1. ORIGINAL ARTICLE
Khalid H. Sait Æ Adnan Ashour Æ Mohammad Rajabi
Pregnancy outcome in non-gynecologic cancer
Received: 13 December 2003 / Accepted: 8 March 2004 / Published online: 2 June 2004
Ó Springer-Verlag 2004
Abstract Objective: The objective was to determine the
prevalence of non-gynecologic cancer in pregnancy and
its maternal and fetal outcome in a single tertiary center
in the Eastern Province of Saudi Arabia. Method: Ret-
rospective chart review was done of 54 patients with a
diagnosis of non-gynecologic cancer in pregnancy at
Dhahran Health Center from January 1990 to December
2001 using the Dhahran Health Information database.
Maternal and fetal outcome were determined for 17
women with active cancer during pregnancy (Group I,
18 pregnancies) and for 44 women in cancer remission
(Group II, 96 pregnancies). Seven women were pregnant
during active cancer and during cancer remission.
Results: There were 114 pregnancies in 54 women with
cancer. The prevalence in pregnancy was 1.5:1,000 (54
cancer in 70,987 pregnancies). Thyroid (33) and breast
(11) cancer accounted for 75% of all cancer. Induced
abortion, spontaneous abortion, stillbirth and low birth
weights in Group I were: 5 (28%), 0 (0%), 1 (6%) and 2
(11%), respectively, and in Group II were: 1 (1%), 11
(11%), 0 (0%) and 3 (3%), respectively. Live births for
Group I, II and all patients with cancer were 12 (66.7%),
84 (87.5%) and 96 (84.2%), respectively, with p =0.025
There were three maternity deaths among 17 women in
Group I. None of 44 women in Group II died. Conclu-
sion: The diagnosis of active cancer in pregnancy carries
a significant increase in perinatal and maternal mortal-
ity. However, pregnancy during cancer in remission has
favorable outcome, pregnancy in this group should not
be discouraged.
Keywords Cancer in pregnancy Æ Prevalence Æ
Outcome
Introduction
Cancer is a major cause of death in women in the
reproductive age. Approximately 1:6,000 women will be
affected by cancer while pregnant. The most frequent
non-gynecologic malignancies in reproductive age group
are lymphoma, thyroid cancer, breast cancer and
malignant melanoma [1]. Although reviews on preg-
nancy outcome in cancer patients have been encouraging
[1, 2], only a small percentage of women get pregnant
after treatment. About 10% of women treated for breast
cancer become pregnant [3, 4]. This may be due to an
increase in infertility secondary to chemotherapy and
radiation therapy [5]. The contributions of patient’s fear
from getting pregnant and possible discouragement by
health care providers to the low pregnancy rate are un-
known. The objective of this study is to determine
pregnancy outcome in women with non-gynecologic
malignancy in a tertiary referral center in the Eastern
Province of Saudi Arabia.
Methods
A retrospective study of pregnant women with the diagnosis, or
history of, non-gynecologic cancer was done at Dhahran Health
Center, from January 1990 to December 2001 using Dhahran
Health Information database. Medical records were reviewed and
the following data were obtained and entered into study database:
type of cancer and its treatment, date and age at diagnosis and the
number of pregnancies during and after cancer diagnosis and
treatment. Maternal and fetal outcome were also determined.
Outcome of pregnancy was classified as live birth, spontaneous
abortion, induced abortion, stillbirth, low birth weight (<2,500 g)
and birth defects. Women were divided into two groups. Group I:
patients with active non-gynecologic cancer during pregnancy.
Group II: patients in cancer remission during pregnancy. Data
were collected and entered into Excel for analysis. Statistical
K. H. Sait (&)
Departments of Obstetrics and Gynecology,
King Abdulaziz University Hospital,
P.O. Box 80215, 21589 Jeddah, Saudi Arabia
E-mail: khalidsait@yahoo.com
Tel.: +966-2-6408293
Fax: +966-2-6408316
A. Ashour Æ M. Rajabi
Departments of Obstetrics and Gynecology,
Dhahran Health Center, Saudi Aramco,
Dhahran, Saudi Arabia
Arch Gynecol Obstet (2005) 271: 346–349
DOI 10.1007/s00404-004-0627-9

2. analysis was performed using the SPS statistics program and chi-
square tests (Statistical significance is defined as p<0.05).
Results
During the 12-year study period, 114 pregnancies in 54
women with non-gynecologic cancer were found with a
prevalence of 1.5 per 1,000 (1 per 623) pregnancies. The
mean pregnancy per woman was two with a range of 1–
7. The mean age and (range) in years at diagnosis for
thyroid, breast and all cancers were 30 (22–41), 28 (22–
41) and 33 (25–41), respectively. Thyroid cancer (30) and
breast cancer (11) accounted for 75% of all non-gyne-
cologic cancer that was diagnosed in pregnant women
(Table 1). Out of 114 pregnancies, 18 (15.7%) occurred
in women with active cancer and 96 (84.2%) occurred in
women in cancer remission.
Eighteen pregnancies occurred in 17 women in
Group I. Fifteen were newly diagnosed cancer at a mean
gestational age of 15 weeks (4–33 weeks). Five women
had elective termination of pregnancy at gestational ages
between 5 and 15 weeks; 3 with breast cancer and 2 with
thyroid cancer. Ten women elected to continue the
pregnancy, 9 fetuses survived and 3 women died. One
woman had fetal distress in labor, she refused Cesarean
section, baby died in utero and she died 2 days later
from stomach cancer metastasis. Two women in Group I
had three pregnancies during chemotherapy treatment
who continued pregnancy. One had normal live birth
after chemotherapy treatment for acute myelocytic leu-
kemia at 18 weeks’ gestation and the other woman had
two live births on tamoxifen for breast cancer. This
patient died 2 months after her second delivery. The
third maternal death was a patient who died 3 months
after delivery of normal baby from breast cancer
metastasis. In Group I, the numbers and (rates) of live
birth, spontaneous abortion, elective pregnancy termi-
nation and stillbirth were 12 (66.7%), 0 (0%), 5(27.8%)
and 1 (5.6%), respectively (Table 2).
Ninety-six pregnancies occurred in 44 women in
Group II. Thyroid and breast cancer were present in 69
(71.9%) and 9 (9.4%) of pregnancies, respectively
(Table 1). None of these patients died. The numbers and
(rates) of live birth, spontaneous abortion, elective
pregnancy termination and stillbirth were 84 (87.5%), 11
(11.5%), 1 (1%) and 0 (0%), respectively (Table 3). There
were three babies with low birth weight and one baby
with osteogenesis imperfecta. Seven women in this study
were pregnant during active cancer and during cancer
remission. Live birth for all patients with cancer was
84.2% (96 out of 114 pregnancies). Live birth for Group I
and Group II were 66.7% (12 out of 18 pregnancies) and
87.5% (84 out of 96 pregnancies), respectively. This dif-
ference was statistically significant (Chi-square; p=0.025;
Table 2). There were 18 abnormal pregnancy outcome in
108 pregnancies (excluding six elective terminations in
Group I and II; Table 3). Abnormal pregnancy outcome
occurred in 23.1% (3 out of 13) and 15.8% (15 out of 95)
in Groups I and II, respectively. The difference is statis-
tically not significant (p=0.508).
Discussion
This is the largest series of pregnancy in non-gynecologic
cancer patients from a single institution. The prevalence
of cancer during pregnancy in our population is 1.5 in
1,000 (1 per 623) pregnancies. This figure is much higher
than previously published reports in other regions that
was reported at 1 in 6,000 pregnancies [1]. Eighty-four
percent of our patients were in cancer remission during
pregnancy. Although active cancer was present in only 1
in 6 women during pregnancy (16%), it accounted for all
the three maternal deaths and over 80% of therapeutic
termination of pregnancy. With a comprehensive mul-
tidisciplinary medical care provided by maternal-fetal
medicine specialists, oncologists and neonatologists, two
thirds of women with active cancer during pregnancy
Table 1 Pregnancies in women with cancer
Cancer types Women
(%)
Group I
active cancer
(%)
Group II
remission
(%)
Total
pregnancies
(%)
Thyroid 30 (55.6) 8 69 77 (67.6)
Breast 11 (20.4) 7 9 16 (14)
Hematological 5 (9.3) 1 7 8 (7)
Melanoma 2 (3.7) – 2 2 (1.8)
Other 6 (11) 2 9 11 (9.6)
All cancer 54 18 (15.7) 96 (84.2) 114 (100)
Table 2 Outcome of pregnancies in women with cancer
Group Women Pregnancies Live birth
(%)
Spontaneous
abortion (%)
Elective
abortion (%)
Stillbirth
(%)
I Active cancer 17 18 12b
(66.7) 0 (0) 5 (27.8) 1 (5.6)
II Cancer remission 44 96 84c
(87.5) 11 (11.5) 1 (1) 0 (0)
Total 54a
114 96 (84.2) 11 (9.6) 6 (5.3) 1 (0.9)
a
Seven women included in the two groups (were pregnant during active cancer and then pregnant again when cancer in remission)
b
Include two babies with low birth weight
c
Include three babies with low birth weight and one baby with osteogenesis imperfecta
347

3. and 87.5% of women in cancer remission had live
newborns. Excluding women who did not abort during
the first trimester of pregnancy, 80% of women with
active cancer and all women in cancer remission had live
newborns.
Onset of malignancy during pregnancy is distressing
for the future parents and raises thorny problems for
the oncologists, obstetrics and gynecologists and neo-
natologist. Although active cancer during pregnancy is
infrequent, its management is difficult for the patients,
family and their physicians. When a woman with can-
cer or a history of cancer becomes pregnant a favorable
outcome is especially uncertain, in part because some
antineoplastic agents are known human teratogens [6–
8]. With rare exceptions, reports of pregnancy outcome
in women with cancer are few and inconclusive espe-
cially with non-gynecological malignancies [9, 10].
Cancer of thyroid was the most common cancer in this
study (77 pregnancies in 30 patients). Subsequent
pregnancy after treatment with 131
I appears to be safe.
Impairment of gonadal function by iodine is temporary
and reversible. There does not seem to be an increased
incidence of adverse pregnancy outcome [11, 12]. It is
recommended to avoid conception for 1 year after
iodine treatment to ensure complete elimination of the
radionuclide [12]. In this study, 14% (11 of 77) preg-
nancies with thyroid cancer in remission had an
abnormal pregnancy outcome (spontaneous abortion
= 8 and LBW = 3). Six of these 11 patients received
postoperative131
I. Abnormal pregnancy outcome (18
pregnancies in 15 patients) and the type of cancer is
presented in Table 3. A review of the recent English
literature on cancer in pregnancy including this study is
presented in Table 4. There were a total of 562 preg-
nancies in 424 women with cancer. The overall live
birth, low birth weight, stillbirth, birth defects, spon-
taneous abortion and therapeutic abortion were 73.3,
10.3, 4.8, 3.8, 8 and 10.9%, respectively. The overall
pregnancy outcome in our study population compared
favorably with previously published studies [13–18]
(Table 4). Women in cancer remission who remain
cancer free during pregnancy are expected to have
favorable pregnancy outcome. Women in active cancer
during pregnancy also carry a significant mortality risk.
One in six women with active non-gynecologic cancer
in this study died during pregnancy or in the immediate
postpartum period from cancer metastasis. The bright
side to the devastating diagnosis of active cancer in
pregnancy is the finding that 4 out of 5 women who
elected to continue the pregnancy did have live new-
borns. The authors emphasis that in preconception
counseling of women with cancer the couple should be
informed about the possible effect of pregnancy on
cancer recurrent and survival especially the estrogen
dependent cancer, i.e., breast cancer which were not
addressed in this study and remain to be determined.
The overall incidence of birth defects of 3.8% is not
significantly higher than the 3% incidence reported in
the general population [6].
In conclusion, the diagnosis of active cancer in
pregnancy carries a significance increase in perinatal and
maternal mortality. However, pregnancy during cancer
remission has a favorable outcome; pregnancy in this
group should not be discouraged. The obstetrician, in
close collaboration with the oncologist has a major role
in choosing the most appropriate diagnostic and thera-
peutic strategy and must keep the couple fully informed.
Cancer in pregnancy requires careful consideration of
multiple complex issues to achieve the most favorable
outcome for mother and fetus.
Table 3 Abnormal pregnancies outcome in cancer women. Group I consisted of women with active cancer, Group II of women in cancer
remission
Abnormal
outcome
Cancer type Treatment Group Age
(years)
Gestational
age (weeks)
Outcome Comment
1 Stomach cancer Patient refused therapy I 29 29 Stillbirth Refused cesarean,
died postpartum
2 AML Chemotherapy II 40 41 Spontaneous abortion –
3 and 4a
Breast cancer Surgery, refused
chemotherapy
I 40 40, 41 Low birth weight · 2 Tamoxifen,
died postpartum
5 Breast cancer Surgery and chemotherapy II 34 39 Spontaneous abortion –
6 Hodgkin’s
lymphoma
Surgery and chemotherapy II 29 31 Spontaneous abortion Normal birth · 1
7 Melanoma Surgery II 20 26 Birth defect Osteogenesis
imperfecta
8 Thyroid Surgery II 22 24 Spontaneous abortion Normal birth · 5
9 Thyroid Surgery II 30 31 Spontaneous abortion Normal birth · 1
10 Thyroid Surgery II 23 25 Spontaneous abortion –
11 and 12a
Thyroid Surgery II 35 36, 37 Spontaneous abortion · 2 Normal birth · 1
13 Thyroid Surgery and iodine therapy II 30 32 Spontaneous abortion Normal birth · 3
14 Thyroid Surgery and iodine therapy II 32 36 Low birth weight Normal birth · 2
15 Thyroid Surgery and iodine therapy II 22 30 Spontaneous abortion –
16 and 17a
Thyroid Surgery and iodine therapy II 22 24, 26 Low birth weight · 2 –
18 Thyroid Surgery and iodine therapy II 23 26 Spontaneous abortion –
a
Women with active cancer and in remission
348

4. Acknowledgments The authors acknowledge the use of Saudi
Aramco Medical Services Organization (SAMSO) facilities for the
research data utilized in this manuscript. Opinions expressed in this
article are those of the authors and not necessarily of SAMSO.
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Table4Outcomeofpregnancyinwomenwithcancer(Englishliterature)
ReferenceTypeofstudyYearCancertypeWomenPregnancyLivebirthLBWSBBirthdefectSATA
[13]USAquestionnaire1992Allcancer661339891014418
[14]Spanishquestionnaire1991Hematologic48564322157
[15]Literaturereview1987Leukemia58582842223
[16]Originalresearch1992Breast11811983NA2NA1222
[17]Originalresearch1992Hodgkin485039NA2154
[18]Literaturereview1992Colon323225105NA11
Present
study
Originalresearch2002Non-gynecologic5411496(84%)5(4.4%)1(0.9%)1(0.9%)11(9.6%)6(5.3%)
Total–––424562412/562(73.3%)30/290(10.3%)24/501(4.8%)19/501(3.8%)40/50(18%)61/562(10.9%)
349