Young Cervical Cancer, Leukemia Survivors at Greater Risk of Obstetric Complications

Young women who survived cervical cancer and leukemia were less likely to give birth and, when they did, sustained greater risk of serious obstetric complications, according to results from a retrospective cohort study.

Among 5-year survivors of cancer diagnosed at age 15-39 years in England, those who had cervical cancer were at 31% to 174% greater risk of a number of complications as compared with the general population — ranging from malpresentation of fetus and obstructed labor to antepartum hemorrhage and preterm birth.

Survivors of leukemia were at 50% to 97% elevated risk of preterm delivery, obstructed labor, postpartum hemorrhage, and retained placenta, reported Raoul Reulen, PhD, of the University of Birmingham, England, and colleagues.

However, other specific cancers were not found to be linked to multiple risks for fewer births and more obstetric complications.

Thus, while a large percentage of these survivors may avoid pregnancy due to concerns about the risk of complications during pregnancy and delivery following a cancer diagnosis, the results of the study provide “reassurance for almost all survivors of adolescent and young adult cancer concerning their risk of almost all obstetric complications,” Reulen and colleagues wrote in Lancet Oncology. The findings should help in development of clinical guidelines for counselling and surveillance of obstetrical risk as well, the group suggested.

In a commentary accompanying the study, Ranjeet Bajpai, MD, and Jyoti Bajpai, MD, both of Apollo Hospitals in Navi Mumbai, India, agreed that the results provide reassurance for many.

However, the study also points to specific groups “for whom pregnancies should be considered high risk owing to their propensity to develop potentially serious obstetric complications,” the commentators added. “For these patients, obstetrician-led expert antenatal and perinatal care is essential.”

Using data from the Teenage and Young Adult Cancer Survivor Study and the Hospital Episode Statistics cohorts over a 25-year period, Reulen and colleagues observed 21,437 births among 13,886 female survivors of adolescent and young adult cancer from England — a rate that was 32% lower than expected (observed-to-expected ratio 0.68, 95% CI 0.67-0.69) compared with the general population.

Survivors of genitourinary cancers and breast cancer had birth rates that were more than 50% lower than the general population, while survivors of leukemia had a birth rate 47% lower than expected for the general population.

Regarding the risk of obstetric complications in these cancer survivors, the authors calculated standardized incidence ratios (SIRs) as the observed versus expected number of births, with SIRs considered moderately increased if 1.25 or higher.

They determined survivors of cervical cancer were at excess risk of the following compared with women in the general population (SIRs):

• Malpresentation of the fetus during labor (1.31)
• Disorders of amniotic fluid and membranes (2.49)
• Premature rupture of membranes (1.57)
• Placental disorders (1.53), including placenta previa (1.60)
• Antepartum hemorrhage (1.45)
• Preterm delivery (2.74)
• Obstructed labor (1.72)

“These increased risks of adverse obstetric outcomes suggest that survivors of cervical cancer require a high-risk pregnancy care plan that requires close monitoring and assessment with input from an obstetric multidisciplinary team,” wrote Reulen and colleagues. “Our results provide evidence for the potential development of guidelines for the management of pregnancies in survivors of cervical cancer to complement existing guidelines on the management of cervical cancer and a benchmark against which the obstetric risks of future cancer treatment can be compared.”

The risk of antepartum hemorrhage was also highly elevated among survivors of other genitourinary cancers (SIR 3.26).

Leukemia survivors were at greater risk of preterm delivery (SIR 1.50), obstructed labor (SIR 1.65), postpartum hemorrhage (SIR 1.25), and retained placenta (SIR 1.97).

The authors acknowledged their study had limitations, including the absence of information on treatment modalities, dose exposure, and age at cancer onset.