After conization, there appears to be no harm in delaying definitive treatment until fetal maturity is achieved in patients with stage Ia cervical cancer (165,167,168). Patients with less than 3 mm of invasion and no lymphatic or vascular space involvement may be followed to term. Historically, these patients were allowed to deliver vaginally, and a hysterectomy was performed 6 weeks postpartum if further childbearing was not desired. However, in a multivariate analysis of 56 women with cervical cancer diagnosed during pregnancy and 27 women with cervical cancer diagnosed within 6 months of delivery, vaginal delivery was the most significant predictor of recurrence. In addition, most recurrences after vaginal delivery involved distant sites. The ideal delivery method for these patients is not known definitively; however, strong consideration should be given to performing a cesarean birth in women with cervical cancer of any stage (169). If vaginal delivery is chosen, close inspection of the episiotomy site is required during follow-up because of rare reports of metastatic cervical cancer at these locations (170).
Patients with 3 to 5 mm of invasion and those with lymph–vascular space invasion may be followed to term or delivered early after establishment of fetal pulmonary maturity (165,168). They may have cesarean delivery, immediately followed by modified radical hysterectomy and pelvic lymphadenectomy. Patients with more than 5 mm invasion should be treated as having frankly invasive carcinoma of the cervix. Treatment depends on the gestational age of the pregnancy and the wishes of the patient. Modern neonatal care affords a 75% survival rate for infants delivered at 28 weeks of gestation and 90% for those delivered at 32 weeks of gestation. Fetal pulmonary maturity can be determined by amniocentesis, and prompt treatment can be instituted when pulmonary maturity is documented. Although timing is controversial, it is probably unwise to delay therapy for longer than 4 weeks (167,168). The recommended treatment is classic cesarean delivery followed by radical hysterectomy with pelvic lymphadenectomy. There should be a thorough discussion of the risks and options with both parents before any treatment is undertaken.
Patients with stages II to IV cervical cancer should be treated with radiotherapy. If the fetus is viable, it is delivered by classic cesarean birth, and therapy is begun postoperatively. If the pregnancy is in the first trimester, external radiation therapy can be started with the expectation
Cancer of the Cervical Stump that spontaneous abortion will occur before the delivery of 4,000 cGy. In the second trimester, a delay of therapy may be entertained to improve the chances of fetal survival. If the patient wishes to delay therapy, it is important to ensure fetal pulmonary maturity before delivery is undertaken. Neoadjuvant chemotherapy has been administered to women during pregnancy with cervical cancer after 13 weeks gestation, without clear short-term harm to the fetus, although longer clinical follow-up is necessary (171).
The clinical stage is the most important prognostic factor for cervical cancer during pregnancy. Overall survival for these patients is slightly better because an increased proportion of these patients have stage I disease. For patients with advanced disease, there is evidence that pregnancy impairs the prognosis (165,168). The diagnosis of cancer in the postpartum period is associated with a more advanced clinical stage and a corresponding decrease in survival (169).