Key content:• Delays in childbearing trends are likely to lead to an increase in breast cancer cases diagnosed during pregnancy. • Presentation is usually late because early diagnosis is more difficult.• Surgery is safe throughout pregnancy, whilst radiotherapy and chemotherapy should be administered after completion of the first trimester. • Breast cancer in pregnancy does not carry any significant obstetrical or perinatal risks. • Termination of pregnancy does not affect maternal prognosis. Learning objectives:• To understand the role of diagnostic and staging procedures.• To understand the various treatment modalities available.• To understand the obstetric management and timing of delivery.• To highlight the importance of the multidisciplinary team. Ethical issues:• At what gestation could termination of pregnancy be warranted?• When should women embark on a further pregnancy after breast cancer treatment?Keywords breast surgery / chemotherapy / imaging / obstetric outcome / radiotherapy Please cite this article as: Padmagirison R, Gajjar K, Spencer C. Management of breast cancer during pregnancy.

Introduction Intrahepatic cholestasis of pregnancy is characterised by pruritus and elevated serum bile acids. The pruritus can be severe, and pharmacological options achieve inconsistent symptomatic improvement. Raised bile acids are linearly associated with adverse fetal outcomes, with existing management of limited benefit. We hypothesised that therapeutic plasma exchange removes pruritogens and lowers total bile acid concentrations, and improves symptoms and biochemical abnormalities in severe cases that have not responded to other treatments. Methods Four women with severe pruritus and hypercholanemia were managed with therapeutic plasma exchange. Serial blood biochemistry and visual analogue scores of itch severity were obtained. Blood and waste plasma samples were collected before and after exchange; individual bile acids and sulfated progesterone metabolites were measured with HPLC‐MS, autotaxin activity and cytokine profiles with enzymatic methods. Results were analysed using segmental linear regression to describe longitudinal trends, and ratio t tests. Results Total bile acids and visual analogue itch scores demonstrated trends to transiently improve following plasma exchange, with temporary symptomatic benefit reported. Individual bile acids (excluding the drug ursodeoxycholic acid), and the sulfated metabolites of progesterone reduced following exchange (P = .03 and P = .04, respectively), whilst analysis of waste plasma demonstrated removal of autotaxin and cytokines. Conclusions Therapeutic plasma exchange can lower potentially harmful bile acids and improve itch, likely secondary to the demonstrated removal of pruritogens. However, the limited current experience and potential complications, along with minimal sustained symptomatic benefit, restrict its current use to women with the most severe disease for whom other treatment options have been exhausted.

We conducted a national survey of consultants in Wales to elicit the opinions on induction of labour in women with a previous caesarean section. A total of 65 of the 87 consultants returned the postal questionnaire (75% response rate) and 54 of them were practising obstetricians. All but one obstetrician (53/54) would consider induction and for post-term indication, 47/53 would offer induction to a woman with a previous section; 40/53 (75%) of obstetricians would consider the prostaglandin method. The majority (36/40) would use prostaglandin tablets/gel; 80% (29/36) would use up to 2 doses (maximum recommended) and two-thirds (36/54) would consider syntocinon for augmentation of labour. A total of 34/54 (63%) consultants felt that Bishop's score would influence their decision to offer induction of labour (IOL) in a woman with one previous section and some 88% (47/53) of obstetricians always mentioned the increased risk of caesarean section and uterine rupture to these women during counselling before offer of induction. In conclusion, our survey reveals the variation in approach to management of postdates in women with previous caesarean section. We recommend a national audit of induction of labour in women with previous caesarean section.