Delivery is usually spontaneous, and presents no difficulties, although in some instances artificial delivery is necessary and is tedious. If the placenta is inserted on the tumor, the danger is extreme, six out of nine patients having perished from profuse hemorrhages. The prognosis is then very serious both for the child and the mother, but especially for the latter. In fact, aside from the dangers to which they may be exposed during pregnancy. by reason of the pathological changes which fibrous tumors may undergo, and the retroversion of the uterus, these growths may become impacted, and may then cause pressure-symptoms referable to the bladder, which may be so excessive as to exactly resemble those duo to incarceration; we should mention also hemorrhages, retardation of labor, abnormal insertion of the placenta, mal-presentation of the fcetus, inversion and rupture of the uterus, etc. To show the gravity of the prognosis, it may be mentioned that out of 287 women observed by Nauss, 123, or 53.92 per cent. succumbed, while out of 147 reported by Susserott, 88, or 53 per cent. died; the festal mortality was in the former instance 57.2 per cent., in the latter, 66 per cent. Even when spontane ous delivery takes place, the children may be compromised by the exist ence of the tumor alone, the festal head being compressed and flattened by the tumor.
There was a case in our clinic, in which pregnancy was complicated by a larger fibroid tumor that was inserted at the junction of the cervix and body, and filled the entire pelvis; the child was living at the beginning of labor, and was delivered spontaneously on the day following the per foration of its head. A second patient was brought to the clinic after having been in labor four days, her abdomen being enormously distended, and so painful that palpation was impossible. The os was partially dilated so that the festal head could be felt; perforation was resorted to, but the child could not be extracted, and the woman died undelivered, the character of the obstruction not being recognized until the autopsy. Fig. 141 explains the condition which existed.
Diagnozii.s.—In some cases this is quite easy, but in the majority it is very difficult and errors are frequent even among the most expert. Sometimes the presence of the tumor is recognized, but pregnancy is not suspected; sometimes, on the other hand, the latter condition is detected, as well as the fact that it is complicated, but the character of the growth is obscure. The rule is to wait, before giving a positive opinion, until the fact of pregnancy is established, and then to investigate the nature of the complication. In many cases women know that they have fibroids; the diagnosis is then complete.
Pregnancy complicated with fibroids has been mistaken for moles and hydatids, multiple pregnancy, luematocele, etc.; the tumors have been taken for festal parts (head, breech, or shoulder). The conditions most
liable to be mistaken for it are extra-uterine pregnancy, hypertrophy of the uterus (especially of the lower segment), thrombus, or cancer of the cervix, tumors of the broad ligaments and ovaries, and, in fact, any ab dominal tumors that have descended into the posterior cul-de-sac. Three of these deserve particular attention, viz.: Retroversion, ovarian cyst, and extra-uterine pregnancy.
1. Retroversion.—This may cause the same pressure-symptoms and pre sent the same sensation to the examining finger; but, in retroversion, the symptoms are not so gradual in their onset as those produced by a fibroid; the tumor appears smoother and more regular, and it is often possible to feel the fatal parts through the uterine wall. Retroversion always occurs in the fourth or fifth month of pregnancy, and all doubts are removed by the reduction of the organ, when this is possible.
2. Ovarian Cysts.—The diagnosis is only really difficult when the cyst is contained within the pelvic cavity. We must then combine the rectal and vaginal touch with palpation, in order to appreciate the physical char acteristics of the tumor. It will sometimes be possible, while holding the pregnant uterus, to displace the tumor which does not form a part of it. More frequently the cyst descends into the posterior cul-de-sac, and by the touch its rounded surface, resistance, mobility and fluctuation may be appreciated. But even fluctuation is not a positive sign, since it may be simulated by a softened fibroid. The differential diagnosis in the case of a solid tumor of the ovary, that had descended into the retro-uterine pouch, would be still more difficult, not to say impossible.
3. Extra-uterine Pregnancy.—The tumors in the two cases are alike in their attachment to the uterus,their continuous growth, and in the fact that localized pains, spontaneous, and on making pressure, are common to both conditions; in both cases there may be hemorrhage. But an extra uterine pregnancy is more elastic to the touch, the fcetal parts seem to be situated just beneath the skin, and, above all, while in pregnancy complicated with fibroid, the uterus and the tumors develop simultane ously, in cases of extra-uterine fcetation the uterus developer much less, and it is sometimes easy to distinguish a distinct division between the two tumors.
Complication..—During pregnancy, there are neuralgia, ob struction of the circulation, oedema, vesical and rectal disturbances, ascites, etc., all of which are referable to mechanical pressure; morbid changes in the tumor may lead to hemorrhage or peritonitis. During labor prolapse of the cord, or of fcetal parts, rupture of the uterus, etc., may occur. Retention of the placenta, inversion of the uterus, and hemorrhage, fre quently complicate the third stage.