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been reported. Patients are likely to present initially when the
patients with papillary thyroid cancer estimated at 80“90%. Cer-
intravascular fluid volume peaks in the latter half of the second
vical metastases are present in 50% of small tumors and in over 75%
trimester, a time when the fetus may be viable but premature.
of larger thyroid cancers. Distant metastases are uncommon, but
Magnetic resonance imaging (MRI) is the preferred method to
lung and bone are common sites. Tumors that invade or extend
establish a diagnosis providing excellent soft tissue resolution
beyond the thyroid capsule have a high local recurrence rate.
while avoiding fetal exposure to ionizing radiation.
Cancer of the larynx is treated with surgery, radiotherapy, or
a combination depending on the stage of disease, histologic
type of disease, and age of the patient. Surgery with immediate
Treatment
reconstruction is the treatment of choice for oropharyngeal
cancer. Postoperative radiotherapy is occasionally needed. Naso- Treatment for CNS tumors during pregnancy depends on the type
pharyngeal cancer is very responsive to a variety of chemo- and grade of the malignancy, the woman™s clinical condition, and
therapeutic agents and radiotherapy can be administered with the stage of pregnancy. Most low-grade, slow-growing tumors
abdominal shielding to minimize exposure to the fetus. Prognosis can be followed by neuroimaging, with treatment deferred until
for small laryngeal cancers that have not spread to lymph nodes is after delivery. Corticosteroids and anticonvulsants help to allevi-
very good, with cure rates of 75% to 95% depending on the site, ate symptoms until fetal maturity. High-grade gliomas or a tumor
tumor bulk, and degree of infiltration.46 Mouth and tongue can- associated with continued clinical deterioration require prompt
cer are often well advanced at the time of diagnosis, and have surgical resection regardless of gestational age.
metastasized beyond the oral cavity. If metastasis has occurred, Radiation therapy and chemotherapy are commonly used as an
the prognosis for oral cavity cancer is poor. The overall five-year adjuvant therapy after resection of many CNS tumors. Cranial



375
5 Other disorders


radiation therapy with abdominal shielding in the late stages of of hydatidiform mole is about 1 per 1000 pregnancies in most
pregnancy is not associated with an increased risk of birth defects parts of the world. Choriocarcinoma is much less common, and
or fetal loss, but carries an increased risk of childhood leukemia.48 estimates of the incidence are highly variable.
There is a strong ethnic difference in the incidence of GTD53
with molar pregnancy three times higher in Japan than in Europe
Prognosis or North America. Higher rates of GTD are also reported among
nonwhite Hispanic, American Indian, Eskimo, and Asian
Overall, prognosis depends on the type of CNS malignancy and
populations.53
the grade of disease. Patients with low-grade astrocytomas have a
The risk of GTD appears to be increased in patients with a
five-year survival rate of 50%, while survival rates of low-grade
oligodendrogliomas approach 30% at ten years.48 Prognosis for previous molar pregnancy, and a partial mole with the coexis-
tence of a fetus is rare. A twin pregnancy consisting of a complete
high-grade gliomas is poor, with a median survival for glioblas-
hydatidiform mole and coexisting fetus (CHAF) is very rare. It
toma multiforme of one year. The five-year survival rate of
differs from a partial mole in that there are two separate concep-
patients with meningiomas is 90%.
tuses, with a normal fetus and placenta comprising one twin and
a complete molar gestation comprising the other.54,
Anesthetic implications
Signs and symptoms
Management must be a collaborative effort by all physicians
involved, and each patient must be assessed individually to
A complete hydatidiform mole presents with irregular vaginal
determine an optimal anesthetic plan. Patients who present at
bleeding between the sixth and the sixteenth week of preg-
term should receive corticosteroids to reduce cerebral edema
nancy.55 Abnormal abdominal swelling, hyperemesis, fatigue,
and then be delivered expeditiously.47 Induction of labor is not
and dyspnea are frequently observed. Symptoms of partial
appropriate in neurologically unstable patients with threatened
hydatidiform moles are less severe than those of complete
herniation, but may be appropriate in more stable patients.
moles. The diagnosis is made by ultrasound and elevated serum
Anticonvulsant levels need to be closely monitored in the preg-
hCG levels.
nant patient because changes in serum binding proteins, albu-
min, and circulating blood volume can change the levels of
active drug. Treatment
Successful anesthesia for craniotomy in the sitting and supine
Most women with GTD are cured by surgical evacuation using
positions during pregnancy has been reported without adverse
suction curettage. The indications for initiating chemotherapy
maternal or fetal outcome.49,50 Care must be taken to maintain
are: (1) evidence of metastases in the brain, liver or gastrointest-
cerebral perfusion pressure and strategies enlisted to decrease
inal tract, or radiological opacities larger than 2 cm on chest
cerebral blood flow and ICP while maintaining placental blood
radiograph; (2) histological evidence of choriocarcinoma; (3)
flow. Fetal monitoring is controversial but may prove useful as a
rising hCG titers.56
monitor for overall organ perfusion. Excessive hydration with
Treatment is tailored according to recognized adverse prognos-
intravenous fluids and hyperglycemia should be avoided.
tic features. There are a variety of systems used to classify patients
Epidural anesthesia is generally contraindicated in patients
into low, intermediate, or high risk. The most commonly accep-
with increased ICP due to the risk of inadvertent lumbar puncture
ted system is to combine the International Federation of
and catastrophic brain stem herniation. Cesarean delivery under
Gynecology and Obstetrics (FIGO) anatomic staging with the
general anesthesia is recommended for patients with significant
modified World Health Organization risk factor scoring system
mass-occupying lesions as many of these patients are confused
(see Tables 21.2 and 21.3).57,58
and uncooperative.51 When neuraxial anesthesia is considered for
Low-risk patients are treated with single agent chemotherapy.
C/S in women with a brain tumor and normal ICP, the potential
Single agent methotrexate, actinomycin D, and etoposide have all
for primary or metastatic disease of the spine and the woman™s
coagulation status must be evaluated.


Table 21.2 FIGO staging
Trophoblastic disease
Stage I Gestational trophoblastic tumors strictly confined to the
Epidemiology
uterine corpus.
Gestational trophoblastic disease (GTD) describes a group of Stage II Gestational trophoblastic tumors extending to the adnexa
uncommon but interrelated clinical conditions derived from placen- or to the vagina, but limited to the genital structures.
tal trophoblasts. Gestational trophoblastic disease includes hydati- Stage III Gestational trophoblastic tumors extending to the lungs,
diform mole and gestational trophoblastic neoplasia (GTN).52 The with or without genital tract involvement.
term GTN is reserved for cases with persistent elevation of human Stage IV All other metastatic sites.
chorionic gonadotropin (hCG) titers after evacuation of hydatidi-
From Benedet et al., 200058
form mole, metastatic disease, or choriocarcinoma. The incidence



376
Chapter 21


pregnancy, and affects about 25% of women with complete moles
Table 21.3 World Health Organization risk factor scoring but only about 4% of women with partial moles. Hyperthyroidism
occurs in about 7% of women with complete hydatidiform moles.
Prognostic 0 1 2 4
Thyrotoxicosis, anemia, and dehydration due to bleeding may
factor
predispose to cardiac dysfunction and respiratory insufficiency.
Age <35 >35
Perioperative management of thyrotoxicosis focuses on the con-
Prior pregnancy mole abortion term
trol of sympathetic activity so that cardiovascular side effects are
Interval <4 months 4“6 months 7“12 months >12 months
minimized. Uterine relaxation may increase blood loss and
Serum B-HCG <10 000 <100 000 >100 000
<1000
inhaled anesthetics with known tocolytic qualities should be
ABO blood
used cautiously. Nitrous oxide, opioids, and muscle-relaxant
group
agents may be preferred. Whereas general anesthesia is likely to
maternal x
be used for surgical evacuation of GTD, the use of spinal anesthe-
paternal OxA, AxO B, AB
sia has been described.61
Size of largest
A surveillance of metastatic disease should be done prior to any
tumor 3“5 cm >5 cm
anesthetic. An invasive mole can penetrate the full thickness of
Number of
the uterine wall and rupture, resulting in severe internal or vagi-
metastases 1“4 4“8 >8
nal bleeding. Invasive moles can also spread to other organs, most
Prior
commonly to the vagina and the lung. Choriocarcinoma can
chemotherapy single agent multiple
spread virtually anywhere in the body but most commonly
Total score: 0“4 low risk, 5“7 intermediate risk, >8 high risk for death.
spreads to the lung, the lower genital tract, brain, liver, kidney,
From Benedet et al., 200058
and the gastrointestinal tract.62
Interactions between chemotherapeutic agents and anesthe-
tics should be reviewed in a woman who has received chemo-
been shown to be effective. Because of its efficacy and safety
therapy. Some concerns include hepatic and renal toxicity from
profile, low-dose methotrexate, with folic acid rescue, remains
methotrexate, an impaired stress reaction, and the risk of devel-
the most widely used therapy for low-risk patients.56 Actinomycin
oping opportunistic infections.12,63
D, etoposide, and cyclophosphamide may be added in patients
who develop methotrexate resistance.
In high-risk patients, multidrug regimens have been developed. Lung cancer
Etoposide, methotrexate, and actinomycin D, alternating weekly
Very few cases of lung cancer during pregnancy have been docu-
with cyclophosphamide and vincristine (EMA-CO), is one recom-
mented. One review of the literature found 35 cases of primary
mended multidrug treatment. However, the best combina-
lung cancer associated with pregnancy.64 The anesthetic techni-
tion chemotherapy regimen for high-risk GTN requires further
que was described in only 5 of 20 cases that required C/S (one
study.59 The majority of patients are cured with chemotherapy.
spinal, three epidural, and one general anesthetic). In the same
Patients with CNS metastases should be treated concurrently
report, the authors describe a patient with metastatic lung cancer
with whole brain irradiation.
who underwent C/S for preterm twin delivery under spinal
The majority of twin pregnancies with CHAF result in eva-
anesthesia with no adverse sequelae.64 Lung cancer can metasta-
cuation of the pregnancy immediately upon diagnosis. Indi-
size to the placenta and the fetus as can other cancers such
cations for immediate evacuation of the pregnancy include
as melanoma, breast cancer, leukemia, lymphoma and
the development of preeclampsia, intractable vaginal bleeding,
sarcoma.65
hyperemesis gravidarum, hyperthyroidism, or evidence of tropho-
blastic embolization.
Melanoma
Prognosis The reader is referred to Chapter 19 for a review of malignant
melanoma in pregnancy.
Overall the prognosis for gestational trophoblastic disease is very
good. Cure rates in the high-risk category are as high as 82% after
treatment with combination chemotherapy.60 Hematological malignancies
However, the outcome for women presenting with metastases
The reader is referred to Chapter 17 for a more complete descrip-
from GTD is poor.
tion of hematological cancers in pregnancy.

Anesthetic implications
Summary
The patient™s coagulation status should be assessed and blood
Although the diagnosis of cancer is always devastating, it is espe-
count, electrolytes, blood gases, thyroid, hepatic and renal func-
cially so in pregnancy.66 However, the occurrence of cancer in
tion, hCG, and chest x-ray should be reviewed. Preeclampsia may
pregnant women is not common but it has the potential to
develop during the first or second trimester of a complete molar



377
5 Other disorders


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PREGNANCY AND TRANSPLANTATION
22
Kerri M. Robertson




Introduction Conception and pregnancy

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