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]
[113] _Jour. Amer. Med. Assoc._, March 24, 1917.
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.
[114] _Ibid._
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]
[115] Cf. Ferreres, _Nouvelle Revue Théologique_, September
and October, 1912, and the appendix of his book _De Vasectomia
Duplici_, Madrid, 1913.
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.
[116] _Jour. Amer. Med. Assoc._, December 8, 1917.
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.