In the later stages good consequences follow the induction of labour and the immediate performance of hysterectomy. Surprising as it may seem, a uterus immediately after labour can be safely extirpated through the vagina.
When the cancer is so advanced as to be inoperable, the pregnancy should be allowed to go to term, and if the cancerous mass offer an impassable barrier to delivery, Cæsarean section should be performed. This operation has been found necessary to extract a dead fœtus.
Most surgeons in dealing with operable cases of this complication of pregnancy remove the parts through the vagina, because in the abdominal operation the septic cervix is withdrawn through the abdomen; this makes it extremely difficult to avoid soiling the pelvic peritoneum.
Concurrent uterine and tubal pregnancy. This condition may require operation in three different circumstances:—
1. Tubal and uterine pregnancy occur simultaneously and the complication is recognized in the early months. Here the operation would be that of oöphorectomy, and the uterine pregnancy may continue undisturbed to term.
2. Intra- and extra-uterine gestation with living fœtuses runs concurrently to term. This is an exceedingly dangerous, though a rare, combination. The table on [p. 35] shows how deadly a compound pregnancy is to the mother: it sets forth also the fate of the children.
3. Uterine pregnancy is complicated by the presence of a quiescent (sequestered) extra-uterine fœtus. Many cases have been reported in which a fœtus of this character has occupied the pelvis, yet the woman conceived and the child was safely delivered at term; but a sequestered fœtus may constitute an impassable barrier and require removal (Operations for Compound Pregnancy, see [p. 33]).
Pregnancy complicated by tumours growing from the pelvic walls. When the pelvis is occupied by a chondroma, osteoma, or a sarcoma growing from the innominate bones or the sacrum, or from the fascia of the pelvis and displacing the gravid uterus, the proper course is to perform subtotal hysterectomy. If the obstruction is not detected until the child is viable, and there is no especial call for urgency, interference should be postponed until near term; the child can then be saved by Cæsarean section, and the uterus removed.
The operation in such circumstances calls for the exercise of judgment, but it is rarely difficult. Among interesting tumours complicating labour and obstructing delivery, special mention may be made of dermoids and teratomata lying in the hollow of the sacrum. Skutsch has collected the chief German records.
Echinococcus cysts (hydatids) have grown in the pelvic connective tissue and obstructed labour. Cases have been reported by Knowsley Thornton, Küstner, Blacker, and others.