Case Report

Cervix Cancer Was Detected in Twenty-Seventh Years Old Woman on Thirty-Fifth

Weeks of Pregnancy at Muara Teweh Hospital

by :

Dr. Muhammad Maulana Shofri

Obstetric and Gynecology Muara teweh Hospital

North Barito Regency, Central Kalimantan 2017

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 Tablet of content

Cover ................................................................................................................................................ 1

Tablet of content ............................................................................................................................... 2

Abstract ............................................................................................................................................. 3

Introduction ...................................................................................................................................... 3

Case .................................................................................................................................................. 3

Discussion ......................................................................................................................................... 4

Conclusion ........................................................................................................................................ 5

Reference .......................................................................................................................................... 6

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Abstract
Background : Cervix cancer is one of the main causes of the death for women in the world. For women who
have not done any screening, the risk of this disease will increase during 20s or early 30s. In these past few
years, cervixes cancer that were detected during pregnancy increased to 1/1.200-10.000 pregnancy. This
problem is challenging not only for patient, but also family and doctor because it will affect the mother and
child inside the womb.
Objective : Presenting a case of cervix cancer detected in third trimester of pregnancy.
Case : A 27-years old woman, gravid 2 para 1 abortion 0 with 35th weeks pregnancy admitted to Muara Teweh
Hospital with chief complaint recurrent profuse vaginal bleeding. These symptoms were first occurred on the
4th weeks of pregnancy after coitus and happened several times between 28th and 32th weeks of pregnancy. She
was a second wife from the current husband and they had been married for 8 years. Physical examination was
normal, obstetric examination: single fetus, intra uterine with breech position and normal fetal heart rate, from
laboratory examination there was a decrease on Haemoglobin count at 9.5 g/dl and increase on leukocyte count
at 19.700/mm3. USG shown a 35th weeks single fetus intra uterine with breech position, placenta at fundus.
Vaginal examination, a single mass 4x5 cm was found and bleed easily when touched. Cancer stage at least IIB.
The pregnancy was terminated with cesarean sectio yielding a viable male infant with APGAR score 8/9/10
and weight 2900 gr. Biopsy performed and the result is cervix cancer epidermoid with moderate differentiation.
Conclusion : Cervix cancer cases that happens during pregnancy is a challenging case for patient, family, and
the doctor. The therapy depends on gestational age, cancer stagging, and consent between doctor and patient.
Keyword : Cervix, Cancer, pregnancy

Background
Majority of cervix cancer were caused by infection of human papilloma virus (HPV), which is signified
by the findings of around 95% of HPV DNA at cervix cancer lesion (Small et al., 2017). HPV with serotype 16
and 18 are the cause malignancy on cervix cancer that mostly reported (Small et al., 2017).
Cervix cancer is one of the main cause of death for woman in the world (Small et al., 2017). Besides
that, cervix cancer ranks 4th in the world. In 2016, there are 12.990 women with cervix cancer in the USA and
4.120 died with average age around 47 years old (Small et al., 2017). In Indonesia, based on Riskesdas (2013),
cervix cancer has highest prevalence number 98.692 with highest number found in Riau archipelago, North
Maluku, and Yogyakarta. For people who have not done any screening, the risk of this disease will increase
during 20s or early 30s (Amant et al., 2014). Due to this, some of the cases were detected during pregnancy
(Amant et al., 2014). These past few years, cancer cervix that were detected during pregnancy increased to
1/1.200-10.000 pregnancy (Favero et al., 2010). This problem is challenging not only for patient, but also
family and medical staff because it will affect the mother and child inside the womb (Favero et al., 2010).

Case
A 27-years old woman gravid 2 para 1 abortion 0 with 35th weeks pregnancy admitted to RSUD Muara
Teweh with chief complaint recurrent profuse vaginal bleeding. The bleeding happened one hour before the
patient arrived at the hospital. It started as blood spot but gradually increased to more fresh blood. The spotting
symptoms happened earlier during the 4th weeks of pregnancy after coitus and happened several times between
28th and 32th weeks of pregnancy. The patient also feel pain in the lower abdomen. Patient indicated that there
were no sign of labor like contractions and blood mucus from vagina. The patient has a 7 year old son. The first
son weight 3800 gram at birth and born pervaginam spontanously. The patient did not do the ANC routinely.
Patient have a history of using contraception injection. As for the history of marriage, patient was a second wife

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from the current husband and they had been married for 8 years. Patient never had an abnormal vaginal
discharge or bleeding outside the cycle of menstruation. Also patient never did IVA test or papsmear screening.
Physical examination from this patient was normal and composmentis with BP 120/80, HR 86x/mins
RR 18x/mins and T 36,8 C. From obstetric examination,single fetus intra uterine with breech position was
found, but has not entered pelvic inlet, fetal heart beat was 142x/mins. During vaginal examination, a single
mass 4x5 cm was found, bleed easily when touched and already reached the bottom one-thirth of the vagina.
USG examination were done to ensure placenta location and fetal condition. USG result showed a 35th weeks
single fetus intra uterine with breech position, placenta at fundus and not blocking the birth way. From
laboratory examination, haemoglobin count was found at 9.5 g/dl, leukocyte count at 19.700/mm3, trombocyte
count 455.000/mm3 and haematocryte 29,0%. During vaginal examination, a fragile single mass was found at
portio that leads to a cancer, after some consideration, termination on pregnancy with sectio cesaria was
selected as the next step and with biopsy to take sample for pathology anatomy. The cesarean sectio yielding a
viable male infant with APGAR score 8/9/10 and weight 2900 gr. During surgery the doctor thought that the
tumor already penetrate to parametrium. From physical examination and examination during surgery the stage
of cervix cancer in these patients is at least IIB. The result of pathology anatomy sample was performed cervix
cancer epidermoid moderate with differentiation (figur 1).
Fig 1. Microspic result from cervix biopsy found a tumor mass from
epithelia, hyperplastic growth with round and oval shape, half of it had
spindel shape. The nucleus were hypercromatic and malignant.

Discussion
Estimated number of cancer that were detected on pregnant women is 0.05%-0,1% (Amant et al., 2014).
Cancer that often happens on pregnant women are cervix cancer, breast cancer, melanoma, lymphoma, acute
leukemia and ovary cancer (Pentheroudakis et al., 2010). The past few years, there has been an increase on
cervix cancer that was detected during pregnancy to 1/1.200-10.000 pregnancy (Favero et al., 2010). On the
other hand, some research indicated that cervix cancer was detected on 1-3% pregnancy (Lin et al., 2013). This
is a rare case which become a dilemma to determine the best therapy without giving any bad influence to the
fetal (Lin et al., 2013). This case happened during pregnancy and on top of it, it also happened in relatively
young age (27 years old) where the patient was sexually active since the age of 19. Cervix cancer is commonly
caused by HPV 16 and 18 which infections were transmitted from sexual behavior of the woman or the partner
(Rudolph et al., 2016). The most frequent risk factors for infection of HPV are an early start of sexual activity,
the number of sexual partners, smoking and use of some contraceptive methods (Boccalini., 2012). Woman
who are sexually active before age 16 are two times more risky than a woman who are sexually active at 20
years old (Kaur et al., 2016). Starting sexual activity at young age is highly correlated with risk of sexually
transmitted HPV infection (Louie et al., 2009). HPV infection is most commonly transmitted through sexual
intercourse at the peak age of 14-24 years old (Roland et al., 2013). This might happen because the cervix at
adolescent is not biologically mature yet and susceptible to persistent HPV infection (Louie et al., 2009). In
another study, cervix cancer was rarely found prior to 29 years old because HPV infection could take several
years to be developed as an invasive cervix cancer (Roland et al., 2013). One of the risk factors in this case is
because the sexual activity started at a relatively young age and sexual activity or sexual history from the
patient’s husband.
According to TNM/FIGO classification, this case at least belongs to IIB clinical stage with more than 4
cm lump mass found, bleed easily when touched, already reached the bottom one-thirth of the vagina and
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invaded to parametrium. The best way to determine the stage of cervix cancer on pregnant women are MRI and
USG that can decide the size of tumor on 3 dimensions and also see the stroma, parametrium invasion, and
infiltration to lymph node (Amant et al., 2014). The use of MRI is considered save because there were no study
about the bad effect to fetal at every trimester (Amant et al., 2014). Besides that, colposcopy and direct biopsy
also needed in diagnosis but it would be safer to be done at the second trimester (Lin et al., 2013). Combination
between MRI and pathology anatomy is the best choice to diagnose (Amant et al., 2014). The use of these
facilities to diagnose and determine the stage on the patient is difficult to do because of some factor such as
limited facilities and infrastructure at the hospital as well as the patient that is psychologically more concerned
about the infant. The procedure to choose modality therapy for cervix cancer with or without pregnancy is the
same (Favero et al., 2010). The main purpose of therapy is to get the same prognosis with non-pregnant woman
(Amant et al., 2014). This is because therapy for cancer during pregnancy are extremely challenging where only
there were a limited number of evidences and also there are no clear guidelines (Amant et al., 2014). According
to Lin (2013), prognosis of the pregnancy affected by cervix cancer such as increased rates of low birth weight
and very low-weight infants. Fetal’s condition need to be considered when conducting therapy on pregnant
women, the therapy should not affect the fetal. Counseling is needed to determine the therapy for cervix cancer
during pregnancy as it needs to consider both the mother and fetal (Kyrgiou et al., 2015). Therapies for
pregnant woman will depend on gestational weeks, stage, and patient’s desire to keep the pregnancy (Amant et
al., 2014). Therapy for woman that do not want to keep the baby would be the same therapy for non-pregnant
woman (Amant et al., 2014). While for pregnant woman that want to keep the fetal, the therapy will depend on
gestational weeks and stage. Some studies listed down some therapies for cancer on pregnant woman. At the
age of 22 to 25 week of gestational, to decide the stage of tumor, colposcopy, conization, and
lymphadenectomy were done (Amant et al., 2014). Early stage IA2-I with tumor size less than 2cm, the therapy
were determined from lymphonody status. We need to terminate the pregnancy if the lymphonody status are
positive (Amant et al., 2014). When the lymphonody status is negative at the early stage, the therapy need to be
postponed until labor and if size of the tumor is more than 2 cm, neoadjuvant chemotherapy need to be chosen
(Amant et al. 2014). NACT (neoadjuvant chemotherapy) also chosen if cervix cancer’s stage is more than IIB
to stabilize the size and to stop the invasion. Besides NACT, the use of laparoscopy radical trachelectomy was
done at the age of 14 week (Kyrgiou et al., 2014). When the cervix cancer was diagnosed at the age of 22 to 25
week, the therapy can be delayed until fetal is mature enough for delivery (Amant et al. 2014). If the cancer
grows progressively, termination is one of the possible choice or if the patient wants to wait until the fetal is
mature enough, the only suitable therapy is NACT (Amant et al., 2014). From the theories above, the
termination at cancer cervix stage IIB on 35 week of gestation is the right decision after the considering of
maternal and fetal, and also limited facilities and infrastructure. Before deciding on terminating the pregnancy,
patient has to wait until fetal is mature enough or already 32 to 35 week of gestation (Pentheroudakis et al.,
2010). The usage of sectio caesarian as a method to terminate is still debated on some study. Pervaginam labor
is more recommended to reduce the loss of blood, operation risk and infection (Amant et al., 2014). While
sectio caesarian is more recommended on cervix cancer that already invaded to bones to reduce risk of fracture
because of lithotomy position. Besides that, sectio has a risk for lymphovaskuler spreading and implantation on
injured incision (Amant et al., 2014). Petheroudakis (2010) indicated that sectio caesarian is a choice of
termination on cervix cancer. In this case, termination by sectio caesarian and biopsy were done to get the
information of tumor cells. Besides that, the other examination is metastasis on placenta. Besides placenta,
physical examination and laboratory examination such as full blood examination and biochemical needed to be
completed at birth, first month, and 6 months after birth (Pentheroudakis et al., 2010).
Conclusion
Cervix cancer is one of the main cause of death of woman in the world. Majority of cervix cancer were
caused by infection of human papilloma virus. The most frequent risk factors for infection of HPV are an early
start of sexual activity, the number of sexual partners, smoking and use of some contraceptive methods. Some
of the cervix cancer were detected during pregnancy. This is certainly a challenge for patient, family, and the
doctor to plan the therapy. Therapies for pregnant women will depend on gestational weeks, stage, and patient’s
desire to keep the pregnancy.

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