The rising maternal age in many populations may partially explain the increased frequency of cancer diagnoses during pregnancy, but this is only part of the story. Enhanced cancer screening protocols and widespread use of advanced diagnostic technologies, including cell-free DNA (cfDNA) prenatal genetic screening, have significantly contributed to the early and sometimes unexpected detection of malignancies in pregnant individuals. This has led to an uptick not only in diagnoses of early-stage cancers but also in identifying metastatic disease that might otherwise have gone unnoticed until later stages.

Historically, managing cancer during pregnancy has been fraught with uncertainty. The dearth of robust clinical research and fear of teratogenic effects from cancer therapies often led to delayed or withheld treatment, with clinicians erring on the side of caution to protect the developing fetus. However, recent advances in oncologic therapies and a deeper understanding of fetal tolerance to various treatments have transformed this paradigm. Today, emerging evidence suggests that many pregnant patients can safely undergo surgery, chemotherapy, and even radiation under carefully controlled circumstances, allowing clinicians to offer treatments that do not compromise pregnancy outcomes.

The newly published SMFM guidelines synthesize the multidisciplinary consensus and scientific literature into practical recommendations. These guidelines address commonly diagnosed malignancies in pregnancy, including breast cancer, cervical cancer, colorectal cancer, thyroid neoplasms, Hodgkin and non-Hodgkin lymphomas, leukemia, melanoma, and ovarian cancer. Each cancer type is examined in the context of disease biology, stage at presentation, and timing relative to gestational age, permitting nuanced management strategies that consider both oncologic control and fetal safety.

Imaging diagnostics have evolved to accommodate pregnancy-specific risks, with ultrasonography and noncontrast magnetic resonance imaging (MRI) now recommended as first-line tools to evaluate suspected malignancies. Such modalities circumvent ionizing radiation exposure, which poses teratogenic risks, thereby enabling clinicians to obtain crucial diagnostic information while preserving fetal integrity. The guidelines underscore that delaying surgical intervention due to pregnancy is unwarranted; surgical procedures can and should proceed when indicated, irrespective of gestational stage, to optimize maternal prognosis.

Thromboprophylaxis emerges as a critical component in the management of pregnant cancer patients due to the recognized hypercoagulable state induced by malignancy and pregnancy alike. The SMFM advises thromboprophylaxis for all patients with active hematologic or gynecologic cancers and recommends individualized assessment for those with other cancer types. Preventing thromboembolic events is paramount, as these complications pose significant risks to both maternal and fetal health, with morbidity and mortality implications.

Chemotherapeutic regimens, once considered contraindicated during pregnancy, have found a place in treatment protocols post-first trimester. Most cytotoxic agents appear to be safer when initiated after 12 weeks’ gestation, coinciding with the conclusion of organogenesis and a reduced risk of major congenital anomalies. The guidelines emphasize individualized consultations with oncology specialists to weigh the risks and benefits of treatment timing, especially when diagnosis occurs in the first trimester and pregnancy continuation is desired by the patient.

The fetal monitoring paradigm has adapted to the complexities introduced by maternal cancer and its treatment. Serial fetal growth assessments every three to four weeks are recommended irrespective of therapeutic approach, recognizing that malignancy and oncologic interventions can adversely affect placental function and fetal development. Such surveillance facilitates early detection of growth restriction or other complications, permitting timely intervention and optimizing perinatal outcomes.

Cancer during pregnancy introduces intricate clinical dilemmas that necessitate a multidisciplinary, patient-centered approach. The guidelines advocate assembling dedicated care teams, including maternal-fetal medicine specialists, oncologists, surgeons, radiologists, and neonatologists, to tailor treatment plans that respect the patient’s values, pregnancy goals, and clinical realities. This team-based approach ensures balanced decision-making that supports both effective cancer management and fetal welfare.

An important aspect of these guidelines is their recognition of the expanding role of prenatal genetic screenings like cfDNA not only in fetal assessment but also as serendipitous cancer detection tools. Incidental findings of abnormal cfDNA results have unmasked occult maternal malignancies, prompting further investigation and early intervention. This phenomenon presents both clinical opportunities and challenges, as unexpected cancer diagnoses during pregnancy require rapid yet thoughtful management strategies.

While the SMFM guidelines represent a milestone in codifying cancer care during pregnancy, they also highlight the ongoing need for research into long-term maternal and infant outcomes following in utero exposure to chemotherapy, radiation, and surgical interventions. Available data have begun to allay earlier fears by documenting reassuring developmental outcomes, but comprehensive, longitudinal studies remain imperative to solidify safety profiles and optimize treatment protocols.

The guidelines underscore that withholding cancer treatment solely based on pregnancy status is unjustified. Ensuring equitable access to the full spectrum of reproductive and oncologic options, from fertility preservation techniques to pregnancy continuation or termination discussions, is essential. These options must be presented without bias, allowing patients to make informed decisions supported by their healthcare team.

Cancer in pregnancy is no longer an insurmountable barrier to therapy. Through the lens of technological advances, multidisciplinary collaboration, and evidence-based protocols, clinicians can now offer personalized and effective treatment strategies that preserve maternal health without compromising fetal outcomes. The SMFM Consult Series #76 sets a new clinical standard, equipping providers worldwide with the tools and knowledge necessary to navigate this complex intersection of oncology and obstetrics.

As cancer incidence continues to climb among younger populations, these guidelines will be pivotal in shaping future research agendas, clinical training, and patient advocacy. By addressing the nuanced challenges posed by cancer in pregnancy, the medical community moves closer to a future where every pregnant patient receives optimal, compassionate, and scientifically grounded care.

Subject of Research: Diagnosis and management of cancer during pregnancy

Article Title: SMFM’s First Evidence-Based Clinical Guidance on Cancer in Pregnancy

News Publication Date: Not specified in the provided content

Web References:
– https://obgyn.onlinelibrary.wiley.com/doi/10.1002/pmf2.70221

References: Not explicitly listed in the provided content

Image Credits: Not specified

Keywords: cancer in pregnancy, maternal-fetal medicine, oncology, chemotherapy during pregnancy, cancer diagnosis, prenatal imaging, thromboprophylaxis, multidisciplinary care, fetal growth surveillance, cell-free DNA screening

Heart disease remains the leading cause of pregnancy-related death in the United States, with a disproportionate impact on non-Hispanic Black populations. The complex interplay between cardiovascular disease and pregnancy poses unique clinical challenges, as physiological changes during gestation can exacerbate existing cardiac dysfunction or precipitate new-onset heart failure. SMFM’s Consult Series #73 recognizes the heterogeneous nature of heart failure, which may involve dysfunction in the left ventricle, right ventricle, or both, and calls for tailored diagnostic and therapeutic approaches based on individual patient profiles, ventricular involvement, and whether the condition is acute or chronic.

Current clinical practice is often complicated by the overlapping symptomatology of heart failure and normal pregnancy, as symptoms such as fatigue and dyspnea are common in both scenarios. This ambiguity can delay diagnosis and management, increasing risks to both mother and fetus. SMFM’s expert panel highlights the paramount importance of early and precise identification of heart failure, recommending that all patients with known cardiac pathology receive comprehensive risk stratification either prior to conception or in early pregnancy. This strategic approach facilitates timely interventions and informed decision-making for contraceptive planning, pregnancy continuation, or termination when necessary.

The guidelines controversially but pragmatically address patients with severe pulmonary arterial hypertension and those exhibiting significantly impaired left ventricular function, particularly with ejection fractions below 30%. For these high-risk groups, offering abortion care is a critical counseling component, supplemented by robust support for those electing to carry pregnancies to term. SMFM underscores the indispensability of specialized Pregnancy Heart Teams, composed of obstetricians, cardiologists, anesthesiologists, and intensive care specialists, to navigate these complex clinical trajectories and coordinate high-stakes care delivery.

Pharmacological management during pregnancy necessitates a delicate balance between maternal benefit and fetal safety, a task complicated by the teratogenic potential and postpartum compatibility of various cardiovascular medications. The new recommendations advocate for the discontinuation of certain agents, such as sodium-glucose cotransporter inhibitors (SGLT2i), spironolactone, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and angiotensin receptor-neprilysin inhibitors (ARNis), due to their adverse fetal effects. These drugs are to be replaced with safer alternatives, including vasodilators like hydralazine, while continuation of beta-adrenergic blockers, including metoprolol and carvedilol, remains encouraged given their established safety profiles in pregnancy.

Breastfeeding introduces additional complexities in medication safety. The comprehensive guidelines recommend cautious use of ACE inhibitors, ARBs, aldosterone antagonists, and SGLT2i during lactation due to potential risks to the neonate. These recommendations demand vigilant pharmacovigilance and tailored counseling to ensure maternal adherence to lifesaving regimens while minimizing neonatal exposure, thereby safeguarding the delicate balance of postpartum maternal-infant health.

Delivery planning constitutes a critical phase in the continuum of care for pregnant patients with heart failure. SMFM advocates for meticulous team-based planning involving multiple specialties, including maternal-fetal medicine, cardiology, anesthesiology, and nursing. The goal is to achieve term delivery wherever clinically feasible, prioritizing vaginal birth unless obstetric indications necessitate cesarean section. This approach aims to mitigate peripartum cardiovascular stress while optimizing neonatal outcomes, reflecting an integration of obstetric and cardiac expertise.

Postpartum care is identified as a vulnerable period, frequently marked by rapid cardiovascular shifts and heightened maternal mortality risk. The guidelines emphasize that many cardiac-related deaths and severe complications manifest after hospital discharge, underscoring the necessity for close postpartum surveillance and outpatient follow-up. Counseling regarding infant feeding and continuation or modification of cardiac medications within the context of breastfeeding forms a cornerstone of this vigilant postpartum strategy.

Importantly, the guidance delves into the nuances of managing patients with peripartum cardiomyopathy, a pregnancy-associated dilated cardiomyopathy that may fully resolve or persist postpartum. Recommendations advocate for individualized counseling on future pregnancy risks, focusing on recurrence rates and severity, offering women vital insights to make informed reproductive decisions. This patient-centered model epitomizes the recent evolution in maternal-fetal care towards multidisciplinary, precision medicine paradigms.

The SMFM Consult Series #73 emerges as a meticulously compiled synthesis of current evidence, supported by the Heart Rhythm Society, designed to inform and transform clinical practice. It embodies an urgent response to the mounting challenge of cardiovascular disease in pregnancy, blending systematic review methodologies with expert consensus. As cardiovascular disease continues to rise globally, these guidelines promise to serve as a template for institutions and clinicians committed to reducing maternal mortality and morbidity from heart failure.

In conclusion, the Society for Maternal-Fetal Medicine’s latest recommendations deliver a pivotal roadmap for improving the care of pregnant and postpartum patients with heart failure. Through early risk assessment, nuanced pharmacotherapy, multidisciplinary delivery planning, and close postpartum monitoring, these guidelines address a critical gap in maternal healthcare. With heart disease disproportionately afflicting marginalized populations, this initiative also represents a meaningful step towards equity in maternal health outcomes. As awareness grows and implementation progresses, the clinical community anticipates these recommendations to catalyze advances in both research and practice, ultimately elevating the standard of care for this high-risk population.

Subject of Research: People

Article Title: Society for Maternal-Fetal Medicine Consult Series #73: Diagnosis and management of right and left heart failure during pregnancy and postpartum

News Publication Date: 22-Sep-2025

Web References:
https://obgyn.onlinelibrary.wiley.com/doi/10.1002/pmf2.70059

Keywords: Prenatal care, Postnatal care, Prenatal screening