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    Pregnancy and cancer: A challenge for obstetrician and oncologist! As the age of child birth is delayed we may be seeing more cases with cancer in pregnancy. At present estimated incidence of cancer in pregnancy is estimated to be around 1 in 1000 livebirths worldwide. Gestational cancer is the term given to cancer occuring in pregnancy and up to one year postpartum. Like in general population the symptoms of cancer are not unique and they mimic with more commonly occuring diseases, similarly many of the symtoms of cancer in pregnancy are often suspected to be due to underlying pregnancy and other common conditions leading to delay in diagnosis. Tissue diagnosis is key to confirm diagnosis in solid tumors like breast , cervix etc. While for hematological malignancy CBC with PBF is basic investigation to start with and further work up is directed based on clinical suspicion of leukemia or lymphoma. Imaging workup for diagnosis and staging should keep in mind that radiation exposure to fetus should be as low as possible. Radiation may lead to either spontaneous abortion, teratogenesis or carcinogenesis. It should be kept in mind that though teratogenesis is dose dependent , with doses greater than 50mGy continue to be more and more teratogenic. However carcinogenesis is not dose dependent and can occur at any dose leading to increased risk of childhood cancers with a risk of 3-4 times as compared to general population. Chest X-ray , mammography with abdominal shield are safe. CT chest can be done with abdominal shielding. MRI without contrast is preferred modality in staging Brain, Bone, Abdomen and pelvis. Gadolinium contrast can be used if absolutely necessary keeping in mind that there is limited data for its safety in pregnancy. Iodinated contrast may be associated with neonatal thyroid disorder and if used , a careful screening of neonatal thyroid functioning should be done. Overall breast cancer is the most common cancer seen in pregnancy, which usually present in stage Il and lll. While cervical cancer is most common gynecological cancer seen in pregnancy and in 75% patients it is diagnosed in stage l. Treatment of cancer in pregnancy is complex and it should involve multidisciplinary team approach including obstetrician, neonatologist and oncology team. Surgery for cancer can be done during any trimester of pregnancy, with increased risk of miscarriage during first trimester. Pelvic and abdominal surgery are associated with increased feto maternal complications and it should be discussed with the patient. Chemotherapy is avoided in first trimester. In second and third trimester chemotherapy can be given , keeping in mind that not all chemotherapy drugs are equally safe. Platinum chemotherapy is associated with small for gestation and paclitaxel is associated with increased NiCU admission based on recent paper in lancet oncology in 2018 which analysed outcome of around 1300 pregnant cancer patients. As far as targeted therapy is concerned , trastuzumab should be avoided in pregnancy as it is associated with oligohydramnios. Rituximab is used in treatment of NHL and when used in pregnancy it is associated with fetal B cell depletion , the risk of which should be discussed with patients and though the recovery may take up to 6 months in neonate but it is usually complete. Radiation treatment should be delayed till delivery for reasons discussed above.
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