Radiologists also assist in discerning which lesions are amenable to biopsy and often perform image-guided biopsies for tissue diagnosis, assessment of tissue genetics, and staging. Once diagnosis and staging have occurred, a comprehensive discussion with the patient about the diagnosis, prognosis, treatment options, potential harmful effects to the fetus, and consequences of deferring treatment during pregnancy should occur. In certain scenarios, a discussion about discontinuing the pregnancy may be appropriate [4]. Given the US Supreme Court’s recent decision to overturn Roe v. Wade, the care team must be aware of state-specific legislation regarding pregnancy termination in order to best counsel the patient regarding logistics of their reproductive options [14]. The repeal of Roe v. Wade has tremendous consequences for both clinicians and patients, the far-reaching effects of which are beyond the scope of this article. The American Society for Reproductive Medicine recommends patients who desire fertility preservation be offered consultation with a reproductive endocrinologist before beginning treatment to discuss anticipated impact on fertility and options for oocyte retrieval and preservation [15].

Radiologic confirmation of gestational age is critical to inform therapeutic decision-making including the safety of systemic therapies and surgical timing [4]. When chemotherapeutics are considered during pregnancy, patients should be counseled by oncologic and obstetric providers who are well versed in fetal effects specific to each drug class [16]. Chemotherapy administered within the first 2 weeks after conception can interrupt implantation, resulting in a miscarriage. However, if the embryo survives, it is often expected to develop normally [17]. Organogenesis occurs during the first 2–10 weeks of gestation. Administration of chemotherapy should be avoided during this time as it is associated with increased risks of congenital malformations [18]. Some chemotherapies can be safely administered during the second and third trimesters, without an increased risk of congenital anomalies [18]. Patients should be informed that the primary risk of chemotherapy administration during pregnancy is preterm birth and neonates being born small for gestational age (SGA), with the attendant complications of prematurity and SGA [18,19,20].

Surgical intervention can be performed at centers with appropriate expertise, if urgently indicated. Retrospective studies of nonobstetric surgery during pregnancy indicate either no change, or a small increase in the risk of complications such as miscarriage, low birth weight, and premature delivery [21]. Any urgently indicated procedure, such as definitive surgery for cancer that will improve maternal prognosis, should be offered without delay by experienced providers (Fig. 3). Clinicians should be familiar with state-specific reproductive health legislation, as certain state mandates may be problematic for providers who offer procedures that benefit the mother but compromise the fetus. There are several alterations to surgical approach to maximize maternal and fetal safety including left lateral positioning after 20 weeks, consideration of fetal monitoring after viability, care from an anesthesiologist with expertise in pregnancy physiology, and consideration of perioperative anticoagulation [22]. When possible, it is preferable to perform pelvic or abdominal surgery in the early second trimester before the gravid uterus interferes with surgical access [4]. In some cases, surgical tumor resection can coincide with cesarean section (Fig. 3).

30-year-old pregnant patient, at 32 weeks of gestation, presenting with persistent headaches and nausea. a Axial non-contrast CT demonstrated a dense mass centered in the right cerebellum with surrounding edema (arrow). b Sagittal non-contrast CT demonstrated downward cerebellar tonsillar herniation (arrow) and acute obstructive hydrocephalous (arrowhead). Emergent treatment was initiated to reduce intracranial pressure. Once the patient was stable, a multidisciplinary team discussed next best steps in management. Despite theoretical fetal risks, the decision was made to pursue an MRI with contrast. c Coronal T2-weighted MRI images demonstrated a hyperintense mass (arrow) with a peripheral rim of hemosiderin and vascular flow voids. d T1-weighted contrast-enhanced MRI axial images demonstrated a well-circumscribed, enhancing mass, (arrow) most compatible with a hemangioblastoma. e Sagittal T2-weighted MRI images demonstrated continued marked mass effect with tonsillar herniation (arrow), upper cervical cord edema, and papilledema. The patient was scheduled for urgent surgery. However, the day before her surgery, she became preeclamptic and was delivered by emergency cesarean section at 33 weeks. After delivery, the patient underwent craniotomy for tumor resection with pathology confirming hemangioblastoma. After resection, the patient reported resolution of her presenting symptoms and is being followed with serial imaging

Radiation therapy is seldom used during pregnancy due to the abovementioned risks related to fetal dose of ionizing radiation and because it is often an adjuvant treatment that can be deferred until postpartum. In rare cases, however, radiation therapy (not including the pelvis) can be considered during pregnancy [23]. In such instances, consultation with a radiation physicist should be performed to guide treatment.

These patients with PAC should be cared for by maternal–fetal medicine throughout their pregnancy, with close fetal surveillance [19]. Monthly fetal growth assessments and antenatal testing initiation by 32 weeks are typically recommended [4]. Timing of delivery is dependent on many factors including whether treatments are being withheld until after delivery, avoidance of chemotherapy hematologic suppression nadirs, and fetal growth status. After birth, the placenta should be evaluated by pathology for metastasis [4].