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:

Cesarean section is followed by radiation therapy.

4. If cancer is inoperable and if the presenting part is through the cervix:

Labor is followed by radiation therapy (as soon as involution permits).