig. 9  . Treatment algorithm of cervical cancer

13
Abdominal Radiology (2023) 48:1679–1693 1689
less than 2 cm) with the presence of nodal metastasis, Fig. 9
algorithm.
If systemic therapy is given during pregnancy, a combi-
nation of cisplatin and paclitaxel is recommended. There
is some evidence that cisplatin is filtered by the placenta,
although the concentration in amniotic fluid at delivery is
relatively low, approximately 11–42% of the concentration
in maternal blood [48, 50]. There may be a risk of fetal oto-
toxicity and transient neutropenia in newborns from intrau-
terine cisplatin exposure [48]. Therefore, therapy should be
discontinued about three weeks before planned delivery to
minimize neonatal marrow suppression and allow time for
cytotoxic drugs to be eliminated and metabolized by the
placenta. Additionally, chemotherapy should be avoided dur-
ing the late third trimester due to increased association with
spontaneous labor. Bevacizumab, an anti-VEGF inhibitor
with an anti-angiogenesis effect, is FDA-approved for cer-
vical cancer treatment in the nonpregnant population but is
contraindicated during pregnancy due to the risk of severe
fetal harm in animal studies [48]. Safety data of chemo-
therapy during pregnancy is limited; however, a systematic
review of 48 human pregnancy exposures to platinum deriv-
atives in 2013 found that 67.3% of neonates were healthy at
birth, and the most significant problem in remaining births
was associated with prematurity, most frequently respiratory
distress [51].
In patients with locally advanced cervical cancer (stages
IB3 or higher) who elect to terminate the pregnancy, there is
increased benefit from concurrent chemoradiation therapy,
which includes external radiation and intracavitary brachy-
therapy. However, in patients electing to preserve pregnancy,
radiation is contraindicated.
Surveillance during pregnancy
Patients with preinvasive disease should undergo colposcopy
examination each trimester of pregnancy. Patients who wish
to delay definitive therapy until after delivery and those on
neoadjuvant therapy should undergo pelvic examinations
every 3–4 weeks during pregnancy. Additionally, pelvic
MRI without Gadolinium contrast should be performed to
monitor for disease progression [48].
Delivery
A term delivery at 37 weeks or later is ideal. However, if
earlier delivery is required to expedite treatment, antenatal
steroids may be administered to reduce respiratory morbid-
ity and mortality.
Vaginal delivery is possible in patients with stage IA1
and IA2 disease, although an episiotomy should be avoided
to prevent tumor seeding [52]. For patients with stage IB1
or higher, a caesarian section should be performed due to
the greater risk of significant hemorrhage and obstruction
of the birth canal [53].
Definitive treatment
Definitive treatment, i.e., hysterectomy or trachelectomy, is
typically deferred until postpartum if pregnancy is preserved
and largely depends on the disease stage and the mother’s
desire to preserve future fertility. For fertility preservation
in stage IA1 disease, therapeutic conization may be all that
is needed. However, in Stage IA2 disease or large tumors up
to 4 cm, a radical vaginal trachelectomy can be performed.
If a mother does not wish to preserve fertility, a laparoscopic
hysterectomy can be performed for Stage IA1 disease, while
a radical hysterectomy is recommended for tumors of stage
IA1 with lymphovascular space invasion up to stage IB1.
Patients with locally advanced diseases requiring neoad-
juvant chemotherapy should undergo a radical hysterectomy.
Fertility sparing in cervical cancer
Several trachelectomy surgical techniques have been
described in the literature with varying outcomes. Vaginal
radical trachelectomy (VRT) has a reported 99% 5-year sur-
vival rate. VRT combines laparoscopic pelvic lymphadenec-
tomy with resection of the parametria at the level of radical
hysterectomy. Subsequently, the cervix is transected 1 cm
above the tumor margin while preserving at least 1 cm of
the cervical stroma. VRT has an overall pregnancy rate of
30% [54].
Abdominal radical trachelectomy (ART) is an alterna-
tive procedure performed abdominally. ART is a modifica-
tion of the radical abdominal hysterectomy approach, which
includes lymphadenectomy and resection of the uterine
artery, parametrium, entire cervix, and vagina. The vagina
is then sutured directly to the remaining stroma. ART has
a reported 88.7- 93.5% 5-year survival rate [55, 56]. The
overall pregnancy rate for ART is 15% [54].
Simple trachelectomy (ST) is a 2-step procedure involv-
ing laparoscopic pelvic lymphadenectomy with sentinel
lymph node mapping (SLNM). A resection of the parame-
trium is unnecessary in cases with negative pelvic lymph
nodes with a tumor size less than 2 cm in diameter. There-
fore only a simple trachelectomy is done, usually one week
after SLNM. The remaining cervix is sutured with the vagi-
nal edges, and cervical cerclage is not performed. If positive
lymph nodes are detected, a fertility-preserving procedure is
not performed. The pregnancy rate for ST is about 50% [57].
Tumor size and location are critical factors in assess-
ing trachelectomy candidacy, with cervix-confined
tumors < 2 cm in size and located > 1 cm from the inter-
nal cervical os considered ideal features. Some centers will
13

1690 Abdominal Radiology (2023) 48:1679–1693

consider trachelectomy for women with tumors < 4 cm or as
close to 0.5 cm from the internal os, Figs. 10 and 11 [58, 59].
Post-operative complications include dyspareunia, dys-
menorrhea, menstrual irregularities, inflammation/infection,
cervical stenosis, and premature labor. The shortened cervix
is a significant risk factor for premature delivery. Therefore
patients should be counseled before and monitored during
pregnancy [57].
Surveillance after pregnancy
The Society of Gynecologic Oncology's 2017 updated
statement on post-treatment surveillance of gynecologic
malignancies emphasized the role of follow-up physical
examination and detailed history, which are the only con-
sistent methods for detecting recurrence [60, 61]. The
patient should be followed at 3–4 month intervals in the
first 2 years and every 6–12 months after. After 5 years of
recurrence-free survival, the patient may return to annual
population-based general physical examinations. If recur-
rence is suspected, additional imaging may be performed.
Routine radiologic imaging in asymptomatic patients is not
recommended as it has not been definitively evaluated [61].
Outcome
The estimated risk of metastatic or recurrent cervical can-
cer is 15–61% of patients, usually within the first 2 years

Fig. 10  Trachelectomy for
fertility-sparing. Intraoperative
images demonstrate at least
1 cm of uninvolved cervix from
the tumor

Fig. 11  Before (a, b) and after (c, d, e) simple trachelectomy images demonstrate the expected post-operative appearance of a shortened cervix
secured by a cerclage postoperatively (arrows)

13
Abdominal Radiology (2023) 48:1679–1693 1691
of completing therapy [62]. A study reported that vaginal
delivery was a significant predictor of recurrence in pregnant
patients [63, 64]. Additional case reports have described
tumor implantation at episiotomy sites and poor prognosis
[65–68]. Most available studies suggest similar outcomes
and prognoses for treated pregnant and nonpregnant cervi-
cal cancer patients when adjusted for the stage. Available
studies observed similar mortality rates in pregnant and non-
pregnant patients with cervical cancer [69, 70]. However,
pregnant women with cervical cancer have a higher rate of
spontaneous abortion and iatrogenic prematurity than those
without cervical cancer [71].
Conclusion
Cervical cancer is increasingly diagnosed during pregnancy
with increased antenatal screening and women delaying
pregnancy to a later age. The FIGO 2018 version and TNM
staging systems primarily rely on imaging as an integral
component of disease management. Special imaging con-
siderations and protocols are required for pregnant patients,
requiring more active research. Although not much data are
available on the therapeutic effect of pregnant cervical can-
cer patients, the available studies suggest similar outcomes
to nonpregnant cohorts when appropriate management is
applied.
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