Gynaecological cancer in pregnancy — structured oral station (12 minutes)

Opening prompt — "How do you stage her cervical cancer in pregnancy?"

Model response — name the imaging approach: ^[1][2]

• "Non-contrast MRI is the first-line cross-sectional modality for local staging — tumour size, parametrial invasion, and nodal status — without ionising radiation."
• "If I need to stage for distant disease, CT or PET-CT should not be withheld when clinically indicated — the diagnostic information outweighs the fetal dose at staged doses."
• "I would not use abdominal shielding during CT — it is no longer recommended because it increases scatter dose internally and degrades image quality (LeJeune 2025)."^[1][2]

Probe 1 — "She is 14 weeks and wishes to continue the pregnancy. What are her management options?"

• "This is a stage IB1 or higher cervical cancer diagnosed in the early second trimester, and she wishes to continue — so the three options are: (1) termination and definitive treatment; (2) neoadjuvant platinum chemotherapy after 14 weeks to bridge to delivery, then definitive chemoradiotherapy or surgery postpartum; or (3) caesarean-radical-hysterectomy at term." ^[1][5]
• "If her tumour were stage IA1 without lymphovascular space invasion, she could be managed conservatively with definitive surgery after delivery. The determining factors are the FIGO stage, the gestational age, the tumour biology, and her values — this is an MDT decision with her at the centre."^[1]

Probe 2 — "When would you give chemotherapy, and which agents must you avoid?"

• "I would start chemotherapy after 14 weeks — organogenesis is complete, so the teratogenic risk falls to near-background — and stop by 35 weeks to allow marrow recovery before delivery. I would not give it within 3 weeks of planned delivery." ^[1]
• "The four contraindicated agents are: tamoxifen — teratogenic; trastuzumab — oligohydramnios and fetal renal injury; checkpoint inhibitors — they disrupt the fetomaternal immune tolerance that sustains pregnancy; and bevacizumab — third-trimester wound healing impairment and bleeding."^[1]

Probe 3 — "Will the chemotherapy harm her baby's development?"

• "The long-term news is reassuring. The Korakiti (2020) systematic review found generally normal neurodevelopment in children exposed to chemotherapy in utero." ^[3]
• "The main driver of adverse neonatal outcome is iatrogenic preterm birth, not the chemotherapy itself. So my priority is to avoid unnecessary prematurity — deliver at term where the cancer treatment allows, and time the last chemotherapy dose to leave at least 3 weeks for marrow recovery."^[3]

Probe 4 — Communication: "She asks what her chances are and whether she can deliver normally. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[1][4]

• "I would sit at her eye level and say: 'The most important thing is that being pregnant does not make your cancer worse — when we treat it properly, your prognosis is the same as if you were not pregnant. We have a plan that protects both you and your baby: chemotherapy after 14 weeks is safe for the baby's development, and the evidence shows children exposed in the womb develop normally. For delivery, because of where your cancer is, I would recommend a caesarean — it protects the cervix and lets us do any surgery needed at the same time. We will plan this together with our maternal-fetal medicine, gynae-oncology and neonatal teams, and you will have a dedicated team supporting you at every step.'"^[1][4]

Probe 5 — "How would you deliver her, and what must you remember at delivery?"

• "I would plan a caesarean delivery, because cervical cancer — especially after biopsy or conisation — makes the cervix unsuitable for vaginal delivery. If she is near term, a caesarean-radical-hysterectomy may be appropriate." ^[1]
• "At delivery I must send the placenta to pathology in every case — placental metastasis, though rare, must be sought and documented. I would also arrange for the neonate to be assessed and monitored for marrow recovery if she had recent chemotherapy."^[1]