DOI: 10.1111/tog.

12367 2017;19:139–46
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Management of gynaecological cancer in pregnancy

a, b c d
Susnata China FRCOG, * Yashashwi Sinha MRes, Deepali Sinha MD MRCOG, Kathryn Hillaby MD MRCOG
a
Consultant Gynaecologist, Worcestershire Acute Hospitals, Worcester WR5 1DD, UK
b
Academic Foundation Doctor, Ealing Hospital, London UB1 3HW, UK
c
Consultant Obstetrician and Gynaecologist, Alexandra Hospital, Redditch B98 7UB, UK
d
Consultant Gynaecological Oncologist, Cheltenham General Hospital, Cheltenham GL53 7AN
*Correspondence: Susnata China. Email: susnata.china@nhs.net

Accepted on 25 July 2016

Key content  To be able to give optimal management of these patients to

 This article summarises the current management and outcome of provide the best outcome for the mother and baby.
gynaecological cancers (cervical, endometrial, vulvovaginal,
Ethical issues
ovarian and fallopian tube cancer) in relation to pregnancy.
 Pre-existing gynaecological cancer and pregnancy planning is
 Sanctity of life – balancing optimal maternal therapy versus
fetal health.
discussed, as well as prepartum diagnosis with or without  Termination of pregnancy and personal beliefs.
intrapartum recurrence, intrapartum diagnosis and
 Utility – benefit over harm and the quality of life for both mother
postpartum management.
and baby given certain outcomes.
Learning objectives
Keywords: cancer / management / multidisciplinary / pregnancy /
 To understand prepregnancy planning with involvement of the
review
multidisciplinary team and counselling.
 To understand how to approach gynaecological cancers in
relation to pregnancy inclusive of patient factor and stage
of malignancy.

Please cite this paper as: China S, Sinha Y, Sinha D, Hillaby K. Management of gynaecological cancer in pregnancy. The Obstetrician & Gynaecologist 2017;19:
139–46. DOI: 10.1111/tog.12367

conflict of interest between the mother’s wellbeing and

Introduction
Malignancy during pregnancy is infrequent, with an
approximate incidence of 1 in 1000 pregnancies.1 This can
pose several challenging situations to the obstetricians,
gynaecologists, oncologists, neonatologists and other
healthcare professionals who are responsible for patient
care.1 This is particularly due to lack of clinical consensus
because of the absence of major cohort studies and
randomised controlled trials.
Current practice in the UK is very similar to the
European recommendations, which state that pregnancy
should be preserved whenever feasible alongside careful
and detailed discussion with the mother by a
multidisciplinary team. The clinician’s role in such cases
involves providing accurate information to the mother and
consideration of her wishes regarding continuation of
pregnancy. Ethical, personal, religious and emotional
factors vary between patients and increase the complexity
of management.
Determining the optimal treatment for cancer in
pregnant women is often complex because there can be a
future against the preservation of pregnancy and the life of
the fetus. Pregnancy as such is not known to cause any
deleterious effect on the prognosis of cervical and ovarian
cancer, and pregnant women with these conditions are
known to have similar outcomes as nonpregnant
women.2–4
The most common tumours presenting in pregnancy are
breast cancer, cervical cancer, melanoma and haemopoietic
cancers.5 The most common gynaecological cancers
diagnosed in pregnancy are of the cervix and ovaries.6
Endometrial cancer in young women of childbearing age is
generally an incidental diagnosis following endometrial
curettage after a miscarriage or delivery. However, with the
increasing prevalence of obesity in young women over the
past 20 years, this is more frequently encountered. Vulval or
vaginal cancers in pregnancy and young women are
relatively uncommon.6,7
The management of breast carcinoma is not included in
this article because obstetricians and gynaecologists in the UK
do not usually deal with breast cancer, although it may be
recognised practice in some parts of Europe.

ª 2017 Royal College of Obstetricians and Gynaecologists 139

 Gynaecological cancer in pregnancy

Pregnancy causes marked morphological changes to the

Gynaecological cancers
Cervical cancer
There has been a significant decrease in the incidence of
invasive cervical cancer in young women in the UK as a result
of the advent of the cervical screening programme. The
incidence of cervical cancer in pregnancy is estimated to be
between 1 and 10 per 10 000 pregnancies,8–10 with almost
two-thirds of cervical cancer cases diagnosed during the first
two trimesters being early-stage disease – up to stage 1B
tumours (Table 1).9
Most commonly, clinicians will be managing women
previously treated for cervical cancer who are now pregnant.
These women may have either had a large loop excision of
the transformation zone (LLETZ) or cone biopsy for very
early disease, or a trachelectomy for early stage 1B1 cancers.
Ideally, prepregnancy counselling should occur, as these
women are at a higher risk of pregnancy complications
compared with the background population and their
pregnancies should be managed by consultant-led care.
Women who have previously been treated with
trachelectomy before becoming pregnant should be
counselled about the need for delivery by caesarean section,
the increased risk of preterm rupture of membranes,
chorioamnionitis, mid-trimester loss and preterm delivery.11
cervix, which include a significant increase in cervical
volume, a bluish hue due to increase in vascularity,
ectropion and inflammatory changes.12 These physiological
changes may appear suspicious to an inexperienced clinician.
Therefore it is recommended that women with a suspected
cervical lesion in pregnancy should immediately be referred
for colposcopic examination by an accredited colposcopist.
Patients with a visible lesion on the cervix should have a
directed biopsy. One directed biopsy from the most
dysplastic area is usually performed to establish the
histological diagnosis. The risk of a punch biopsy during
pregnancy is increased bleeding due to increased vascularity
of the cervix but there are no increased risks to the
pregnancy. Performing a cervical smear during pregnancy is
not recommended.13 Cervical smears performed during
pregnancy frequently cause concern as the presence of
decidual cells can be mistaken for atypia.
Staging of cervical cancer is based on clinical examination
but in the UK magnetic resonance imaging (MRI) and
computed tomography (CT) staging is also used. MRI is the
best imaging modality for assessment of local and regional
spread and is safe in pregnancy.14 CT scanning carries a risk
of radiation exposure to the fetus in pregnancy and so is not
used in assessing pregnant women with cervical carcinoma.

Table 1. FIGO classification for cervical cancer44

FIGO stage Extent of disease

I Cervical carcinoma confined to the cervix (extension to the corpus should be disregarded).
IA Invasive cancer diagnosed only by microscopy; stromal invasion with a maximum depth of 5.0 mm measured from the
base of the epithelium and horizontal spread of 7.0 mm or less; vascular stage involvement, venous or lymphatic, does not
affect classification
IA1 Measured stromal invasion of ≤3.0 mm in depth and ≤7.0 mm in horizontal spread
IA2 Measured stromal invasion of >3.0 mm and ≤5.0 mm in depth with a horizontal spread ≤7.0 mm
IB Clinically visible lesions confined to the cervix or microscopic lesions greater than stage IA
IB1 Clinically visible lesions ≤4 cm in greatest dimension
IB2 Clinically visible lesions >4 cm in greatest dimension

II Cervical carcinoma invades beyond the uterus but not to pelvic wall or to lower third of vagina
IIA Tumour without parametrial invasion
IIA1 Clinically visible lesion ≤4.0 cm in greatest dimension
IIA2 Clinically visible lesion >4.0 cm in greatest dimension
IIB Tumour with parametrial invasion

III Tumour extends to pelvic wall and/or involves lower third of vagina and/or causes hydronephrosis or non-functioning
kidney
IIIA Tumour involves lower third of the vagina, no extension to pelvic wall
IIIB Tumour extends to pelvic wall and/or causes hydronephrosis or non-functioning kidney

IV Tumour invades mucosa of bladder or rectum and/or extends beyond true pelvis (bullous oedema is not sufficient to
classify a tumour as stage IV)
IVA Spread of the growth to adjacent organs
IVB Spread to distant organs

140 ª 2017 Royal College of Obstetricians and Gynaecologists


Four principal criteria are considered in the management of
cervical cancers in pregnancy: tumour size and nodal status,
which determine the stage of disease, and gestational age and
histological subtype.1
In patients with early-stage disease (up to and including
small volume stage IB1 – up to 2 cm) and in the absence of
any nodal disease, the current trend is continuation of the
pregnancy after treatment with LLETZ, conisation or a
radical trachelectomy and consideration of pelvic
lymphadenectomy to assess disease spread. Cases of stage
IA1, IA2, and IB1 cervical cancers should be managed on an
individual basis, the tumour type and size being key factors in
determining treatment. Stage IA1 tumours can be managed
by LLETZ or cold-knife cone alone. LLETZ or cold-knife
conisation should be undertaken early in the pregnancy; the
choice between these procedures depends on the size of the
cervical lesion, the clinical team’s preference and the degree
of suspicion.12,13,15–17 The indication for conisation decreases
as the pregnancy progresses because of the risk and morbidity
of this procedure, including bleeding in 4–15% of cases,
pregnancy loss, premature delivery or premature rupture of
membranes, which increases with gestational stage.15,17
Lymphadenectomy is performed to assess spread of the
disease including and beyond stage IA2, and to gain
prognostic information which helps in further management
of the disease; for example, postoperative chemoradiotherapy
will usually be advised if the lymph nodes are positive.
Assessment of pelvic node status by means of laparoscopic
pelvic lymphadenectomy is an appropriate diagnostic
procedure during first and early second trimester, but
becomes very challenging beyond 15 weeks of gestation.
The gold standard for assessment of nodal status is usually
based on histopathological assessment of lymph nodes.
Histopathological analysis of nodes can be difficult to
interpret because of decidual changes in pelvic nodes,
which can mimic nodal metastases, particularly in cases of
squamous cell carcinoma.18
Smaller volume, superficial tumours may be managed by
loop excision or conisation and, in very small tumours,
lymphadenectomy may not be indicated. Slightly larger
stage IB1 tumours up to 2 cm with no obvious nodal
spread may be managed with radical trachelectomy in the
first trimester, thereby preserving the pregnancy. In 2015,
Kyrgiou et al.19 published a case report of laparoscopic
radical abdominal trachelectomy for the management of
stage 1B1 cervical cancer at 14 weeks of gestation. This is
the first example of use of this technique in pregnancy and
the woman went on to have a live baby at 36 weeks by
caesarean section.
In women diagnosed with stage IIB1 cervical cancer at a
later stage in their pregnancies, delivery should be by
caesarean section once viability has been achieved,
immediately followed by radical hysterectomy and pelvic
ª 2017 Royal College of Obstetricians and Gynaecologists
China et al.
lymphadenectomy by a gynaecological oncologist.
Obstetricians, neonatologists and gynaecological oncologists
should work together closely when dealing with such women
to optimise outcomes for both the woman and her baby.
For women diagnosed with more advanced cervical cancer
than stage IB1, standard management is with chemo-
radiotherapy. However, some cases of stage IB2 and IIA
tumours may be suitable for surgical management.20
Detection of positive nodal status has implications on
further management and can also alter the outcome of
pregnancy. These cases should be managed on an individual
basis. Multidisciplinary team discussion and management in
a tertiary centre is mandated. The prognoses for these more
advanced cervical cancers are not as good as for early stage
cancers. Chemo-radiotherapy is often suggested in such cases
and discussion with the patient is necessary; consideration
should be given to terminating the pregnancy if it is at an
early stage, or precipitating delivery if the fetus has attained
viability to enable treatment to be started as quickly
as possible.
Generally the prognoses of squamous cell carcinoma,
adenocarcinoma or adenosquamous carcinomas are the
same. However, rarer subtypes, such as small-cell
carcinoma hold a poorer prognosis, as in nonpregnant
women.21 In cases of aggressive disease with relatively poorer
prognosis, termination of pregnancy should be considered
and the woman should be treated following termination to
optimise the outcome for the patient.1
Postpartum follow-up is the same as for nonpregnant
women. In women who have undergone hysterectomy or
chemoradiotherapy, this involves general examination,
examination for peripheral lymphadenopathy, and
abdominal and vaginal examination. In women treated
with LLETZ or conisation, follow-up is cytological along
with examination as described above, and is often best
performed in the colposcopy setting because of difficulties in
obtaining adequate cervical cytology samples. Women
treated with trachelectomy should also be followed-up in
the colposcopy setting with clinical examination, cytology
and MRI examinations in accordance with the protocol of
the treating cancer centre.
It should be remembered that the majority of women with
cervical cancer have a good prognosis, with 5-year survival
rates in women with stage I disease exceeding 95%.21
Ovarian and fallopian tube cancers
Ovarian cancer is the second most frequent gynaecological
malignancy occurring in pregnancy.22 However, adnexal
masses diagnosed during pregnancy are rarely malignant
(2–10 per 100 000 pregnancies), with a high rate of
spontaneous remission within the first trimester.22
Histological types of ovarian malignancies include germ cell
(6–40%), borderline (21–35%), epithelial (28–30%) and sex
141
 Gynaecological cancer in pregnancy
cord stromal (9–16%) origin, a distribution which is similar
in the non-pregnant population.23,24 The most common
ovarian malignancies within the younger age group are:
borderline ovarian tumours, non-epithelial invasive cancers
(germ cell and sex cord-stromal tumours) and epithelial
invasive cancers.25
Preoperative ultrasound may be helpful in differentiating
benign from malignant ovarian cysts. CT imaging is not
recommended in pregnancy because of the risks of radiation
to the fetus, and MRI of the abdomen and pelvis should be
used to further characterise ovarian masses and define the
extent of disease. The tumour marker CA125 is not very
reliable during pregnancy, particularly in the first trimester,
with concentrations reported as being more than 65 IU/ml in
16% of patients.26 The CA125 serum level returns to within
normal limits in the second or third trimester but may rise
again immediately following delivery.27
Definitive diagnosis is based on removal of the adnexal
mass, inspection of the abdominal cavity and biopsy of any
suspicious lesions, with necessary cytological analysis.28
Surgery for asymptomatic masses should only be
undertaken where the mass has obvious malignant features.
When suspicion of malignancy is low (using the risk of
malignancy index), expectant management can be adopted
without necessitating surgery.29 Surgery is generally indicated
if the patient is at risk of an acute abdominal event such as
ovarian torsion or rupture. Surgery should ideally be
performed between 12 and 27 weeks of gestation.25
Laparoscopic management is possible if the risk of
malignancy is thought to be low and generally
recommended up to about 20–22 weeks of gestation.25
However, this can be very challenging and should be
performed by clinicians with appropriate experience. It is
recommended that these patients are referred and managed
in cancer centres. If the risk of malignancy is thought to be
high, these cysts should be removed by open surgery to allow
full staging to occur, but also to reduce the risk of surgical
spillage, which can upstage a malignant ovarian cyst. The
mode of delivery is determined by the extent and timing of
treatment through the pregnancy.
The management of borderline ovarian tumours during
pregnancy is similar to that in nonpregnant women. The
general recommendation is for continuation of the
pregnancy with the aim of having a normal delivery
irrespective of the time of diagnosis. These tumours have a
good prognosis and can be managed surgically in the
postpartum period.1
Patients with non-epithelial cancers are often
symptomatic, frequently due to a large mass and are
usually at stage I (Table 2) when diagnosed in pregnancy.
Fertility-preserving surgery with a unilateral salpingo-
oophorectomy is indicated with full peritoneal staging,
generally without lymphadenectomy, unless suspicious
142
lymph nodes are visualised during surgery.30
Alphafetoprotein is raised in pregnancy, but the levels in
women with germ cell tumours are significantly higher than
those found in normal pregnancies.
Management of epithelial cancers depends on the stage at
presentation. Involvement of the multidisciplinary team is
essential. With stage I (Table 2), treatment is similar to that
of non-pregnant women and in accordance with National
Institute for Health and Care Excellence (NICE) guidelines.
This may involve adnexectomy with surgical peritoneal
staging. Ipsilateral pelvic and para-aortic lymphadenectomy
should not be performed in a systematic fashion but only be
done when suspicious nodes are identified, thereby
preserving the uterus and contralateral ovary.31,32 NICE
guidance recommends that women with stage IA or IB grade 1
or 2 disease who have had optimal surgical staging and who
have low-risk disease should not be offered adjuvant
chemotherapy, and only those women who have been
found to have high-risk stage I disease (stage IC or
grade 3) should be offered adjuvant chemotherapy with
single-agent carboplatin. Women who appear to have stage I
disease, but who have not undergone optimal surgical
staging, should have a discussion about the individualised
risks and benefits of chemotherapy with a medical oncologist.
In patients with advanced or unresectable disease (FIGO
stage IIIC–IV; Table 2) neoadjuvant chemotherapy and
interval debulking surgery are offered given the poor
prognosis these stages hold for the mother. For women with
stage II–IIIB disease, debulking should be undertaken as soon
as possible and involves a hysterectomy and termination of the
pregnancy; therefore management options need to be discussed
with the woman. If she wishes to continue with the pregnancy,
neoadjuvant chemotherapy should be offered in the second and
third trimesters until fetal maturity, with the aim to complete
cytoreductive surgery following delivery.25
Women who have previously been treated for ovarian
malignancy should be carefully monitored in pregnancy. Only
a small proportion of patients with advanced disease attain
sustained remission following initial treatment of ovarian
cancer23 and achieve pregnancy. CA125 should not be
routinely measured as it can be elevated in pregnancy. A
CA125 test and an MRI scan should be performed if the woman
has symptoms or there is strong clinical suspicion of
recurrence. An increase in tumour marker level or a change
in imaging findings may indicate recurrence and active
treatment regimens must be assessed in this group of
pregnant women. Recurrence holds a poor prognosis and the
goal is often to prolong effective quality of life and survival.
Treatment may involve surgery, cytotoxic chemotherapy or
hormonal therapies. Choice of chemotherapeutic agent is
based on sensitivity to platinum-based chemotherapy agents.31
Hormonal therapy with tamoxifen or an aromatase inhibitor
can be used if appropriate.1,31
ª 2017 Royal College of Obstetricians and Gynaecologists
 China et al.

Table 2. FIGO staging for ovarian cancer45

FIGO stage Extent of disease

I Tumour confined to ovaries or fallopian tube(s)

IA Tumour limited to one ovary (capsule intact) or fallopian tube, No tumour on ovarian or fallopian tube surface.
No malignant cells in the ascites or peritoneal washings.
IB Tumour limited to both ovaries (capsules intact) or fallopian tubes
No tumour on ovarian or fallopian tube surface
No malignant cells in the ascites or peritoneal washings
IC IC tumour limited to one or both ovaries or fallopian tubes, with any of the following:
IC1: Surgical spill intraoperatively
IC2: Capsule ruptured before surgery or tumour on ovarian or fallopian tube surface
IC3: Malignant cells present in the ascites or peritoneal washings

II Tumour involves one or both ovaries or fallopian tubes with pelvic extension (below pelvic brim) or peritoneal cancer (Tp)
IIA Extension and/or implants on the uterus and/or fallopian tubesand/or ovaries
IIB Extension to other pelvic intraperitoneal tissues

III Tumour involves one or both ovaries, or fallopian tubes, or primary peritoneal cancer, with cytologically or histologically
confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes
IIIA Metastasis to the retroperitoneal lymph nodes with or without microscopic peritoneal involvement beyond the pelvis
IIIA1 Positive retroperitoneal lymph nodes only (cytologically or histologically proven)
IIIA1i Metastasis ≤10 mm in greatest dimension (note this is tumour dimension and not lymph node dimension)
IIIA1ii Metastasis ≥10 mm in greatest dimension
IIIA2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodes
IIIB Macroscopic peritoneal metastases beyond the pelvic brim ≤2 cm in greatest dimension, with or without metastases to the
retroperitoneal lymph nodes
IIIC Macroscopic peritoneal metastases beyond the pelvic brim ≥2 cm in greatest dimension, with or without metastases to the
retroperitoneal nodes (Note 1)

IV Distant metastasis excluding peritoneal metastases

IVA Pleural effusion with positive cytology
IVB Metastases to extra-abdominal organs (including inguinal lymph nodes and lymph nodes outside of abdominal cavity) (Note 2)
Note 1 Includes extension of tumour to capsule of liver and spleen without parenchymal involvement of either organ
Note 2 Parenchymal metastases are stage IV B

Postpartum follow-up is based on several factors including Endometrial cancer

severity of cancer symptoms, whether they are currently
undergoing chemotherapy and should be based on local
guidelines. Pelvic examination should be done at 3- to
6-monthly intervals and tumour markers such as CA125
should be assessed in those with clinical symptoms. If there
are signs of recurrence, then a whole body CT scan
is recommended.
More recently, an increasing number of cases of what were
thought to be ovarian malignancies have been diagnosed as
primary fallopian tube cancers. Very little is found in the
literature about the management of fallopian tube cancer in
pregnancy. Therefore, fallopian tube cancer should be
managed in the same way as in epithelial ovarian malignancy.
A recent hypothesis with a growing body of evidence states
that the majority of serous tumours appear to originate from
dysplastic lesions in the distal fallopian tube. Therefore, what
we have traditionally considered ‘ovarian’ cancer may in fact
be tubal in origin. However, further molecular and genetic
studies need to be undertaken to establish this.
Endometrial carcinoma is rarely diagnosed in pregnancy,
with most case reports being in women who have undergone
endometrial curettage for miscarriage or termination
of pregnancy.3,14
Increased incidence of obesity in younger women is linked
to an increased incidence of endometrial carcinoma
diagnosed in a relatively younger age group.3 This poses a
challenging problem in younger women who may wish to
preserve their fertility because 4% of cases of endometrial
cancer are diagnosed in women under 40 years of age.33
While the standard treatment for endometrial carcinoma
remains total hysterectomy and bilateral salpingo-
oophorectomy, in young women, case reports and series
have been published on managing atypical hyperplasia or
grade 1, stage IA endometrioid cancers with progestogens and
surveillance hysteroscopy and achieving successful
pregnancy outcomes.34
A review article in 2012 by Gunderson et al.34 looked at
oncologic and reproductive outcomes in women with

ª 2017 Royal College of Obstetricians and Gynaecologists 143

 Gynaecological cancer in pregnancy
endometrial hyperplasia or grade 1 endometrial carcinoma,
with no myometrial invasion as assessed by MRI (apparent
stage IA disease). Their review identified 391 subjects, of
whom 77% responded to hormonal treatment, with a
complete response in 65.8% of women with hyperplasia,
and 48.2% of women with endometrial cancer. In the report,
41.2% of women with hyperplasia and 34.8% of women with
endometrial cancer became pregnant, resulting in 117 live
births.34 However, this is not the recognised standard
treatment for endometrial carcinoma.
As the number of younger women who are managed
conservatively with progestogens and surveillance
hysteroscopy are on the rise, units managing such women
in pregnancy should seek advice from the cancer centre.
These cases should be discussed in multidisciplinary team
meetings in specialist centres and guidance should be
provided to the clinicians responsible for management of
these women during pregnancy.
Vulval and vaginal cancer
Vulvovaginal cancer in pregnancy is very rare, with less than
5% of vulval carcinomas arising in women under 40 years of
age. The incidence in pregnancy is reported to be between 1
in 8000 and 1 in 20 000 births, and the majority of the
literature on this involves case reports.1,3
Most women present with a mass on the vulva but may
also present with pruritus or ulceration.
The course of vulval carcinoma is not affected by
pregnancy. The majority (60%) of women present with
stage I disease and squamous cell carcinomas are the
commonest type in pregnancy (47%).3
Management involves taking an incision biopsy from the
lesion. Once confirmed, it should be managed surgically as in
nonpregnant women, with vulvectomy and inguinal
lymphadenectomy (where appropriate) depending on the
stage. Inguinal lymphadenectomy in women with early
disease can be associated with high morbidity, and several
trials have shown that sentinel lymph node sampling may be
a safe alternative for these women.35 The GROningen
INternational Study on Sentinel Nodes in Vulvar Cancer
(GROINSS) VII is an international trial currently recruiting
women with unifocal squamous cancers of less than 4 cm
who do not have any enlarged inguinal lymph nodes on CT
imaging. It is hoped that this technique will be as equally
efficacious as full inguino-femoral lymph node dissection for
detection of nodal metastases, with a lower morbidity.
Pregnancy is a contraindication to trial recruitment and
there are currently no reports for the use of this technique in
pregnancy. There have been reports for the use of this
specialised procedure in pregnant women with breast
carcinoma, which have shown negligible or very low risk to
the fetus. This method involves injecting a radio labelled
isotope and contrast dye around the tumour. The pros and
144
cons should be discussed with the patient to allow her to
make an informed decision.
In women of 36 weeks of gestation or above, it is
recommended that surgery should be delayed until
after delivery.36
Previously diagnosed and treated vulval carcinoma is not a
contraindication to pregnancy. In women with a history of
lateral disease, which was previously managed with surgery
alone, vaginal delivery can be considered. However, cases of
periurethral or perivaginal tissue removal in the past are
relative contraindications to vaginal delivery and patients
should be managed on an individual basis.3,37
Patients who have been treated with radiotherapy in the
past are at an increased risk of intrauterine growth
retardation because of potential impairment of the
uterine vascular supply and radiation fibrosis affecting the
myometrium.38 Therefore increased fetal surveillance is
required with consideration of an early delivery at 34 weeks.
With regard to vaginal carcinomas in pregnancy, only
50 cases have been reported in the literature, with the
commonest type being squamous cell carcinoma.39
Management involves taking a biopsy from the lesion and
subsequent staging with MRI and treatment planned on a
case-by-case basis. Stage I tumours arising in the upper third
of the vagina should be managed by radical hysterectomy,
upper vaginectomy and bilateral pelvic lymphadenectomy.
With women presenting in their first and second trimester, a
potential need to terminate the pregnancy must be discussed.
In the third trimester or late second trimester, early delivery
can be considered to allow treatment. In cases more advanced
than stage I, radiotherapy is the mainstay of treatment.1,40 In
women with tumours arising from the lower two-thirds of
the vagina, this form of surgery will not be of benefit and
treatment involves radiotherapy. The radiotherapy field
needed to treat this type of cancer is likely to involve the
uterus and thus the fetus, and is not compatible with fetal
life. These cases need to be managed by a multidisciplinary
approach. Consideration should be given to termination of
the pregnancy in the first or early second trimester, or
treatment should be delayed to achieve viability in
later gestations.
Use of chemotherapy and radiotherapy
Life-saving chemotherapeutic agents for the mother can be
life-limiting for the fetus. The use of chemotherapy (such as
paclitaxel-carboplatin during pregnancy) must be carefully
balanced with a particular focus on the type of tumour,
gestation and patient factors. These women should be
managed jointly with a medical oncologist, as part of a
multidisciplinary team. In accordance with NICE guidance,
chemotherapy is recommended for pregnant women
diagnosed with ovarian cancer more advanced than grade 1,
ª 2017 Royal College of Obstetricians and Gynaecologists

stage IA. Chemotherapy should be avoided in the first
trimester because of an increased risk of prematurity,
congenital malformations and fetal toxicity.25 In women
with ovarian cancer, upfront surgery should be performed in
stage I–IIIB and in women who appear to have operable stage
3C disease. In women who have stage IV disease or stage IIIC
disease that does not appear to be operable, chemotherapy
should be given first and then operability reassessed after
three cycles of chemotherapy. If the cancer has responded to
the chemotherapy, surgery should be undertaken about 3 to
4 weeks after the last dose of chemotherapy and then a
further three cycles of chemotherapy given commencing
approximately three to four weeks after the surgery.1,31
Bevacizumab, a vascular endothelial growth factor A
monoclonal antibody, which can be used in the
management of advanced ovarian cancer is contraindicated
in pregnancy because of teratogenic effects noted in animal
models.41 There is no role for chemotherapy in pregnancy in
the treatment of endometrial or vulval carcinoma. In women
with cervical carcinoma, combination chemoradiotherapy is
usually used outside of pregnancy, typically involving
cisplatin concurrently with external beam radiotherapy
followed by internal radiotherapy (brachytherapy).
Cisplatin is thought to be probably safe in the second and
third trimesters of pregnancy but pelvic radiotherapy is not
compatible with fetal life. Of note is that carboplatin,
paclitaxel and cisplatin are all excreted in breast milk and
continue to be so for more than 2 weeks after administration
of the drugs, therefore breastfeeding should be avoided in
women receiving such treatment.
Pelvic radiotherapy should ideally be avoided during
pregnancy and is contraindicated in the majority of cases.
However, in cases where this is a necessity (cervical
carcinomas and vulval and vaginal carcinomas as previously
discussed), it can be given in the third trimester.38 If needed,
delivery should be performed at a suitable gestation to
maximise viability by caesarean section and the ovaries
transposed at the time of caesarean section so that they are
out of the radiotherapy field. These women, as well as women
receiving radiotherapy for other forms of malignancy in
pregnancy (most commonly breast), should be managed
jointly with a clinical oncologist. In treating other
malignancies with radiotherapy in pregnancy, attempts are
usually made to delay the treatment to attain viability. Where
this is not possible, attempts should be made to delay
treatment until the third trimester and limit the radiation
dose to the fetus as much as possible with lead shielding.
Careful monitoring of fetal growth must occur during
such treatment.
Radiation therapies that involve injection of a radioactive
isotope, such as those used to treat thyroid malignancies,
should be avoided in pregnancy because these cross
the placenta.
ª 2017 Royal College of Obstetricians and Gynaecologists
China et al.
Ethical issues
The approach to treatment of gynaecological malignancies in
pregnancy brings forth controversy in people’s beliefs, unique
ethical demands and difficult decisions. Patients, their
relatives and clinicians should allow sufficient time for the
medical and ethical issues to be understood for their
individual case and be well informed on all the available
treatment options and their consequences. This should be
done in a supportive environment without bias or judgement
because an easy solution is not always achievable.42
A decision may often be needed to prolong or abandon the
pregnancy and optimise maternal therapy; however, several
factors contribute to this decision. Termination of pregnancy
may not always be feasible, for example, for social or religious
reasons, and therefore other treatment options must be
explored.43 The clinician needs to adopt a sensitive approach
when broaching this topic as personal beliefs vary greatly.
Conclusion
The multidisciplinary approach to management is essential to
accommodate a multitude of unique patient factors and
ethically challenging decisions. Effective and individualised
treatment is achievable despite a complex conflict between
maternal and fetal health needs. The patient should be well
informed of the available treatment options, their
complications and implications to their pregnancy or to
the fetus.
Currently, the scientific basis for the management of
gynaecological cancers in pregnancy is largely drawn from
retrospective studies, case reports or from management in the
nonpregnant population. Ideally, there is a need for
prospective studies on the analysis of treatment options with
a greater emphasis on long-term outcomes of managing cancer
during pregnancy. However, given the small number of cases
and high level of anxiety and emotive issues around these cases,
this is unlikely to happen. A national or international database
of pregnant women diagnosed with cancer would be of huge
benefit to these women and their clinicians. This could be
coordinated by the national or international cancer societies
and would allow consensus to be reached more rapidly and
enable clinicians to share their experiences of managing these
women with newer developments in this area, which will
provide benefit for all patients in future.
Disclosure of interests
The authors of this article have no conflicts of interest
to disclose.
Contribution to authorship
All authors (SC, YS, DS and KH) made substantial
contribution to conception, drafting the article and
145
 Gynaecological cancer in pregnancy
subsequent critical intellectual content revisions. The
manuscript has been approved by all authors.
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ª 2017 Royal College of Obstetricians and Gynaecologists