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CHARLOTTE, N.C. Two years after a miscarriage and eight weeks into her second pregnancy, Kristina Fiumara relaxed when the ultrasound detected her unborn baby's heartbeat strong and steady.
But when she shifted, for a different view on the monitor, the fetus disappeared and darkness filled the screen.
"That's not supposed to be there," the technician said.
The grapefruit-size mass appeared to be a benign cyst, doctors said. To be safest for the baby, they waited until she was 12 weeks pregnant to operate.
The surgery on Aug. 24 was supposed to last one to two hours. Fiumara's husband, Dan Miller, was still waiting and worried when doctors came to see him three hours later. The mass looked cancerous, they said. A rapid biopsy confirmed low-grade ovarian cancer. "I felt like somebody had smacked me in the face," Miller said.
When she got home from the hospital, Fiumara, 32, a recruiter for an executive search firm in Charlotte, went to the Internet to find more about cancer during pregnancy.
By the time her doctors at Carolinas Medical Center recommended chemotherapy, she knew that a growing number of studies show anti-cancer drugs do not damage a fetus if they're given after the first 12 weeks of pregnancy.
She also knew that having cancer during pregnancy is rare about 1 in 1,000.
Fiumara's obstetrician, Dr. Devin Millard, and her maternal-fetal specialist, Dr. Courtney Stephenson, had each seen only one other case of ovarian cancer in pregnancy in their careers. Her oncologist, Dr. Jim Hall, said he sees one or two cases a year.
"Even the oncologists had to huddle and come up with a plan," Millard said, "because there is no standard treatment."
Ten years ago, pregnant women with cancer would face a dramatic choice: Terminate your pregnancy, or risk your life and the life of your baby. Doctors believed high doses of cancer-fighting drugs would damage the unborn child or that the stress of pregnancy itself would reduce a woman's chances for survival.
But as more research has become available, doctors now believe chemotherapy can be delivered safely to mother and fetus after the first trimester of pregnancy, after the fetal organs have developed.
There's no data on how babies of chemotherapy patients fare into adulthood.
Dr. Elyce Cardonick, a maternal-fetal specialist at Cooper University Hospital in Camden, N.J., began collecting cases in 1996 after becoming involved with three cancer patients who were told they should terminate their pregnancies to get treated.
The patients, who had Hodgkin's disease, breast cancer and melanoma, eventually received treatment after the first trimester without damage to their babies. Cardonick realized other doctors and patients needed to know this.
"No physician wanted to be the first person to treat a (pregnant) patient with cancer," she said. "No one person had a lot of experience because it was rare."
Cardonick's registry includes 200 women. With other cases reported in medical journals, she's found about 400 cases since 1966. Most had breast or cervical cancer.
Even though it made treatment more tricky, Fiumara's pregnancy enabled her to be diagnosed with ovarian cancer early. Ovarian cancer is called a silent killer because symptoms often don't appear until the cancer is advanced.
A week before Fiumara's first chemotherapy in October, she had a chest X-ray. Doctors were surprised to see spots on her lungs. More tests followed. Doctors couldn't tell for sure if the spots were cancer, but they worked under that assumption.
Suddenly, Fiumara's low-grade cancer had become more serious. Instead of two or three chemotherapy treatments, she was now scheduled for six.
Her husband, 31, a civil engineer, accompanied his wife to each one.
The treatments lasted six or seven hours, and afterward, Fiumara would be ill and tired for days. While she recovered, Miller kept busy, painting the nursery and laying tile in the kitchen of their home.
Fiumara lost her hair, and wore a blue-jean cap to cover her bald head. Once in a while, she allowed herself an "ugly cry," but mostly, Fiumara kept a positive attitude and a sense of humor.
By the end of January, when Fiumara had her final treatment, the drugs had shrunk the spots on her lungs.
She had about four weeks before the baby was due. Doctors hoped that would give them both time for their immune systems to recover. But Fiumara went into labor just five days later. Millard, the obstetrician, decided to deliver the baby by Cesarean section to protect both mother and child.
Hope Savannah Miller was born Feb. 4. Despite the doctor's warning that she might be tiny and without hair because of chemotherapy, she weighed 6 pounds, 1 ounce, and has thick black hair. "She is vigorous and healthy," Millard said.
Soon after Fiumara and Miller took their daughter home, a wooden stork, made by a neighbor, showed up in their front yard, announcing Hope's arrival. But the couple's joy in their baby's every squirm and squeal is dimmed by anticipation of what will come.
A follow-up PET scan last month showed the spots in Fiumara's lungs are indeed cancer, and it has spread to lymph nodes around her abdomen. After a biopsy of the lymph nodes, she and her doctors will talk about how to proceed.
"It's a little hard at the moment," Fiumara said last month. "We just have to wait and see how much of a long road we have."
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