American Journal of Obstetrics and Gynecology
Colon cancer in pregnancy with elevated maternal serum α-fetoprotein level at presentation
A case of colon cancer in pregnancy is presented in which the maternal serum a-fetoprotein level was elevated. Failure to evaluate colon cancer as a cause of the elevated maternal serum a-fetoprotein may have accounted for the poor outcome.
References (2)
- H Lau et al.
Alpha-fetoprotein
Am J Obstet Gynecol
(1976) - H Allen et al.
Cited by (21)
Flexible Sigmoidoscopy and Colonoscopy During Pregnancy
2006, Gastrointestinal Endoscopy Clinics of North AmericaGastrointestinal, pancreatic, and hepatic cancer during pregnancy
2005, Obstetrics and Gynecology Clinics of North AmericaColon cancer during pregnancy
2003, Gastroenterology Clinics of North AmericaThe fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy
2003, Gastroenterology Clinics of North AmericaColon cancer during pregnancy: The gastroenterologist's perspective
1998, Gastroenterology Clinics of North AmericaColon cancer in pregnancy is a distinct entity from colon cancer in the general population. Pregnancy affects the clinical presentation, evaluation, therapy, and prognosis of colon cancer. Pregnant patients typically present with advanced colon cancer, which is usually due to delayed diagnosis: Patients frequently delay self-referral because of confusion of symptoms from cancer such as rectal bleeding, nausea and vomiting, and constipation with symptoms of a normal pregnancy, and physicians may delay diagnostic tests because of potential fetal risks and because of inattention to the potential significance of symptoms owing to the relative rarity of colon cancer in this young population. Although the evaluation of colon cancer in the general population includes abdominal computed tomography (CT) to detect pericolonic extension and intraperitoneal metastases, abdominal CT is generally contraindicated during pregnancy, particularly the first trimester, because of radiation teratogenicity. Although colonoscopy is the standard procedure to evaluate suspected colon cancer in the general population, it is not yet an established procedure during pregnancy because of concerns about fetal safety.
Colon cancer therapy during pregnancy raises major ethical and medicolegal questions because of the disparate, often conflicting interests of mother and fetus.150, 176 Generally in pregnancy, what benefits the mother benefits the fetus because of fetal dependence on maternal nutrition and homeostasis for normal fetal growth and development. This general principle fails, however, in the therapy of colon cancer. Laparotomy for colon cancer during early pregnancy is beneficial to the mother but may be detrimental to the fetus. Adjuvant chemotherapy for Dukes stage C colon cancer is beneficial to the mother but detrimental to the fetus, particularly during the first trimester. Adjuvant radiotherapy for locally advanced rectal cancer during pregnancy is beneficial to the mother but highly detrimental to the fetus. Colon cancer therapy has to be modified during pregnancy to avoid radiation teratogenicity and to minimize fetal risks from cancer surgery and adjuvant chemotherapy. Beyond the conflicts between maternal and fetal interests, the father also has concerns and interests in the fetal and maternal outcome. To advise, guide, and treat properly the pregnant patient facing these emotionally charged, difficult, complex, and delicate decisions regarding therapy requires a medical team including a gastroenterologist, gastrointestinal surgeon, obstetrician, oncologist, anesthesiologist, nutritionist, and social worker. The health professionals should develop expertise in the areas of colon cancer and high-risk pregnancy as well as a sensitivity to and understanding of the psychological and emotional consequences of a life-threatening illness in a young and pregnant patient.
Delayed diagnosis of colon cancer often leads to a poor prognosis: the demise of a pregnant woman in young adulthood from a potentially curable disease and of a fetus who was otherwise viable. Arguably, pregnancy should provide an opportunity to diagnose colon cancer earlier than usual in the general population because of frequent routine office visits by the pregnant patient to the physician. This article reviews this disease with a focus on the differences between colon cancer in the pregnant patient versus the general population. The aim of this article is to make the clinician more aware and better informed of this uncommon but not rare entity to facilitate earlier diagnosis, to provide proper therapy during pregnancy, and to improve the maternal and fetal prognosis.
The literature on colon cancer during pregnancy suffers from a preponderance of case reports and small clinical series that are retrospective and uncontrolled. With one notable exception, the modern studies consist of five or fewer patients. The single large study, consisting of 41 patients, although a significant contribution to the literature, was obtained by a mailed survey of colorectal surgeons.18 This mailed survey is subject to a selection bias because of voluntary reporting by physicians and a recall bias because of the retrospective nature of the questionnaire. The literature also suffers from variable and inconsistent medical evaluation, inconsistent pathologic staging and histologic grading of colon cancer, inconsistent therapy, and frequently short-term postoperative follow-up. Nonetheless, a literature review reveals consistent, repeatedly replicated, results and findings. Thus, the clinician faced with a pregnant patient with colon cancer can be offered guidance and guidelines, with the caveat that some generally accepted principles have not been rigorously proven.
The safety and efficacy of gastrointestinal endoscopy during pregnancy
1998, Gastroenterology Clinics of North AmericaEndoscopy has a central role in the diagnosis and a significant role in the therapy of gastrointestinal bleeding and other gastrointestinal disorders. Although safety and clinical efficacy of gastrointestinal endoscopy are generally established,4, 55, 102, 161 safety and efficacy in pregnant patients are not well known. Pregnant patients not infrequently suffer from gastrointestinal conditions, such as gastrointestinal bleeding or complicated cholelithiasis, that are strong indications for endoscopy in nonpregnant patients. The indication rate during pregnancy for esophagogastroduodenoscopy (EGD) is at least 12,000 per year and for sigmoidoscopy or colonoscopy is at least 6000 per year.38 These numbers represent nearly 0.4% of all endoscopies performed in the United States.125 Thus, a busy general gastroenterologist may encounter a pregnant patient with a strong indication for gastrointestinal endoscopy perhaps once per year. For example, the author has performed about a dozen endoscopies on pregnant patients in a dozen years of a general, academic, hospital-based, gastroenterology practice; the author has not performed endoscopy on several other pregnant patients because of weak indications or patient refusal. Diagnostic and therapeutic endoscopy may be particularly valuable in pregnancy because diagnosis by barium radiography is relatively contraindicated owing to radiation teratogenesis,31, 32 because empirically prescribing gastrointestinal drugs without a definitive endoscopic diagnosis is undesirable owing to medication teratogenesis,52 and because the alternative therapy of gastrointestinal surgery for active bleeding is not desirable owing to the risk of fetal wastage.121, 199, 222
Endoscopy during pregnancy raises the unique issue of safety to the fetus in utero because of the risks of induction of premature labor or teratogenesis. Endoscopy could potentially cause fetal complications because of medication teratogenicity,75, 147, 190 placental abruption or fetal trauma during endoscopic intubation, cardiac arrhythmias,66, 100, 138, 142, 154, 177, 215 systemic hypotension or hypertension,66 and transient hypoxia. The fetus is particularly sensitive to maternal hypoxia and hypotension.121 Causes of hypoxia during EGD include respiratory compromise from administered medications,193 vagally mediated bronchospasm, laryngeal impingement during esophageal intubation,63, 128, 138, 191, 194 and pulmonary aspiration.94, 126, 178, 223 Causes of hypoxia during sigmoidoscopy or colonoscopy include intravenous sedation63, 145 and neurohumoral responses to colonic distention.100, 215
Analysis of endoscopic safety during pregnancy is important for the physician to make a judicious decision about whether to recommend endoscopy and for the pregnant patient to make an informed decision about whether to undergo endoscopy and whether to receive sedative medications for endoscopy because of possible medication teratogenicity. The physician can decrease fetal risks from endoscopy by reducing, substituting, or avoiding potentially teratogenic endoscopic medications; by appropriate fetal and maternal assessment before endoscopy; by appropriate fetal and maternal monitoring during endoscopy; and by appropriate therapy before and during endoscopy. Malpractice judgments in cases of poor fetal outcomes are sometimes astronomically large.87 It is important to document the relative safety of certain endoscopic procedures, when properly indicated and performed, during pregnancy to prevent unnecessary lawsuits.
The limitations in the current knowledge of endoscopic safety during pregnancy must, however, be recognized. All the published studies on endoscopy during pregnancy are retrospective. Although a large case-controlled study of 83 EGDs did not report any risk from EGD during pregnancy,39 this study had insufficient power to exclude a small, but clinically significant, association between endoscopy and congenital malformations. Despite the outstanding contributions by Briggs and coauthors33 and by Heinonen and colleagues104 on fetal drug safety, studies of fetal effects of maternal drug exposure during the first trimester, when available, tend to be small and retrospective. Drug teratogenicity studies in laboratory animals are not necessarily applicable to humans because of species specificity. For example, the teratogenic potential of thalidomide in humans was not demonstrated in animal studies before medication approval for human use.91, 162 Drug studies on human infants, even newborns, are also not necessarily relevant to fetal risks. Yet, despite the current uncertainties, the physician faced with an indication for gastrointestinal endoscopy in the pregnant patient can be provided guidance and guidelines. This article examines information on indications, contraindications, safety, and efficacy of gastrointestinal endoscopy in pregnancy and the fetal safety of endoscopic medications.