Gynaecological cancer in pregnancy — structured SAQ (15 marks)

(a) Governing principles and the decision variables (3 marks)

One mark for the multidisciplinary standard-treatment principle, one for the three variables, one for the patient-values/consent point. [1]

• Principle: treatment during pregnancy should adhere to standard oncological management as much as possible to optimise maternal prognosis, always taking fetal wellbeing into account, within a multidisciplinary team — the aim is standard treatment that preserves maternal prognosis while protecting the fetus.[1]
• Three variables: tumour type and stage; gestational age; and the patient's values (fertility, continuation vs termination).[1][2]
• The decision is values-based informed consent, balancing maternal and fetal risks and benefits.[2]

(b) Diagnostic approach and staging (3 marks)

One mark for ultrasound/MRI, one for ALARA/no gadolinium, one for the NIPT or CA-125 pitfall. [2]

• Ultrasound first-line; MRI without gadolinium for local staging of the cervical tumour; CT reserved for necessary staging under the ALARA (as low as reasonably achievable) principle.[2][6]
• Gadolinium avoided in pregnancy; cervical biopsy of a visible lesion is safe.[1]
• Pitfall: CA-125 is unreliable in pregnancy (may be physiologically elevated); and NIPT results may be inconclusive in women with cancer, so alternative prenatal anomaly screening should be used.[6]

(c) Cervical cancer management allowing continuation of pregnancy (5 marks)

One mark for the principle of preserving maternal prognosis, one for neoadjuvant chemotherapy, one for the Karam/definitive-surgery rationale, one for fetal surveillance, one for recognising when definitive treatment cannot wait. [1]

• The goal is to control the tumour while the fetus matures to a gestational age where delivery is safe, without compromising maternal prognosis.[1]
• Neoadjuvant chemotherapy to control the tumour while the fetus matures, followed by definitive surgery (including radical hysterectomy at caesarean) closer to term — the strategy described by Karam and colleagues for bulky cervical cancer in pregnancy.[4]
• Serial fetal surveillance — growth scans and cervical-length assessment throughout, especially during chemotherapy.[6]
• Where disease is advanced or definitive treatment cannot wait, the balance may shift to ending the pregnancy to deliver standard treatment — decided with the patient.[1]
• Do not convert to radical surgery at an unplanned caesarean without staging and consent; close, stage, and return with the MDT.[1]

(d) Chemotherapy trimester rule, contraindicated agents, and delivery timing (4 marks)

One mark for the trimester rule with data, one for the malformation numbers, one for the contraindicated list, one for delivery timing. [2]

• Trimester rule: avoid the first trimester; after 12 weeks the malformation rate approximates the background population rate.[3]
• Data (van Gerwen, INCIP): in 755 women, major malformation rate was 3.6% overall; before 12 weeks it was 21.7% (OR 9.24); after 12 weeks it was 3.0% — similar to the general population.[3]
• Contraindicated regardless of gestation: methotrexate; hormonal therapies; HER2-targeted agents; VEGF and PARP inhibitors; antibody-drug conjugates; all cellular therapies.[2]
• Delivery: plan delivery at or after 37 weeks, with the final chemotherapy dose scheduled 2 to 4 weeks before birth to avoid maternal (and neonatal) haematological nadir.[2]