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Ovarian cysts complicating pregnancy
598
AMERICAN
JOURNAL
DR. CHAR.LW E. CAVER.LY
Cysts Complicating
OF
OBSTETRICS
(by invitation)
Pregnancy.
(For
AND
GYNECOLOGY
read a paper entitled OVarian original artivlc SW page 566.)
1~18CUSS10N DR. CHARLES A. GORDON.-It is certainly hard to standardize and of course not even advisable to try to standardize treatment in any way because SO muelI its character, if that can be dedepends upon the size of the cyst, its location, termined, and the status of the woman, as to whether she is a primipara, au old primipara, very anxious for a baby, or a multipara with a history of repeated easy labors. If I were to crystallize my thoughts in the matter I would say that no operation should be done before the third month, and not even then unless necessary for some reason or other; that the patient should be carried to as near term as possible; and that delivery should be effected by cesarean section with removal of the cyst after the closing of the wound in the uterus. If labor is spontaneous, either by accident or design, operation should be done in the puerperium for any untoward symptom which the patient presents. Operation should be done before she leaves the hospital anyway, if possible, and the patient should be warned of the seriousness of the condition in the event of another pregnancy. Dermoid is not at all uncommon and the tragic consequences of dermoid rupture should be borne in mind. DR. ONSLOW A. GORDON, JR.-While we may draw different conclusions from the same set of figures, it urould seem to me from the figures presented by Dr. Caverly that it is more logical to conclude, not as Dr. Charles Gordon did, that the time to operate upon these cysts is some time after the third month, but as soon as discovered t,o remove them, and then permit the woman to have a normal labor. That seems to me to be far more preferable because then you have a woman who is not liable to the complications subsequently and to cesarean section in subsequent pregnancies. DR. B. P. WATSON.-One of the interesting things which has been brought out in this paper is the comparative harmlessness of the dermoid today as contrasted with what it was, say, fifteen or twenty years ago. We were taught that the dermoid was the tumor which was most likely to cause complications during pregnancy and especially during labor. The reason was that it was a tumor of the pelvis and obstructed labor. Nowadays we discover these tumors earlier in pregnancy and remove them, hence, we do not get the number of obstructed labors from pelvic tumors that we formerly got. That is very well brought out in Dr. Caverly ‘s statistics as compared with those of McIierron, which were compiled in 1903. I fee1 that if the tumor is not discovered until late in pregnancy it is much better, providing it is not obstructing the pelvis, to allow normal labor to go ou and then do an ovariotomy in the puerperium rather than do ovariotomy plus cesarean section which might prejudice the patient’s future pregnancies and future labors. DR. CHARLES E. CAVERLY.-Dr. Gordon mentioned a particular ease of a very large cyst which was diagnosed, I believe, only after labor. Several such cases were seen among the 83 eases which I collected where the abdominal dietention, unexplained and undiagnosed during pregnancy, was determined to be due to an ovarian cyst only after labor,‘when the small, hard uterus could be felt definitely separate from the soft, flaccid tumor mass above. I agree with Dr. Gordon that ovariotomy should be postponed if possible until aftor completion of the third month of pregnancy because that is the period of greatest danger of abortion from whatever cause. I do not think that it is in line with my findings to defer operation until full term because to do so is to ignore
NEW
YORK
OBSTETRICAL
SOCIETY
9iw.
risk of symptoms caused by the tumor and that of complications which may occur in the tumor. As Dr. Gordon says, if a cyst is first diagnosed near the end of pregnancy, if the patient can be kept under observation, and if labor and delivery promise to be not unduly complicated, then it is hetter t,o await full t,ernt and possible spontaneous delivery, rather than to do a cesarean section, because lherehy can be avoided an incision in the uterus which might necessitate subsequent section with other pregnancies. Dr. Watson says that labor obstructed hy a dermoid cyst in the pelvis is seldom seen now, although formerly not uncommon. That is due, I think, to the more thorough antepartum examination and treatment, certainly in an obstetric hospital practice, of the present day as compared with former times.
the
DR. JAMES A. CORSCADEN read a, paper entitled The Late Aalttomic Efpect of the Radiotherapeutic Menopause. (To he published in :I later issue of the JOURNAL.]
XEW
YORsK OBSTETRICAL MEETING
SOCIETY
OF l?ECEMBEE
9, 13.30
DR. C. E. GALLOWAY, Evanston. Ill., presented (invitation) a paper entitled Postpartum Care. (For origina. art,icle see page 558.) ABSTRACT
OF
DISCUSSTON
DR. WILBUR WARD.-What struck me as the most practical care in the intermediate stage. I do not helievr a woman can go nancy and labor, get into a chair on the sixth day. he on her feet day, go home on the twelfth day and resume her normal activities care of the baby, herself, her family, and household. Dr. Galloway% his own locality of having some one representing him go out to patients when they are not able or qualified to look after themselves how to do things to relieve the burden is subject to modifications localities, but it is a mighty good idea.
point was the through pregon the seventh at once, take method in the homes of and tell them in the various
DR. 0. PAUL HUMPSTONE.-I wonder if the exercise that the doctor advises after labor is not begun too soon. The careful observation of whether there is [any subinvolution which might cause an emholus is not always carried out in a hospital, and the woman is routinely told to ts.ke the knee-chest exercise beginning the twelfth day. I might report that we have had two cases of embolus following this and now we do not begin any pnstpartum exercise until the fourth week when the patient begins with her knee-chest exercises and two weeks later begins her abdominal exercise. DR. E. C. LYON, JR.-Our cnstom has heen to watch the patient carefully during pregnancy for anemia and with certain low prrrentages of hemoglobin and red hlood cells to always have the donor ready nntnidc the delivery room, snd in that way we feel we areomplish a good dral in xwiiling postpsrtnm hlerding nllicll might otherwise become serious. SYMPOSIUM
DR. DOUGLAS MURPHY
tor Treatment
ON
(by
RESUSCITATIOS
OF
invitation)
described
of the Immediate
Asphyxirt
original article see page 52S.1
THE.
NEWBORN
the Drinker Bespira(For of the Newborn.
AMERICAN
JOURNAL
DR. CHAR.LW E. CAVER.LY
Cysts Complicating
OF
OBSTETRICS
(by invitation)
Pregnancy.
(For
AND
GYNECOLOGY
read a paper entitled OVarian original artivlc SW page 566.)
1~18CUSS10N DR. CHARLES A. GORDON.-It is certainly hard to standardize and of course not even advisable to try to standardize treatment in any way because SO muelI its character, if that can be dedepends upon the size of the cyst, its location, termined, and the status of the woman, as to whether she is a primipara, au old primipara, very anxious for a baby, or a multipara with a history of repeated easy labors. If I were to crystallize my thoughts in the matter I would say that no operation should be done before the third month, and not even then unless necessary for some reason or other; that the patient should be carried to as near term as possible; and that delivery should be effected by cesarean section with removal of the cyst after the closing of the wound in the uterus. If labor is spontaneous, either by accident or design, operation should be done in the puerperium for any untoward symptom which the patient presents. Operation should be done before she leaves the hospital anyway, if possible, and the patient should be warned of the seriousness of the condition in the event of another pregnancy. Dermoid is not at all uncommon and the tragic consequences of dermoid rupture should be borne in mind. DR. ONSLOW A. GORDON, JR.-While we may draw different conclusions from the same set of figures, it urould seem to me from the figures presented by Dr. Caverly that it is more logical to conclude, not as Dr. Charles Gordon did, that the time to operate upon these cysts is some time after the third month, but as soon as discovered t,o remove them, and then permit the woman to have a normal labor. That seems to me to be far more preferable because then you have a woman who is not liable to the complications subsequently and to cesarean section in subsequent pregnancies. DR. B. P. WATSON.-One of the interesting things which has been brought out in this paper is the comparative harmlessness of the dermoid today as contrasted with what it was, say, fifteen or twenty years ago. We were taught that the dermoid was the tumor which was most likely to cause complications during pregnancy and especially during labor. The reason was that it was a tumor of the pelvis and obstructed labor. Nowadays we discover these tumors earlier in pregnancy and remove them, hence, we do not get the number of obstructed labors from pelvic tumors that we formerly got. That is very well brought out in Dr. Caverly ‘s statistics as compared with those of McIierron, which were compiled in 1903. I fee1 that if the tumor is not discovered until late in pregnancy it is much better, providing it is not obstructing the pelvis, to allow normal labor to go ou and then do an ovariotomy in the puerperium rather than do ovariotomy plus cesarean section which might prejudice the patient’s future pregnancies and future labors. DR. CHARLES E. CAVERLY.-Dr. Gordon mentioned a particular ease of a very large cyst which was diagnosed, I believe, only after labor. Several such cases were seen among the 83 eases which I collected where the abdominal dietention, unexplained and undiagnosed during pregnancy, was determined to be due to an ovarian cyst only after labor,‘when the small, hard uterus could be felt definitely separate from the soft, flaccid tumor mass above. I agree with Dr. Gordon that ovariotomy should be postponed if possible until aftor completion of the third month of pregnancy because that is the period of greatest danger of abortion from whatever cause. I do not think that it is in line with my findings to defer operation until full term because to do so is to ignore
NEW
YORK
OBSTETRICAL
SOCIETY
9iw.
risk of symptoms caused by the tumor and that of complications which may occur in the tumor. As Dr. Gordon says, if a cyst is first diagnosed near the end of pregnancy, if the patient can be kept under observation, and if labor and delivery promise to be not unduly complicated, then it is hetter t,o await full t,ernt and possible spontaneous delivery, rather than to do a cesarean section, because lherehy can be avoided an incision in the uterus which might necessitate subsequent section with other pregnancies. Dr. Watson says that labor obstructed hy a dermoid cyst in the pelvis is seldom seen now, although formerly not uncommon. That is due, I think, to the more thorough antepartum examination and treatment, certainly in an obstetric hospital practice, of the present day as compared with former times.
the
DR. JAMES A. CORSCADEN read a, paper entitled The Late Aalttomic Efpect of the Radiotherapeutic Menopause. (To he published in :I later issue of the JOURNAL.]
XEW
YORsK OBSTETRICAL MEETING
SOCIETY
OF l?ECEMBEE
9, 13.30
DR. C. E. GALLOWAY, Evanston. Ill., presented (invitation) a paper entitled Postpartum Care. (For origina. art,icle see page 558.) ABSTRACT
OF
DISCUSSTON
DR. WILBUR WARD.-What struck me as the most practical care in the intermediate stage. I do not helievr a woman can go nancy and labor, get into a chair on the sixth day. he on her feet day, go home on the twelfth day and resume her normal activities care of the baby, herself, her family, and household. Dr. Galloway% his own locality of having some one representing him go out to patients when they are not able or qualified to look after themselves how to do things to relieve the burden is subject to modifications localities, but it is a mighty good idea.
point was the through pregon the seventh at once, take method in the homes of and tell them in the various
DR. 0. PAUL HUMPSTONE.-I wonder if the exercise that the doctor advises after labor is not begun too soon. The careful observation of whether there is [any subinvolution which might cause an emholus is not always carried out in a hospital, and the woman is routinely told to ts.ke the knee-chest exercise beginning the twelfth day. I might report that we have had two cases of embolus following this and now we do not begin any pnstpartum exercise until the fourth week when the patient begins with her knee-chest exercises and two weeks later begins her abdominal exercise. DR. E. C. LYON, JR.-Our cnstom has heen to watch the patient carefully during pregnancy for anemia and with certain low prrrentages of hemoglobin and red hlood cells to always have the donor ready nntnidc the delivery room, snd in that way we feel we areomplish a good dral in xwiiling postpsrtnm hlerding nllicll might otherwise become serious. SYMPOSIUM
DR. DOUGLAS MURPHY
tor Treatment
ON
(by
RESUSCITATIOS
OF
invitation)
described
of the Immediate
Asphyxirt
original article see page 52S.1
THE.
NEWBORN
the Drinker Bespira(For of the Newborn.