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My Toughest Case Operating on a Pregnant Woman With Cervical Cancer

Nadeem Abu-Rustum, Oncology Surgeon, Memorial Sloan-Kettering Cancer Center

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The patient was diagnosed with cervical cancer one week after she learned she was pregnant. She had other children, but she was almost 38 and this was probably her last chance to have more. She came to my office and said, “Can we do everything to keep this pregnancy?” The standard treatment would be to focus on treating the cancer and terminating the pregnancy, or ignoring the cancer, delivering the baby, then treating the cancer. But she was so early in her pregnancy that it would have meant waiting many weeks until the fetus reached the point of viability. And she had a significant lesion, which she didn’t want to let grow. She was very clear: She didn’t want a termination, and wanted to treat the cancer without delay.

The uterus has two parts: the part where the baby lives, called the fundus, and the door to the uterus, or the cervix. The cancer was in the cervix, so the plan was to remove the cervix with the tumor and the blood vessels around it. The procedure is called radical trachelectomy. We’ve been doing it since 2001 on young women with cervical cancer who want to preserve their fertility. But I’d never done it with a pregnancy.

We counseled the patient closely, because there was a good chance she would miscarry during surgery. And I told her that if we found that the cancer had spread more than we thought, we would have to expand the surgery and terminate the pregnancy. This was something new, and we usually don’t operate on pregnant patients where the risk of losing the pregnancy is so high. I had to get a lot of clearances from higher up in the institution. I also had her see other obstetricians to consult on the decision. The patient had some fears and concerns, but she was prepared for all scenarios. She’s a strong person. All along, she said, “This is what we should do. I know my options, and I want to try everything so I won’t have regrets.” She made it easier for me by having such clarity about it. Because we were under pressure with the timing—every day the pregnancy was getting further along, which would make the surgery more difficult—we did the operation on Christmas Eve. The surgery is like half a hysterectomy: You remove the cervix, then reattach the uterus to the vagina. But doing the procedure with a pregnant patient isn’t well described in books—we had to invent it as we went along.

The first steps went well, but as we went on, the operation became dangerous. The uterus has four main blood vessels, and they are engorged in pregnancy. One ruptured, and the patient had a massive hemorrhage—about one and a half liters of blood in a minute. At that point, I thought the uterus would collapse and the baby would die. But we did an ultrasound, and the baby was fine.

We had removed the cancerous tissue of the cervix, and I sent a section for testing. The results came back that I didn’t have the clean margins I needed—I would have to cut deeper to get an extra centimeter. I feared that by cutting more, we would rupture the amniotic sac or cause a miscarriage. I thought, Really, it will take a miracle for this baby to survive. But after I went in for the additional margin, we did a second section, and that one came back clean. We finished reconnecting the uterus, and closed the abdomen.

When I saw the patient in recovery, I told her we got a clear margin and so far the baby was fine. She stayed with us over Christmas and New Year’s, and went on to carry the baby to 39 weeks and deliver at term. She had a scheduled C-section and a hysterectomy at the same time, and there was no cancer left. The baby is about 1 year old now, and she’s beautiful. I keep a photo of the family in my office.


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