Cancer diagnosed during pregnancy presents complex management challenges due to risks to both the mother and fetus. Treatment options are limited and none are ideal. For early-stage cancers detected in the first trimester, termination may be recommended to allow standard treatment. For late-stage or aggressive cancers, delaying treatment could risk the mother's life but termination is not acceptable to all. Collaboration between medical specialists is needed to determine the safest individualized approach.
Surgical Management of Cervical Cancer 11052023 FOGSI PAC LECTURE WEBINAR.pptxNiranjan Chavan
Cancer of the uterine cervix is the third most common gynecologic cancer diagnosis and cause of death among gynecologic cancers. Cervical cancer has lower incidence and mortality rates than uterine corpus and ovarian cancer, as well as many other cancer sites. However, in countries that do not have access to cervical cancer screening and prevention programs, cervical cancer remains a significant cause of cancer morbidity and mortality. This PPT intends to teach about surgical management of Ca Cervix.
Surgical Management of Cervical Cancer 11052023 FOGSI PAC LECTURE WEBINAR.pptxNiranjan Chavan
Cancer of the uterine cervix is the third most common gynecologic cancer diagnosis and cause of death among gynecologic cancers. Cervical cancer has lower incidence and mortality rates than uterine corpus and ovarian cancer, as well as many other cancer sites. However, in countries that do not have access to cervical cancer screening and prevention programs, cervical cancer remains a significant cause of cancer morbidity and mortality. This PPT intends to teach about surgical management of Ca Cervix.
Fertility And Pregnancy Outcome In Cancer PatientsMamdouh Sabry
Better life of Cancer patients during childhood and age reproductive period regarding fertility, fertility preservation and pregnancy outcome is the main concern.concentrating upon different safe diagnostic modalities, management and outcome.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
7. Management of cancer in pregnancy
There are not many options and
none of them are ideal
8. For women diagnosed with cancer
waiting for 40 weeks
could be a death sentence
particularly with high-grade, aggressive
or metastatic cancers.
9. To delay treatment until the child
can be safely delivered
• For mother this poses the risk that may be hard to quantify
• It also means that she will have to care for a very premature
baby while coping with the side-effects of cancer treatment
This option is more viable
the lower the risk posed by the cancer and
the more advanced the pregnancy
First option
10. To terminate the pregnancy to allow normal
treatment to go ahead
• This may be the safest option for the mother s health
• Unacceptable to some mothers
More likely to be considered early in pregnancy
Second option
11. To treat the cancer as effectively as possible
while continuing the pregnancy and trying to
minimize the risk for the fetus
Third option
12. Problems in treatment of cancer in pregnancy
• Late diagnosis
• Damaging effects of radiotherapy
• Consequences of chemotherapy
13. Delay in diagnostics
• Presenting symptoms often attributed to pregnancy
• Anatomical and physiological changes of
pregnancy may compromise the physical examination
• Tumor markers are increased in pregnancy
(beta HCG, AFP, CA 125... )
• Imaging techniques or invasive procedures
14. Cancer in pregnancy is often detected later
because the symptoms are masked by other,
usually physiological, body changes
15. Cancer in young women
Site Age 15-44 (%)
Cervix 35
Ovary 15
Lymphoma 23
Thyroid 50
Melanoma 27
Breast 15
Leukemia 10
16. Cancer incidence in Pregnancy
Site Est. incidence / 1000 pregnancies
Cervix
Non-invasive
Invasive
1.3-1.7
1.0
Breast 0.33 – 0.7
Melanoma 0.14
Ovary 0.10 ( 0.01%)
Thyroid Unknown
Lymphoma 0.01
Leukemia 0.01
Colon 0.20
17. Factors influencing the management
of pregnant women diagnosed with cancer
• Stage of cancer and associated prognosis
• Age of gestation- fetal viability
• Possible adverse effects of treatment on fetus
• Risk for mother from delay of therapy
• Risk for fetus of premature delivery
• Potential need to terminate the pregnancy
19. Difficulties in diagnostics & staging
Some techniques are unreliable
• Mammogram
• Blood tests- tumor markers
Some techniques are dangerous
• CT scan
• Radioisotope investigations
• Cervical conisation
20. Effective Radiation dose with
background radiation exposure
Procedure Radiation
dose in
millisieverts
Comparable
to
background
radiation for:
Additional lifetime
risk of fetal cancer
CXR 0.1 5 years Low
Abdominal
XR
2.2 9 months Very low
CT abd/
Pelvis
15 5 years Low
CT abd/pelvis
with contrast
30 10 years Moderate
Mammogram 0.4 7 weeks Very low
1 cGy = 1J/kg; 1 Sv = 1J/kg.
21. Three stages of Embryogenesis
• I – First 2 weeks – Blastocyst resistant to teratogens.
Blastocyst has NOT differentiated.
• II – Organogenesis – 3rd to 8th week. Maximal
teratogenesis. Ends by 13th week
• III – Increase in fetal and organ size. CNS development
complete by 16 weeks. Brain and gonadal tissue
will continue to develop. Teratogens will cause
IUGR but no organ malformation
22. Radiotherapy
• Contraindicated in pregnancy
• Possible in early pregnancy with lead
shielding
• Maybe also consider in late pregnancy for
the chest with shielding
23. Risks of radiotherapy
Therapeutic doses of 5000-6000 cGy
expose the fetus to 10 cGy in early pregnancy
and 200 cGy or more in later pregnancy
Doses over 2.5-5 cGy pose high risk
for malformation early in pregnancy
With 10 cGy the risk is 50%
24. Conception to days 9/10 Lethal
Weeks 2-6 Malformation
Growth retardation
Weeks 12-16 Mental and growth
retardation, microcephaly
Weeks 20-25 to birth Sterility, malignancies,
genetic disorders
Effects of radiotherapy
25. Risks of chemotherapy
Almost all drugs cross the placental
barrier to some extent
As chemotherapeutic drugs work
by inhibiting cell division,
they pose a risk to the developing fetus.
26. Risks of chemotherapy
• Spontaneous abortion
• Malformations
• Teratogenesis
• Mutations
• Carcinogenesis
• Organ toxicity
• Retarded development
27. First trimester
• Most likely in the 1st trimester.
• Fetal malformation rate 12.7-17% with single-drug
regimens and up to 25% with combination regimens
(cf - general population rate 1-3%)
• Low birth weight ~ 40%
Second and third trimester
• Relatively low risk
• It is preferable to wait until the development of CNS
is complete, around 16 weeks
Risks of chemotherapy
28. Delivery
If a baby is delivered within 2 weeks of the last
chemotherapy dose, there is a risk of a neutropenic baby
being born to a neutropenic mother
Breastfeeding
Breast feeding is not advisable for women who have
recently been on chemotherapy
Risks of chemotherapy
29. Lancet Oncology ,Amant et al, Feb 2012
• 68 pregnancies
• 236 cycles of chemotherapy
• Safe in the 2nd and 3rd trimester
• No association with CNS, Cardiac or Auditory morbidity.
Risks of chemotherapy
31. Incidence of cervical pre-invasive
and invasive cancer in pregnant women
is similar to the incidence in general population
Pregnant women (4230) 0.17%
Non-pregnant women (107230) 0.18%
Bokhman JV, 1998.
32. The disease has been detected
during the pregnancy or postpartum
period
in 1.7 to 3.1%.
In reproductive age ≈10%
Creasman WT et al., 1970
33. Screening for invasive cervical cancer
should be performed during
the first antenatal examination
Harper DM, Roach MS. J Fam Pract, 1996; 42: 79-83
34. Management of abnormal cervical smear
during pregnancy
Pregnancy is not a contraindication for a pap smear
Abnormal cytology (5%)
Colposcopy
Biopsy
35. Indications for colposcopy
• Clinically SUSPICIOUS cervix
• Recurrent and otherwise unexplained
BLEEDING
• ABNORMAL pap
36. The aim of colposcopic examination
during the pregnancy
is to exclude invasion
46. Conization in pregnancy
• MICROINVASION confirmed by biopsy
• Pap suggestive of INVASION
• ??? Unsatisfactory colposcopic
examination in a histologically proven
high grade lesion
47. Management after the histological finding in pregnancy
CIN Microinvasive cancer Invasive cancer
Conization
Postpone further Radical
diagnostic and hysterectomy
therapeutic procedures or
for post-partum period radiotherapy
Targeted biopsy
48. Treatment of cervical cancer in pregnancy
is affected
• by the stage of the disease
• by the age of gestation
• mother’s belief regarding pregnancy termination
• future childbearing desires
49. The treatment of invasive cervical cancer
in pregnancy
should proceed without regard for the fetus,
unless the lesion is diagnosed at a stage
close to fetal viability
51. Cervical cancer in pregnancy
I trimester: Surgery with embryo in utero
III trimester: Radical Caesarean hysterectomy
II trimester ? Medical and ethical problem
52. Invasive cervical cancer in second trimester
Before 20-24 weeks
Evacuating pregnancy by hysterotomy
and immediately after radical hysterectomy
After 24-28 weeks
Waiting for fetal maturity
53. Delay of treatment for 2-10 weeks
• Small tumor
• Stage < IIB
• Gestational age > 20 weeks
van Villet W i sar. Eur J Obst Gynec Reprod Biol, 1998; 79: 153-7
54. Adnexal masses during pregnancy
1:1000 deliveries
Most masses are benign. Malignant tumors are
generally low grade and stage with survival of
75%
Ovarian cancer 1 per 10.000 – 100.000 births
Ovarian tumors and the pregnancy
55. Most frequent types of ovarian tumors
in pregnancy
Benign cystic teratoma ................. 36%
Serous cystadenoma ................ 25%
Mucinous cystadenoma ................. 12%
Corpus luteum cyst ................. 5.5%
Malignant tumors ................ 4%
56. Malignant ovarian tumors and pregnancy
In non-pregnant woman 20% ovarian tumors
are malignant.
In pregnancy this percentage is
decreased to 5% ( 3% - 9.7%)
- - Epithelial carcinomas 33-65%
- - Germ-cell tumors 17-40%
- - Sex cord-stromal tumors 9-13%
57. Malignant ovarian tumors and pregnancy
• Only 16% of ovarian tumors detected in the first
trimester
• 20% diagnosed during CS or after delivery
• Almost 25% have an acute presentation (torsion)
If there are no complications, the best timing for surgery
of persistent ovarian mass in pregnancy is between
16 to18 weeks of gestation
58. If adnexal mass is < 8 cm, unilateral,
mobile and asymptomatic:
- observation and repeat U/S at 14 to 16
weeks.
If adnexal mass is > 8 cm, solid or of complex
appearance, bilateral or persists into 2nd
trimester:
- laparotomy
Management of ovarian mass in pregnancy
59. Breast cancer
• 3% of breast cancers is associated with pregnancy
• In the reproductive period patients, breast cancer
associated with pregnancy in 14% cases
• The incidence of breast cancer in pregnancy is 0.03
(1: 3000-1:10 000 pregnancies)
• Pregnant women have a 2.5 fold higher risk to
present with advanced cancer
60. Breast cancer in pregnancy
• Delay in starting the treatment is not recommended
• Mastectomy with axillary lymph node dissection
does not jeopardise pregnancy
• Conservative surgery ?
• Chemotherapy can be administered in pregnancy
• There is no consensus regarding radiotherapy
Survival is equal as in non-pregnant patients
if the stage of the disease is considered
61. Breast cancer in pregnancy
• Later pregnancies do not influence overall survival
• Next pregnancy should not be planned at least
for 2 years after treatment
62. The patient, her partner and her doctor
are required
to take a difficult decision without always a
clear answer
(rights of the fetus ≠ rights of the mother)
When should therapeutic abortion
be recommended?
63. Therapeutic abortion- general considerations
- Absence of guidelines.
- Final decision is not always easy
- Issue becomes more important when cancer
diagnosis is made during the first trimester
Most important parameters are:
- the stage
- the indication for treatment
- the curability of the disease.
64. Recommendations for therapeutic abortion
during the first trimester
1. Primary aggressive breast cancer
2. Advanced breast cancer
3. Stage III-IV aggressive NHL or
Hodgkin s disease
4. Acute leukemia
65. Conclusion
• Malignancy is rare in pregnancy
• Consideration of mother and fetus
• Close coordination also required between
patient, obstetrician, neonatologist and
oncologist