If the child is viable it must be delivered as quickly as possible. If it is dead and the head is developed, craniotomy should be done to hasten extraction. When the abruptio takes place before the seventh month of gestation the fetus will die in about ten minutes, whether in the uterus or outside it; no matter what method might be adopted to empty the uterus, the child would be dead before delivery. The diagnosis would have to be made and instruments prepared, and this would take up more than the ten minutes of life left to the fetus. It is necessary to get the fetus out to stop the bleeding of the open sinuses by contraction of the uterus.
The removal of the fetus here is not like an artificial abortion. In abortion the abortionist separates the placenta from the uterine sinuses and so kills the fetus; the removal from the uterus is secondary to that separation which kills. The common notion of moralists that death is caused in abortion by taking the child out of the uterus is inexact—tearing loose the placenta is the real cause. In a removal of the fetus after an abruptio placentae the death of the fetus is not caused by the physician at all, but by the force that effected the abruptio. As the child will be dead before sufficient dilatation of the cervix to deliver it can be attained, there is no objection to beginning the delivery as soon as the diagnosis is clear.
[CHAPTER IX]
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.