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Management of labor/ delivery with pre existing hypertension 3 страница
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Sometimes a slight icteritiousness of skin and eyes is observed. On abdominal palpation tenderness in the area of pancreas projection is marked.
Data of additional methods of examination are the same as in acute pancreatitis.
Treatment of exacerbation of chronic pancreatitis is based on the same principles as of acute pancreatitis. Diet therapy is the basic and most essential link of complex therapy of chronic form of disease. In the period of remission it is necessary to take food 4-5 times a day. Food should contain the excess amount of carbohydrates, water soluble vitamins, substances with lipotropic action, limited quantity of fats at normal or increased quantity of proteins. Cold drinks, cakes, pastry, beef tea or fish broth should be excluded.
At exacerbation of chronic pancreatitis during the first 3 days the fast and thirst regimen is administered. Subsequently a low-caloric diet is recommended, excluding fats, salt, nitrous extractive substances increasing a secretory activity of the stomach and causing intestinal bloating. Further a carbohydrate and protein diet is primarily administered. Of medicines spasmolytics and sedatives, antienzymic preparations are given.
In the period of remission of chronic pancreatitis pancreatin (1 g 3 times a day after meals) or preparations containing enzymes of stomach, pancreas and small intestine, such as holenzim, panzinorm, festal (1-2 pills 3 times a day after meals) should be administered.
Effect of Chronic Pancreatitis on Pregnancy
Pregnancy in 28 % of such patients is complicated by toxemia of early terms of pregnancy (nausea, vomiting), and quite often the vomiting proceeds for 16-17 weeks of pregnancy. Chronic pancreatitis does not produce essential effect on the course of second half of pregnancy and on delivery.
Effect of Pregnancy on the Course of Chronic Pancreatitis
Changes of hormonal status characteristic of pregnancy promote the development and exacerbation of pancreatitis. However, the most frequent reasons of development of pancreatitis during pregnancy are diseases of gallbladder, cholelithiasis (approximately in 55% of cases). Different infectious processes (acute pyelonephritis, thrombophlebitis), as well as overeating, alcoholism, application of anticoagulants are instrumental in development and exacerbation of pancreatitis in pregnancy.
Management of Pregnancy at Chronic Pancreatitis
At stable remission of chronic pancreatitis, in the absence of marked dysfunctions of pancreas and complications, such as diabetes mellitus, pregnancy in patients with chronic pancreatitis may be continued.
From the first weeks of pregnancy the woman with chronic pancreatitis should be under supervision of obstetrician-gynecologist and therapeutist in order at occurrence of first signs of exacerbation of disease the proper medicinal therapy was started.
At exacerbation of disease the obstetric management is the same as at acute pancreatitis.
Neoplasms in pregnancy.
Fibromyomas (Fibroids, Myomas)
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The effects of gestation on fibromyomas are as follows: During pregnancy fibroids which were not noticeable before take part in the general succulency and hypertrophy of the uterine muscle and enlarge, chiefly, and perhaps only, in the first half of pregnancy. However, some authors maintain that there is no hypertrophy of the smooth muscle fibers or hyperplasia of the connective tissue stroma within fibroids during pregnancy.
Large fibroids, especially if located in the pelvis, may enlarge so much that incarceration and dangerous compression of the pelvic organs result. Aside from enlargement and increased vascularity of fibromyomas, cystic and other degenerative changes occur in most cases and in rare instances suppuration and gangrene take place. The so-called " red degeneration" is one of the most serious changes. If it is associated with pain, fever, leukocytosis and rapid sedimentation time myomectomy or hysterectomy may be necessary. A frequent occurrence is dislocation or " wandering" and a change in the shape of the tumors. Myomas attached to the cervix respond to the upward traction of the corpus uteri and fortunately rise into the abdomen; otherwise they would block delivery. This retraction of the tumor above the brim may occur even during labor, and the physician may be most agreeably surprised to find that what promised to be a formidable case became a simple one. The fibroid may be flattened by the growing ovum or if several tumors are present, they may be separated from each other. Subserous myomas may become twisted and necrotic or they may prolpase into the pelvis; interstitial tumors usually become more superficial; submucous fibroids, which are rare, are likely to become polypoid and may then be extruded through the cervix during the puerperium. During labor fibroids may be crushed by the advancing head, by attempts at delivery or by a too strong Crede expression. In the puerperium myomas usually involute with the rest of the uterus. The tumors in all instances are as large as, or even larger, than they were before pregnancy, though smaller than they were during gestation. Necrosis and infection of the tumors may occur, but this accident is unusual. It is favored by the immense size of the growth, by bruising during delivery and particularly by infection, which results from wounding of the endometrium over the tumor.
The influence of pregnancy on the symptoms caused by myomas is also one of aggravation. Pain is pronounced in nearly all cases and hemorrhage, simulating threatened abortion, occurs in many. If the tumors are large the abdomen becomes enormously distended and the patient may have dyspnea as the result of pressure on the diaphragm.
The effects of myomas on pregnancy are variable. Women with such tumors are frequently sterile. Abortion occurs twice as frequently in women with fibromyomas as in other women. This is particularly true in women who have submucous tumors. Interstitial myomas have less effect and the subserous ones, unless large or near the cervix, hardly any. Placenta praevia seems to be favored by the presence of uterine tumors, probably through the concomitant changes in the endometrium. In labor fibroids usually do not cause complications unless they are impacted or adherent in the pelvis or unless the placenta is attached to the tumor. A subserous impacted myoma causes the worst difficulty, because it is less likely to be elevated by the contracting and retracting uterus. Interstitial tumors may be flattened against the wall of the pelvis so that they allow the child to pass or they may be retracted upward.
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Fibromyomas exert an influence on the mechanism of labor. The uterine contractions are usually strong and painful; in fact when delivery is blocked by a tumor, rupture of the uterus may ensue. However, weak pains, even atony, may be present; abnormalities of position and presentation such as face, breech and shoulder are prone to occur; prolapse of the cord and inversion of the uterus have also been observed.
In the third stage hemorrhage is common because the distorted uterus has difficulty in compressing the vessels of the placental site. Anomalies in the separation of the placenta are especially apt to occur when it is adherent to the tumor as abnormal adherence is the rule in such cases. If the uterine cavity is distorted, the placenta may be incarcerated.
During the puerperium fibroids may obstruct the lochial flow and cause lochiometra; they always delay involution; they predispose to phlebothrombosis, and when they are gangrenous or infected the worst types of sepsis may result.
Diagnosis
The most complicated diagnostic problems are presented to the obstetrician and mistakes have been made frequently. If a woman who is known to have myomas becomes pregnant the diagnosis is not difficult and will rest on some of these points: cessation or irregularity of the menses, rapid enlargement of the uterine tumor, the development on it of a soft area, contractions of the uterine tumor and fetal heart tones. All of these may be equivocal except the last and even the fetal heart tones may be inaudible if covered by an immense tumor. If the diagnosis of an existing pregnancy is made it is usually easy to determine that there are fibroids in addition but even then mistakes have occurred because a twin, an ovarian tumor, double uterus, fibroma of the abdominal wall, fat, hematoma and Littre's hernia have been mistaken for uterine tumors. During delivery the myomatous nodules are made prominent when the uterus hardens and, unless hidden behind the uterus, are almost always discoverable. If located in a position which causes interference with the mechanism of labor new problems are presented for diagnosis. When the uterus is emptied, its large size and the presence of nodules will easily indicate its presence. In the puerperium the corpus remains high and involution proceeds slowly. Infection of a tumor is made evident by the usual signs of sepsis.
The differential diagnosis between a large symmetric interstitial fibroid and pregnancy is sometimes difficult. Indeed it may be almost impossible to distinguish the two, even after the tumor is in the hands of the operator in the opened abdomen. (Table 23)
Table 23
Differentiation between Uterine Tumors and Pregnancy
| Symptoms and signs | Myoma | Pregnancy |
| Nausea and vomiting Menses Shape of the uterus Consistency of the uterus Contractions of the uterus Location of round ligaments, tubes and ovaries Condition of the cervix Auscultatory signs of pregnancy Sonography Pregnancy tests | absent present Usual uterine tumor is usually asymmetric or nodular usually hard rare anomalously located The cervix is retracted, high in the pelvis, hard and a sort of appendix to the tumor. absent shows the tumor of the uterus negative | present absent usually symmetric or characteristically deformed soft usual and involve the whole organ normally placed The cervix is low in the pelvis, large, soft and is part of the uterine wall. present after the 5th month of gestation shows the fetus, placenta, etc. positive |
After the abdomen is opened the differential diagnosis is established by the dark color of the pregnant uterus, the congested, thickened tubes and ligaments, especially the round ligaments, the presence of a large corpus luteum in one ovary, ballottement and the contractions of the tumor, which molds itself on the promontory. A fibroid is usually light in color, it rocks heavily on the promontory and it is asymmetric, as are the round ligaments. The experienced operator usually can determine from the feel whether pregnancy exists or not. If doubt cannot be dispelled, then 1 ml (5 units) of pituitrin should be injected directly into the uterine musculature. A pregnant uterus will contract quickly and become blanched. Likewise it is justifiable to insert a wide-bore needle into the tumor. If a pregnancy is present amniotic fluid will be aspirated. Finally the tumor may be incised slowly layer by layer and, should an ovum be discovered, the wound is to be immediately sutured and the abdomen closed unless other indications exist. Pregnancy is usually not interrupted by an exploratory operation.
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Prognosis
Without doubt the dangers of myomas complicating pregnancy are misrepresented by reports; this is due to the fact that only the severe cases are considered worthy of publication. Unless the tumor obstructs delivery there are few serious complications, but the fetus is more endangered.
Treatment in Early Pregnancy
It is almost never necessary to induce abortion since the majority of pregnant women with fibroids go to and through labor without difficulty. Indeed the interruption of pregnancy is difficult because of the distortion of the uterine cavity and dangerous because of the hemorrhage and the likelihood of infecting the tumors. Excessive pain and repeated and profuse hemorrhages may require treatment and, if ordinary means do not suffice, an operation may be necessary. It is best, whenever possible, to wait until or near term before operating. It may even be wise to try a test of labor because nature sometimes accomplishes wonders in getting the tumors out of the way of the child's delivery. Therefore in the absence of unbearable pain, of severe hemorrhage, of extremely rapid growth, of great distress from overdistention of the abdomen, of signs of necrosis of the tumor, torsion or " acute abdomen, " it is justifiable to wait and watch. To assist nature in elevating the tumors out of the pelvis the patient should assume the knee-chest position frequently every day. However, a laparotomy may have to be performed if a woman has a great deal of pain, impaction of the fibroid uterus, extremely rapid growth of the fibroids or excessive bleeding. Before viability it is simply best to remove subperitoneal or interstitial fibroids and to leave the pregnancy undisturbed, unless a special reason exists for amputating the uterus, such as innumerable fibroids, extensive degeneration of one or more tumors or excessive bleeding during operation. Abortion and premature labor occur in a fair proportion of cases after myomectomy. However, even if this does take place, the patient is better off because she may conceive again and she will most likely carry the gestation to term.
A surgeon should not definitely promise a patient that only a myomectomy will be performed. After opening the abdomen he may find that it is far safer for the patient to have a hysterectomy; therefore he should always have the patient's consent to do whatever he finds necessary. At term a Porro operation may be performed or, if delivery can be accomplished from below, a hysterectomy can be done a few months after delivery.
Myomectomy performed before or even during pregnancy with retention of the gestation is not necessarily an indication for cesarean section because in most instances this surgical wound heals perfectly.
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Treatment near Term or in Labor
(a) Clean Cases. — Should the woman approach the end of her pregnancy a careful examination is made to determine whether the tumors will obstruct labor. It must be borne in mind that a contraction of the parturient passage caused by a fibroid is worse than the same degree of narrowing caused by a contracted pelvis, because of the possible sloughing of the tumor resulting from crushing during spontaneous, but especially operative, delivery. Should a subserous or intramural cervical myoma be so large or so firmly fixed in the pelvis that it apparently will completely block delivery, cesarean section is to be performed near term or as soon as labor has begun. After the child and placenta are removed, an attempt should be made to raise the tumor out of the pelvis and to extirpate it. If this is impossible because the fibroid is too densely adherent or because it has grown into the broad ligaments, the uterus should be totally extirpated. Only a skilful obstetric surgeon may attempt such an operation because hemorrhage is often profuse. If there are a number of intramural tumors, it is best to perform a hysterectomy rather than multiple myomectomies.
Smaller tumors may be left for the test of labor and as a rule they will be retracted or softened and flattened so as to allow the passage of the fetus.
Operations in the uterine cavity, as version and manual removal of the placenta, may be rendered laborious by obstructing fibroid tumors and it may be necessary to push the masses up before the hand can be introduced into the uterus. Removal of a placenta adherent to a submucous fibroid may require the digging out of the two at once, but care must be exercised not to puncture the uterus. If perforation of the uterus occurs or if the extraction of the placenta fails abdominal section is indicated.
(b) Infected or Possibly Infected Cases. — When labor has been in progress for a long time, when the woman is presumably infected, or when unsuccessful attempts at delivery or reposition of the tumor have been made, the condition becomes formidable. Supravaginal amputation or total extirpation of the uterus should be performed. If the child is dead, it is best to remove the uterus in its entirety, without opening it to extract the child, the object being to prevent contact of the infectious uterine contents with the peritoneum. Even with a live child the entire uterus with the child may be removed. In definitely infected cases the danger of peritonitis should be pointed out to the husband, and the removal of the uterus advised, but in presumably infected cases an extraperitoneal cesarean section may be done with safety.
(c) During the Puerperium.
Unless symptoms are present, the myomas are not disturbed. Ergot is best omitted. Hemorrhage may require immediate operation. Sloughing, pedunculated tumors are removed per vaginam, but not too soon after delivery. If the tumors become infected expectancy is practiced until the immunities of the puerpera are developed. Precipitate laparotomy might cause fatal peritonitis. During a laparotomy for sloughing fibroids the peritoneum is to be walled off as carefully as possible and the cutting across of the pedicle, after ligation of the broad ligaments, done with the electric cautery. Drainage through the vagina should be carried out. Penicillin or the sulfonamides should be given.
Ovarian Tumors
Ovarian tumors are much rarer than fibroids during pregnancy. Since cysts of the ovary are common the conclusion seems justified that they predispose to sterility.
The influence of pregnancy on the non-malignant tumor is usually not bad. Most women go to term without the knowledge of its existence and the growth of the neoplasm is not accelerated as it is in the case of fibroids. While dyspnea and palpitation, due to excessive size of the tumor, are rare, torsion of the pedicle, hemorrhage into the cyst, suppuration and necrosis occur occasionally. Labor exerts no influence unless the tumor lies in the pelvis, exposed to the trauma of delivery. In this case it may burst or be crushed or its pedicle torn. The puerperium has no special influence but complications are likely to arise as the result of bruising of the tumor. Torsion has been observed much more frequently than in non-pregnant women.
Pregnancy is but little affected by ovarian cysts. Abortion is common only when the tumors are extremely large or incarcerated in the pelvis, when they interfere with the growth of the uterus or when they become twisted or infected. In labor ovarian cysts exert a harmful action only when they are incarcerated in the pelvis and block the path of the child. To a certain extent, but not as much as with fibroids, the tumor is drawn out of the way. A small or soft tumor may allow the passage of the child. Malpresentations are common. The puerperium is often stormy because of the bruising of the tumor, necrosis, hemorrhage, infection and suppuration, sometimes with the escape of pus into adjacent organs. Tumors which become adherent to the rectum are likely to be infected with colon bacilli. Dermoid cysts are the most dangerous because if they burst during labor fatal peritonitis may result. Usually dermoids can be detected in roentgenograms.
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Diagnosis
In the early months it is usually easy to differentiate the pregnant uterus from the rounded, movable, pedunculated tumor lying at its side, but sometimes great difficulties are encountered. When the tumor is intraligamentous or prolapsed in the pelvis behind the uterus, a differentiation from ectopic gestation and retroflexed gravid uterus must be made. A large tumor may conceal the uterus and give the impression of a pregnancy and since the signs and symptoms of the latter are present this mistake is likely to be made. Fibroids and splenic and renal tumors must be considered in the differential diagnosis. One should remember that torsion of an ovarian cyst simulates ruptured ectopic pregnancy and appendicitis.
In the later months and during labor various difficulties are encountered in locating the tumor. If high in the abdomen it may slip under the liver or spleen. If adherent to the uterus the suspicion of twins, fibroid or double uterus arises. If attached low in the pelvis a shoulder presentation might be considered. Tumors incarcerated in the pelvis during labor are discovered easily but their nature and origin are not determined so easily. A cyst under the compression of labor becomes as hard as a fibroid and if it is adherent it may simulate a tumor of the pelvic periosteum. Rectal examination will exclude this class of neoplasms. An ovarian cyst has been mistaken for the head of a second twin and forceps have been applied; or when enucleation of a supposed fibroid was attempted a prolapsed kidney, a full rectum or a hematoma were encountered.
An important part of the diagnosis is the decision as to whether the tumor will block the delivery; in estimating this one must never forget to measure the bony pelvis also.
Prognosis
At present few women die from this complication because the troublesome tumors are usually removed as soon as found and because operation substitutes for the brutal obstetric deliveries of former times.
Treatment during Pregnancy
Most authors are strongly in favor of immediate removal of the tumor when discovered but we believe one must individualize. However, an operation should be performed in most cases when the cyst is large and in all cases when sudden symptoms of torsion of the tumor develop. There is not much danger of abortion. Even if the tumor contains the corpus luteum of pregnancy, there is rarely any risk in removing the tumor if the pregnancy is twelve or more weeks old. Therefore, if an ovarian cyst is detected at the beginning of pregnancy and it is to be removed, it is advisable to wait until the end of the third month or beginning of the fourth month of pregnancy. If the tumor can be shelled out of its bed, leaving part of the ovary, this should be done. There are forty-six reported cases in which both ovaries were removed during pregnancy because of bilateral dermoid cysts. In twelve cases the pregnancy continued to full term in spite of the fact that the operations had been done within the third month. If a cyst is not removed and the pelvis is not obstructed labor may be allowed to take place as usual, and the tumor extirpated afterward. Rapid growth of the tumor in pregnancy suggests malignancy.
Indications for immediate operation in pregnancy are: suspicion of malignancy, torsion of the pedicle, signs of infection of the tumor and overdistention of the abdomen. The pregnant uterus must be handled as little and as gently as possible and progesterone is to be given for several days afterward in an attempt to restrain excessive uterine action.
Treatment during Labor
The location of the neoplasm, the state of the parturient canal as regards infection, the tumor as regards prolonged pressure, bruising from attempts at reposition, delivery and the like are also to be considered. Abdominal ovariotomy is followed by delivery from below and laparotrachelotomy is followed by extirpation of the ovarian tumor.
After delivery of the child an immediate laparotomy is performed and the tumor is extirpated. It is best not to delay the removal of the cyst because the latter may have been ruptured or injured by the manipulations or delivery, and delay might mean fatal peritonitis.
In the puerperium ovariotomy is to be performed in all cases in which a large ovarian cyst is still present, and preferably within twenty-four hours. If operation is postponed a careful watch is kept for the first symptoms of infection of the tumor or torsion of its pedicle.
Carcinoma of the Cervix
The incidence of carcinoma of the cervix is 0. 015-0. 7 per cent. Most of carcinomas of the cervix complicating pregnancy are squamous cell epitheliomas. The rarity of cancer during pregnancy may be ascribed to the fact that cancer occurs mostly past the reproductive period. It is seen almost exclusively in multiparas. It is the most unfortunate complication. Cancer of the body of the uterus almost excludes the possibility of pregnancy. Only eight proved cases have been reported.
It has long been held that the physiologic changes in the pregnant cervix cause cancer there to grow faster and to invade the lymph ducts and glands sooner, but now there is a contrary view.
In patients of equal age with carcinoma of the cervix the death rate is lower among those who are pregnant or in the puerperium than it is among nonpregnant women. Some authors maintain that pregnancy does not stimulate existing carcinoma of the cervix or breast but often retards it. On the other hand the termination of pregnancy by birth or abortion significantly intensifies the malignant growth and aggravates the prognosis. This may be due to the fact that during pregnancy the corpus luteum hormone, progesterone, checks the blastomogenic action of estrogen. After pregnancy is terminated estrogen can act unopposed because the amount of progesterone is considerably diminished. While cancer may begin after conception usually the growth was present before. Hemorrhage and necrosis with putrid, sanious leukorrhea are pronounced in most cases. Labor may disrupt the tumor and the more or less deep lacerations cause hemorrhage, sepsis and rapid extension of the neoplasm. In the puerperium these changes become evident quickly and the consequent prostration and cachexia are striking.
Cancer of the cervix exerts a bad influence on pregnancy, labor and the puerperium. In the first place sterility is the rule in cancer, especially in advanced cases and because of endo-cervicitis and endometritis; secondly, abortion is frequent because of the infection and death of the ovum, hemorrhages and restriction of the growth of the uterus by the neoplasm. If the carcinoma is not treated the pregnancy will proceed to full term in about two thirds of the cases but only a third of the infants will survive delivery by the vaginal route. Labor is obstructed not so much because of the size of the mass but because of the rigidity of the cervix produced by the carcinomatous infiltration. If the tumor is soft and takes up part of the cervix then the rest may dilate and allow the child to pass. If the whole cervix is involved and in a hard mass, obstruction is produced and the case is formidable. Should the cervix give way the tear may extend into the parametrium, giving rise to profuse bleeding.
Diagnosis
Every woman who has irregular hemorrhages or purulent or putrid leukorrhea should be examined for cancer of the cervix. Bleeding is the first symptom of cancer in almost 90 per cent of the cases. Even if the menopause has taken place pregnancy should be suspected when the uterus is enlarged. In doubtful cases a piece of the tumor should be removed and examined microscopically. Pregnancy will not be interrupted by excising a bit of the cervix. Syphilis must be ruled out.
Treatment
There is no unity of opinion concerning the best treatment for cancer complicating pregnancy and labor chiefly because no obstetrician has personally had a large series of cases.
The following may be presented:
Cancer Discovered during Pregnancy
1. If cancer is operable and the child is not viable either of the following is indicated:
Radical excision (Wertheim) of the unopened uterus. The prognosis for the mother is comparatively good.
Radium therapy; if not followed by abortion then the uterus should be evacuated by abdominal hysterotomy or the child may go to viability and be delivered by cesarean section. The prognosis for the mother is favorable. Abortion usually follows; abnormalities are frequent among the children who survive.
2. If cancer is operable and the child is viable:
Cesarean section is followed by Wertheim's operation. The prognosis for the mother is unfavorable but there is a good chance of the child surviving. Or radium therapy is preceded or followed by cesarean section (according to the period of gestation). The prognosis for both the mother and the child is comparatively favorable.
3. If cancer is inoperable and the child is not viable:
Radium therapy is followed by delivery by abdominal hysterotomy. (In accordance with religious principles, pregnancy may be allowed to continue with delivery by cesarean section at or near term. )
4. If cancer is inoperable and the child is viable:
Radium therapy is preceded or followed by cesarean section (according to the period of gestation).
Cancer Discovered at Labor
1. If cancer is operable, the baby is alive and the presenting part is still in the uterus:
Cesarean section is followed by Wertheim's operation.
2. If cancer is operable, the baby is alive and the presenting part is through the cervix:
Labor is followed by radiation treatment (as soon as involution permits). Roentgen-ray therapy may be begun a few days after delivery and intracavitary radium as soon as practicable. The beginning of treatment should not be delayed beyond the ninth or tenth day.
3. If cancer is inoperable and if the presenting part is in the uterus:
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