The management of the prenatal and the postnatal cervix

'riiE MANAGEMENT OF THE PRENATAL AND 'l'HE POSTNATAL CERVIX MARIO

A.

CAsTALLo.

M.D.,

AND THADDEus

PHILADELPHIA,

L.

:MoNTGOMERY,

::VLD.,

p A.

(Frmn the Department of Obstetrics, ,Jefferson 11fedical College Hospital)

HE purpose of this presentation is to discuss the problems of cervical disease as they are met in obstetric practice, and to define the responsibilities of the obstetrician who has to deal with them. The substance of the paper is based upon observations which have been conducted in the department of obstetrics of the ,Jefferson Medical College Hospital during a nine-year period. Contributions that have been made by this clinic to the study of cervical pathology from time to time are incorporated, and the methods of treatment that are now in vogue are described. The two types of cervical disease which concern the obstetrician in modern day practice are the inflammatory and the precancerous, or cancer predisposing. Of the two, the inflammatory lesions are a particular consideration of the antenatal period and the cancer predisposing of the postnatal. In a publication five years ago, Dr. J. Bernard Bernstine and one of us (Montgomery) discussed the importanee of cervical infection in obstetrics and presented the results ·which ·were obtained from 1925 to 1928 in a special clinic for the treatment of gonorrhea complicating pregnancy. The results proved quite satisfactory in the lo'wering of puerperal morbidity and in the lessening of ophthalmia neonatorum. An outstanding feature of the study was the proof that the cervix can be treated without danger to the mother or to the embryo. Abortion, miscarriage, and premature labor occurred no more frequently among the treated patien1s than in the others of the service. These findings encouraged us to continue with our efforts to treat cervical inflammation of thi::; type and better prepare the birth canal for delivery. A recent revie"T of our statistics reveals that from 1928 to 1932 the laboratory diagnosis of gonorrhea (positive smear) was made in 84 of the 3,586 patients who were later delivered under our supervision. In no instance among these 84 patients treated for gonorrhea complicating pregnancy did ophthalmia neonatorum occur in the newborn. During the same time there were fifteen eases in the nontreated patients. In two of the 84 treated patients pregnancy terminated prematurely, once by abortion and once by premature labor.

T

37

38

AMERICAN ,JlWHNAI, OJ<' OB:-;TETIUC:" A:'>Tl OY:-.:E('Ol.OG'\:

We concluded that it i~; rperal JWl'iod. ME'l'HOD

'l'he treatment consistH of certain mrusun·,.: ,,·hidt art) perfomwd hy the patient in her home, and otlwrs \vhieh are eondw·tod in the antenatal clinie. The home care consists of a daily Lugol 's solution douche ( J teaspoonful of liquor iodi compositu,.: to 2 quarts of warm boiled water) :ulministerod with a ,; pt>r t·ent watery solution of mercuroehrnmB or a, 1 : J 000 wa,tery solution of nH'ta ph en. The solu· tion is earried with a Rwa b well up int1.1 the n•rvkal canal. With a i\econd small swab it is instilletl in the anterior portion of tl11' urethra. 1f tlw. granulationli of an ukeratt:J <·enix are etl'usive, they ~m' tuudwtl up lightly ll'it.h the electri•· eautery.

We have no hesitancy in applying this same treatment to the nonspecific infections of the cervix in pregnancy. Any doubt as to the infective nature of these lesions is dispelled by histologic study of the involved tissue. In 20 instances vve collected tissue for biopsy from cervices of this type. Exam]nation of the histologic sections revealed in eaeh instanc<~ desquamation or: the squamous epithelium, purulent fluid exuding from tlw eervieal glands, :md an extensive leucocytic infiltration of the adjace11t ('erviral stroma. 'l'he picture iR that of an opPn ulerr (11-,igs. 1 and 2). 'l'hese nonspecific infections of the eer·vix ehallenge thr watchfulness of the obstrtrician and also c•all for active treatment. In such instances more relianeP is to be placed upon the prenatal care than upon the practice of trying to sterilize the birth canal at the time of labor. While not h1 anr 1va~· minimizing the impt•rtance of careful antiseptic preparation of the birth l'anal at the timf' of delivery, it is ,'lo obviously impossible to carry lllP11ication into the infected lumina of the cervical glands that the prac·.t ice of repeatedly instilling antiseptics into the vaginal tract during the <·ourse of labor and especially of massaging them into the cervix appears not only futile but also not E>ntirely devoid of danger. The paramount eo!lcern of the labilr period is earefnl management and conservation of the defenf'iVP fot'!'(!S of the vatieni. Of particular importance to this end are thf' following pointR: first, preservation of the membrane::; and noninterferelll't' in the ::;tagf' of !l ilatinp:, a strict policy of "handR off" dming th(~ tinH' that nature i8 gently thinning and dilating the cervix; second. a reasonably prompt delivery of the fetus when the stage of dilatation is completed; third, careful atten-

CASTAI,LO-MONTOOMERY:

I'REKATAIJ A::-
3!)

tion to the placental stage with prompt expulsion of that organ wh en it has separated from the wall of the uterus, a policy which calls for arrest of anesthesia and postponemrnt of repair until the third stage is complrtrd and the empty uterus firmly rf'tracted; fourth, tampon-

Fig. 1.-Acute ulcerative encloccr-,·ic itis complicating pregnancy. Note the loss of squamous epithe lium, the pus exiHling from th e cervica l gla nd, th e extensive leucocytic exudate in the stroma. ( l'hotomierograph 60 x.)

Fig. 2.-Acute ulcerative enrJoc;,rvicitis compliC'ating· pregnan(·y. High-er power magnifica ti on t a k<'n n t the o.~tium or th• · ,.,.,·v ical g-lan
age of the uterus wh e neY(~L' that orga.n fails to contract properly or when moderate bleedi11g occurs; fifth. ayoidance of exposure or manipulation of the cervix after dclivel'y excPpt for the purpose of arresting traumatic hemorrhage.

40

AMERICA:\" .TOrR:\" AL

0~'

OBSTETIUCS A K T> C \'0: Ef'OLOGY

'\Vt• haY e bee 11 partieHlal'ly in1t • r <' ~tt ' d iu thP rff PI't that pt·emature l'llptlll'P of t!JP lllt>lllhl'
Fig. 3.-.\cuh· infl :llllll J"tiun of tltt: mar~in o t' tiH' p la •:•·n t". filtra tion extend ing· f r u lll th t• 111 t' lllbra rw~ t o ttw c.·onv~pnn
~"'ig.

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l a ;·e r~

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( Photl) nJi<: J'OgTa ph ;,7 )<. .)

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uf a

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of the intinn1, tht~ lllU Sele w a ll , a n (l lh t~ p!·l'i\'H:·wula r ti ~Slh ' tlf on tht-' f etal ::-nrf:lf~P of t he plrH·t:-ntn . ( Ph ntn n1krog-raph 411 :">\ . J

Lt~uvul·-vtic n tH• o f 'tht~

inftltr·ation

hu·ge ve ins

1wral morbidit~· ha~ hn' n ft· t•qHPntl~- • · tnpliCI~izt' d. hut the pat·t they play in et'eating· ksiom; of th P plaePnta and fPtal t'irenlation has not been so well re<:ognized.

CASTALLO-MONTGOMERY:

PRENATAL AND POSTNATAL CERVIX

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Significant contributions in the latter field have been made by W arnekros, Siddall, Slemons, and others. The attention of one of us (Montgomery) was directed to the problem during the course of a histologic study of 650 freshly delivered placentas. In 67 specimens of this group ( 10 per cent) acute inflammatory lesions were found . The inflammatory reaction apparently develops during the course of labor and is associated particularly with instanees of premature rupture of the membranes, prolonged labor, and difficult operations of vaginal delivery. The infection apparently beg-ius in the membranes at the margin of the cervical aperture, ascends to the edge of the placenta (Fig. :3 ) , is taken up by tl1e fetal vessels of the placenta (Fig. 4) , gives rise not infrequ ently to thrombophlebitis of the cord vein (Fig. :) ) .

Fig. 5.-Acute thrombophlebitis of cord vein. Leucocytic infiltration in the interstices of the muscle wall a nd intima . Meshwork of fibrin and leucocy t es p1·oj ecting into the vessel lumen.

As a result of this infection of placental vessels, fetal bacteremia may develop (Kobak) and neonatal illness or death occur. The manner in which the inflammatory h•sion starts at the margin of the cervical aperture emphasizes again the importance of the cervix as an etiologic focus of disease. CANCER PREDISPOSING LESIO:-
The conclusion of labor t!'rminates the obstetrician's ehance to forestall the ravages of cervical infection. The patient's fate, thenceforth, depends upon the strength of her resistance and 11pon the virulence of the bacteria which inhabit her birth canal. The attention of the physician is now directed to measures of restoration, restoration of the pelvic floor and perineum to their cus-

tomary eonfigm·ation, mul part i<·nlarly of lilt• t'<'l'Vix to a ttormul 1mlliparom:-likP <·e that prenatal treatnwnt of tltP infPetPd eenix is llt'l:f•ssary for tl!P pl'<'Yl'ntion ot ]mt>qwral inft•t•tion. so also is po;.;hwlal l't•storatioll of tht• ePrYix l'!'· qnirPd for 1l11• ]WP\'t•ntion of t't'l'l'i•·nl I'Hllt't'l'. If ow· t·onld ;.;aft•ly St' and ,ntnre 1lw <;en;ix aft<>r dPliYPr~-, primat·,\· rt•]mit· .,f tlti" ,.Jtilllllt>l wonl111' <'XJll'l'l<'lH'P thai sndt mtwatTanted rislr •lt>lin•r.\· tltat JllOJ'l' i;-: lost in 11tt• ront inr· applieation of this proeednn· thm1 i;.; g·aill<'d i11 th•· i'<·w ••nses llwt at·t• f Sllilll'l'. \VI' find \'t•t·y fE'\\' \'IIS!.'S of' I'Xl<'!L'>in• 1'1'1'\'ll'iil dcl!llilg'P whPil til<• <'Ont'S<' of labor ltas h<'<'l! proJH'i'l.'· (•nwluet(•d t)ur immeclifltsions is 1hP !.'tmization mt"thod of Hymu:-<. ]\fore extensiYI' rl<•g'J'<'t's of <·eryieal dmnH g·p ;n·p ll111l'l1abiP tn eorreetion hy intPJ'llll'diate m· s<'<'OJHl satisfadory. 'l'Jw opt•ration is o[J<•tJ follo\Yl'tl h.'· n liiOI'hi1l l<'lliJH'l'ahil't' n•ae1ion, llowPYer. aml tlH' stn~- i11 till' hospital i:; (•onsi;l(•rahl.>· p1·nlmlgt'1L RPpair prrfornwd SP\'Pral Jllnnths aflt•r atPl' signifi<·ant·<· as more srientifi<· nwtlwth: of st1td~· lun P lw1•n th•,·isPd. PanieHlarl,v iN this true in thP tll't!;l'tinn or (•('J'Yll'al pHtho!og-y. Tile fiJH]ings ot: JW]Yit• ('Xaminlltion !tan liCit hPPll hi1Jwrto ('()J1lj)ll'tt•Jy satisfal'tory. Lt>sions haY!' lw!'ll df't•~dPd nnl,\' in tlwir full;' deYf'loped state. ..:\s a result, out of fjy,. wonwn upon ,,·hom a !liag·nnsis of eareinoma of the <·PrYix is ma!k. foul' dit• within ilY<' .\'f'at·s.

CASTALLO-MOXTGOMERY:

PRENATAL A~D POSTNATAL CERVIX

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It is now agreed that if we are to lower the mortality rate from it will have to be clone by making the diagearcinoma of the nosis earJier, and by prophylactic measures. ~urgery and radium in the treatment of this disease entity seemingly have rea<~hed their height of nsefulneHs. In spite of propaganda to the laity, and the furtherance of the regular medical examinations, there has been uo apprrciable reduction of the dt'ath rate. \Vhile it is true that more and more eases are being diagnosed than there were ten years ago, nPVE'rtheless they are being SCl'll too late for pffective treatment to a Iter materially tJw percE>nta ge of cures. It has been said that a latent pE'riod of earcinoma extends over a pet·iorl of years lwfon' the (lisrasc bceoml'S a elinieally demonstrable entity. Bland states that mice sub,jeeted to long-continued irritation b~' tar will deYPlop newg-rowtlts in about f\ix months, one-sixth the nonna l span of a mouse's life. AppliN1 to man, this would correspond to from ten to fifteen years. This statement is supported by obRervations on occupational carcinoma, which do not manifest themselves until ten to fifteen ;Hars after the occupation haR bePn started. Periodic yaginal examinations. as they are done today, and biopsy of the cerYix are doing· much to hri11g individnals to early treatment. As a rule, however, it is not rarly enough. If we are to dett>ct the small areas of early carcinoma whieh are present before ulceration occurs, >Ye must look to methods not in general nse. 'l,o this end Hinselmann designed the "colposcope" and reported upon its use in 1H28. Closely following this treatise Schiller advocated the usc of Lugol'ii solution for the detection of clinically undistinguishable careinoma of the cervix. By these methods, it is rlBimed, a suspicions Ht'Pa is more rasily detrcted, and biopsy more accurately procured. TECHNIC OP TEST

We began the study of the cervix with the Schiller test some five montlt8 ago. After experimenting with the colposcope, various types of lenses and lJinoeulars suggested by Hirst, \Ye deyeloped the fo1lowing· pweedures: A preliminary examination is made without lubricating the fingers, and a ;;;peeulum is inserted without the use of lubriennts. 'rhe cervix is wiped clean of mucus with n swnh of absorbent cotton, care bP.ing taken not to traumatize the epithelium. TlH' R:tmt' type SW3b is illlllH'T~etl in rull strength Lugol ,, ~nlution (other en tried without the same degree of snc,·ess) ana the entire eervix is bathed, making- sure that the surrounding areas are indudecl. E;;pe•oially m'e we careful to distend the folds 5urrounding the een·ix so that the entire area i~ well Fltained. After u. minute the oxePss is remoyerl with ahsorlwnt l'ntton. 'l'he magnifying apparatus is then set up and the renical Ppitltelium inspected. Biop~y is taken from stain ue.lieient areas. Por this purpose the rutting current loop is pat·tieularly well adnpterl. Bleeding is arreste•l by electroeoagulation or with the t'antery. If the eeTVix iR examined without previous staining, nny area whieh presents a dull, opaque, or wrinkled appearance against the normal glistening surface of tlw c·pithelium is the point nt which a biop~y is taken.

i'~h.-ltillPr ad\'o(·atP~ ta]\in~; tot· diagno~i:-~ ouly :t ~mall pi~~~·t• 11f t.I1P stu·f:tt'(~ ('JIJ· thPiium. For thi~ purpo~,, lit· u~<'~ a ~J•oon •·•1ro•tt••. II•• ,.,nt•·nd, that till' slight· ,.;,t ••hrmge in tl"· "'"rJ.!wl"MY of tht• l']'itlll'iial <"l'lls i:< ~" •·h:tr:u·t<•riMi•· that. tli!· diagnn~iR of •·an·inoma lliay '"' madt• fn1111 it alont•. Otlll'r pathologists, irH'IUtlinl: Dr. BaxtPr Crawf<•nl, d11 not agn•t• with tl1i~ l'i<'ll·, •·ontl'ndirll: thnt it is too m••agt•r

a J•ritt)rion.

Dr. Crawford sta!t•s tl1at n diagnosis .,f •·art·inmna <':ll'ill~lllhnnw. For this rpason "'' tnk•• n gt•twrous hiorn•y whid1 diJ>s int .. tl11· undnlying rnus•·ulatnll•.

j,. inl'a~ion

Every postpartnn1 ··•·rl'ix is !'XIlllliu•·d J,y t•ithPr •>r both nf tl11• nhovt• muntiunt•d mPthods. Any t•r•!Tix whid1 HJ'JII':tJ·s al>nornwl during tht• antPnat:Ll l'Xamination is aJ;;, n•.fprn•d f,r stu11y. (",ntrnindil'nti .. ns to th•• nHt· of th :-;,.J,illc·r tt·.-t and tl!P •·olpm;t·opi•· \'X:tlllination~ Hl'P 1111!. ofll'n lliPiltiolH'
('A~E~

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NumlH'I' j>o~it.il"<' Hehillt•.r t<'~IH Of tl!" positiw N•·hiller gToup L'ri migm vi
].i

Oprmtiw Yaginal

year~

( iaesarean HP<'tlon

II ];)

"\.-IHlllg;CRt

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Olde't

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;!fl.::n Hetwern :\0·411 (hl'r 40 Biopsies takt>n Biop"Y r·r·port ( 'hroui<' ,·pn·i<'iti~ 'rhiekenetl (•pith. Hurfal'e BPtm~en

IJ;n,erkerutosi~

Keratinized area!l Fihroglandular polyp" t't•J·rix (Fig. H1 Tn>atment nsetl EIP<'tri<: l'aUtl'ry GO pN eent silwr nitrnttNo treatnll'llt

II

...,., ..

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It is our ('\!~tom t" have the parturiPnt rdum for hl'l' t\r~t l'<>Ht part\! ill ••xamma· tion six weeks Hft<~r tlelivery. At this time tiH· ustml po~trmtal exmnination iR made ancl the patient is directed to return in one month. At th .. se('on•l Yi~it thP Sehillf'r test tm
CAS'l'ALLO-:MONTGOMERY:

PRENATAI, AND POS'l'?·U'rAI; CERVIX

45

S(•me form of treatment of the cervix. The Sehiller test and colposcopic examination performed at the sixth week postpartum are distortrrl hy the edema and the results are. not completely satisfa<'tory. Althong·h no instanees of early malignancy have as yet been diseovered, this method of examination has discloseLl a number of important lesion~. We feel that progress has been made in the trratment of the postnatal eNvix, and tlwt the«e spe· eial sturliE>s fully justify tlw time anrl attention whieh are dE>voterl to them. SU:M:MARY

A resume of the management and treatment of the cervical lesions which complicate obstetric practic<> has been presented. 'l'he responsibilities of the obstetrician in this connection have been pointed out. 8pecial attention has bern directed to six points:

1. The importance of detecting- cf'rviea l inft'etion and recognizing its rtiologie relationship to pn<>rperal infeetim1. 2. 'l'lw Pffica\:y ancl Rafetr of tr·eatmPnt of the cervix during the JWriocl of prrgnancy. :3. The necE>SHity of pnrl';uing- a consrrvatiw ann indicated, of op<>rative repair during the postnatal pt'riod. fi. 'l'hf' valne and thf' method of application of nt>w methods of diagllof:i:.; in early carcinoma of the eervix. The authors wish to express their gratitude to Dr. P. Bt·ooke Bland for his interest and material help in carrying on these studies. They are also deeply indebted to Dr. Baxter Crawford and th
Bernstine, .1. B .• and Nontgomery, '!''. L.: J. Urol. 22: 430, 1!l3S. Bland, P. BroukP: N. K ,J. .\leiE('. 25: 320, J!l3:l. Preissrcl;er, E.: Wien. klin. Wchnschr. 42: I:-153, 1939. S(lhill1'1·, W.: Zentralhl. f. Gyniik. 53: 1056, 193~1. Schiller, W: Surg. Gynec. Obst. 56: :no, 193:1. Sirldall, R. S.: AM. J. OB:ST. & GYNEC. (In Pre~s.) Slemons, J. Morris: .J. A. M. A. 45: 1265, 1915. Tfohlv·ill, Friedrich, and Bo<'k, Hans Echard: Beitr. z. Path. Anat. u. z. Allg. Path. ~5: 46\1, 1930. ~48 ROU'l'II TWENTY-FIRST' STREET

] !):·)0 CHEH~'Kl'T RTREET