Pregnancy following major thoracic surgery for tuberculosis

PREGNANCY CLAIR

E.

FOLSOME,

FOLLOWING MAJOR THORACIC FOR TUBERCULO$IS” M.D.,

(Prom the New York Medical

AND

College

C.

DONALD

KUNTZE,

and the Metropolitan and Gynecology)

M.D., Hospital,

SURGERY NEW

YORK,

Division

T

N,

of

Y.

Obstetrics

HE employment of major thoracic surgery in the management of extensive unilateral pulmonary tuberculosis has increased greatly in recent years. The ready availability of multiple antibiotics, improved anesthetic methods, blood transfusions, metabolic drugs, and newer means in physical therapy have contributed to the steady shift of emphasis toward the surgical management of tuberculosis wherein one lung exhibits cavitation, ulcerative lesions, or a widespread diseased process. Segmental or total lung resection, threestage thoracoplasty and cavernostomy are no longer surgical rarities in tuberculosis treatment. While these procedures are formidable in themselves they do offer in selected cases a greater hope than the slower collapse methods to restore these tubercular women to their home and family life. It is for these same reasons that the obstetrician and phthisiologist should review the reproductive status of these surgically salvaged tubercular women. Together they can provide clinical judgment for the woman and her husband on the difficult decision whether subsequent pregnancies shall be permitted or interdicted. In the clarification of joint judgment it is logical we should review the experience of others and ourselves to arrive at a sounder factual basis in support of these opinions. Manifold articles, texts, and symposia have been concerned with the effects of tuberculosis upon pregnancy or pregnancy upon the tuberculous case. The present-day consensus that pregnancy has no deleterious effect upon pulmonary tuberculosis has many ardent supporters.1-*4 Today there are but rela,tively few dissenting opinions.25-35 This evidence gains added credence by ,the increased number of authors who state that the interruption of pregThere are nulnerous writnancy is rarely, if ever, indicated. 5, 16,19, 22, 23, 33, 36-40 ers who indicate that the interruption of pregnancy is especially more harmful if performed after the first trimester53 I21I51I73*S 24*25,32s=, 40-47and other autlhors are even more positive and state unequivocally that the interruption of pregnancy can be more harmful than term delivery.22s 41-45 Gohen,17l20 Friedman and Garber,lg Schaefer,47 and Johnson and his coworkerP have written extensive valuable monographic articles upon the foregoing problems. It is not our purpose to allude to these general propositions, Since it appears well established that the pregnant tubercular patient does as *Read

at

a meeting

of

the

New

York

Obstetrical 1319

Society,

Dec.

9, 1952.

Well

as

or

better

than

her

~uJl~~)IY!#IIa~~t

Sister”

!!’

I”

I3

We

M’ei’e

illwrested

in

determining whet~her the additional factor of prior or concurrent thoracic surgery for pulmonar:tuberculosis alters the obstetric situation. We also sought to learn if variables existed between the lpregnanc)- ancl mat,ernal outcome and the various types of major chest surger>-. It has been 45 years since t,he first modern thoracoplasty was performed in 1907 by Prieclrich”s at I~aura’s suggestion. Iieidrnhain49 is usually credited for doing the first successful. lohectomy in 1901. C:rahamJ” in this country in 1933 was the first to do a successful one-stage pne~ullonectollly. In the past twenty-eight years there has been an increasin g number of case reports of thoracoplasty prior to or during pregiia.iicy. It is unfortunate that these stndies range from a few well-cioclurlented articles to many others which mention in only a few lines their follow-up observat,ions about the outcome of pregnancy or the effect of repeated pregnancies upon the tubereulous process fol which the patients underwent operations. Thoracopla.sty was first, performed during pregna.ncy in 1924 by Saye.:jl The first to report about pregnancy following thoracoplasty was F. JessensZ in 1929. Since t.hese dates we have been able to collect from the world litera.ture 119 cases wherein thoracoplasty was performed during pregnancy or pregThirty-four of these pa.tients were nancies followed this type of surgery. operated upon during their pregnancieP> 64,“3 i0-7G and 85 additional patients were noted t,o ha,ve ninety-eight, pregnancies subsequent to their thoracoplasties.14s I68 3i, 52-69 The limited analysis of this experience is summarized in Table 1. TAsr,e 1. WORLD Imxna~u~~, PREGNANCY

/ TYPE OF SURGERY

J~obeetomg or Pneumonectomy During Ref ore Tl~oracoplasty During Before __Total .-___-

1

ABORTIONS

SPONTAEOUS

1

-

TO 1952 ___-

I-

OUTCOME I

THERAPEUTIC

1924

MATERNAL I

PREMATCRE BIRTII

OUTCOME LIVING

I

/ TERW BIRTH

ACTIVE DISEaSE

1 APP~:Em ACTIVF I DISEBRE ---

2 6 3 3

2

8 8

34 85 127

a

1

1

4 5

7 8

32 74 114

Tn. the world literature we have heen able to collect only one case of pneumonectomy performed during pregnancy. Thompson and Bressler of the Nelv \;ork Medical College performed the first pneumonectomy upon a pregnant womani in 1949 at the Metropolitan Hospital. This case is included in our study. Schaefer and Epstein’” reported one case of lohectomg during pregnancy. Six additional cases of pregnancy subsequent to lohect,omy or pnenmonectomy for tuberculosis have also been noted.s”

Volume 65

PREGNANCY

Number6

E’OLT,OWING

MAJOR

THORACIC

SURGERY

1321

Material From the records of the Metropolitan Hospital we have been able to assemble data upon a series of 25 women who submitted to major thoracic surgery during pregnancy or who became pregnant following extensive chest surgery for pulmonary tuberculosis. The period of time covered in this series was 95 months, Jan. 1, 1945, to and including Nov. 30, 1952. In this interim there were 13,770 deliveries and 236 cases of tuberculosis in term or near-term pregnancy including the 25 patients who were treated by thoracic surgical methods. The incidence of tuberculosis in pregnancy was 1 case for each 59 term or nearterm pregnancies, or 1.71 per cent. The incidence of tuberculosis at Bellevue Hospital was 1 case in every 56 pregnancies, 1.83 per cent, while that at New York Lying-In Hospital was 1 casein every 125 pregnancies, 0.82 per cent. These figures like those of other city hospitals are large, though comprehensible when we consider that our service provides obstetric care for the tuberculosis unit of the West Pavilion of the Metropolitan Hospital, the Chest Clinic of the Welfare Island Dispensary, and receives also a moderate number of tubercular pregnant women from other city institutions through emergency ambulance assignment. Further, it is routine on our obstetrical service to include an antepartum chest x-ray of every pregnant patient. The incidence of patients who had thoracic surgery prior to or concurrent with pregnancy was 1 case in every 551 pregnant women, 0.18 per cent of the total number of deliveries. Another factor to be considered in the higher incidence of tuberculosis in pregnancy is the race and social status of our clinic cases. In our series of 25 pa,tienhs there were 13 Puerto Rican, 4 Negro, and 8 white patients all of whom were indigent cases. Cur patients ranged in age from 18 to 39 years and three-fourths of them were 21 to 30 years of age (Table II). TABLE II. I AGE RANGE (YEARS)

Total

TYPE PNEUMOKECTOMY LOBECTOMY

15-20 21-25 26-30 31-35 36-40

AGE

DTJRING

/

2

1

2

/ DVRING

:

2

1

OF CHEST SURGERY / THORACOPLASTY

1 BEFORE

1

OF SOOTHERS

1;

NO.

I7

I

2:

CENT

4 40 36 12 8

9 3

1 I2

TOTAL / PER

1:

4 2

:

1 /

j BEFORE

I

100

Among the 25 patients in our series, 2 women had a lobectomy, 14 women Two a, pneumonectomy, and 9 women submitted to three-stage thoracoplasty. of the 14 operations for pneumonectomy were done during pregnancy. It is interesting to note that the remaining 12 women became pregnant 22 times following pneumonectomy. Two of the 9 patients who had three-stage thoracoplasty were operated on during pregnancy while the remaining 7 women were pregnant 13 times following this procedure. Nine of these 25 patients had more than one pregnancy. One patient bore 3 full-term children by cesarean section, had one therapeutic abortion, and is presently 8 months pregnant, all within the past 6 years. Three others each had 2 pregnancies. Another patient. was pregnant three times following resection of the left lung. There was, therefore, a total of 37 pregnancies concurrent with or following major thor;scic surgery. Twenty-one of the 25 patients are still living, a 16 per cent mortality. This is a considerably higher figure than assessedfrom the world literature,

in,. :. Obst, & Gynei. June, 1953

3.1 per cent.

However,

it may

be true

that

the unreported

ease is more

often

the one in which the result was poor. One of the four deaths occurred three months following delivery and may be considered a maternal death though the remaining 3 patients lived 12, 16, and 21 months following their delivery date. Johnson and associates33Ornstein and Epstein,14 Schaefer,7S and Cohen and co-workers40 reported 9.3, 14.6, 19.8, and 20.1 per cent mortality in all types of pregnant tubercular patients. With reference to our selected group Gutheil and collaboratorsso and Rubin and KlopstockTQ both reported 8.3 per cent late mortality in poslthoracoplasty nonpregnant tubercular patients. If we do not consider the deaths occurring later than one year following delivery our mortality is two cases, or 8 per cent. Both of t,hese deaths occurred in the thoraeoplasty group and both patients were primiparas. Of the remaining two Most authorities do not feel that patients who died! one was a, primipara. parity is a factor m the prognosis for the tubercular mother.40*73r75 Our figures are small a,nd probably insignificant on this point. Table III illustrates t,he distribution of these 25 patients according to the variety and time of chest surgery as related to pregnancy and the outcome of the mother and infant. TABLE

111.

NEW

YORK

MEDICAL

COLLEGE

JAN. 1, 1945,

SERIES,

_-.. PREGNANCY T;gsy

1 s;e;yEl

SI-RGERY

TERM DEAD

3

4

2

1 5

1 2

1

4

LIVING (IhoAPPAREKT ACTIVE / DISEASE

DEAD

1

1

1

1 10

1

1

2 10

1

1 10 23

1 1 4

1

6” 20

1 2

LIVING ACTIVE DISEASE

OUTCOME

BIRTH 1 ALIVE

1

Lobeetomy Pneumoneetomy During Before Thoracoplasty During Before Total

OCT. 31, 1952

MATERNAL

OUTCOME 'R::::?; DEAD 1ALIVE,

TO

I

There were 14 primigravidas, 56 per cent ; 6 primiparas, 24 per cent; and 5 patients para ii to para vii. See Table IV for this distribution as related to the variety and relationship of time of the surgery to their pregnancies. TABLE ~-__

PARITY Fira

IV.

PARITY

__-

0

Para i Para ii to iv RWX v to vii Total

I I

1

TYPE PNEUYONECTOMY

j LOBECTOMY

/

DURING

1

1 2

/ BEFORE 8

2

2 2

2

12

OF CHEST

SURGERY

THORACOPLASTY 1 DURING

TOTAL

/ BEFORE

2 2 2

7

1

NO.

14 6 4 1 25

1 PER

CENT

56 24 16 4 100

The 37 pregnancies were terminated as normal spontaneous deliveries in 17 cases,45.9 per cent ; by forceps delivery 5 times, 14.5 per cent ; by 7 elective iow-flap ceearean sections, 18.9 per centi ; one by cesarean hysterectomy because nf a ruptured uterus after a previous cesarean section. Five pregnancies were interrupt,ed, by dilatation and curettage in 4 instances and partial hysterectomy on one occasion, while the remaining 2 pregnancies were terminated as chest Spontaneous abortions. The interrelationships of t.he varieties of major surgery to the time of it,s performance and method of termination of pregnancy aYe demonstrated in Table v.

PREGNANCY

TABLE

METHOD OF TERMTNATION ._____ Normal

spontaneous

LOBECTOYY 2

FOLLOWING

V.

METHODS

MAJOR

THORACIC

OF PREGNANCY

SURGERY

TERMINATION

TYPE OF CHEST SURGERY PNEUMONECTOMY THORACOPLASTY DURING 1 BEFORE ) DURING 1 BEFORE

2

delivery Forceps delivery Elective cesarean section Cesarean hysterec-

5

1323

2

6

5 4

3 1

/

NO.

TOTAL 1 PER

CENT

17

45.9

5

14.5

7

18.9

1

0.8

5

14.5

2

5.4

t01Lly

Therapeutic abortion Spontaneous abortion Totall

1

3

1

2 2

3

19

2

11

37

100

The average duration of labor was roughly the same with multiparas as with primiparas, about 10 hours. Among the 17 normal spontaneous deliveries, 7 patients were in labor 0.5 to 4 hours ; 6 patients 4 plus to 12 hours, and in 4 cases the total labor duration ranged from 19 to 24 hours. All but one of the 5 forceps deliveries were outlet forceps with a range of time in labor of 2 to 13 hours; the single patient delivered by midforceps labored 23 hours. The average duration of labor in the I7 normal spontaneous deliveries was 8.7 hours while the average duration of labor in the 5 forceps deliveries was 11.6 hours. Six of the 7 low-flap cesarean sections were performed before labor while the seventh patient was in labor but 4 hours while enroute to the hospital. Three of the elective cesarean sections were repeat operations while a fourth was performed because of a fulminating severe pre-eclampsia with a blood pressure of 230/110, 4 plus proteinuria and 4 plus edema refractory to medical therapy during the thirty-second week. The remaining three cesarean sec,tions were performed early in this series prior to our ultimate policy of awaiting a test of labor. As previously mentioned, one patient had a cesarean hysterectom;y, after being brought into the hospital as an emergency and with a history of a prior section. All the therapeutic abortions were performed between 1.946 and 1950. Pudendal block was performed on 8 occasions, gas-oxygen-ether was administered to only one patient, 5 patients received no anesthesia or analgesia because of very rapid labors, 13 received supplemental Demerol while all who had low-flap sections were given a spinal anesthetic except one operated upon recently with local infiltration. The maternal obstetric complications in addition to the concurrent or previou.s chest surgery included one case of ruptured uterus, one case of severe pre-eclampsia and two spontaneous abortions at 2 and 2.5 months. One patient also was treated during pregnancy for secondary syphilis. Dyspnea during pregnancy or labor was not a factor in any of our cases. This agrees with the Mueller,59 findmgs of Seeley and associates w but not with those of Jameson, Boquist and co-workers,62 McIntyre,68 and Koske,66 among others. The time elapsed between the first major chest surgery and the first subsequent pregnancy was 1 to 3 months in 4 cases; 7 to 12 months in 2 cases; 1 to 3 years in I4 cases, and 3 to 4 years in 5 cases. Table VI shows the distribution of this time interval.

Among the 37 progeny of these 25 mothers 7 resulted in therapeutic or spontaneous abortions and each fetus weighed less than 500 grams. There were 4 infants born with premature weights, 11.8 per cent, and 3 of these babies are still alive, 75 per cent. This is hardly more than the usual incidence of premature births of all types. The one premature deat,h of the 2,100 gram baby occurred on the third postpartum day. There were 26 near-term or at-term infants all of whom weighed more than 2,500 grams, 70.3 per cent, and 24 of these 26 infants were presently alive a,nd well, 92.3 per cent. These two deaths included the 2,900 gram still born infant of the patient with the ruptured uterus, while the second infant died at the age of 15 months of tuberculous meningitis. Parenthetica,lly, it is noted that t,he mother of this infant is alive and exhibits no signs of active clisea,se, while the father to whom the care of the baby was The smallest baby welghed entrusted also died of tuberculous meningitis. I>480 grams and the heaviest 3,930 grams. The average birth weight was just over 3,000 grams which is about the average birth weight among our predomiTable VII illustrates the weight, of nantly Puerto Rican and Negro patients. the infants to the time and t,he variety of chest surgery on the mother.

WEIGHT IN GRAMS

/

PNEUMOKECTOMY

1

!JliRING

1 BEFORE

1

5

1

1

1 I

1

6 4 0

0

3

19

I,OBECTOMJ-

Relow 500 l.,OOO-1,500 1,501.2,000 2,001.2,500 1,501-3,000 :-q1-3,500 3,5lll-4,000 Total

--2

I1

..-~3i ~

100

Two of the 4 deaths 01 mothers were caused by the development of bronehiogenic fistula with massive pulmonary collapse 3 and 12 months following delivery and 21 and 24 months, respectively, following their primary major thoracic surgery. One mother died of widespread pulmonary tuberculosis 57 months after a lobectomy and 21 months post partum. The remaining mother died of far-advanced generalized tuberculosis with amyloid disease of the liver and kidneys 29 months following her three-stage t,horacoplasty and 16 mont,hs following her delivery. Table VIII illustrates a summarized analysis of these dea.ths.

Volume Number

65 6

PREGSANCY

FOLLOWING TABLIE

STUDY -__

CASE

NO.

TYPE OF CHEST SURGERY

MAJOR

VIII.

&~ALYSIS

THORACIC

SURGERY

OF DEATHS

OF MOTHERS

DATE OF CHES'1 SURGERY

DELIVERY DATE

Lobectomy

sept*,

1946

Sept.

15

3 stage right thoracoplasty

Dec.,

1946

Jan.

17

3 stage left thoracoplasty

May,

3945

June

14, 1946

27

Resection of right lung

E'eb.,

19‘49

Feb.

2, 1962

3

14, 1949

1, 1947

1325

DATE AND CAUSE OF DEATH OF MOTHER

June 13, 1951. Far-advanced pulmonary tuberculosis Jan. 2, 1948. Bronchiogenic fistula, pulmonary collapse Oct. 4, 1947. Far-advanced tuberculosis ; amyloid disease of liver and kidneys May 11, 1952. Bronchiogenie fistula, pulmonary collapse

Among the surviving patients there is but a single one exhibiting evidence of tuberculous activity while in the remaining 20 cases there is no demonstrable evidence of reactivity of tuberculosis. Summary Olver a period of 95 months, Jan. 1, 1945, to and including Nov. 30, 1952, there were 25 women who became pregnant 37 times during or subsequent to major thoracic surgery employed to control extensive unilateral pulmonary tuberculosis. The three major chest surgical procedures considered in correlation with pregnancy included lobectomy in 2 cases, pneumonectomy in 14 cases, and This series is compared to 119 cases of three-stage thoracoplasty in 9 women. thoracoplasty and 8 cases of lobectomy or pneumonectomy during or prior to pregnancy derived from the literature. There were 4 maternal deaths in our series, 16 per cent. Among the 37 progeny there were 10 infa.nts lost through abortion, spontaneous on 2 occasions, therapeutic in 5 instances, one stillbirth following rupture of the uterus, and 2 infant deaths; one infant died of prematurity at 3 days and one 19Among the 21 surviving month-old infant died of tuberculous meningitis. mothers only one exhibits tu.berculous activity after pregnancy following or concurrent with major chest surgery. These figures compa.re favorably with those collected from the literature.

Conclusion In conclusion we reiterate that our original goal was to determine any possible interrelationship between pregnancy subsequent to or concurrent with maFrom the obstetrical viewpoint jor thloracic operations on tubercular patients. solely there are four principal findings : 1. Pulmonary tuberculosis can be treated prior to or during pregnancy with major thoracic surgery without jeopardizing bhe pregnancy. 2. Major thoracic surgery for pulmonary tuberculosis prior to or during a pregnancy is not an indication for therapeutic abortion.

FOLSOME

1326

AND

KUNTZE

.im. J. Obsi. 24Gym June,

1953

3. The e~urse of i&or, the management at delivery, and the prognosis for the infant do not differ from those in the tubercular patient who has not undergone such surgery. 4. The evidence seems to indicate that lung resection is a more favorable procedure than thoracoplasty with regard to the maternal outcome in a subsequent pregnancy. We wish to extend our gratitude and appreciation to Dr. Salvatore Carrabba, former resident at the Metropolitan Hospital, Department of Obstetrics and Gynecology, for his assistance in partial collation of clinical records, and to Miss Eva Ader, Medical Social Worker, Welfare Island Dispensary, Metropolitan Division, for her splendid efforts in, making possible the complete accuracy of the follow-up of patients and their infants in this study.

References 1 i: 3. 4. 5. 6. 7. 8. 9. ii). il. 12. 13. 14. 15. 16. 17. 18. 19. “0. 21. “2. 23. 24. “5. 26. 27. “8. 29. :?O. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 13. 44. -15. 46.

Dumarest, F., and Brette, ID.: Presse mgd. 30: 531, 1922. Forssner, H.: Rev. de la tuberc. 5: 730, 1925. Hill, A. M.: Am. Rev. Tuberc. 17: 113, 1928. Schrag, E.: Ztschr. f. Tuberk. 51: 119, 1928. Barnes, H. L., and Barnes, L. R. P.: AM. J. OBST. & GYKEC. 19: 490, lY30. Marshall, 6.: Brit. M. J. 1: 140, 1931. Marshall, G., et al.; Lancet 1: 186, 1931. Forssner, H.: Acta gynec. Scandinav. 3: 256, 1932. Jennings, F. L., Mariette, E. S., and Litzenberg, J. C.: Am. Rev. Tuberc. 25: 673, 1932. Jameson, E. M.: Gynecological and Obstetrical Tuberculosis, Philadelphia, 1935, Lea & Febiger. Omstein, G. C., and Kovnat, M.: Am. Rev. Tuberc. 31: 224, 1935. Royston, G. D., Jensen, J., and Hauptman, H.: Ar& 5. OBST. & GYNEC. 34: 811, 1937. Jameson, E. M.: AI& J. OBST. & GYNEC. 36: 59, 1935. Omstein, G. C., and Epstein, I. G.: Quart. Bull. Sea View Hosp. 4: 420, 1939. Mathews, H. B.: Am. J. Surg. 48: 23, 1940. Mariette, E. S., Larson, L. M., and Litzenberg, J. C.: Am. J. M. SC. 203: 866, 1942. Cohen, R. C.: Brit. M. J. 2: 775, 1943. Hull, E.: New Orleans M. & 8. J. 96: 321,1944. Friedman, L. L., and Garber, J. R.: Am. Rev. Tuberc. 54: 275, 1946. Cohen, R. C.: Brit. J. Tuber& 40: 10, 1946. Bridge, E. : Am. Rev. Tubere. 35: 471, 1947. Barone, C. J., Fino, J. A., and Hetherington, L. H.: AM. J. OBST. & GYNEC. 54: -lS& 1947. Bluhm, I.: Acta med. Scandinav. supp. 197: 1,1947. Schaefer, G.: S. Clin. North America 27: 461, 1947. Morris. C. C.. and Landis. H. R. M.: J. A. M. A. 70: 362. 1918. Rist, E.: Rev. de la tub&e. 2: 244, 1921. Mathews, H. B., and Bryant, L. S.: J. A. M. A. 95: 1707, 1930. Ferguson, J. H.: Edinburgh M. J. 39: 165,1932, Flovd. C.: New Eneland M. J. 212: 379. 1935. Poliack, B. S., and Potter, B. P.: Tube&e 21: 128,194O. Roe, I. R., and Morris, S. I.: Dis. of Chest 6: 327, 1940. Cutler, J. W.: AM. J. OBST. & GYKEC. 47: I, 1944. Johnson, H. E,, Burch, J. C., Bayer, D. S., and McClellan, G. S.: J. Thoracie Burg. 17: 646. 1948. McIntyre, J. P.: Edinburgh M. J. 56: 615, 1949. Turner, H. M.: Lanoet 1: 697, 1950. Skillen, J., and Bogen, E.: J. A. M. A. 111: 1153, 1938. Seeley, W. F., Siddall, R. S., and Balzer, W. J.: AM. J. OBST. & GYNEC. 39: 5, 1940. Falls, F. H. : Dis. of Chest 7: 360, 1941. Cooper, D, A.: M. Clin. North America 29: 1454, 1945. Cohen, J. D., Patton, E. A., and Badger, T. L.: Am. Rev. Tuberc. 65: I, 1952. Schaefer, G.. and Eustein, H. H.: A&l. J. OBST. & GYNEC. 63: 129. 1952. Cohen, R: C.! Brit.&M. J. 2: 751, 1936. Seeley, W. F., Siddall, R. S., and Balzer, W. J.: AX J. OBST. & GPNEC. 37: 741, 1939. New England M. J. 226: 224, 1942. Baker, R. H., and Ward, A. N.: Stewart, C. J., and Simmonds, F. A. H.: Brit. M. J. 2: 726 1947. Bull. New York Acad. Med. 26: 721, 19!iO. Studdiford, W. E.: I

-~

PREGNANCY

FOLLOWING

MAJOR

THORACIC

SURGERY

1327

47. Schaefer, G.: Obst. & Gynec. Surv. 6: 767, 1951. 48. .Friedrich, P. L.: Verhandl. d. deutsch. Gesellsch. f. Chir. 37: 534, 1908. L.: Verhandl. d. deutsch. Gesellsch. f. Chir. 30: 636. 1901. 49. .Heidenhain. 50. Graham, E.‘A., and Singer, ,J. J.: J. A. M. A. 101: 1371, 1933. ’ Saye: Cited by Busch, F.: Beitr. z. Klin d. Tuberk. 74: 223, 1930. Z: Jessen, F.: Ztschr. f. Tuberc. 53: 214, 1929. 53. Busch. I?.: Beitr. z. Klin. d. Tuberk. 74: 223. 1930. Bull, P.: Dia med. 5: 729, 1931. 2: .Riemer, K.: Beitr. z. Klin. il. Tuberk. 78: 184, 1931. 56. Albert& L. : Med. Welt. 6: 1137, 1932. ’ f. Tuberk. 63: 152, 1932. 57. (Jessen, H. : Ztschr. 58. Hiebert, H. J., and Hastings, J. R.: Journal-Lancet 52: 328, 1932. H. C.: Med. Welt. 6: 1756, 1932. 59. Mueller, 60. Haymaker, W.: J. Thoracic Surg. 3: 322, 1934. G. C.: Gazz. internaz. med.-chir. 44: 15, 1934. 61. Vanucci, H. S., Simons, J. H., and Myers, J. A.: Am. Rev. Tuberc. 31: 48, 1935. 62. :Boquist, 63. Blisnajkaja, A. I., and Lasarevetch, A. I.: Gym%. et obst. 34: 207, 1936. America 20: 811, 1936. 64. Kovnat, M. : M. Clin. North 65. .Harttung, H.: Zentralbl. f. GynLk. 62: 2865, 1938. Beitr. z. Klin. d. Tuberk. 93: 392, 1939. 66. Koske, T.: 67. Stefanezik, 8.: Wien. klin Wchnschr. 56: 254, 1942. 68. ‘McIntyre, J. P.: J. Obst. & Gynaec. Brit. Emp. 5~5: 445, 1948. A. L., Cosgrove, R. S., and Cosgrove, S. A.: Virginia M. Monthly 78: 8, 1951. 69. .Kruger, Cited by Amorin, A.: Rev. de phtisiol. 15: 461, 1934. 70. :Rist, E.: A.: Rev. de phtisiol. 15: 461, 1934. 71. .Amorin, A., and Chabeaux: Rev. m&l. de Nancy 65: 30,1937. 72, Guillemin, 73. ISchaefer, G., and Law, D. E.: Quart. Bull. Sea View Hosp. 6: 65, 1940. Beitr. z. Klin. d. Tuberk. 102: 127, 1949. 74. iSeeger, J., and Jahn F.: 58: 503, 1949. 75. Schaefer, G. : AM. J. OBST. & GYNEC. 76. McIntyre, J. P.: J. Thoracic Surg. 19: 882, 1950. 77. ‘Thompson, 8. A., and Bressler, S.: Surgery 26: 24,1949. AM. J. OBST. & GYNEC. 64: 188, 1952. 78. )Schaefer, G., and Epstein, H. H.: Am. Rev. Tuberc. 60: 273,1949. 79. Rubin, M., and Klopstock, R.: 80. (Gutheil, D., Steele, J. D., Cadden, A. V., and Sakaguch, 8.: Am. Rev. Tuber-c. 62: 645, 1950. 1249

FIFTH

AVENUE,

NEW

YORK

29,

N.

Y.

Discussion DR. ALFRED C. BECK, Brooklyn, N. Y.-From the changes that take place normally in pregnancy which alter the thoracic cage, and result in an increase in vital capacity, we would think that interference with these changes would jeopardize the chance of having a living child. I was, therefore, surprised to see the results in this respect. Were any tests made of vital capacity, tidal air, and so forth, in the course of the pregnancy in these cases? Do you think, as a result of your studies, that pregnancy should be permitted in such parents? We all dislike abortions but most of US do not hesitate to advise contraception. Experience such as you have reported might lead us to recommend the avoidance of pregnancy in some of these cases. Is that your opinion?

DR. I. C. RUBIN, New York, N. Y.-This report can be reckoned as an item of progress because certainly the relationship between thoracic surgery for tuberculosis and the eventuality of pregnancy is not commonly known in obstetric practice. I should have been at a loss in the management of such a patient. Although twenty-five cases is not a large series, this combination is probably going to occur more often in the future because tuberculosis of the chest will be attacked more and more safely and successfully. DR. SAMUEL A. COSGROVE, New York, N. Y.-Dr. Rubin That is, of course, true, but thoracic surgery itself small series. the speci.alties, and up to this time has had only limited application much less to tuberculosis in the pregnant woman. Dr. Folsome’s reported from any single clinic.

has said that this was a is one of the infants of to tuberculosis itself, series is the largest yet

l-Y~1230YE

132i-s

.iN)

\,I,.

KlTNT%E

‘.

Oh.

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DR. ROBERT 8. MILI,EN, Westbur>v, I\‘. Y.--Tul~ercu!osis chest surxey films are a [“erequisite for admission to the obstetrical section of The North Country C’ommunit)Hospital in Glen Cove. During t,he past six years more than six thousimd x-ray pictures have been taken and, although a small number of lesions have been found and shown by additional large films to be apical fibrosis or a minimal healed tuberculous lesion, there have actually been found only two lesions of active tuberculosis. I mention these figures to point out that active tuberculosis is not as common in all localities.

quite

DR. F. C. FREED.-To different than at Harlem

answer Dr. Hospital.

Millen’s

point,

the population

he has in Glen

Core

is

DR. HENRY 8. ACKES, *JR., Brooklyn, K. Y.-It has been my good fortune to have some experience with this problem of tuberculosis in pregnancy. Some of those patients have had thoracoplasty operations and they did well. I would like very much to substanti.ate the statement made by Dr. Folsome in regard to these patients. They go through their pregnancies and n?thstand normal labor extremely well. One thing that should be stressed is the fact that these patients should not be sub ,jectod to undue labor, but should have cesarean section if there is evidence of uterine inertia or any marked pelvic disproportion. Since my small series mere all pril-ate patients and were cared for by phthisiologists, we have been able to follow them veq rarefully throughout a long period. There have been no deaths whatever over that extended period of time. The incidence of prematurity has been low, as Dr. Folsome has suggested, and the lmbies have done extremely well. One of the things that impressed me very much in going over my owr! series was the fact that the babies were unusually large. The vast majority of them weighed 8 pounds or over. DR. CHARLES M. MeLANE, New York, N. Y.-I can add nothing to Dr. Folsome’s paper because I have seen no patients delivered after major thoracic surgery for tuberculosis. I can corroborate Dr. Posner’s figures on the increase in the incidence of undiagnosed pulmonary tuberculosis picked up by the routine x-raying of all obstetrical patients in the obstetrical clinic of the Kew Sork Hospital. In the past 1 or 5 years our incidence It is possible that if routine chest x-rays were has increased from 0.5 to 1.5 per cent. raken on all obstetrical patients, more of them Rould not later have to have thoracic surgery. DR. ARTHVR V. GREELEP, Xew York, ?rT. Y.-I have a very small series of cases, in fact consisting of one patient with a pneumonectomy. This patient presented a problem because she had very marked tachycardia and very low vital capa& and was unable to lie flat in bed. She presented more of a problem from a cardiac standpoint than from the pulmonary. 8he had a positive sputum during the latter part of her pregnancy. When she came to delivery, the labor was very easy and uneventful. She was a primipara. She was delivered in a semi-upright position with pudendal b1oc.k and low forceps. It is about three years now, I think, since delivery and she has done well. The baby has done well. I wondered if that problem has presented itself in any of your cases, the question of tachycardia and low vital capacity. DR. BERNARD J. PIMNI, Kew York, 9. T.-I thought you would be interested to know that within the structural framework of’ the Veterans Administration, with its tremendous numbers of tubereulous veterans, about one-twelfth of the veterans’ population with tuberculosis are women. They have had, within the last 24 mont,hs, 12 patients throughout the country who have had pre@lancies after major surgery, with results that, as far as I know, concur with Dr. Folsome’s results. Within the past year here in this city there have been two patients with segmental resections who have been delivered with good results. &~e was done by Dr. Ch:iml,ers and one by Dr. Miscal.

Volume

65

Number 6

DR.

PREGNANCY

FOLLOWING

MAJOR

THOR’ACIC

SURGERY

1329

FOLSOME (Closing).--We did review the vital capacities of these patients. We aware then that this aspect of these cases was of more value in a larger series of cases than in this special subseries. In a subsequent paper concerned with 236 cases of tuberculosis associated with pregnancy we plan to evaluate the more detailed vital capacities with the phthisiologists. Because of the variables in these problems we conAned the present paper exclusively to the obstetrical aspects in this special group of women pregnant following major surgery. In reply to those who inquired about tachycardia and dyspnea itself, we found no significant change in any of these 25 patients though we did make a meticulous search for these particular symptoms. In a review of these cases we could find no unusually different pulse or respiratory rates from those seen in normal labor. AS Dr. Freed pointed out, we did note an increased incidence of tuberculosis in the pregnant clinic case4 as opposed to the private cases, 1.71 per cent as opposed to 0.8 per cent. At Bellevue Hospital, a city institution much like ours, the rate was 1 tuberculous pregnant patient to each 56 nontuberculous maternal cases. At Metropolitan the incidence was 1 to 59 cases while at Sew York Lying-In Hospital the rate was 1 cas:: in 125 maternal cases; or half as frequent. In regard to our choice of method for termination of pregnancy we find, as Dr. Acken so well points out, that cesarean section is definitely not the answer. During the first four years of this study the section rate was higher primarily because the obstetricians permitted the thoracic surgeons to decide that cesarean section was the approved method of termination of pregnancy. Since 1950, however, and up to the present time, our obste-trieians have individualized every case primarily upon their obstetrical judgment. It is int,eresting to report that they have, since 1950, obtained a lowered section rate. In fact, excluding one patient sectioned primarily because of an abruptio with a fulminat,ing toxemia, the only sections done in this type of case were in those patients who had been delivered by eesarean section earlier. Thus the main indication in this small group was repeat section. Earlier, the added socioeconomic factors of the pregnant tubercular patient evidently did enter into the medical decision to interrupt such pregnancies. These have not been factors in the past four years. Between 1915 and 1950 there were 5 therapeutic abortions in this small series of patients; however, since 1950, during which period we have had more pregnancies in patients following major thoracic surgery, there were no therapeutic abortions. in our experience, to be more easily tolerated by The obstetrical burdens appear, patients whose tuberculous process was treated by lung resection. The burden of pregnancy seemed to be less well tolerated by patients previously treated by three-stage thoracoplasty. We note that the lung resection group, however, were generally younger, so that age and a lessened prior surgical trauma may be partly responsible for our better results in the pneumonectomy group. The thoracoplasty group in our series fell principally in the age range of 26 to 31 years, while the lung resection group were on the whole several years younger. Likewise, the prior tuberculous process had existed longer in the thoracoplasty group, hence the degree of tissue destruction or surgical trauma may be an additional factor. Again, in summary, we subscribe to the principle that the management of each pregnancy is a highly individualized process and that tuberculosis treated by major thoracic does not alter our subsequent obstetrical surgery and controlled properly 7 by this means management.

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