PREGNANCY. PARTURITION AND CHILDBED IN CANCER OF THE UTERUS.
In cases of carcinoma uteri pregnancy occurs most readily during the initial stage of the disease, where the carcinomatous infiltration is con fined to the deeper layers of the mucous membrane, or where the affection presents as slight papillary excrescences. When the diseased parts have once begun to break down, not only is cohabitation more seldom practised, but the contact of semen with the ovum is impeded by various obstacles.
Per contra, the literature of the subject abounds in examples of preg nancy in cases of far-advanced sloughing cancer of the cervix uteri (com pare Bagli and Cazel, Chantreuil, 1. c., p. 6).
In 127 cases Cohnstein ' found twenty-one — which the disease had been detected quite a time, as much as a year, before the incep tion of pregnancy. When, however, Cohnstein attempts from this collection of cases to draw the conclusion that cancer of the cervix uteri actually favors conception, he is contradicted not only by most authors, but also by the fact that the complication of cancer of the cervix with pregnancy is, in general, exceedingly rarely observed. At the same time, it is quite remarkable that in fifty-eight cases of this de scription Cohnstein found sixteen between twenty-seven and thirty-three, nineteen between thirty-four and thirty-seven, and twenty-three between thirty-eight and forty-nine years of age. Carcinoma of the cervix uteri occurs infrequently before the age of thirty, while parturition also occurs infrequently after the thirty-eighth year. At all events the above small figures are not sufficient to prove that carcinoma of the cervix favors con ception.
The course of pregnancy seems to depend essentially upon the loca tion, or, to speak more precisely, upon the extent of the disease. The more the degeneration is restricted to the external os, especially if but one lip be involved, the less likelihood is there of pregnancy being interfered with; while in proportion as the affection extends higher up into the cervix, and particularly when it has penetrated up to or beyond the internal es, the greater is the probability of an abortion or a premature birth, proba bly as a consequence of diminished capability of development of the lower segment of the uterus. In other cases the interruption of pregnancy is
due to a succession of severe hemorrhages, for which reason it may be said that epithelioma is more likely to cause a miscarriage than is true carcinoma.
Lewes states that forty per cent. of 120 women affected with cancer of the cervix aborted (cited by Chantreuil, 1. c., p. 14). Cohnstein found that the proportion of premature births was lower. Thus, in 107 cases delivery took place eighty-eight times at full term, while abortion occurred fifteen times, and in two instances the duration of pregnancy was longer than normal.
The last-mentioned occurrence, so-called " missed labor," has been ob served in several cases of cancer of the cervix uteri, and is certainly a re markable phenomenon. The best-known example of the kind is that of Menzies.' In this instance, after pregnancy had already lasted seventeen months, the woman died undelivered; the foetus was flattened out, and showed no trace of decomposition, while the amniotic fluid bad been entirely absorbed. Judging solely from the report of the case, as given by Chantreuil, it seems to me not improbable that it was a case of extra uterine fcetation, complicated with epithelioma of the uterus. Depaul Schmidt's'ease cannot be reckoned with certainty as one of missed labor, for while it is stated that the patient was affected with carcinoma of the lower segment of the uterus, and was somewhere in the tenth or eleventh month of pregnancy, it was not possible to determine the exact duration, and the pains were lasting and energetic, although not powerful enough to accomplish the delivery of the child.
The only undoubted cases of missed labor, caused by carcinoma of the cervix, are the following. Miller's' patient died some time after the nor mal end of pregnancy, without having been delivered; mild pains had occurred on several occasions, but had not led to the initiation of labor. Playfair ' reported an instance of cancer of the uterus, in which violent hemorrhage led to the death of the foetus in the sixth month of pregnancy; this was followed by labor pains, not strong enough, however, to accom plish the delivery of the fetus. The product of conception underwent decomposition, and was expelled in fragments at•long intervals.