General Care for Pregnant Women with Lymphoma

After diagnosing the specific lymphoma subtype, care for pregnant women differs on the basis of which trimester each patient is in.

During the first trimester, organogenesis is ongoing until 10-weeks’ gestation. While organs are forming the risk for teratogenicity is increased and exposure to any drug or potentially damaging agent should be avoided. Throughout the second and third trimester, while the fetus is developing, risk for growth restriction from exposure to medications remains, however gross structural abnormalities are rare.5-6

When the patient is within her third trimester of pregnancy, timing the birth is an important factor to consider. It is inadvisable to induce labor before 37 weeks’ gestation, as this would subject the infant to higher risk for complications. In utero exposure to chemotherapy causes neutropenia decreasing the immune response. As such, a chemotherapy cycle should not occur within 3 weeks of birth.


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Regardless of the pregnancy stage, ionizing radiation should be avoided. The typical imaging techniques used for diagnosis and monitoring disease progression among patients with lymphoma must be altered for pregnancy. 18F-flurodeoxyglucose positron emission tomography (FDG-PET) and FDG-PET/CT incur an effective fetal radiation dose of 1.4-5.2 mSv and 10-22 mSv, respectively.7-9 Whole-body magnetic resonance imaging (MRI) without gadolinium does not expose the fetus or mother to potential harm from ionizing radiation and may be a prudent alternative to FDG-PET.

Final Advice

One of the most important factors when formulating a treatment plan for a complex condition in the setting of pregnancy is to collaborate with a multidisciplinary team, which may include oncologists, hematologists, obstetricians, neonatologists, and anesthesiologists. Moreover, it is key “to actually discuss the case with somebody who really understands the condition and has lots of experience treating it,” Dr Dunleavy asserted.

“I meet many women with all sorts of cancers, who have been told that they need to have a termination because they can’t possibly get any treatment,” added Dr McLintock. “To do the best for the woman and her baby, you should speak to someone with experience. The minute you tell a woman that she needs to think about a termination, that colors all the other conversations. You should feel comfortable with telling a woman that you might not know all the answers, but you can talk to someone who does.”

References

  1. Van Calsteren K, Heyns L, De Smet F, et al. Cancer during pregnancy: an analysis of 215  patients emphasizing the obstetrical and the neonatal outcomes. J Clin Oncol. 2010;28(4):683-689. doi:10.1200/JCO.2009.23.2801
  2. Lee Y Y, Roberts C L, Dobbins T, et al. Incidence and outcomes of pregnancy-associated cancer in Australia, 1994-2008: a population-based linkage study. BJOG. 2012;119(13):1572-1582. doi:10.111/j.1471-0528.2012.03475.x
  3. Amant F, Vandenbroucke T, Verheecke M, et al. Pediatric outcome after maternal cancer diagnosed during pregnancy. N Engl J Med. 2015;373(19):1824-1834. doi:10.1056/NEJMoa1508913
  4. Dunleavy K and McLintock C. How I treat lymphoma in pregnancy. Blood. 2020;blood.2019000961. doi:10.1182/blood.2019000961
  5. Pereg D, Koren G and Lishner M. The treatment of Hodgkin’s and non-Hodgkin’s lymphoma in pregnancy. Haematologica. 2007;92(9):1230-1237. doi:10.3324/haematol.11097
  6. Cardonick E and Iacobucci A. Use of chemotherapy during human pregnancy. Lancet Oncol. 2004;5(5):283-291. doi:10.1016/S1470-2045(04)01466-4
  7. Zanotti-Fregonara P and Stabin M G. New fetal radiation doses for 18F-FDG based on human data. J Nucl Med. 2017;58(11):1865-1866. doi:10.2967/jnumed.117.195404
  8. Pahade J K, Litmanovich D, Pedrosa I, et al. Quality initiatives: imaging pregnant patients with suspected pulmonary embolism: what the radiologist needs to know. Radiographics. 2009;29(3):639-654. doi:10.1148/rg.293085226
  9. Tirada N, Dreizin D, Khati N J, et al. Imaging pregnant and lactating patients. Radiographics. 2015;35(6):1751-1765. doi:10.1148/rg.2015150031

This article originally appeared on Hematology Advisor