Abdominal Tumors in Pregnancy
Tumors in or near the uterus may be obstacles to delivery or they may through malignancy endanger the woman's life. The commonest tumors complicating pregnancy are fibroids, cancers, and ovarian tumors, especially cysts and dermoids, but tumors of other kinds are not frequently met. Schauta, in 111,112 pregnant women, found fibroids in 86, one in 1292 cases; Pinard, in 13,915, found 84, one in 165 cases; Pozzi, in 12,050, had 83, one in 133 cases; in St. Petersburg, in 13,076 deliveries, there were only 4, one in 3269 cases; and in the Charité in Berlin, 6 in 19,052 births, one in 3175 cases. The ovarian cyst in pregnancy is rarer than the fibroid—5 in 17,832 births, one in 3566 cases, in the Berlin Frauenklinik. Cancer of the cervix also seldom appears—once in about 2000 cases. Other very rare conditions, related to these, are polyps of the cervix, enlarged and prolapsed kidneys, extrauterine pregnancy combined with intrauterine, echinococcus cysts, parametric abscesses, cancers of the rectum, rectal strictures, tumors of the bladder, stones in the bladder, tumors of the pelvic bones or cartilages, and tumors of the vagina or vulva.
Fibroids, called also fibromyomata, fibromata, and myomata, in the uterine muscle or adnexa commonly enlarge during pregnancy, and if they are big enough and low in the pelvis may block the parturient canal. These tumors may suppurate, grow gangrenous, or take on red degeneration; they may cause abortion, peritoneal adhesions, pain, or hemorrhage; simulate threatened abortion; bring on retroflexion of the uterus, placenta praevia, abnormal presentations, sometimes weak pains or pains so strong as to rupture the uterus, and they may check contraction after delivery so as to start hemorrhage. They may so kink the uterus as to incarcerate the placenta and cause sepsis. The percentage of degeneration in fibroids taken generally is 22, according to William Mayo.[113]
Myomata often obscure the diagnosis in pregnancy. The tumor may be mistaken for a twin child, or vice versa. A large symmetrical interstitial myoma may be mistaken for pregnancy, or vice versa. Sometimes, even after the belly has been opened, it is difficult to be sure whether the condition is pregnancy or a tumor. As eminent a surgeon as Deaver says this diagnosis cannot always be made by any one no matter what his experience.
We cannot give a general mortality average for myomata in pregnancy because only bad cases are reported, but in bad cases the mortality is very high—50 per cent. for the mother and about 60 per cent. for the children, with almost 30 per cent. of abortions. The majority of women who have myomata go on to delivery without trouble. In some there is much pain or hemorrhage, and these conditions may finally oblige the obstetrician to operate, but the operation should be deferred as long as possible. Where there are signs of necrosis of the tumor, operation is necessary at once to prevent sepsis. Removal of a myoma during pregnancy does not always cause abortion. The statistics are that about 83 per cent. of those operated upon are removed without abortion. In the Mayo Clinic[114] fourteen cases of degenerating fibroids in pregnant wombs were removed and the majority went on to term. The removal is always a very bloody operation, and it requires great surgical skill. Where enucleation of the tumor alone was intended it may finally become necessary to amputate the uterus to stop hemorrhage.
When the case has gone on to labor at term the diagnosis as to position and size of the tumor is to be made, and what the effects will be as to blocking the canal or crushing the tumor so as to bring on sloughing. If a tumor blocking the canal cannot be pushed up out of the way of the child, a cesarean section should be done immediately. In such an outcome as section the experience of the operator must decide whether the tumor is to be removed then or at a more favorable opportunity. It may be necessary to do cesarean section to liberate an incarcerated placenta.
Sometimes the fetus is so involved with a gangrenous myoma that enucleation of the tumor will kill or hasten the death of the fetus. When, in such a complication, it is evident that the life of the woman depends on the immediate removal of the tumor, yet a second but evil effect follows from the operation, namely, the unavoidable death of the fetus, the removal is morally licit provided the operator has the proper intention. The death of the child as an effect in this case is only indirectly voluntary from the physical point of view, and only permissively voluntary from the moral aspect.[115]
Ovarian tumors in pregnancy are, as has been said, rarer than myomata. Such tumors are mostly cysts and dermoids. In 862 cases collected by MacKerron, 68 per cent. were cysts, 23 per cent. dermoids, 5 per cent. malignant tumors, and a few were myomata. Cysts and dermoids do not, like the myomata, grow bigger during pregnancy, but they may hinder delivery or grow gangrenous and septic. When treated early the mortality in pregnancy is from 2.1 to 5.9 per cent for the women, but delay gives a maternal mortality of from 31 to 39 per cent. The fetal mortality in Heiberg's statistics of 271 cases was 66 per cent.
Most obstetricians advise the removal of an ovarian tumor in pregnancy as soon as diagnosed, provided it is of a size to cause difficulty in parturition, but such a removal causes abortion in over 20 per cent. of the cases. The expectant treatment causes abortion in about 17 per cent. If the child is viable, Fehling, Martin, Norris, and De Lee are in favor of the expectant treatment. Late operators leave weak scars at labor. When there are symptoms of torsion of the pedicle of the tumor, infection, incarceration in the pelvis, involvement of the uterine broad ligament, or overdistention of the belly, the tumor must be removed immediately. Whether vaginal puncture or laparotomy is the better method is to be decided particularly. Dermoid cysts are likely to bring on sepsis if they are broken in enucleation, and the diagnosis and operation must be carefully made. When it is necessary to save the life of the woman to remove an ovarian tumor, the risk of abortion may be taken permissively.
Cancers of the cervix uteri are always malignant and cause death if they are not removed before they have gone on to metastasis. As this tumor commonly appears after the child-bearing age, it is rare in pregnancy; the ordinary ratio is one in 2000 deliveries, but De Lee saw only one in Chicago in 16,000 consecutive labors. Abortion occurs in from 30 to 40 per cent. of the cases. Spontaneous rupture of the uterus may happen, and placenta praevia is frequent relatively. Pregnancy hastens the growth and spread of cancer very much. Eight per cent. of the women die undelivered, and 43 per cent. die during labor or immediately afterward. Of all uterine cancers, 80 per cent. are cervical.
The diagnosis should be as certain as possible. Rarely nodules which are not cancerous appear in the cervix during pregnancy, and these are to be examined microscopically. Snipping out of a piece of the nodule for examination does not cause abortion. Vaughan of Michigan University, who is a skilful and careful observer, said[116] that in an investigation of 200 cases of cancer, upon which more than 30,000 differential blood-counts were made, he discovered a method of diagnosing the operability of a cancer as follows: He makes a blood-count and then injects intraperitoneally one c.c. of placental residue. The next day he begins a series of blood-counts, and if the number of polymorphonuclear cells decreases the case is operable, no metastasis has occurred; if there is no change in the number of the polymorphonuclears, or an increase with a corresponding decrease of the large mononuclears, the case is inoperable, metastasis has begun.
In cancer of the cervix operability does not mean curability always. Inoperability signifies that the woman has no chance at all for life and that it is useless to do anything; operability means that she has one chance in four and that it is worth while taking the chance. The following conditions may be met:
1. The case may be operable and the child inviable.
2. The case may be operable and the child viable.
3. The case may be inoperable and the child inviable.
4. The case may be inoperable and the child viable.
In the first case the supposition is that the case is operable but the child inviable. To save the woman the uterus, with its adnexa, must be removed, and this, of course, kills the fetus. The case differs from the enucleation of a gangrenous myoma which involves the death of an inviable fetus. In the myoma case the woman has practically every chance for her life through operation; in this cancer case the woman has only one chance in four, as 75 per cent. of such operations fail through recurrence of the cancer.
The child has about one chance in two of going on to viability, owing to the tendency to abortion, if no operation is done; but the mother loses her chance for life if the operation is not done at once, as the cancer will spread beyond cure. Zweifel has seen such a growth extend a finger's breadth in one week. The one chance in four in immediate operation gives the mother a solid ground for hope, and the probability is sufficient, in my opinion, to permit the operation with a permissive loss of the fetus.
In the second case the cancer is operable and the child is viable. The child should at once be delivered by cesarean section, and the uterus with its adnexa removed.
The third case is that of an inoperable cancer and an inviable child. There the operation should be deferred, if possible, until the child becomes viable.
The fourth case supposes the cancer is inoperable but the child viable. In the interest of the child, immediate cesarean section is the best thing to do; it is much better than waiting until term. At term this operation will have to be done anyhow, and the earlier it is done, the better the woman can stand the strain. There is a risk that she will die from the first operation done to deliver the viable child, but she may licitly take this risk, as she might licitly run into a burning house to save a child, even if not her own. She may also licitly refuse the first operation.