Ethical and therapeutic dilemmas in glioblastoma management during pregnancy: Two case reports and review of the literature

Abstract

Introduction: There are no guidelines about the management of glioblastoma multiforme (GBM) during pregnancy: treatment of these patients presents therapeutic and ethical challenges. Case Description: Two patients, respectively, 28 years old at the 14th week of gestation with a thalamic GBM and 38 years old at the 28th week of gestation with fronto-mesial GBM. Patients and their relatives were deeply informed about the natural history of GBM and potential risks and benefits of surgery, radiotherapy (XRT), and chemotherapy (CTX) for both, mother and fetus. The first patient’s will was to preserve her fetus from any related, even minimal, risk of XRT, and CTX until safe delivery despite progression of GBM, accepting only surgery (tumor debulking and shunting of hydrocephalus). The second one asked to deliver the baby as soon as possible (despite the risks of prematurity) to receive the standard treatments of GBM. The two patients survived, respectively, 16 and 46 months after delivery. The first patient’s son is in good clinical conditions; the second one suffered problems linked to prematurity. Conclusions: Standard treatment of GBM in a pregnant woman could improve the mother’s survival but can expose the fetus to several potential risks. Ethically, relatives should understand that mother has anyway a poor prognosis and, at the same time, fetus prognosis depends on mother’s condition and therapy. It is not possible to warrant absence of risk for both. Considering the absence of guidelines and the relatively poor current data available about management of GBM in a pregnant woman, after a deep explanation of the situation, we think that the will of the mother and her relatives should prevail.

Cancer During Pregnancy: How to Handle the Bioethical Dilemmas?—A Scoping Review With Paradigmatic Cases-Based Analysis

“…In these difficult cases, mainly before the third trimester, the sovereign decision should be taken after thorough discussion between mother (or legal substitute) and the treating physician (42)(43)(44)(45)(46). While respecting the principle of autonomy, another final ethical issue is the right of the physicians to conscientiously object to certain treatment options.…”

Letter to editor regarding “Neurosurgical emergencies during pregnancy-management dilemmas”

“…Intraoperative blood loss and anesthesia can induce hypotension, which increases the risk of fetal hypoxia; maintaining stable blood pressure and oxygenation is vital in protecting the developing fetus. [ 10 ] Next, the optimal timing of surgical intervention is critical, with the second trimester being the preferred period. [ 6 , 10 , 11 ] The first trimester is associated with an increased risk of miscarriage due to fetal vulnerability, while the third trimester is associated with intracranial hemorrhage.…”

“…[ 10 ] Next, the optimal timing of surgical intervention is critical, with the second trimester being the preferred period. [ 6 , 10 , 11 ] The first trimester is associated with an increased risk of miscarriage due to fetal vulnerability, while the third trimester is associated with intracranial hemorrhage. [ 10 ] Moreover, the tumor’s size and edema have been shown to intensify during pregnancy, adding complexity to the surgery.…”

“…[ 6 , 10 , 11 ] The first trimester is associated with an increased risk of miscarriage due to fetal vulnerability, while the third trimester is associated with intracranial hemorrhage. [ 10 ] Moreover, the tumor’s size and edema have been shown to intensify during pregnancy, adding complexity to the surgery. [ 6 , 12 , 13 ] A comprehensive evaluation is necessary, including factors such as gestational age, maternal and fetal physiology, and drug dynamics.…”

“…[ 6 , 12 , 13 ] A comprehensive evaluation is necessary, including factors such as gestational age, maternal and fetal physiology, and drug dynamics. [ 10 , 12 ] Tracheal intubation is effective in reducing intracranial pressure during pregnancy, and general anesthesia is considered safer than epidural or spinal anesthesia. [ 6 ] The dorsal decubitus position optimizes maternal preload, thus minimizing hemodynamic risks.…”