Jennifer Peterson was 35 and barely one week pregnant when she noticed a lump the size of half a banana in her breast. A few weeks later, tests showed she had invasive breast cancer.
The irony was mind-numbing: A potential new life beginning inside her, her own life threatened. For months, Jennifer, a resident of Manchester, N.H., who runs a small Boston law firm with her husband, had been trying to get pregnant. Now, the choices were stark: If they waited to treat the cancer until Jennifer gave birth, her survival could be greatly diminished. If they terminated the pregnancy, they might never conceive again, because chemotherapy can put a woman into premature menopause.
And then there was the third terrifying option, the one they chose: To go ahead with both treatment and the pregnancy.
“There were bad times – three surgeries and three months of chemo. I was bald, fat and one-breasted,” she said. But, through it all, Jennifer said, husband Karl Sucheki “loved me and was just as excited as I was.” Their “chemo kid,” Michael, was born full term and healthy two years ago.
Not long ago, many prospective parents – and doctors, too – would have shuddered at the very idea of subjecting a pregnant woman and her fetus to powerful drugs or surgery. But growing evidence suggests that, in many cases, such interventions may not only be safe but essential to protect both mother and fetus.
Mercifully, the collision of pregnancy and serious illness is not an everyday occurrence. But some cancers, notably leukemia and some types lymphoma, often strike in the mid to late 20s, said Dr. Lawrence Shulman, an oncologist at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital. Breast cancer is an even bigger threat, now occurring in one in 3,000 pregnancies, according to the National Cancer Institute. That figure is likely to rise as more women have babies later in life.
Other serious problems, including depression, asthma, epilepsy and infections also can occur during pregnancy and may need to be treated just as aggressively as if the woman were not pregnant, said Dr. Michael Greene, director of maternal-fetal medicine at MGH.
The biggest problem is drugs that cross the placenta, which nourishes the fetus. Once inside, some drugs can cause congenital malformations, especially during the first trimester of pregnancy, when the major organs are forming.
But, surprisingly, few prescription drugs are “absolute no-nos,” Greene said. Those are Accutane, an acne medication; thalidomide, now used to treat leprosy; ACE inhibitors to control blood pressure; Cytotec, which both causes birth defects and induces abortion; methotrexate, an anticancer drug that also induces abortion; and Coumadin, a blood thinner that can induce fetal hemorrhage.
Not quite as dangerous but still risky are some antiseizure medications and drugs used to control an overactive thyroid gland. Curiously, some over-the-counter drugs may also carry risks, especially aspirin and the NSAIDS (nonsteroidal anti-inflammatory drugs like ibuprofen).
With those caveats firmly in place, however, it’s often better for both mother and fetus to treat a serious disease than leave it untreated.
Take depression. For many years, doctors thought the sheer bliss of expecting a baby – not to mention the hormone surges of pregnancy – meant “that patients would do fine psychiatrically without medications even if they had been on them for many years,” said Dr. Lee Cohen, director of the perinatal and reproductive psychiatry research program at Mass. General.
It is now clear, Cohen said, that women who stop antidepressant medications during pregnancy fare poorly, generally relapsing in three to six months. That prospect terrified a Boston lawyer, now in her mid-30s, who had been taking Prozac for years and didn’t want to stop when she got pregnant. She “had to keep on working and stay highly functional,” she said, and knew her own “mental health would be important for the baby.”
Indeed, leaving depression untreated can be life-threatening for women who are suicidal and may be bad for the fetus as well because of the stress hormones that accompany depression. Pregnant women who are depressed are more likely to have obstetrical complications, including premature labor, low-birth-weight babies and to have babies who are cognitively impaired, Cohen noted.
Once the baby comes home, women who were depressed during pregnancy are five times more likely to suffer postpartum depression, which can interfere with parent-child bonding.
Moreover, some antidepressant medications appear to be quite safe for the fetus, particularly Prozac, a so-called SSRI (selective serotonin reuptake inhibitor) whose effects have now been tracked in 2,000 pregnant women.
In a major study published in 1997 in the New England Journal of
Medicine, Canadian researchers studied the children of 80 mothers who took Prozac or an older type of antidepressant drug such as Tofranil and Pamelor during pregnancy. As other studies had hinted, no matter when in the pregnancy a woman took the medications, there were no congenital malformations in the fetus, said psychiatrist Donna Stewart, who heads the women’s health department at the University of Toronto and was a co-author of the study.
In fact, the researchers followed the children for up to seven years and still could find no evidence that those exposed in utero to antidepressants were any different from unexposed children in global IQ, language or behavioral development A separate study in California in 1996 did show a slightly increased risk that babies with in-utero exposure to antidepressants would be placed temporarily in intensive care nurseries for observation, but more recent research by Cohen’s team at MGH refutes this.
For pregnant women with manic depression, severe anxiety or schizophrenia, it may also make sense to continue on medication. Lithium, a major treatment for manic depression, has caused concern because it can raise the risk of congenital heart disease. But the risk with lithium is smaller than once thought, Cohen said. He calls lithium “100 times safer than
Depakote,” an antiseizure drug that’s often used in manic-depression, but that can significantly raise the risk of spina bifida (incomplete closure of the spinal cord) in the fetus.
For pregnant women who are schizophrenic, older antipsychotic drugs such as Haldol and Stellazine do not increase the risk of birth defects, though there’s less data on newer antipsychotic drugs such as Zyprexa and Risperdal. Anxiety and especially panic attacks may also need treatment during pregnancy, either with antidepressants (that combat anxiety, too) or low dose benzodiazepines such as Klonopin if psychotherapy fails to help.
For pregnant women with cancer, the decision to treat the cancer is a delicate balancing act that is slightly easier at the extreme ends of pregnancy.
If a woman develops acute leukemia in the first few weeks of pregnancy, said Shulman of Dana-Farber, “you have little option to” wait because the woman could die quickly, which means terminating the pregnancy often makes sense. And if a woman is close to the end of pregnancy – say, 30 weeks (a normal pregnancy is 40 weeks) – doctors can often deliver the baby safely and then treat the mother’s cancer.
But for women who learn of their cancer mid-pregnancy, the choices get tougher. Fortunately, some chemotherapy drugs such as Cytoxan appear to
be safe for the fetus, at least in the last trimester, even though such drugs often act on rapidly dividing cells (and a fetus could be viewed as a collection of such cells).
Radiation is usually avoided during pregnancy because of possible damage to the fetus, but if the mother has a tumor that’s pressing on major blood vessels in the chest, it may be necessary. Jennifer Peterson, for example, delayed radiation treatment for her breast cancer until six days after her son, Michael, was born.
On the other hand, surgery – except on the uterus itself – is often safe for pregnant women. Even general anesthesia is not a big deal, said Greene of MGH. “The fetus gets sleepy, but it wakes up” when the operation is over.
No pregnant woman, of course, wants to have any of these interventions if she can help it.
Chemotherapy, in particular, is terrifying, Jennifer Peterson said. “You are putting a highly toxic substance into your body at this sacred time in life when your body is supposed to be a temple and all of a sudden you’re turning it into a toxic waste dump.”
But right after Michael, her “chemo kid,” was born, she and her husband began thinking of having another child. Their second gorgeous baby, Matthew, was born two months ago, and Jennifer has no signs of cancer.
“I think the human body is truly amazing,” she said. “And it’s never more awe-inspiring than during pregnancy and birth. My beautiful son, Michael, is testament to the fact that you and your in-utero baby can endure surgery and chemotherapy while pregnant and both end up healthy. And my wonderful newborn, Matthew, is proof that the circle of life does, indeed, continue to miraculously turn.”