Small cell neuroendocrine tumour of the cervix in pregnancy: the importance of multidisciplinary management

  1. Esme Bain 1,
  2. Sarah Louise Coleridge 2 , 3 and
  3. Jo Morrison 2
  1. 1 Obstetrics and Gynaecology, Somerset NHS Foundation Trust, Taunton, UK
  2. 2 Department of Gynaecological Oncology, Somerset NHS Foundation Trust, Taunton, UK
  3. 3 Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
  1. Correspondence to Jo Morrison; jo_morrison@doctors.org.uk

Publication history

Accepted:29 Aug 2021
First published:13 Sep 2021
Online issue publication:13 Sep 2021

Case reports

Case reports are not necessarily evidence-based in the same way that the other content on BMJ Best Practice is. They should not be relied on to guide clinical practice. Please check the date of publication.

Abstract

A woman in her mid-20s presented with bleeding at 18 weeks gestation from a cervical ‘polyp’. Histopathology demonstrated a rare small cell neuroendocrine of the cervix. There were only 18 cases of neuroendocrine tumours of the cervix in and around pregnancy in the literature, so the evidence base for treatment was scarce. She was treated with neoadjuvant chemotherapy, using a regimen used for small cell neuroendocrine tumours of the lung, to allow for fetal lung maturity. Disease initially responded, then progressed and she was delivered at 32 weeks by caesarean radical hysterectomy. Adjuvant treatment included further chemotherapy and radical pelvic radiotherapy. The woman and her child are doing well over 6 years after treatment, although the woman has significant side effects of both radical surgery and radiotherapy. This case emphasises the need for excellent communication between multidisciplinary professionals, patients and their families and using external colleagues to help with rare clinical problems.

Background

Neuroendocrine tumour (NET) of the cervix is a rare and aggressive subtype of cervical cancer, accounting for as little as 1%–2% of all cancers of the cervix.1 Treatment regimens are not well established, comprising a mixture of chemotherapy and surgical intervention, with guidance regarding chemotherapy being taken from the more routinely practised treatment of small cell cancers of the lung.

Vaginal bleeding in pregnancy is very common and cervical cancer is a rare, but important cause. It can be difficult to diagnose due to physiological changes in the cervix due to pregnancy. There is a high risk of significant bleeding from a cervical biopsy in pregnancy, hence the threshold for biopsy is much higher than in a non-pregnant patient, unless there's suspicion of invasive disease. Punch biopsy is not recommended in pregnancy, as it cannot rule out invasive disease, and the risk of haemorrhage with biopsy in pregnancy is around 25%.2

Cancer during pregnancy presents its own medical and ethical dilemmas, which can feel all the more acute when it is the very organs carrying the pregnancy that are affected by malignancy. Cancer in pregnancy is becoming increasingly common, due to delaying childbearing. The peak incidence of cervical cancer in 2016 in England and Wales was in the 25–30 years age group, while the average age of a first-time mother is now 29 years.3 4 Management of cancer in pregnancy requires careful collaboration between a wide multidisciplinary team and the patient. Sharing experience of successful treatment in pregnancy is, therefore, extremely important, to inform women and caregivers about available options, since clinical trials in this setting do not exist and are unlikely ever to do so.

Case presentation

A woman in her mid-20s, 18 weeks into her second pregnancy, was referred for colposcopy by her general practitioner (GP) after concerns regarding a mass on her cervix. She had initially presented to her GP with several days of vaginal bleeding and they saw a polypoid lesion on examination. Her pregnancy had otherwise been unremarkable up until this point and her cervical screening had been normal 18 months previously. At initial colposcopy, a 1 cm polypoid mass was seen, located posterior to the squamocolumnar junction of her cervix. It had appearances in keeping with a possible fibroid polyp, with inflammatory changes, possibly due to decidualisation. There were no acetowhite changes or features consistent with cervical intraepithelial neoplasia (CIN) or microinvasion. A prebiopsy MRI scan was arranged urgently to further evaluate, as there were clinical concerns, despite absence of changes consistent with CIN. A clinical review, for MRI results and recolposcopy, was arranged for 2 weeks hence.

The patient continued to have some vaginal bleeding and at repeat colposcopy the mass was found to have more than doubled in size, with evidence of epithelial loss/necrosis. At this point, it was felt that malignancy could not be excluded, and a plan for biopsy in theatre was made due to risk of bleeding.

A small diagnostic diathermy loop biopsy was performed in theatre with local anaesthetic and full theatre team/anaesthetic support. Bleeding was minimal and the patient went home the same day to return to clinic for the results within a few days.

Investigations

MRI was performed 2 weeks after the initial colposcopy and showed a well-demarcated lesion on the posterior lip of cervix, with no evidence of nodal involvement or evidence of disease elsewhere in the pelvis (figure 1). A subsequent CT scan of her chest did not demonstrate any evidence of distant disease.

Figure 1

MRI scan (T2 weighted) demonstrating polypoid lesion arising from cervix (sagittal and transverse sections). Tumour indicted by white arrows.

Histology revealed a necrotic tumour with a high mitotic rate; differential diagnoses included a small cell carcinoma or a squamous cell carcinoma on morphology. Immunohistochemistry and a second opinion confirmed small cell NET of the cervix as the most likely diagnosis (figure 2).

Figure 2

Histopathology of cervical biopsy demonstrating appearance with H&E stain and immunohistochemistry staining with p16, Ki67, CD56 and synaptophysin antibodies.

Differential diagnosis

Initially, the differential included a cervical polyp or small fibroid that had under gone decidualisation secondary to hormonal changes in pregnancy. A cervical cancer was considered, but she did not have the classical features of HPV-related cancer, since there were no background changes consistent with CIN and her previous cervical screening tests had been normal and were in date. The level of suspicion at that time was not high enough to warrant the risks of a biopsy in pregnancy, hence why an MRI scan was arranged urgently, on a ‘suspected cancer’timeframe and follow-up with results and for repeat examination 2 weeks after the initial consultation.

At repeat examination the mass had doubled in size and had necrotic changes, a cancer was thought the most likely diagnosis, hence why a biopsy was performed, despite the risks of bleeding in pregnancy. Following histology, the diagnosis was of a very high grade, poorly differentiated cervical cancer. Immunohistochemistry was more in favour of a small cell carcinoma of neuroendocrine type.

Treatment

The diagnosis and options were discussed with the patient and her partner following advice from colleagues at other specialist cancer centres. Options included immediate definitive surgical management with a radical hysterectomy and pelvic lymph node dissection, requiring termination of the pregnancy by hysterotomy or attempt to delay surgery, with the use of neoadjuvant chemotherapy (NACT) to allow for fetal maturity, aiming to deliver around 35–36 weeks gestation, depending on response to treatment. The patient was keen to maintain her pregnancy and so a decision was made for NACT, followed by a planned caesarean Wertheim’s hysterectomy.

The patient was started on carboplatin and paclitaxel with the aim of giving 4–5 cycles prior to delivery. This was chosen due to less experience with etoposide in pregnancy, and concerns regarding fetotoxic effects, was in line with recent guidelines for treatment of cervical cancer in pregnancy,5 and predates the 2018 systematic review of cervical NET, which recommends platinum-based chemotherapy and etoposide.6 She experienced an allergic reaction to paclitaxel in cycle one and so continued with single agent carboplatin for a further two cycles. Initially, a positive clinical response was seen, with a reduction in the size of the lesion on examination, confirmed on repeat MRI imaging. However, the mass began to increase in size prior to cycle 4. Initial plans for delivery and hysterectomy at 35 weeks were expedited, following administration of dexamethasone for fetal lung maturation. A caesarean Wertheim’s hysterectomy, bilateral salpingo-oopherectomy and pelvic lymph node dissection performed at 32+2 weeks, and the baby was admitted to SCBU postoperatively, minimal supportive care was required.

Results of histology confirmed stage 1b2 small cell cancer of the cervix with closest radial margin of 18 mm, although with evidence of extensive lymphovascular space invasion. Etoposide and cisplatin were started as adjuvant treatment in the postpartum period with two cycles given prior to concomitant chemoradiotherapy (45 Gy in 25 # external beam radiotherapy plus intravaginal brachytherapy). She received two cycles of cisplatin and etoposide during chemoradiotherapy and a further two cycles following chemoradiotherapy to complete a total of six cycles cisplatin/etoposide.

Outcome and follow-up

The patient has been followed up regularly by both oncology and gynae-oncology specialists, since definitive treatment for her disease. At her 5-year end-of-treatment review, she was well, although with significant side effects of radical treatment, and shows no evidence of disease recurrence. She keeps in touch with us and sends us updates about her healthy child, who has started primary school and shows no negative consequences of having received chemotherapy in utero. We are grateful for her input into the case report, since she was keen to share her experience to help others in her situation.

Discussion

Pregnancy-associated cancer

Pregnancy-associated cancer is defined as cancer diagnosed during or within 1 year following a pregnancy. While diagnosis of malignancy during pregnancy is uncommon, affecting only 1 in 1000 maternities,7 age-standardised incidence rates suggest that cancer incidence is 48% higher than in the non-pregnant population.8 This finding is attributed to a greater interaction with healthcare professionals throughout pregnancy, and therefore an increased likelihood of detection, with limited evidence to demonstrate a direct pathophysiological effect of pregnancy on cancer progression.

It is possible that a deleterious interaction between pregnancy and cancer progression may occur, even without evidence for a direct pathological sequence. A tendency to assume that abnormal symptoms are a result of being pregnant, coupled with a reluctance to perform invasive or radiation-based testing for fear of causing harm to the fetus, results in cancers being diagnosed at a later stage than in the non-pregnant population.9

The increased complexities involved in diagnosing cancer in a pregnant woman are echoed in the management of cancer in pregnancy. Pregnancy may greatly alter the investigations and management strategies available, and consideration of termination, early delivery, or delay of treatment should be considered for all patients. This is an emotive and potentially ethically challenging topic for many, and to help with this a wide multidisciplinary team are needed to create an appropriate individualised plan for each woman.

Cervical cancer in pregnancy

Cancer of the cervix is the second most common cancer diagnosed in pregnancy,8 10 11 as peak age of incidence of cervical cancer in more developed countries coincides with that of pregnancy, and up to 3% of all cervical cancer diagnoses are made during pregnancy.9 Rates vary from 1.4 to 4.6 per 100 000, depending on availability of screening programmes.5 Most patients are diagnosed with early stage disease, and overall the course of cervical cancer is found to be much the same as that in the non-pregnant patient.12

Diagnosis

Diagnosis of cervical cancer in the pregnant patient can be challenging. Cervical screening is not a routine part of antenatal care in the UK and current guidelines suggest that it should be deferred until 12 weeks after pregnancy in those with normal screening prior to pregnancy.2

Cytology is a screening test and not a diagnostic test for invasive disease. NET develop within cervical glandular tissue and invade deep to the stroma, so cells may not be present on the surface for sampling and cytology, both conventional and liquid based, have low sensitivity in NET, even outside of pregnancy.13 14 Furthermore, the patient was in-date for cervical screening and so any sample would have been rejected by the laboratory, in line with national guidance.2

Direct visualisation of the cervix via a speculum may occur at some point during routine obstetric care, although this can be challenging as numerous physiological changes occur to the cervix during pregnancy; in particular, the cervix becomes more vascular, and shows higher instances of ectropion.7 If there is any doubt surrounding appearances of the cervix, or if a suspicious lesion is seen, onwards referral for colposcopic evaluation by an experienced practitioner is essential.15 Loop, wedge or cone biopsies at colposcopy may then be taken to provide histological diagnosis, as punch biopsies cannot reliably exclude invasion.2 Taking a biopsy of the highly vascularised cervix during pregnancy presents an increased risk of haemorrhage (estimated at 25%) and appropriate safety precautions should be taken to limit risk; in this case our patient underwent a small loop biopsy in theatre.2

Alongside a histological diagnosis, disease staging encompasses additional investigations and a full physical examination. MRI scanning is the imaging modality of choice for cervical cancers in pregnancy; it provides detailed depictions of pelvic soft tissues and viscera, without causing risk to the fetus.16

Management

Cancer management while a woman is pregnant presents additional challenges, and a conversation regarding the continuation of pregnancy, or not, will depend on the gestation of the pregnancy and is relevant to guiding treatment. For women who wish to continue pregnancy, NACT is recommended in order to prevent cancer progression while allowing time for fetal maturity. Chemotherapy is generally regarded as safe to use in pregnancy after the first trimester. However, evidence is based on a few case reports and small case series only17 and consideration of the pharmacological properties of each agent should therefore be considered prior to administration. Platinum-based compounds are used in the treatment of cervical cancer in the non-pregnant patient and are considered generally safe to administer during pregnancy are they are in part-filtered by the placenta.18

Alongside NACT, a plan regarding delivery is key in the management of pregnant women with cancer. Every attempt should be made to continue to a gestation past the point of viability, and as close to term as possible, balancing risks of continuation of pregnancy for the mother against the risks of prematurity for the baby. Planned caesarean delivery is considered safest for women with high-grade cervical cancers, as vaginal deliveries demonstrate high instances of bleeding and obstructed labour, as well as the risk of disease spread through labour.19 Ideally, NACT should be stopped at least 3 weeks prior to delivery to reduce the risk of neonatal neutropenia and other potential adverse effects.20 A neonatologist should be involved in the multidisciplinary team and should be present during delivery. If preterm delivery becomes necessary, steroids should be administered to promote fetal lung maturation.

Following delivery, definitive treatment with surgery and/or chemoradiotherapy is then possible. If suitable for surgical treatment with a radical hysterectomy and pelvic node dissection, this may be either at the same time as caesarean section, or as a separate postpartum surgery.

NET of the cervix

NETs of the cervix are a rare subtype of cervical malignancy, accounting for only 1%–2% of all cervical cancers.21 Such tumours are classified into four types; classical carcinoid, atypical carcinoid, large cell carcinoma, and, relevant to this case, small or oat-cell carcinoma. Small cell is the most common neuroendocrine carcinoma of the cervix (NECC), and is also the most aggressive, with 5-year survival rates quoted at around 35%, lower than other histological subtypes.6 Most recurrences occur within the first 2 years after diagnosis. In a systematic review of NET of the cervix, including 3538 patients from 112 studies, a combination of radical surgery and NACT or adjuvant chemotherapy was the most common treatment, with or without radiotherapy.6 The most common chemotherapy regimen was cisplatin/carboplatin and etoposide, which the authors recommended as standard of care in the absence of clinical trials.

Our patient is only the 19th reported case of a woman with NECC in and around pregnancy following a thorough literature search, as outlined in table 1, and only the 14th diagnosed prior to labour. As a result, there were no specific evidence-based guidelines for her management.

Table 1

Summary of reported cases of neuroendocrine carcinoma of the cervix in pregnancy and the puerperium

Reference Gestation (weeks) at diagnosis Age
(years) at diagnosis		 Stage Treatment Pregnancy outcome Patient outcome Notes
Diagnosed peri/postpartum
Pan et al 22 PN day 20 for continued PPH 27 III TAH; 4 cycles EP adjuvant CT; declined radiotherapy EMCS due to haemorrhage (gestation not given); live male infant 1980 g Died 11 months from diagnosis Mass initially diagnosed as cervical fibroid at 34/40; emergency C/S for bleeding and emergency TAH for continued PPH. Diagnosis made postoperative.
Wang et al 23 PN day 47 18 Ib2 4 cycles EP NACT; EBRT/brachytherapy Term delivery prior to diagnosis - mode of delivery not given NED 5 months post treatment  
Balderstonet al 21 30 (twins) 22 IIa C/S followed by 3 cycles EP NACT; RT; 4 cycles EP adjuvant CT C/S NED at 5 years Presented in preterm labour.
Perrin et al 24 25 23 IIa RH+LSO+PLND at time of C/S C/S DOD  
Canto et al 25 36 30 IVb 1 cycle palliative CT with EP before deterioration IOL and SVD live male 2450 g DOD at 1 month Presented with PPROM and PET; definitive diagnosis made PN.
  Diagnosed antepartum
Liu et al 14 32 33  IIa RH +PLND at time of C/S; 3 cycles carboplatin/VP16; RT C/S live male 1770 g DOD 3 months Presented with vaginal bleeding and assumed APH with no examination; diagnosis made >1 month later after continued APH with biopsy 2 weeks after cervical cytology; diagnosed with liver metastasis on staging CT scan performed after C/S RH.
Teefey et al 26 10+ 31 Ib1 cervical conisation at 13/40; 4 cycles EP NACT; RH/BSO/PLND at time of LSCS C/S at 36/40; live birth 2806 g Well 24 months postoperative Diagnosed on routine cervical screening; declined termination of pregnancy.
Chun et al 27 25+5 27 Ib1 3 cycles TP NACT; C/S with RH and PPALND C/S at 35+/40; live birth 2570 g Intramedullary mass C2–3 with spinal cord compression 46 months postsurgery; emergency chemoRT but patient DOD 3 months later Partial response to NACT in pregnancy; child ‘well and healthy’.
Chun et al 27 28+5 26 IIa 1 cycle TC NACT - patient refused further cycles; type III RH with PPALND at time of LSCS; refused adjuvant treatment (not specified) C/S at 33+3/40; live birth 2190 g Recurrent pelvic disease with hydronephrosis diagnosed at 32 months postsurgery; agreed to start chemoRT—longer-term outcome not reported Partial response to NACT in pregnancy; child developing normally at 48 months post-NACT in utero.
Chun et al 27 28+4 27 Ib2 2 cycles TP NACT; type III RH with PPALND at time of LSCS; 4 cycles adjuvant chemo C/S at 36+5/40; live birth 2600 g NED at 5 years post-treatment Declined termination of pregnancy; partial response to NACT in pregnancy; child developing normally at last FU.
Smyth et al 28 23 26 Ib2 3 cycles Adriamycin/cyclophosphamide NACT; C/S; 4 cycles EP NACT followed by RT started post NACT. No surgical treatment. C/S at 35/40, live birth 2700 g NED at time of publication, but short FU as starting adjuvant pelvic RT. Patient declined termination of pregnancy; good response to NACT in pregnancy (85%)—early delivery for IUGR; ‘healthy’ baby at delivery.
Ohwada et al 29 27 27 Ib1 RH at time of C/S with PLND; 4 cycles EP C/S 29/40, live birth NED 13 months from treatment  
Leung et al 30 31 26 Ib2 C/S followed by CRT; LH +BSO C/S NED 14 months from treatment  
Chang et al 31 36 27 Ib RH +PLND+appendicetomy and mitomycin-C i.p. chemotherapy at time of C/S; postoperative RT C/S, live birth 2700 g DOD from brain metastasis 2 months after diagnosis Breast metastases found during postoperative RT; lumpectomy performed but brain metastasis found postoperative.
Turner et al 32 26 26 Ib RH +PPALND at time of C/S; adjuvant CT (6 cycles VAC; 2 cycles EP) C/S DOD at 9 months  
Lojek et al 33 25 28 IIa C/S with PLND; RT C/S at 32/40 DOD 30 months Extensive vaginal disease at delivery. Cushing’s syndrome at relapse with vertebral metastases causing spinal cord compression, and chest wall disease.
Jacobs et al 34 10+ 25 Ib Cisplatin NACT (one dose); RH +PLND ; RT Pregnancy terminated by RH Alive at 9 months  
Kodousek et al 35 28 24 Ib RH +PLND at time of C/S; adjuvant EP C/S DOD at 6 months Widespread metastatic disease 3 months after diagnosis (including liver, lymph nodes, ovaries, brain, meninges, bones).

  • APH, antepartum haemorrhage; BSO, bilateral salpingo-oophorectomy; CRT, chemoradiotherapy; C/S, caesarean section; CT, chemotherapy; DOD, dead of disease; EP, cisplatin/etoposide; FU, follow-up; IOL, induction of labour; i.p., intraperitoneal; IUGR, intrauterine growth restriction; N/A, not applicable; NACT, neoadjuvant chemotherapy; NED, no evidence of disease; PET, Pre-eclamptic toxaemia; PLND, pelvic lymph node dissection; PN, postnatal; PPALND, pelvic and para-aortic node dissection; PPROM, preterm premature rupture of membranes; RH, radical hysterectomy; RT, radiotherapy; SVD, spontaneous vaginal delivery; TAH, total abdominal hysterectomy; TC, paclitaxel/carboplatin; TP, paclitaxel/cisplatin; VAC, vincristine/doxorubicin/cyclophosphamide.

Even in the non-pregnant patient NECC incidence is very low and there is an absence of randomised control trial evidence or evidence-based guidelines. Chemotherapy regimens are, therefore, guided by those used in bronchogenic NET; small cell cancers of the lung show a similar histology and response to chemotherapy to their cervical counterparts, but are significantly more common.

In such rare cases, a wide multidisciplinary team is essential, with involvement of gynaecological oncology, clinical and medical oncology, obstetric, anaesthetic and neonatal colleagues, clinical nurse specialists and midwives, as well as taking advice from colleagues at other centres. Communication with the patient and her family regarding the lack of evidence base and the rationale for treatment recommendations is essential, but can be unsettling for all involved.

Patient’s perspective

A week before Christmas in 2013, I was about 18 weeks pregnant when I started to bleed. My husband and I went to the hospital where I was examined. The midwife who examined me said she'd found, what she thought, was a polyp on the outside of my cervix. She wanted to get a second opinion from an obstetrician, who then wanted me to see a gynaecologist the same day. So, after waiting around for a couple of hours, we walked over to the gynaecology department and I was examined in more detail with a camera. Again, the gynaecologist thought it was probably a polyp and that it had been angered by my pregnancy causing it to bleed. However, when I went back for another check-up after Christmas, the grape sized lump had increased in size. This concerned the gynaecologist, so the following Monday, she performed a biopsy. On Wednesday that same week, I received an appointment letter for the Friday. I was almost 22 weeks pregnant by this point and had found out 2 weeks previous that we were having a baby girl. When my husband and I arrived at my appointment, we were greeted by the gynaecologist, a specialist nurse, an oncologist and an obstetrician. It dawned on me then that it was not going to be good news. The gynaecologist confirmed that the lump was a rare and aggressive small cell tumour. I was told that it wouldn't have shown up on a smear test because of the type of tumour it was. My first thought was that I was going to die and that I would leave my 2-year old son without his Mum, my husband without his wife and my Mum without her daughter. At 27, I would never have imagined something like this would happen. It’s that old cliché, ‘you never think something like this will happen to you’.

I was offered a termination, but it wasn't even an option for me. If it wasn't for the pregnancy, I wouldn't have been concerned about the abnormal bleeding to begin with and the tumour probably wouldn't have bled as early on as it did, therefore it would have continued to grow quickly without me knowing - our baby had given me a chance. The gynaecologist explained that my situation was very rare and not something she, nor the oncologist, had dealt with before so they would be contacting The Royal Marsden Hospital, amongst others, for advice on the best way to treat me and to keep our baby free from harm. I was told I would have to have a radical hysterectomy and caesarean, when necessary, hopefully around 38 weeks into the pregnancy.

The next step was chemotherapy, using 2 different drugs that were safe during pregnancy. My hair gradually started to fall out, so I wore a wig after a few weeks of beginning treatment. Unfortunately, I had a reaction to one of the drugs which caused a red, itchy rash all over my body and a fever. After an overnight stay in hospital, I was allowed to go home. Due to the reaction I'd had, I could only have one of the chemotherapy drugs on my second and third round of treatment.

Just before my fourth round, at 32 weeks pregnant, I was told that the tumour had grown and that the chemotherapy was no longer working; I needed surgery ASAP, which happened 3 days later. My caesarean was done under local anaesthetic, which meant that my husband and I got to see our beautiful baby girl arrive at 10 am on the 1st April 2014, weighing 3lb 15oz. She was tiny, but perfect. Ten minutes or so after her arrival, she went off in an incubator to the Special Baby Care Unit (SCBU). My husband gave me a kiss goodbye and followed after her. It was then time for the next part; I was given a general anaesthetic to undergo the 6-hour operation of a radical hysterectomy.

The surgery went well and I recovered well. She was out of SBCU two and a half weeks after being born. She'd done amazingly well, she'd surprised everyone including all the doctors and people looking after her. I enjoyed 3 days at home with my beautiful family before under-going more chemotherapy—this time, much more intense using two stronger drugs which made me so sick. I lost a stone and a half in a few weeks. After each cycle, I spent the first and most of the second week in bed. I gradually started to feel better during the third week for it to then start all over again. I had 6 lots of chemotherapy, 5 weeks of chemoradiotherapy and brachytherapy.

After my treatment had finished, I had regular check-ups for 5 years. I had my last check up in June 2019, but I have been reassured that the door is always open, if I have any concerns.

I had the best care from my gynaecologist, oncologist and everyone else who played a part in helping me during my treatment. I will be forever grateful to them all—their knowledge, skill and care they gave me mean that I’m still here today, for my children, my husband and my Mum. They saved my life and words will never express my thanks to them.

I have some physical after effects of all the treatment and a fair few emotional scars. Having said that, I am so lucky to be here and I will never take my life for granted. I try to stay focused on the moment and not let my mind run-away with me, which is easier said than done! I've got 2 beautiful children, an amazing husband and a wonderful Mum—they are my focus and bring out my strength. I will be forever grateful to them too.

Learning points

  • Cervical cancer in pregnancy is rare, but should be considered in all women with bleeding in pregnancy and a speculum cervical examination should be performed to exclude a cervical abnormality.

  • Never be too quick to jump to conclusions and remain prepared to consider alternative diagnoses.

  • Time is an important diagnostic tool.

  • Effective multidisciplinary working is crucial, especially when dealing with very rare cases; always be willing to ‘phone a friend’ and take second and third opinions.

Ethics statements

Patient consent for publication

Acknowledgments

We are very grateful to the following who were all closely involved with the patient’s management: Drs Surabhi Agrawal and Sue Slater for histopathological advice and images; Dr Paul Burn for radiology advice and preparation of key images for the publication; Drs Emma Cattell and Petra Jankowska for oncological advice, management and review of the paper; Miss Melanie Robson (obstetrics) and Drs Sarah Bridges (neonatal) and Dr John Clear (anaesthetics) for their advice and support. Oncology and gynaecological oncology colleagues nationally, especially Dr Alexandra Taylor and her MDT colleagues at the Royal Marsden Hospital, London, for their advice and support. Finally, we are very grateful to the patient and her family for agreeing to share their story to help other women in the future.

Footnotes

  • Twitter @DrJoMorrison1

  • Contributors JM had the original idea to write the case report. EB, SLC and JM wrote and edited the report and approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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