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Case History

image A 34-year-old woman presented with cervical lymphadenopathy, without fever, night sweats, or weight loss. Her past medical history included two previous spontaneous miscarriages and obesity (body mass index 50). Recently she had been trying to become pregnant. Biopsy revealed a Nodular Lymphocyte Dependant Hodgkin Lymphoma (NLPHL). A PET/CT revealed stage 3 disease with splenic involvement. The multidisciplinary team recommended rituximab, doxorubicin, vinblastine and dacarbazine treatment (R-AVD) in attempt to preserve fertility and respiratory function. She was referred to the Assisted Conception Unit but was not eligible for intervention due to morbid obesity. During the consent process for R-AVD, the importance of avoiding pregnancy on chemotherapy was explained by the treating team, and confirmed in the regimen-specific consent form; barrier contraception advice was given. The patient was not asked if she could be pregnant. It was not routine practice to conduct pregnancy testing nor for chemotherapy nurses to ask patients about the possibility of pregnancy. Cycle 1 R-AVD was administered. Nine days after the first cycle of chemotherapy, the patient suffered 7 days of heartburn and nausea; a home pregnancy test was positive. A transvaginal ultrasound 2 weeks later confirmed an 8-week gestation viable intrauterine pregnancy. The patient was counselled regarding potential fetal and maternal risks of pregnancy having received chemotherapy in the first trimester of pregnancy, and advised to terminate the pregnancy. However, the patient wished to continue with the pregnancy and requested to await her 12-week scan before deciding. Systemic treatment was put on hold. The 12-week scan showed a viable 12-week gestation pregnancy, and the patient decided to proceed with the pregnancy. However, at 13-week gestation, the patient had an incomplete miscarriage, requiring evacuation of retained products of conception and a blood transfusion. This was very distressing for the patient, and staff involved. Three weeks later, the patient restarted treatment.

An internal investigation resulted in a new pregnancy status policy, requiring all potentially fertile women to undergo risk of pregnancy counselling from a doctor and a clinical nurse specialist or chemotherapy nurse, a pregnancy test on the day of their first systemic treatment and questions prior to each subsequent systemic treatment to ascertain if they could be pregnant.

What precautions and advice should be given to women of reproductive age prior to starting systemic anti-cancer treatment (SACT)?

What are the best practice guidelines for a systemic therapy unit to follow to avoid this situation happening?

How should we advise this woman with NLPHL just starting chemotherapy and found to be 8 weeks pregnant?

How should we advise women with cancer on different anticancer treatments if found to be pregnant?

What are the ethical considerations of advising termination in early pregnancy?

What precautions and advice should be given to women of reproductive age prior to starting systemic anti-cancer treatment (SACT)?

Women of reproductive age should be advised not to become pregnant prior to commencing, during, and for at least ...

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