Gynaecological cancer in pregnancy — structured SAQ (15 marks)

(a) Imaging approach (3 marks)

One mark for the first-line modality, one for CT and PET, one for the shielding position. ^[1][2]

• Non-contrast MRI is the first-line cross-sectional modality for local staging of cervical cancer in pregnancy — no ionising radiation, good for tumour size, parametrial invasion and nodal assessment. Gadolinium is avoided unless essential as it crosses the placenta.
• CT, gadolinium-enhanced MRI and PET-CT should not be withheld when clinically indicated — the diagnostic information outweighs the fetal dose at staged doses. A whole-body staging CT delivers well below the threshold for deterministic fetal harm.
• Abdominal shielding is no longer recommended during diagnostic CT in pregnancy (LeJeune 2025) — it increases scatter dose internally and degrades image quality. Remove the lead, get the scan.^[1][2]

(b) The three cervical cancer management paths (4 marks)

One mark per path (3) plus one for the determining factors. ^[1][5]

• (i) Termination and definitive treatment — the option for early diagnosis where the woman chooses not to continue the pregnancy or the disease is advanced.
• (ii) Neoadjuvant platinum chemotherapy after the first trimester to bridge to delivery, then definitive treatment (chemoradiotherapy or surgery) postpartum — the option for disease diagnosed in the first or early second trimester where the woman wishes to continue.
• (iii) Caesarean-radical-hysterectomy at term — the option for disease diagnosed near term, with definitive chemoradiotherapy deferred to the postpartum period.
• Stage IA1 without LVSI is managed conservatively — definitive surgery after delivery. The determining factors are the FIGO stage, the gestational age at diagnosis, the tumour biology, and the woman's values.^[1][5]

(c) Chemotherapy windows and contraindicated agents (4 marks)

One mark for the 14-week window and rationale, one for the 35-week window and rationale, one for the 3-week rule, one for four contraindicated agents. ^[1][4]

• After 14 weeks — organogenesis is complete, so the teratogenic risk falls to near-background. This is the window for chemotherapy in pregnancy.
• Stopped by 35 weeks — to allow marrow recovery before delivery and avoid a neutropenic or thrombocytopenic neonate. Do not give chemotherapy within 3 weeks of planned delivery.
• Rationale: the windows protect the fetus at organogenesis and at delivery, the two points of maximum vulnerability.^[1][4]
• Four contraindicated agents: tamoxifen (teratogenic), trastuzumab (oligohydramnios and fetal renal injury), checkpoint inhibitors (fetomaternal immune-tolerance disruption), bevacizumab (third-trimester wound healing and bleeding).^[1]

(d) Delivery recommendations and the placenta (2 marks)

One mark for the delivery recommendations, one for the placenta. ^[1]

• Caesarean for cervical cancer (especially after conisation or trachelectomy) and for vulvar cancer with a perineal wound; vaginal delivery allowed in most ovarian cancers (Amant 3rd consensus 2019).
• Send the placenta to pathology in every case — placental metastasis, though rare, must be sought and documented.^[1]

(e) Long-term neurodevelopmental outcome (2 marks)

One mark for the neurodevelopmental finding, one for the main driver. ^[3]

• Prenatal chemotherapy exposure is generally reassuring for long-term neurodevelopment — the Korakiti (2020) systematic review found generally normal neurodevelopment in children exposed in utero.
• The main driver of adverse neonatal outcome is iatrogenic preterm birth, not the chemotherapy itself — avoiding unnecessary prematurity is the priority.^[3][4]