SURGICAL 0OMPLIO&TIOIm D ~ G AND LABOR* WILLIAM i .
SCOTT.
PIK~ANCY
A.B.. M . D , TORONTO, CAX.
~F r o m the Toronto G ~ere~l Hospita? l
w o m a n is subjec~ to the same surgical lesions as tile T nHoEn ppr er eggnna annt t patient and. in m a n y instances, the complication oi" p r e g n a n c y m a k e s little, if any, difference in the m a n a g e m e m of her case. F r a c t u r e s and other t r a u m a l.ic injuries, for instance, h a v e no obstetric significance, tithers, such as hemorrhoids and varicose veins. are more common during p~'egnancy but require ouly simple instruction. or occasionally a minor surgical procedure, sueh as the openine ' of a thrombosed hemorrhoid u n d e r local anesthesia. I n cases of otitis media, unless acute, most hernias, a n d other conditions of no immediate urgency, operation is best d e f e r r e d until a f t e r eonfinement. A n o t h e r g r o u p of palients av~ those in whom the p r e g n a n c y itself requires surgical treatment. These comprise abortions, ectopic gestations, accidental hemorrhage, placenta previa, r u p t u r e of the m e r u s . a n d cesarean section. These conditions would each w a r r a m a separate diseussion and will not be u:eated in this paper, which will be confined to a consideration of those suruieal conditions where p r e g n a n c y complicates the diagnosis and l r e a l m e n L 11 is difficult for an obstetrician to be dogmatic r e g a r d i n g 1lie pt'oper eon(hlct of m a n y surgical conditions, and the views here expressed are the inq)vessions t h a t have resulted front a s t u d y of the histories of the surgical eollditions complicated by p r e g n a n c y in this hospital dut'ina' the past eighl years. )~any o~ these patients were seen in the obstetl'ic and gynecologic services: the r e m a i n d e r were a(huitted to the sure ioal services, and my knowleda'e (if thenl, for the mosl 1)art. is derived only f r o m a study of their histories. The discussmn will be divided into gynecoh)gi(, conditions during' l lregnaln.y an(t g(,neval sm'aical comtitions i~) the i/re~nant
Y~'olnall.
Fibroids and Pregnancy A u t o p s y statistics indicate that about 20 per cem of women beyond the age (ff 35 have fibroids, yel these tumors are J'Cl)orted iti only a p p r o x i m a t e l y 1 per cent of pl'egmlm women. It would appear, therefore, thai m a n y of the smaller utmovs are um'ecognized during pregnancy. I t is also ~i fact t h a t the, iucidenee or" sterility ]s increased m women with fibroi(ls. Their presence m a t e r i a l l y increases the inci* R e a d a t the F i f t y - S i x t h A n n u a l M e e t i n g or t h e A m e r i c a n A s s o c i a t i o n of O b s t e t r i c i a n s , G y n e c o l o g i s t s a n d A b d o m i n a l S u r g e o n s , H o t S p r i n g s , Vat., Sept. 7, 8. a n d 9, 1944. 494
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dence of abortion, miscarriage, premalure labor, dystocia, and postpartum hemorrhage. Because of their tendency to cause sterility and to result in complications during pregnancy, myomectomy may be advisable when sterility is the only indication. In many cases the first subsequent pregnancy may result in abortion or miscarriage. Small tumors discovered during pregnancy are usually of little significance, and even large tumors may not seriously interfere. Size alone may be an indication for myomectomy, and this is particularly true in the first pregnancy. In such cases, myomectomy done before complicacations have developed may result in a miscarriage but will leave a uterus capable of future pregnancies, whereas operation required later in pregnancy may demand hysterectomy as well as the loss of the p r e g n a n c y . All cases of degeneration of fibroids during pregnancy do not require surgical treatment, for the process frequently becomes quiescent under conservative management and the pregnancy may go to term. Torsion of a peduneulated tumor requires immediate operation. TABLE I.
FIBROIDS AND PREGNANCY
Number of cases Operation during pregnancy Operation at labor Palliative t r e a t m e n t Myomectomies Confined at term Aborted Died (pulmonary embolism) Cesarean section and myomectomy Hysterectomies During pregnancy At labor Palliative t r e a t m e n t Delivered at term Aborted
51 17 3 31 8 5 1 1 ] 12 10 2 31 22 9
In the series under study there were 51 cases in which fibroids were discovered in pregnant women. Of these, 17 required operation during pregnancy, 3 were dealt with at the time of labor, and 31 did not require treatment but only palliative measures. Seven of the seventeen patients requiring surgical treatment during pregnancy were treated by myomectomy; five of these were subsequently confined at term; one had an incomplete abortion and was curetted at the time of the myomectomy; and one died of pulmonary embolism following operation. Ten patients were treated by hysterectomy for various reasons. One patient, aged 40, with two children, had a large tumor and had severe pain and slight bleeding when four weeks pregnant. Under expectant treatment the symptoms disappeared but recurred a month later. The bleeding was so severe that it was felt the pregnancy would not go to term. The second.patient, para ii and six months pregnant, had multiple fibroids, was bleeding freely and having pains at the time of operation. The third patient,
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a primipara, was six weeks p r e g n a n t and had a mass of fibroids rising to the umbilicus and wa~ sufferino' from severe pressure symptoms, She had two cervical t u m o r s and dense adhesions from a previous a p p e n d e e t o m y . M y o m e e t o m y was a t t e m p t e d in one case, in which ~ large t u m o r had u n d e r g o n e deg:em?ration when lhe patienl was six weeks pregnant, but bleeding at ~he lime of operation m~(.essi~aied hystereetomy. The fifth patienl, p a r a ii, h a d a large cervical fibroi~l and signs of inevilahle abortion. In the sixth p a l i e n t bleeding had been present for three weeks, a f l e r which pain developed. Hysterect o m y was done beeause of the position of the mulliple fibroids. The seventh p a t i e n t had f o u r living ehildren, an early p r e g n a n c y , a.ud aetive p u l m o n a r y tubereulosis. I n two eases the p a t i e n t s stated that they had not missed a period and early p r e g n a n c y u as diseow, red only a f t e r the speeimens were opened h~ the patholog'ic d e p a r t m e n l . The last p a t i e n t had four children and had acute degeneralion of a lar~'c t u m o r when three and one-half ,,onths l)regnanl Nhe was treated e x p e e t a n t l y but did not respond There were three eases in whieh u ' e a t m e n t was called fur at the time of labor. The first p a t i e n t was a p r i m i p a r a at term with a l u m o r m the pelvis which could not be dislodged by manipulation. She was delivered by cesarean section and a m y o m e c l o m y was done. The seeend p a t i e n t was also a p r i m i p a r a at temn : a large eervieal fibroid filled the pelvis and a cesarean section and h y s t e r e c t o m y were done. The t h i r d p a t i e n t had had a m y o m e e t o m y before marriag'e and had gone lo t e r m in her first p r e g n a n c y but was delivered by ~esarean section heeause of disproportion. She subsequently developed anolher fibroid the size of a large orange. This p r e g n a n c y also want ~,~ 1arm. ttn(t a f t e r delivery by section a h y s t e r e c t o m y was done. Thirty-one patients did no~ require any surgieal t r e a t m e n t durinu p r e g n a n e y and labor. Nine of these aborted s p o n t a n e o u s l y ; one ai these had previously been delivered at term. and a n o t h e r went to ,;arm in a subsequent p r e g n a n e y . T w e n t y 4 w o patients had no u n t o w a r d s y m p t o m s during their pregnancies and were confined at 1arm. In ,me of these, death of the fetus had occurred in utero, thirleen had normal deliveries, and nine were delivered b y forceps. Nix t h a t were to term had s y m p t o m s of degeneration, which responded to e x p e e l a n t m~asures. One patient, a f t e r a norma~ delivery, bad a /)ostpar~um hemorr h a g e which was followe
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to note that only one of the patients suffered from postpartum hemorrhage and that one required manual removal of the placenta.
Ovarian Tumors and Pregnancy Ovarian tumors complicate pregnancy less frequently than do fibroids, but conservative measures play a smaller role in their treatment. It is true that with small tumors there may be a doubt whether they are simply retention cysts or neoplasms, and such tumors, if they do not increase in size, may be left alone until after delivery. The danger of malignancy in younger women is slight, particularly in the case of small tumors. The possibility of twisted pedicle, however, is greater with the smaller sized tumors, a~ld in those eases treated expectantly this danger must always be kept ill mind. Large ovarian tumors should always be removed because of the inevitability of distressing pressure symptoms as the uterus enlarges and because of the danger of complications such as pressure-necrosis, hemorrhage into the tumor, interference with delivery, and malignancy. Borderline tumors, larger than a small grapefruit, are better removed , but, if possible, operation should be delayed until after the end of the third month. At operation, the uterus and the opposite ovary should not be handled. If the corpus luteum of pregnancy is incorporated in the tumor, the postoperative administration of progesterone has been advocated as a prophylaxis against abortion, but even when this is not given many pregnancies go to term. An ovarian tumor with a twisted pedicle is an acute surgical emergency demanding immediate operation. If an ovarian tumor is first discovered during labor and lies above the pelvic brim or can be displaced to such a position, labor should be allowed to proceed. The danger of a twisted pedicle, however, remains throughout the puerperium, and operatio, should be carried out as soon as any symptoms arise. TABLE I I .
OVARIAN TUMORS AND PREGNANCY
Number of cases (all operated upon) Dermoids Brenner tumors Retention cysts Cystadenomas Course of pregnancy Abortion Premature labor Term Size of tumor Small (both twisted pedicles) Medium (four twisted pedicles) Large (one aborted)
3 1 1 11
16
3 1 12 2 8 6
There were sixteen patients with ovarian tumors in this series. Ten were in the first pregnancy, two in the second, two in the third, one in the fifth, and one in the sixth pregnancy. All of these patients were
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t)perated upon. One patient was s¢~ven months p r e g n a n t al the time of operation for bilateral d e r m o i d s : ,me t u m o r had a twisted p e d M e . She came in labor a few days later, and the b a b y survived. A se(.ond patient was suffering from inevitable abortion at the time of operation for a large t u m o r filling the pelvis, and a curettage was done a~ the time the cyst was removed. Two olher patients aborted, one three and the other twelve clays a f t e r operation. The remain(ter of the patients were delivered at lerm. Torsion of the p e d M e had o('('urred in six patients, in one of which the p r e o p e r a t i v e diagnosis was acute appendicitis. E i g h t patients had no s y m p t o m s referable to the l u m o r . l'he r e m a i n i n g lwo patients eomplained of pain and bleeding: one went to t e r m and the other aborted, as noted. Eighl patient.s were ~perated u p o n a f t e r t h e y had passed the third month of the pregnancy; one of these aborted and one went into p r e m a t u r e labor. In the other six. the p r e g n a n c y was not disturbed. The size of the t u m o r s was of some interest. In two patients the tumors were small but had twisted pedicles. Dne of these p a t i e n t s went to term. and the other had p r e m a t u r e labor. E i g h t patients had medium-sized tumors, of which four had twisted pedieles, and two o[ these patients aborted. Six patients h a d large tumors, n o n e of which had twisted pedicles, and one abortion followed operation in this group. £hree of the sixteen tumors were ,termoid~. and one was a B r e n n e r {lnl/()r. TABLE ]]][
POTASSIUM PEI~MANGANATE ~UttNS
Number of cases Not pregnant Aborted in hospital Aborted later Confined at term Wre,~tment Pallitttiw, Packing l, igature
:~2 4 8 4 16 17 1l
We f r e q u e n t l y see patients in our clinic bleeding f r o m the vagina after the insertion of a potassium p e r m a n g a n a t e tablet in an a t t e m p t to induce abortion. It a p p e a r s to be a g r o w i n g belief t h a t this is an efficient method of p r o d u c i n g abortion. I n most eases the insertion of the tablet is followed b y bleeding from the resulting ulceration, and this bleeding is i n t e r p r e t e d b y the p a t i e n t as abortion, and. therefore. it is difficult to convince women of its d a n g e r and uselessness. Potassium p e r m a n g a n a t e tablets can be bought without a p h y s i c i a n ' s prescription. There were t h i r t y - t w o of these p a t i e n t s in our w a r d s in the last five years, t)f these, four were not p r e g n a n t at all : eight of t h e m aborted while in the hospital; four left the hospital a n d subsequently aborted and r e t u r n e d to hospital ; sixteen of the p a t i e n t s went to term. some of t h e m in spite of severe h e m o r r h a g e . Six p a t i e n t s required
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transfusions and all of these went to term. In seventeen the bleeding had ceased~ either before the patient entered the hospital or shortly afterward and requi~'ed only palliative treatment. Many of these patients denied having attempted to produce abortion, but inspection with the speculum revealed the characteristic punched-out ulcer, surrounded by a deep purple stain, which, once seen, cannot be mistaken.
Cancer of the Cervix Complicating Pregnancy The cancer clinic of the Toronto General Hospital treats about eighty new cases of cancer of the cervix each year, and during the past ten years only four cases have been complicated by pregnancy. One of these patients was a woman 32 years of age, who entered the hospital because of an incomplete abortion, and at the time of the curettage an early carcinoma was discovered. One patient, four months pregnant, had a stage 2 carcinoma of the cervix. The uterus was emptied by supravaginal hysterotomy and the cancer treated by the usual radiologic methods. Two patients were discovered to have carcinoma after delivery, one-from our wards and one from another city. The first, aged 40, para v, had an early carcinoma. Notwithstanding treatment by high voltage and radimn, she died in three years. The other was aged 33, and the cancer was discovered eight weeks after her seventh confinement. She now has no clinical evidence of the disease three years after radiologic treatment. On the basis of this meager experience, it is difficult to justify any dogmatic opinion, but in general, it is our view that if the pregnancy is near term treatment can be delayed in the interests of the child, but in other cases the pregnancy should be terminated immediately after the diagnosis is made. Abdominal hysterotomy is the method of choice. The carcinoma is then treated by high voltage therapy followed by the use of radium.
Vaginal Cysts Complicating Pregnancy and Labor Apart from small inclusion cysts near the introitus, the common cystic tumor of the vagina arises from remains of Gartner's duct. The cyst is usually thin walled and flaccid and frequently is not discovered during pregnancy. With 1he onset of labor and the descent of the presenting part, the fluid in the upper part of the tumor is forced down and may present as a mass sufficient to encroach seriously upon the diameter of the vagina. By displacing the presenting part and putting pressure upon the tumor, its contents can again be forced above the presenting part, which will then descend normally. We have encountered five patients with such tumors, and the suggested procedure was successfully carried out in four of them. In the fifth it was necessary to evacualc the contents of the tumor with a syringe.
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General Surgical Conditions Complicating Pregnancy As previously stated, it is our intention to discuss only the more serious surgical complications of pregnancy. In reviewing the surgical conditions, however, it was a matter of surprise to discover how many operations of election were carried out on patients who were pregnant. It was equally a matter of surprise to find how infrequently abortion followed such surgical procedures. A striking example of an extensive surgical procedure is that of the patient, four months pregnant, who developed a pulmonary abscess in the lower left lobe. A lobectomy was done and the patient was successfully delivered at term. A list of operations on pregnant patients during this period includes nephrectomy, removal of a fibromyoma of the jaw, removal of several nonmalignant tumors, two herniotomies, operations for osteomyelitis, open reduction of fractured long bones , tonsillectomies, and operation for mastoiditis. Appendicitis.--Appendicitis is by far the commonest indication for an operation of necessity during pregnancy, although the incidence of the disease is probably no greater during pregnancy t h a n at any other time. There seems to be little doubt that acute appendicitis during pregnancy is a somewhat more serious condition than in the nonpregnant patient, and the seriousness increases considerably when the uterus has risen above the pelvic brim. The localization of the inflammatory process tends to be interfered with and the probability of general peritonitis is increased. The necessity of correct diagnosis and early operation is, therefore, particularly desirable, but the great difficulty appears to lie in making a correct diagnosis. This, of course, also applies t o the nonpregnant patient, but there are certain pitfalls in diagnosis during pregnancy. Keeping in mind these special difficulties, to which reference will be made later, operation is the safest procedure when the symptoms and findings strongly indicate a probable acute appendicitis, even though the removed appendix is subsequently found to be not acutely inflamed. TABLE IV Operations during pregnancy (6 aborted) Operations after labor (1 death) Pathologic Reports ., Acute appendicitis Chronic appendicitis Normal appendix Twisted ovarian cyst Acute salpingitis Attempted abortion Cases not operated Diagnosis not confirmed Becoming quiescent Diagnosis changed
18 2 20 8 8
24 11 3 10
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There were forty-two pregnant patients sent to the hospital with a diagnosis of acute appendicitis. In twenty-one of these the diagnosis was concurred in after admission, although in one patient a diagnosis of pyelitis of pregnancy at seven months was first made, and three days later it was necessary to do an emergency operation, when a gangrenous appendix was removed. The patient went into labor prematurely and developed general peritonitis but eventually recovered. Eighteen of the twenty-one patients with a diagnosis of appendicitis were operated upon, and following operation six abortions occurred. There were no deaths. Only six of the eighteen patients operated upon were reported as having acute appendicitis by the pathologic department; eight were reported as having chronic appendicitis, although in one of these the appendix was engorged with pinworms. One was reported as having a normal appendix. Incorrect diagnosis was made in three of the eighteen patients operated upon. One had a small ovarian cyst with a twisted pedicle; one had an acute salpingitis early in pregnancy; the third patient was a w i d o w who gave a history of normal periods and denied the possibility of pregnancy even after operation. Her symptoms were due to taking drugs with the idea of causing abortion. She did not abort, even after operation. The diagnosis was not confirmed in eleven of the twenty-four patients not operated upon. The majority of these patients had some pain in the lower right abdomen and were sent to the hospital with a tentative diagnosis of appendicitis, but as no other evidence of the disease could be discovered, and the pain quickly disappeared, the diagnoses were simply listed as " n o t confirmed." Three patients were thought to have had acute appendicitis but were definitely becoming quiescent at the time of admission and were treated expectantly, with the advice that the appendix should be removed after delivery. In ten patients other diagnoses were made. One was the vomiting, of early pregnancy, one was diagnosed "hysteria," and one was pye]itis of pregna~o,y. Seven patients presented difficulty in diagnosis because of attempts to produce abortion by medicinal or other means and concealed this information. The possibility of error in diagnosis in these cases is great. The patients complained of low abdominal pain, often confined to the right side, which was frequently accompanied by nausea and vomiting. When mechanical means were employed to produce abortion, abdominal tenderness and rigidity were sometimes present and also some degree of fever and leucocytosis. Abdominal tenderness may also be present when intestinal irritants have been taken. Apart from attempts to produce abortion, the vomiting of early pregnancy is not infrequently accompanied by localized abdominal pain. In addition to these cases of appendicitis during pregnancy, two patients developed acute ap.pendicitis during labor. In both instances the diagnosis was missed during the process of parturition, but one
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case was recognized a few hours after delivery and the patient was successfully operated upon. The svvon(t case was n(}~ ~.e(.ok,'nized as an acute appendix until the third da) after delivery, am[ by the ~ime ttw operation was performed the appendix had r u p t u r e d aml a e'eneral peritonitis had developed. This patient died.
Intestinal Obstruction. lnlestina/ obstruction occurring durinR' pre~'nancy presents m a n y difficulties in diagnosis, and the delay in operalion due to these m a y prove falal. The obstruetion is usually secondary to pre-existing adhesions, and the dane'er of its occurrence is accentuated by the mechanical effeels of the enlar~'ina, uterus. It sometimes arises when no previous oper:ltion has been perfo/'med and. in these cases, a history suggestive of appendicitis or a previous pelvic inflammation may be obtained. The diffi(.u[ty in diaanosis is due lo the fact that lhe classical symptoms of eramplike abdominal l)ai~l and vomiting are nol infrequently seen in normal preunaney. After delivery, either normal or operative, i|eus occasionally develops, and the marked distention is sometimes mistaken for mechanical ()bstruelion. Such cases of ileus may be accompanied by vomitina', but (.ramptike abdominal pain is usually absent. It sometimes requires great elinieat acumen to avoid operating upon nonobstruetive ilells and t(, opel.ale early when true obstruction exisls. TABLE V.
INTESTINAL OBSTRIICT/oN
Number of eases Number of operations Carcinoma of the si~moid Adhesions
Strangulated umbilical hernia Postoperative obstruction Treated expectantly
f~ 2 '2
1 1
In this series there were seven eases of intestinal obstrueti(m d u r i n g pregnancy. Two were due to eareinoma of the sigmoid. One of these was in a woman 42 years of age and a eotostomy was done. She was seven months pregnant in the fourth pregnancy and had a p r e m a t u r e labor. She survived the operation but died in two months. The other patient was 82 years of age and was seven and one-half months pregnant in the first pregnancy. Medieal induction was done before operation and a live baby obtained. The patient was operated upon two days after delivery and died the following day Two eases were due to adhesions. One patient was four months pregnant and subaeute obstruction from a previous a p p e n d e c t o m y was diagnosed. At ,,peration m a n y adhesions were encountered but no acute bowel obstruction. The patient was delivered at term. The other patient had an acute small bowel obstruction due to adhesions followina a previous operation for ovarian cyst. She was operated upon when four months p r e g n a n t in the second p r e g n a n e y and the obstruction was relieved.
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She was subsequently confined at term, and a month later developed a volvulus which required intestinal resection. In the fifth case, the patient was six months pregnant in the fifth pregnancy. An umbilical hernia had been present for several years and became strangulated with symptoms of obstruction. At operation strangulated omentum only was encountered. The patient was delivered at term. The sixth case was of unusual interest. The patient entered the hospital when three and one-half months pregnant with general peritonitis. A month previously she had been in the hospital with a potassium permanganate burn. When operated upon for general peritonitis, the right tube and the appendix were both removed, but it could not be decided whether the peritonitis was secondary to the previous permanganate lesion or to an acute appendicitis. Three weeks after the primary operation she developed acute intestinal obstruction requiring a second operation, following which she aborted. After a stormy convalescence, she recovered. The last patient had had seven pregnancies, the last of which had been at term five months previously. She was again two months pregnant and was sent to the hospital with a diagnosis of acute obstruction. The symptoms, however, subsided under expectant treatment; the patient was not operated upon and went to term. This case was probably not one of intestinal obstruction although it was so diagnosed. Although no history of interference could be obtained, it was more probably the real cause of her symptoms. Hyperthyroidism During Pregnancy.--Some enlargement of the thyroid gland occurs in nearly a third of all pregnant women. This, in addition to the frequent nervous instability of pregnancy, often accompanied by tachycardia, may rouse the suspicion that hyperthyroidism is present. The true diagnosis is made more difficult by the fact that the basal metabolic rate is often raised during pregnancy. Baer's study showed forty-four normal women with basal metabolic rates of plus 30 to 55 during the last trimester of their pregnancy. Some observers maintain t h a t pregnancy does not alter the course of exophthalmic goiter, while others believe that pregnancy tends to aggravate its course. Hyperthyroidism accompanies two distinct types of thyroid disease: diffuse hyperplasia of the gland (exophthalmic goiter) and nodular hyperplasia. In the former, remissions are not uncommon, although recurrent exacerbations are the rule, any one of which may proceed to a thyroid crisis. On the other hand, an adenomatous goiter with toxic symptoms usually becomes progressively worse, and the effect of iodine therapy is not only uncertain, but transitory at best. Those observers who believe that hyperthyroidism is frequently made worse b~y pregnancy advocate the emptying of the uterus. It is our opinion, however, that therapeutic abortion is not indicated in these patients, and the hyperthyroidism should be treated appropriately without regard to the pregnancy. When operation is indicated,
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it may be carried out with little, if any, greater risk than ih the nonp r e g n a n t patienl, t)n the other [mini. iI" a palienl with exophlhalmic ta'oiter responds to medical tl'eatmenl. ,'mtl the pregl~ant'y is advam'(,,l it is probably besl to delay operation until after deliv(,~'y_ T A B L:~I r [ .
| ] VI'EWI~tlY I~ ~i]~INM
~ ' u m b e r of cases . . . . . . . . . . . . . . . . N u m b e r of operations N u m b e r of a b o r t i o n s Simple colloid goiter Hyperplasi~ due to pregnancy Toxic a d e n o m a ( o p e r a t e d Exophthalmic goiter (oper,tted)
,6. . . . . . . . . . . . . . . . . . :~ 0 .5 l I
There were nine cases in this series in which the patients were admitted to the hospital with a diagnosis of h y p e r t h y r o i d i s m during pregnancy. ()f these, five diagnoses at the hospital were simple colloid grater, the symptoms being interpreted as the result of pregnancy. ] ' h e y were all treated expectantly, and all went to term. Three of the patients were in the first pregnancy, one in the sixth, and one in lhe eighth One woman, who was three and one-half months pregnant, had a goiter with suggestive symptoms, tt was decided, however, that the goiter was a hyperplasia due to pregnancy. ~he was nol operated upon and went l o term. Three eases were true toxic goiters, o , e bein~ an exophthahnic goiter, and the other two toxic adenomas. These patients were three mm~ths, five months, and seven months pi~gnam. respectively. Two o( them were primiparas and the third was in the f o u r t h pregnaney. All three patients were operated upon and in no ease did miscarriage occur. Two ol: them had a very s t o r m y vow vatescenee, but all three recovered.
Summary 1. When fibroids complicate pregnancy, conservatism in treatment is usually indicated. 2. Ovarian neoplasms usually t'eqmre operation d u r i n g pregnancy. 3 Correct diagnosis of appendicitis d u r i n g p r e g n a n c y is frequently difficult. 4. Symptoms due to the p r e g n a n c y or to attempts to produce a b o f tion may lead to erroneous diagnosis. A large percentage of pregnam patients sent To hospital because of acute appendicitis do no~ have the disease. 5. [n the treatmem of h y p e r t h y r o i d i s m and p r e g n a n c y the fo/lowina' points are i m p o r t a n t : (a) Is h y p e r t h y r o i d i s m really present? (b) If so. is the condition an exophthahnie goiter, or a toxic adenoma? I f the former, conservative treatment will often l), satisfactory, but if toxic adenoma is presenL surgical u'eatment is indicated. 170 ST. GEORGE STREET.
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Discussion DR. F R E D E R I C K H. FALLS, C~IIOA~o, ILL.--~Ve note in general a thread of conservatism r u n n i n g t h r o u g h the m a n a g e m e n t of these cases which we highly approve. We see also a willingness to accept the responsibility of p e r f o r m i n g an unnecessary operation when the diagnosis was in doubt in order to safeguard the p a t i e n t from the risk of development of lesions so f a r advanced as to be beyond surgical remedy. I n this viewpoint we also concur. We would like to stress the value of corpus ]uteum e x t r a c t injections as a prophylactic measure to avoid abortion in all of these surgical complications of pregnancy. We would also suggest t h a t i t would be for the benefit of all concerned i f all surgical procedures of p r e g n a n t women have the benefit of obstetric consultation before surgical t r e a t m e n t is applied. This would result in a b e t t e r u n d e r s t a n d i n g of these relatively rare complications by the surgeon and the o b s t e t r i c i a n and b e t t e r t r e a t m e n t for b o t h mother and baby. W i t h regard to ovarian tumors we tend to conservatism unless there is evidence of rapid increase in size or t w i s t i n g of pedicle either ante or post partum. During labor, i f cysts block the inlet paracentesis may be employed for decompression. For cervical carcinoma, if operable, hysterectomy should be done regardless of the pregnancy, followed b y x-ray and radium. I t is a rare condition b u t p r o b a b l y not as rare as Dr. S c o t t ' s figures would indicate. For years no case of this k i n d was diagnosed a t the Cook County Hospital in Chicago. I n the last two years eight cases were recognized because the staff had become conscious of the possibility of such complications. I t is significant t h a t two of these cases were not discovered u n t i l a f t e r delivery. This means t h a t either the p a t i e n t s were not examined b y the obstetrician a t t e n d i n g the case or they were not recognized as carcinomas when seen bcause of the r a r i t y of the lesion. How can we diagnose an early carcinoma of the cervix w i t h o u t a vaginal e x a m i n a t i o n and careful inspection of the cervix w i t h a good light, followed b y biopsy in suspected cases ? I n h a n d l i n g vaginal cysts we would evacuate w i t h a syringe a t labor and dissect out later. I n 44 p a t i e n t s w i t h a t e n t a t i v e diagnosis of appendicitis only t w e n t y were operated upon and ten proved to have acute appendicitis at operation. These figures illustrate the desirability of a conservative attitude. When, however, the p r e g m m t woman develops the symptoms of acute appendicitis in sequence, as pointed out b y Dr. J . ' B . l~hrphy, pain diffuse then local, nausea and vomiting, chill, leucocytosis, r i g h t rectus rigidity, operation should not be deferred. I t is well to r e m e m b e r t h a t a f t e r the fifth m o n t h the pain and tenderness are not over M c B u r n e y ' s point b u t higher due to upward displacement of the appendix unless bound down b y adhesions following previous attacks. I n three of seven cases so diagnosed the p a t i e n t s did not have i n t e s t i n a l obstruction. I n the first case of carcinoma of sigmoid, careful m a n a g e m e n t of the bowel m i g h t have p e r m i t t e d the p a t i e n t to go to seven and one-half months or longer, when induction m i g h t have saved the baby. W i t h a tumor developed to this degree the outlook for the m o t h e r is poor and delay of operation for a few weeks to give the b a b y a b e t t e r chance is justifiable. There is almost always some hyperthyroidism during normal p r e g n a n c y as shown b y increased size of the gland and increased basal metabolic rate and other symptoms of h y p e r a c t i v i t y of the thyroid gland. This is physiologic and desirable. W h e n this increase of gland a c t i v i t y goes beyond the physiologic limits; toxic symptoms m a y d e m a n d t r e a t m e n t . Bed rest and L u g o l ' s solution are al! t h a t are necessary in the g r e a t m a j o r i t y of cases. This m a y be continued
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f o r w e e k s d u r i n g p r e g n a n c y , t h e o p i n m n of n i n n y t h y r . i d
gllrKeOllS l(t the coIi-
trary notwithstanding. F o l l o w i n g l a b o r , w h i c h is u s u a l l y v e r y well t o l e r a t e d , t h e a c u t e s y m p t o m s . f h y p e r t h y r o i d i s m u s u a l l y s u b s i d e a n d o p e r a t i o n is not n e e e s s ' l r y . We h a v e not h a d to o p e r a t e upon a s i n g l e p a t i e n t b e f o r e t h e t e r m i n a l i o n . f p r e g n a n c y , t ' r e ~ n a n c y in t h e w o m a n who h a s p r e v i o u s l y be e n o p e r a t e d upon f o r h y p e r t h y r m d i s m a m y be u c o m p l i c a t e d t h e r a p e u t i c p r o b l e m . S uc h p a t i e n t s m a y become ve ry n e r v o u s f o l l o w i n g d e l i v e r y of t h e b a b y and in one of my p a t m n t s s u i c i d e restrtted. [ w o u l d d i s a g r e e w i t h Dr. Scott in l h r s t a t e m e n t t h a i f r a c t u r e s a n d o t h e r i n j u r i e s h a v e no o b s t e t r i c s i g n i f i c a n c e , arLd [ a s s u m e t h a t he di d n o t m e a n l h i s s t a t e m e n t to be t a k e n l i t e r a l l y . F o r e x a m p l e , a b o r t i o n is c e r t a i n l y p r e d i s p o s e d to a n d r u p t u r e of the u t e r u s h a s been a s c r i b e d to v i o l e n t tr~tunla. T h e r e is some e v i d e n c e to show t h a t f r a c t u r e s do not a l w a y s he a l as well a,~ in the n o n p r e g n a n t w o m a n , w h i c h m a y be due to a l t e r e d c a l c i u m m e t a b o l i s m d v r i n g gestati~)n. V a r i c o s e v e i n s may become t h r o m b o s e d e m b o l i s m e i t h e r a n t e p a r t u m or post p a r l u m .
and
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As m e n t i o n e d , a b o u t 20 per' c e n t of womer~ b e y o n d ;~5 y e a r s h a v e iibroids. b u t r e l a t i v e l y few of t h e s e b e c o m e p r e g n a n t . W o m e n u n d e r 25 y e a r s r a r e l y h a v e fibroids of sufficient size to influence t h e course r,f p r e g n a n c y a n d lakmr. I n our e x p e r i e n c e 40 per c e n t of the ease s n e e d i n g s u r g i c a l i n t e r v e n t i o n is too h i g h , b u t t h e i n d i c a t i o n s g i v e n i n ~he c a s e s he re r e p o r t e d seem e n t i r e l y j u s t i f i e d . M y o m e e t o m y is e s p e c i a l l y a d a p t e d to s u b s e r o u s v a r i e t y . In c a s e s of s t e r i l i b" w i t h s u b m u c o u s fibroids, a b d o m i n a l h y s t e r o t o m v s h o u l d be do~e, In s uc h cases. i f p r e g n a n c y r e s u l t s , c e s a r e a n s e c t i o n is a d v i s a b l e , e s p e c i a l l y if t h e patier~l i~ an elderly primipara. DR. W I L L I A M H. VOGT, ST. L o u i s . Mo. A m a t t e r t h a t i n t e r e s t e d me was th e h a n d l i n g of a ease of c a r c i n o m a of the c e r v i x a s s o c i a t e d w i t h p r e g n a n c y . Dr. S c o t t s a i d t h a t l h e d e s i r a b l e t h i n g to do in l a t e p r e g n a n c y is lo w a i t f o r a s h o r t t i m e . do a s e c t i o n , a n d then t r e a t the r'orvieal s t u m p w i t h r a d i u m . [n t h e e a r l y eases he a d v i s e s t h e e m p t y i n g of t he u t e r u s , t ~ r e f e r a b l y b v h v s t e r o t o m y . a n d t h e n t r e a t i n g the case in the u s u a l m a m : e r w i t h r a d i u m . Ir~ :~ ~'atholit' h o s p i t a l w h e r e I w o r k y o u c a n n o t e m p t y a u l e r u s for a p r e g n a n c y a s s o c i a t e d w i t h a c a r c i n o m a , but y o u are p e r m i t t e d to t a k e out t h a t u t e r u s . I f it is not .~n o p e r a b l e case. we w o u l d o r d i n a r i l y use r a d i u m , b u t t h i s would p r o b a l d y p r o d u c e an a b o r t i o n . DR. H E R B E R T E, S t ? H M I T Z CHICAGO, [ b L . - - I s ha l l a t t e m p t to a n s w e r the q u e s t i o n of Dr, V o g t because I. ~oc. work i n a C a t hol i c hospital. In a ~'ase of c a r c i n o m a of the cervix c o m p l i c a t i n g p r e g n a n c y , we a re p e r m i t t e d , as Catholics, l o t r e a t the carcinoma. I f it is b e f o r e the period of v i a b i l i tv. we ma y use x - r ~ t h e r a p y a p p l i e d e x t e r n a l l y because we are not a t t e m p t i n g 1:o d e s t r o y the innocent v i c t i m but a r e t r e a t i n g the carcinoma. I f the f e t u s is viable. ~v~ remove t h e pregn a n t v by c e s a r e a n section, which is permissible, and t he n t r e a t the c a r c i n o m a e i t h e r b y t o t a l r e m o v a l of the u t e r u s or by l e a v i n g the u t e r u s behind. [f t he u t e r u s is l e f t behind, we m a y b e g i n e x t e r n a l irradi'~ t i on two or three d a y s p o s t o p e r a t i v e t v, s t e r i l i z e the c a r c i n o m a as much as possible b e f o r e the i n s e r t i o n of r a d i u m , w h i , h should not be done b e f o r e c o m p l e t e i n v o l u t i o n ha s t a k e n place. DR. J A M E S R. B L O S S . HUNTINGTON, \V. V,*.. I n M a r c h a D P A ease was b r o u g h t in to us, a p a r a vii, who had been i n l a b o r u n d e r the care of a m i d w i f e f o r f o u r days. E x a m i n a t i o n s h o w e d a v e r y e x t e n s i v e c a r c i n o m a of t h e u t e r u s a n d a d e a d f e t u s . A c l a s s i c a l c e s a r e a n s e c t i o n was done. I t w a s f o u n d t h a t t h e base o f t h e b l a d d e r a n d t h e s i g m o i d w e r e i n c o r p o r a t e d i n t o a m a l i g n a n t m a s s so t h a t one could not e v e n a t t e m p t a h y s t e r e c t o m y . A d r a i n w a s p u t i n on each s i de o f
SCOTT:
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the uterus, the p a t i e n t was given three transfusions of bank blood and deep x-ray t h e r a p y s t a r t e d ten days a f t e r operation. Six weeks later this p a t i e n t was able to walk out of the hospital. The drainage had stopped and the abdominal wound was closed. She w e n t home to the country and she is still alive. DR. WILLARD R. COOKE~ GALVESTON, TEXAS.--I can agree very fully with all tire principles enunciated in the paper except in regard to the treatment of fibromyomas during pregnancy. Although we have many cases of fibromyomas complicating pregnancy in our part of the world, we have not done a myomectomy during pregnancy for over twenty-five years except in cases of acute necrosis and in one or two cases where the abdomen was opened in error and the fibromyoma exposed. Ordinarily we do not do a myomectomy at the time of cesarean section unless there is some real indication for it because of the risks of additional serious hemorrhages and of disseminating potentially i n f e c t e d fluids and clot. Unless there is a real indication for myomectomy, we prefer to t r e a t cases of fibromyomas by hysterectomy, unless we w a n t to preserve the uterus for future childbearing. Myomectomy for multiple or large fibromyomas is frequently justifiable and should be done without hesitation in cases of sterility in which the tumor is considered as a potential factor in the sterility. As a general rule, fibromyomas which are not giving rise to symptoms are .merely kept under periodic observation, operation being resorted to only for specific indications. Complete or supravaginal hysterectomy is usually selected on the basis of the condition of the cervix and of the factor of added risk involved in cases of technical difficulty in the performance of complete hysterectomy. DR. SCOTT.--I believe if a p a t i e n t with cancer of the cervix and a nonviable child came under my care, and I was allowed to remove the uterus, I would do so by subtotal hysterectomy. Our t r e a t m e n t of cancer of the cervix begins with deep x-ray t h e r a p y lasting four to eight weeks, a f t e r which radium is applied. I t is my opinion t h a t in such cases there is no advantage in doing an ordinary total hysterectomy in place of a subtotal. Regarding our myomectomies, seven were done during pregnancy and one at the time of labor. Some of these had undergone degenerative changes which did not respond to t r e a t m e n t ; in other cases it was our opinion t h a t the size or position of the fibroid made operation advisable during the pregnancy. As to the importance of surgical consultation, I agree most decidedly. The closer cooperation between the general surgeon and the obstetrician and gynecologist, the b e t t e r for both. There was a time when many surgical and some medical conditions were found to be complicated by pregnancy, t h a t the opinion of the obstetrician was sought solely on the question of whether or not the uterus should be emptied. This, in general, is no longer true.