Introduction

Malignancy complicates between 0.02% and 0.10% of all pregnancies and in one study cancer diagnosis was associated with 1 in 1000 deliveries. Pregnancy does not affect the frequency of cancers seen in women of childbearing age. Melanoma may be the most frequent malignancy seen during pregnancy (1:350), followed by cervical cancer (1:2250), Hodgkin lymphoma (1:3000), breast cancer (1:7500), ovarian cancer (1:18,000), and leukemia (1:75,000). However, the National Cancer Institute maintains that breast cancer is the most common cancer seen in pregnant and postpartum women at 1:3000 pregnancies (www.cancer.gov/cancertopics/pdq/treatment/breast-cancer-and-pregnancy).

In general, the prognosis for pregnant women with malignant lesions is the same, stage for stage, as for nonpregnant women. However, for many reasons, diagnosis of cancer during pregnancy occurs at more advanced stages of the disease.

Typically, during pregnancy, what benefits the mother also benefits the fetus. However, that is not true in the case of the pregnant woman with cancer as treating the cancer often means compromising the pregnancy. Depending on the type of cancer and gestational age at diagnosis, treatment can sometimes be delayed until the fetus is either viable or mature. In some cases, protection of maternal and fetal health are congruent, but when care of the mother imposes iatrogenic risk to the fetus, the mother may decide to delay or alter her treatment for the good of the fetus, potentially to her own detriment.

Fetal monitoring

Fetal and uterine monitoring during cancer surgery is controversial.

Introduction

Maternal vascular lesions that become apparent during pregnancy may be present before conception but only become symptomatic as a result of the physiologic changes of pregnancy. Blood vessels are weakened by an increase in blood volume and cardiac output (CO); a decrease in systemic vascular resistance (SVR); and hormonal changes. Hence, aneurysms can expand and rupture, or arteriovenous (AV) malformations can grow and, if present in the pulmonary circulation, can worsen a preexisting shunt. Some of the rare conditions described in this chapter affect blood vessels in discrete areas of the body whereas others affect all blood vessels. Often the disorders described are part of an autoimmune disease process that impacts other organ systems. Many of the vascular disorders are associated with high maternal and neonatal mortality. For example, rupture of an enlarging aneurysm can cause abrupt, catastrophic blood loss and poor peripartum outcomes. Likewise, pulmonary hypertension worsens during pregnancy and is often associated with maternal and/or neonatal death. This chapter discusses the clinical implications for the obstetric anesthesiologist of most vascular lesions seen during pregnancy. Intracranial aneurysms during pregnancy are discussed in Chapter 9.

Primary pulmonary hypertension

Primary pulmonary hypertension is a progressive disease that produces a sustained rise of at least 25 mmHg in mean pulmonary artery pressure and an increase in pulmonary resistance, in the absence of an identified pulmonary or cardiac lesion. This inevitably leads to right ventricular (RV) dilatation and RV hypertrophy progressing to RV failure and death.