Terminalion.—The thrombus may become absorbed, may rupture sub sequently, may be cured by adhesion of its walls, by suppuration, or by gangrene. Suppuration may follow spontaneous rupture or artificial opening of the tumor.
Diagnosis.—These tumors have sometimes escaped notice, or have been mistaken for other growths, the bag of water, the inverted or pro lapsed uterus, or vagina, etc. These errors will be avoided by noting the phenomena which accompany the appearance of the enlargement.
Prognosis.—This is extremely grave when the thrombi are intra-pelvic, less so (though still serious) in other cases. If they occur before delivery they almost always result fatally for mother and child if after delivery, the child is unharmed and the mother's risks are somewhat lessened. How ever, the hemorrhage, and the possible occurrence of suppuration, ren der the prognosis grave.
Treatment.—This is preventive and curative; the former consists in relieving venous stasis (and the resulting varices) by insisting on the patients keeping a horizontal posture. The curative treatment varies ac cording as the thrombus appears during pregnancy, labor, or after deliv ery; but, in general, we may say that the primary indication is to wait, and be ready to interfere if accidents seem to be imminent. During pregnancy, interfere only when the thrombus ruptures spontaneously. To make an incision is only to give freer vent to the hemorrhage, while it does not prevent internal bleeding, while astringent injections only cause the clots to be detached, and thus set up fresh oozing. Wait until the thrombus ruptures, then tampon with cotton, dry, or soaked in as tringent solution, pure alcohol being preferable to perchloride of iron, since the latter favors suppuration. If the accident occurs during labor,
the latter should be terminated as rapidly as possible by the forceps, rather than by version, and we should resort to incision only when it is unavoidable. Most authorities, however, are in favor of immediate in cision, urging in support of it: 1. The necessity of removing the obsta cle to the passage of the child; 2. The danger of extension of the ex travasate through the pelvic cellular tissue; 3. The fact that rapid delivery does not always prevent rupture; 4. Immediate incision prevents the formation of clots and the consequent dangers of suppuration.
To these arguments we reply, with Hervieux: 1. The tumor is so soft that the foetal head can easily pass it when aided by the forceps; 2. Intra-pelvic thrombi are rare, and the fear of their possible occurrence is not sufficient to justify operative interference; 3. If we tampon immedi ately after making an incision, the effect will be the same as if the tumor was let alone; 4. Fatal hemorrhages have occurred more frequently after the operation than when nothing was done; 5. Sloughing is more likely to follow premature opening of the thrombus.
After delivery operative interference is necessary after the hemorrhage has ceased, most of the blood has coagulated, and evidences of suppuration or gangrene are present. A free incision should be made, and the cavity should be thoroughly irrigated and drained.