Key points: See Table 1 and Figure 4 (original paper). ● Clinicians should order ultrasound as the first-line imaging tool whenever possible due to its safety and absence of radiation exposure ● Clinicians may administer alkylating agents such as cyclophosphamide, ifosfamide, and dacarbazine in the second and third trimesters. ● Clinicians should not administer methotrexate in any trimester due to its teratogenic and abortifacient effects. Alternative treatments should be offered, or therapy should be delayed until after delivery. ● Clinicians may administer platinum agents such as carboplatin, cisplatin, and oxaliplatin in the second and third trimesters. Carboplatin is preferred over cisplatin due to lower fetal ototoxicity risks when compared with cisplatin. ● Clinicians may administer anthracyclines such as doxorubicin, epirubicin, and daunorubicin in the second and third trimesters. ● Clinicians should avoid the use of idarubicin in all trimesters, due to risk of congenital malformations, fetal cardiotoxicity, and pregnancy loss. If no other anthracycline is felt to be an appropriate substitute, the patient should be counseled about limited safety data for using idarubicin in pregnancy. ● Clinicians may administer topoisomerase inhibitors such as irinotecan and etoposide in the second and third trimesters. ● Clinicians may administer vinca alkaloids such as vincristine, vinblastine, and vinorelbine in the second and third trimesters. ● Clinicians may administer taxanes such as paclitaxel and docetaxel in the second and third trimesters. ● Clinicians may administer ABL-targeted tyrosine kinase inhibitors such as imatinib and nilotinib in the second and third trimesters. ● Clinicians should not administer dasatinib in any trimester due to risks of teratogenicity, growth restrictions, and spontaneous abortion. Alternative treatments should be offered, or therapy should be delayed until after delivery. ● Clinicians may administer CD20-targeted agents such as rituximab in the second and third trimesters with close monitoring for fetal development and neonatal hematologic abnormalities. ● Clinicians should generally avoid antibody-drug conjugates such as brentuximab vedotin, during all trimesters of pregnancy due to concerns for fetal toxicity based on mechanism of action and lack of safety data. ● Clinicians should avoid the use of checkpoint inhibitors such as nivolumab and pembrolizumab in all trimesters due to potential fetal immune system disruption, fetal autoimmune complications, and increased risk of miscarriage, stillbirth, and preterm labor. If use is essential, restrict to 12-32 weeks of gestation. ● Clinicians may administer interferon-α for chronic myeloid leukemia in any trimester. ● Clinicians should not use cellular therapies, hematopoietic cell transplant, and radiopharmaceuticals due to insufficient safety evidence. Alternative treatments should be offered, or therapy should be delayed until after delivery. ● If radiation therapy is required for pregnant patients with cancer, the radiation oncology team should ensure cumulative fetal exposure remains below 100 mGy and use appropriate abdominal shielding to reduce fetal exposure. Abdominal and pelvic radiation should be avoided to minimize fetal risks. ● Clinicians may offer antiemetics such as ondansetron or metoclopramide for treatment-induced nausea and vomiting. Use of other antiemetic agents such as prochlorperazine, olanzapine, and NK1 receptor antagonists should be guided by multidisciplinary consultation, as efficacy for treatment-induced nausea and vomiting and/or fetal safety data remain limited. Glucocorticoids, preferably prednisolone or methylprednisolone, may be used when needed. ● Clinicians may offer G-CSF to reduce the risk of febrile neutropenia when clinically indicated, such as with myelosuppressive chemotherapy. Decisions should be based on individual risk factors, gestational age, and benefits versus risks. |
