When the case has gone on to labor at term the diagnosis as to position and size of the tumor is to be made, and what the effects will be as to blocking the canal or crushing the tumor so as to bring on sloughing. If a tumor blocking the canal cannot be pushed up out of the way of the child, a cesarean section should be done immediately. In such an outcome as section the experience of the operator must decide whether the tumor is to be removed then or at a more favorable opportunity. It may be necessary to do cesarean section to liberate an incarcerated placenta.
Sometimes the fetus is so involved with a gangrenous myoma that enucleation of the tumor will kill or hasten the death of the fetus. When, in such a complication, it is evident that the life of the woman depends on the immediate removal of the tumor, yet a second but evil effect follows from the operation, namely, the unavoidable death of the fetus, the removal is morally licit provided the operator has the proper intention. The death of the child as an effect in this case is only indirectly voluntary from the physical point of view, and only permissively voluntary from the moral aspect.[115]
[115] Cf. Ferreres, _Nouvelle Revue Théologique_, September and October, 1912, and the appendix of his book _De Vasectomia Duplici_, Madrid, 1913.
Ovarian tumors in pregnancy are, as has been said, rarer than myomata. Such tumors are mostly cysts and dermoids. In 862 cases collected by MacKerron, 68 per cent. were cysts, 23 per cent. dermoids, 5 per cent. malignant tumors, and a few were myomata. Cysts and dermoids do not, like the myomata, grow bigger during pregnancy, but they may hinder delivery or grow gangrenous and septic. When treated early the mortality in pregnancy is from 2.1 to 5.9 per cent for the women, but delay gives a maternal mortality of from 31 to 39 per cent. The fetal mortality in Heiberg's statistics of 271 cases was 66 per cent.
Most obstetricians advise the removal of an ovarian tumor in pregnancy as soon as diagnosed, provided it is of a size to cause difficulty in parturition, but such a removal causes abortion in over 20 per cent. of the cases. The expectant treatment causes abortion in about 17 per cent. If the child is viable, Fehling, Martin, Norris, and De Lee are in favor of the expectant treatment. Late operators leave weak scars at labor. When there are symptoms of torsion of the pedicle of the tumor, infection, incarceration in the pelvis, involvement of the uterine broad ligament, or overdistention of the belly, the tumor must be removed immediately. Whether vaginal puncture or laparotomy is the better method is to be decided particularly. Dermoid cysts are likely to bring on sepsis if they are broken in enucleation, and the diagnosis and operation must be carefully made. When it is necessary to save the life of the woman to remove an ovarian tumor, the risk of abortion may be taken permissively.