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.