Perinatal care plan for a woman with coexisting cervical cancer

INTRODUCTION

Pregnancy-associated cancers refer to cancers diagnosed during pregnancy or within one year after delivery [1]. Any pregnancy in which cancer is diagnosed is classified as high-risk and presents significant diagnostic and therapeutic challenges because it requires the safeguarding of both the mother’s and the foetus’s health. A holistic approach that views the patient as an integrated individual, considering not only the physical aspects of the disease but also its psychological, social, and emotional impact on the woman and her family, is essential [2].
Cancers in pregnant women are diagnosed in only 0.02-0.1% of all pregnancies. However, with the steadily increasing average age of women choosing to procreate, there has been a corresponding rise in cancer diagnoses during pregnancy [2]. Breast cancer remains the most commonly diagnosed cancer in pregnant women, followed by cervical cancer, which occurs at a rate of 0.8-1.5 cases per 10,000 pregnancies [3]. Routine screening, including cytology and ultrasound, facilitates the early diagnosis of gynaecological cancers, enabling the implementation of more effective therapeutic strategies and improving the prognosis for both the mother and the foetus [4].
Risk factors for cervical cancer include human papillomavirus (HPV) infection, multiple sexual partners, early onset of sexual activity, polysexuality, smoking, insufficient sexual education, and inadequate access to medical care and preventive services [4].
Treatment of cervical cancer during pregnancy requires balancing the needs of the mother with the safety of the foetus. Treatment decisions must consider factors such as the cancer stage, the patient’s health status, and gestational age. Available treatment options include surgical removal of tumour lesions, pharmacological therapy, and radiation therapy, depending on the clinical circumstances [5]. Therapy for pre-invasive stages or carcinoma in situ is usually delayed until the postpartum period due to the low risk of progression to invasive cancer during pregnancy (0.0-0.4%). This approach allows for a wait-and-see strategy to monitor the patient’s health [6].
Surgical treatment is considered in the early stages of cervical cancer, particularly in stage I. In such cases, procedures like conisation, simple trachelectomy, or lymphadenectomy are used. In stages II or III, hysterectomy or radical trachelectomy may be necessary, which often requires the termination of pregnancy and the relinquishment of future motherhood [6].
Chemotherapy for cervical cancer can be initiated no earlier than the 14^th week of pregnancy because the risk of complications is significantly higher during the first trimester when intensive cell differentiation and organ formation occur. It is recommended that therapy be completed by the 35^th week of pregnancy, with at least a 3-week interval before delivery, allowing for bone marrow regeneration in both the mother and foetus. The current chemotherapy regimen is based on cisplatin and paclitaxel, administered at 3-week intervals [6].
Radiation therapy is used in cases of advanced cervical cancer; however, its use during pregnancy is highly restricted because radiation may cause serious complications for the foetus, including organ damage, developmental delays, and an increased risk of cancer later in life [2].
In cases of advanced cervical cancer, caesarean delivery is recommended to minimise the risk of lower uterine trauma and ensure the safety of both mother and baby. Natural childbirth is possible for patients with early-stage disease; however, perineal incisions should be avoided to prevent cancer expansion. The treatment team should also take measures to prevent preterm labour, but they may decide to terminate the pregnancy early based on the mother’s health [2, 6].
A cancer diagnosis during pregnancy evokes complex emotions, including fear, uncertainty, and frustration. Cancer patients often face difficult treatment decisions that may impact the course of the pregnancy and the health of the baby. Psychological care is a crucial component of treatment, as it helps support the patient’s ability to cope with the emotional burden and improves the quality of life for the patient and her family [7].
The need for further research into the diagnosis and treatment of cervical cancer arises from the limited knowledge about the disease’s impact on pregnancy, as well as the long-term effects of cancer treatment on both the mother and the child. Additionally, there is a need to develop more effective psychological support strategies for patients during this difficult period.
The purpose of this study is to identify the nursing problems of a pregnant and postpartum woman with coexisting cervical cancer, based on which an individualised care plan was developed in accordance with the guidelines of the International Classification for Nursing Practice (ICNP^®).

MATERIAL AND METHODS

To prepare the case report in this article, the CARE (Case Report Guidelines), an international standard for medical case reporting, was followed. These guidelines provide detailed recommendations regarding the structure and content of case reports, including a comprehensive presentation of the patient’s history, diagnostic information, therapeutic interventions, and treatment outcomes [8]. This study focuses on the case of a woman in the perinatal period diagnosed with cervical squamous cell carcinoma during pregnancy. The patient provided informed consent to participate in the study and for her medical records to be reviewed for research purposes. Consent was also obtained from the authorities of the medical facility where the patient was hospitalised. The study was approved by the Independent Bioethics Committee for Scientific Research at the Medical University of Gdańsk, Poland (KB/410/2024). A range of research methods, including interviews, clinical observation, analysis of medical records, vital sign measurements, and physical examination, were employed to gather detailed information about the patient. During her stay in the Pregnancy Pathology Unit, the EPDS (Edinburgh Postnatal Depression Scale) was used to assess the risk of postpartum depression [9]. Additionally, the C-HOBIC scale (Canadian Health Outcomes for Better Information and Care) was utilised to assess the patient’s functionality and monitor her clinical status [10]. The individualised care plan was developed based on the ICNP^® [11-13] and data collected using the EPDS and C-HOBIC scales.

CASE STUDY

A 37-year-old woman, in her second pregnancy and status post caesarean section, was admitted to the hospital at 37 + 3 weeks of gestation, due to a diagnosis of cervical cancer during pregnancy, for planned pregnancy termination by caesarean section. Her first pregnancy ended in caesarean section due to orthopaedic indications (scoliosis). During the current pregnancy, the patient experienced swelling in the lower extremities, gastrointestinal symptoms (nausea, vomiting, diarrhoea, constipation), and generalised itching. The patient reported an allergy to clindamycin, which previously caused a septic reaction. She denied the use of stimulants. The woman described her living conditions as good, residing with her family in a small town in northern Poland. Before the pregnancy, the patient rarely underwent cervical screenings, and approximately 6 years had passed since her last cytological examination when the disease was diagnosed. The patient had no known risk factors for cervical cancer. In the first trimester of pregnancy, she was diagnosed with G1 cervical squamous cell carcinoma with microinvasion and associated HSIL-type lesions (according to FIGO staging). The patient underwent 4 cycles of chemotherapy, administered consecutively at 23, 26, 29, and 32 weeks of pregnancy. Throughout the treatment, the patient experienced chemotherapy-related symptoms, including hair loss, fatigue, as well as nausea and vomiting. A chorionic villus biopsy was performed during the pregnancy due to a rare genetic defect detected in the partner’s child. During the pregnancy, the woman was found to have anaemia and bilateral ovarian cysts, which were suspected to be either a monstrosity or endometrioma. The foetus was diagnosed with SGA.
On admission, the patient’s general condition was assessed as good, and her vital parameters were within normal limits. These included a respiratory rate of 16 breaths per minute, blood pressure of 122/81 mmHg, a pulse of 68 beats per minute (regular), and oxygen saturation of 99%. The woman was conscious, fully oriented, and easily engaged in verbal communication. The patient’s weight was 69 kg, with a height of 171 cm. Her nutritional status was normal, her skin was pink and warm, with no visible pathological changes, except for a scar from a previous caesarean section. Swelling of the lower extremities was noted, but varicose veins were not observed. Amniotic fluid was intact, and no bleeding from the genital tract was observed. The patient denied pain. The CTG recording was reactive, with a foetal heart rate of approximately 140 beats per minute, and no uterine contractions; uterine tone was normal. An ultrasound was also performed: a single, viable foetus in the cephalic presentation was present in the uterine cavity. The placenta showed no signs of detachment, with no risk of previa. The estimated foetal weight (EFW) was 2689 g (ninth percentile according to FMF), with a normal amniotic fluid volume and an MVP of 30 mm. Blood flow was assessed as normal. Laboratory results showed mild anaemia: erythrocytes: 3.39 mln/µl (normal range: 3.9-5.1 mln/µl), haemoglobin: 10.9 g/dl (11.2-15.7 g/dl), haematocrit: 33.1% (34.1-44.9%), MCV: 97.6 fl (79.4-94.8 fl).
The pregnant woman was admitted to the Pregnancy Pathology Unit, where CTG recordings were taken twice daily and the foetal heart rate was monitored every 3 hours. The patient exhibited signs of a depressed mood and, during the conversation, expressed concerns about her illness and the health of her baby. The EPDS scale was used to assess the risk of postpartum depression. The scale consists of 10 questions, each of which can be scored from 0 to 3 points, with a maximum possible total score of 30 points. This tool evaluates the patient’s emotional state over the past 7 days, focusing on symptoms such as sadness, anxiety, apathy, and thoughts of self-harm. A score of 13, as obtained by the patient, indicates an increased risk of depression, suggesting the need for further psychological evaluation. Due to the coexisting cancer, it was necessary to implement measures to facilitate the resumption of oncological treatment as soon as possible. The pregnancy was terminated at 37 + 5 weeks of gestation by elective caesarean section. The newborn was delivered in good condition (Apgar score: 10/2520 g/51 cm). The estimated blood loss for the patient was 400 ml.
The woman in puerperium, in good general condition, along with the newborn, was transferred to the Maternal Care Unit. Immediately after the operation, a sandbag was placed on the uterine fundus for 3 hours, and bleeding from the genital tract, along with the patient’s vital parameters, was closely monitored. As part of the postoperative pain management, the patient was administered 2 doses of intravenous nalbuphine (20 mg/2 ml) at a 6-hour interval and intravenous paracetamol (1000 mg/100 ml) 4 times a day at 6-hour intervals, which provided noticeable pain relief. The newborn was fed milk from the Breast Milk Bank through a bottle with a pacifier, while the patient began non-pharmacological methods to suppress lactation. On the second postoperative day, the patient was observed to be experiencing a depressed mood, attributed to longing for her older child and uncertainty regarding further cancer treatment. A consultation with a psychologist was suggested, but the patient declined. On the fourth postpartum day, the onset of milk let-down was noticed, and pharmacological inhibition of lactation with cabergoline (0.5 mg) was initiated. Due to severe leg oedema, the patient was advised to rest with her legs elevated. As part of anticoagulant prophylaxis, the patient received daily subcutaneous enoxaparin (40 mg/0.4 ml). From the first day of postpartum, the patient showed signs of anaemia, and her haemoglobin levels were monitored daily with the following results: 8.8 g/dl, 8.5 g/dl, and 8.3 g/dl. Pharmacological treatment with ferrous sulphate (80 mg twice daily) was introduced. Due to the need for phototherapy in the newborn and the mother’s anaemia, the obstetric patient and her baby were discharged on the seventh day following the caesarean section.

CARE PLAN

Based on data collected through observation, interviews, use of the EPDS scale, and the C-HOBIC scale, which evaluates variables related to basic activities of daily living (Table 1) and pain (Table 2), an individualised care plan was developed in accordance with the ICNP®.
Based on the pain assessment terminology from the C-HOBIC scale for continuous comprehensive care and long-term care, one negative diagnosis was made:
Diagnosis 1: Pain (10023130 + 2), L: Abdomen (10000023).
Interventions (IC):
• Managing pain (10011660),
• Administering pain medication (10023084),
• Nurse controlled analgesia (10039798),
• Monitoring pain (10038929),
• Chest therapy (10004221).
Outcome: Reduced pain (10027917).

Based on the EPDS scale, one diagnosis was proposed:
Diagnosis 2: Depressed mood during postpartum period (10029771).
Interventions (IC):
• Screening for depressed mood (10045022),
• Providing emotional support (10027051),
• Promoting family support (10036078),
• Facilitating ability to communicate feelings (10026616),
• Teaching about disease (10024116),
• Teaching relaxation technique (10038699).
Outcome: Improved mood (10050027).

Other diagnoses:
Diagnosis 3: Lactation problem (10029943).
Interventions (IC):
• Counselling about breastfeeding (10035229),
• Examining breast (10051253),
• Teaching about breast care during postpartum period (10032885),
• Feeding infant with a bottle (10035168),
• Milking (10012079),
• Teaching about infant feeding (10037139),
• Administering medication (10025444).
Outcome: Knowledge of infant feeding (10045756).

Diagnosis 4: Lack of knowledge of disease (10021994).
Interventions (IC):
• Teaching about disease (10024116),
• Teaching about hospitalisation (10042480),
• Assessing attitude toward disease (10024192),
• Teaching about treatment regime (10024625).
Outcome: Knowledge of disease (10023826).

Diagnosis 5: Peripheral oedema (10027482), L: Leg (10011298).
Interventions (IC):
• Teaching about oedema (10045183),
• Assessing oedema (10045177),
• Encouraging rest (10041415),
• Applying cold pack (10036468).
Outcome: Peripheral oedema (10027482).

Diagnosis 6: Risk for infection (10015133).
Interventions (IC):
• Using aseptic technique (10041784),
• Teaching about wound care (10034961),
• Monitoring signs and symptoms of infection (10012203),
• Monitoring wound healing (10042936).
Outcome: No infection (10028945).

Diagnosis 7: Anxiety (10000477).
Interventions (IC):
• Teaching about child safety (10037160),
• Providing emotional support (10027051),
• Providing health promotion service for child development (10032533),
• Promoting self-care (10026347),
• Promoting acceptance of health status (10037783).
Outcome: Reduced anxiety (10027858).

Based on the ADL (Activities of Daily Living) scale, 4 diagnoses were proposed:
Diagnosis 8: Impaired ability to bathe (10000956).
Interventions (IC):
• Teaching about postpartum care (10045385),
• Promoting family support (10036078),
• Assisting with self-washing (10051442),
• Maintaining dignity and privacy (10011527).
Outcome: Impaired ability to bath (10000956).
br/>Diagnosis 9: Impaired ability to perform hygiene (10000987).
Interventions (IC):
• Surgical wound care (10032863),
• Wound dressing change (10045131),
• Teaching about wound care (10034961),
• Teaching about hygiene (10044549),
• Promoting hygiene (10032477).
Outcome: Able to perform hygiene (10028708).

Diagnosis 10: Impaired walking (10001046).
Interventions (IC):
• Debriefing patient after restraint (10036239),
• Assisting with walking (10051442),
• Assessing mobility (10030527),
• Managing pain (10011660),
• Teaching how to increase activity tolerance (10024660).
Outcome: Able to walk (10028333).

Diagnosis 11: Impaired ability to transfer (10001005).
Interventions (IC):
• Assisting with walking (10051442),
• Managing pain (10011660),
• Assessing risk for transfer injury (10030723),
• Teaching about fall prevention (10040253).
Outcome: No transfer injury (10033659).

DISCUSSION

Prenatal exposure to cancer treatment, including chemotherapy, can have long-term effects on a child’s overall health, cardiac function, and cognitive-behavioural development [14]. Additionally, the preterm birth rate among children exposed to maternal cancer treatment was 61.2%, significantly higher than in the general population. While recent studies indicate that most children exposed to chemotherapy show normal development, the full extent of the long-term effects remains unclear. A study involving 129 children exposed to maternal cancer treatment found no significant differences in growth, cognitive development, or health compared to a control group. However, these children were only followed until 36 months of age, raising concerns about the potential long-term effects of chemotherapy during pregnancy [15].
The case presented here illustrates the complex challenges associated with treating cervical cancer during pregnancy. By employing a multidisciplinary and individualised approach, it was possible to successfully administer oncological treatment while preserving the pregnancy. These findings contribute to the expanding body of scientific literature supporting the safe administration of chemotherapy during specific trimesters of pregnancy. Notably, chemotherapy administered after the first trimester may minimise risks to the foetus while effectively treating maternal cancer. Nevertheless, there is a need for further research, particularly long-term studies, to assess the quality of life of children exposed to such prenatal treatment [16].
The holistic care plan in the discussed case encompassed not only oncological and obstetric aspects but also psychological and social ones. The use of tools such as the EPDS enabled early detection of mental health disorders, which are a common consequence of the stress associated with cancer. Monitoring mental health, supported by the systematic use of the EPDS, should be standard practice in the care of pregnant oncology patients [17]. Tools such as C-HOBIC and ICNP^® play a crucial role in planning, documenting, and monitoring health care, supporting both continuity of treatment and effective collaboration within the interdisciplinary team. In the case of managing a pregnancy in a cancer patient, the team consists of representatives from various medical professions, such as oncologists, obstetricians, psychiatrists, midwives, psychologists, and physiotherapists. Each of these specialists brings unique knowledge and experience, essential for providing comprehensive care for the patient and her child. Interdisciplinary collaboration in such cases presents many challenges. One of them is appropriately adjusting cancer treatment to the woman’s health condition and the stage of pregnancy. Monitoring foetal development, preventing complications associated with preterm birth, and developing a safe birth plan that minimises risks for both the mother and the child are other important tasks for the team. Such comprehensive care requires constant and effective communication among all team members. The development of tools supporting this process, such as C-HOBIC and ICNP®, can significantly improve the quality of collaboration between specialists, ultimately ensuring better therapeutic outcomes [18].

CONCLUSIONS

The use of the ICNP^® enabled precise identification of the patient’s health problems, the planning of appropriate interventions, and the achievement of expected outcomes in most areas. Through interventions such as pain therapy and pain monitoring, significant alleviation of pain was achieved, which positively impacted the recovery process and the patient’s overall comfort. Education about the postpartum, the illness, treatment, and newborn care played a key role in the therapeutic process, enhancing the patient’s adaptation to the new situation. Interventions focused on emotional support contributed to an improvement in the patient’s mood and a reduction in depressive and anxiety symptoms.

Disclosures

This research received no external funding.
The study was approved by the Independent Bioethics Committee for Scientific Research at the Medical University of Gdańsk, Poland (Approval No. KB/410/2024).
The authors declare no conflict of interest.

References