A diagnosis of lymphoma during pregnancy poses challenges to women, their unborn babies, their families, and medical teams. Your haematology team and antenatal team will work together to care for you and your baby.
Hodgkin lymphoma is more common in pregnancy compared with non-Hodgkin lymphoma. This is because HL is common in people between the ages of 15 and 34 years of age which are the childbearing years.
If non-Hodgkin lymphoma is diagnosed in pregnancy it is usually an aggressive (fast growing) type. An example of this is diffuse large B-cell lymphoma (DLBCL). NHL has fewer cases of pregnancy compared to HL possibly because it is more common in people over 55 years.
Lymphoma behaves the same for women who are pregnant or those who are not. The cancer grows and spreads the same.
Lymphoma is not fuelled by the pregnancy hormones.
Symptoms of pregnancy and lymphoma can be similar. This often leads to a delay in diagnosis
These symptoms may include:
- Fatigue-extreme tiredness
- Anaemia- low red blood cells which makes you feel tired
- Thrombocytopenia-low platelets which causes increased bleeding and bruising
- Aches and pains
- Increased sweating
- Itchy skin
A lymph node biopsy is needed to diagnose lymphoma. A lymph node biopsy can be done under local anaesthetic in pregnancy without harming your unborn child.
Staging tests will need to be done once a diagnosis of lymphoma is confirmed. This is usually x-rays, CT scans or PET scans. These tests use radiation. Doctors tend to avoid these tests during pregnancy due to the radiation. Your doctor may do an MRI scan or ultrasound instead as these tests do not use radiation. The scans used will depend on what trimester of pregnancy you are in.
Once your baby is born your doctor may request that you have a CT scan, PET scan or x-rays done. You will be advised not to breastfeed your baby for a few hours after the PET scan. Breastfeeding and close contact with your baby after CT scans and x-rays is safe.
There are no fixed rules on treatment of lymphoma during pregnancy. Treatment is tailored to each woman.
If HL needs to be treated in pregnancy it should be delayed until after the first trimester, if possible.
If diagnosed during the second half of pregnancy and it is not causing any problem, a woman can often wait until the baby is born before starting treatment. This is the safest option for the baby.
Your treatment will be carefully planned by your medical team. It will depend on:
- Type of lymphoma
- Where it is in the body
- Whether it is an indolent or an aggressive subtype of lymphoma
- What trimester of pregnancy you are in?
- Your personal requests
Chemotherapy is often used to treat lymphoma. The safety depends on the combinations of chemotherapy used and how far along you are in your pregnancy.
The use of chemotherapy during pregnancy should be weighed against the effect of treatment on maternal survival.
First trimester- first 12 weeks
During this period, all the major organs and body systems are forming. Your unborn child is most vulnerable at this time. There is a higher risk of miscarriage and stillbirth if you have chemotherapy during this trimester. Chemotherapy and radiotherapy during the first trimester of pregnancy are associated with increased risk of congenital malformations
Doctors will postpone treatment until the second trimester if possible. Steroids can be safely used in pregnancy to allow delay in treatment.
Second trimester and third trimester
Chemotherapy is generally considered safe for unborn babies after the first trimester of pregnancy. The placenta provides a barrier to stop many drugs reaching the baby. Two chemotherapy regimens that can safely be used in pregnancy are CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) and ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine)
Chemotherapy given during the second and third trimesters is associated with early labour and low birth weight.
Chemotherapy is not advised in the last month of pregnancy. This is to allow your blood counts to return to normal.
Radiotherapy is sometimes given to treat or manage symptoms of lymphoma. Radiotherapy uses a type of radiation.
Doctors may wait until the birth of your child before using radiation as there is a small risk to your unborn child. Precautions can be taken if radiation is required urgently. It may be delivered to areas far away from the womb with careful shielding of the abdomen from arrays.
Radiotherapy after the first trimester is usually more harmful to your unborn child. It could increase your child’s risk of developing cancer. Affects later in life include a decreased IQ and mental retardation
There are many types of Targeted therapies used to treat lymphoma. Targeted therapies are new drugs which means there is not a lot of data about their possible long-term effects on newborn babies. Rituximab is a common targeted therapy used to treat lymphoma. Possible risks for babies include:
- Low B- cells at birth
- High risk of pre-term delivery (before 37 weeks)
- Low birth weight
Up to 70% of patients suffer from nausea or vomiting following chemotherapy.
No association has been found between treatment with metoclopramide, antihistamines and ondansetron based anti-emetics and congenital malformations.
Since pregnant women with lymphoma may be treated with antibiotics, due to neutropenic fever. The foetal safety of penicillin, cephalosporins and erythromycin is well established.
Frequently asked questions
It is rarely necessary to terminate a pregnancy when someone is diagnosed with HL. It is only recommended if the disease is so advanced that the life of the mum is threatened or makes a viable delivery impossible.
The available data suggests that lymphoma treatment given according to guidelines is unlikely to have long-term harmful effects on your baby.
Chemotherapy, steroids, and targeted drugs can get into breast milk. Your health care team will give you advice following your treatment on the safety of breastfeeding.
The health of the mother and baby often means pregnant and breastfeeding women cannot participate in trials
Current data suggests that pregnancy does not affect the prognosis of women who have had lymphoma.