The symptoms of pregnancy, combined with those of the tumor, have led, in a few cases, to the diagnosis of extra-uterine pregnancy, the inac curacy of which has been demonstrated by the occurrence of spontaneous and normal labor. Madge' and Simpson° described such cases. The patient of the latter observer died two weeks after her normal confinement, and a sub-serous uterine fibroma, the pedicle of which had been torn from its uterine attachments by the process of involution, was found fixed by adhesions to the anterior abdominal wall.
The treatment, during pregnancy, must be expectant and symptomatic. If symptoms of incarceration of the tumor in the pelvis appear, efforts at reposition must be made as soon as possible. Should these attempts fail, abortion or premature labor must be artificially induced, if possible, before the symptoms have reached a dangerous degree of intensity.
These views have recently been opposed. It has been pointed out that abortion is dangerous to the mother, owing to the tendency to hemorrhage caused by the presence of the tumor, and again because the growth might undergo disintegration in child bed. Influenced by these considerations, Schroder' has done laparotomy for the removal of a myoma in the sixteenth week of pregnancy. The patient recovered and gave birth to a child at full term. The same surgeon did two similar operations in the third month of pregnancy, and both patients recovered.' These operations were performed on account of the dangerous condition of the patients, brought about by the rapid growth of the tumors.
Ilegars removed a sub serous myoma of the uterus in the third month of pregnancy; the patient died of septicemia. Kaltenbach' performed a successful operation of this kind in the fifth month of pregnancy. Wasseige ° had a similar but unsuccessful case. Studsgaards° removed a pediculated sub-serous fibroid in the third month; the woman recovered and did not have an abortion.
Thornton' had a similar but fatal case. Wan° performed an operation of this kind, but overlooked the existing pregnancy (fifth month) on account of the enormous size of the tumor. The patient aborted but recovered.
Landau' removed two sub-serous pediculated tumors in the third month, the patient recovering and giving birth to a child at full term.
Owing to these favorable results, it is certainly justifiable to remove fibroids during pregnancy, if these tumors produce serious symptoms.
The induction of abortion, apart from its inherent dangers, does not rid the patients of their tumors.
The influence of these tumors is still more marked upon parturition than upon pregnancy. The number and size of the fibroids is of less importance, with reference to their effect upon parturition, than their seat. Although tumors located in the cervix often obstruct labor owing to their size, the obstruction may usually be readily removed by the euucleation of the fibromata. Such cases are reported by Danyau,'° Langenbeck' and by Braxton Hicks' who enucloated from the anterior lip of the cervix a myoma which weighed one pound and had prevented the entrance of the head into the pelvis. The labor was easy and the case resulted favorably for mother and child.
Sub-mucous fibro-myomata, particularly if pediculated, give rise to comparatively few disturbances of parturition. When located in the lower segments of the uterus they may be expelled in advance of the presenting part of the child, and are often spontaneously separated from their uterine attachment, provided the pedicle be long and slender. Forget, Ramsbotham, Marchal de Calvi (Demarquay and Saint vel., malad. de l'uter.). Dubois anI Depaul have observed cases of this kind. In other instances it was necessary to separate a pediculated tumor from its attach ments before the expulsion of the child, because the former offered an obstacle to delivery or occasioned profuse hemorrhage. J. Bell' and Fergusson" describe such cases. A calcified fibroma was in one instance mistaken by the physician for the child's head, and delivered with the forceps. The pedicle was next severed, and the child, which presented transversely, extracted by means of version. The tumor weighed about eleven ounces, was nearly four inches in length and three inches wide. (Saxinger°). A similar diagnostic error, committed by Fergusson," had a less fortunate sequel. He mistook"a soft, pediculated myoma for the child's head, applied the forceps and extracted the tumor after tearing through the pedicle. The patient died after forty-eight hours, and a laceration of the uterus was found at the point of insertion of the pedicle.