HYPEREMESIS GRAVIDARUM
Hyperemesis Gravidarum, the Pernicious Vomiting of Pregnancy, is
commonly classified among the toxemias; but as the etiology is not
known definitely, this classification is one of convenience more
than exactness. Nausea and vomiting occur so frequently in the early
months of gestation that they are deemed almost physiological,
but when these symptoms become very grave and persistent they are
undoubtedly pathologic, and are said to be pernicious, as they may
lead to abortion, or to the death of the woman. In 1813, Simmond
first successfully employed artificial abortion to save the woman
in this condition, and thus added a possible moral quality to the
disease. Therapeutic abortion was used in 1608, and Soranus of
Ephesus, in the second century, mentions it.
The pernicious nausea commonly begins in the second month of
pregnancy, less frequently in the fourth month, but it may be delayed
until the sixth month; if it occurs after the sixth month it is,
almost as a rule, an evidence of nephritis. It may last from about a
month and a half to three months, but in toxemic cases it may result
in death in two weeks. Sometimes remissions occur.
In 1852, Paul Dubois described the disease, and his division into
three stages is still used in articles on pernicious vomiting,
although these stages are not clearly marked clinically. In the
early months of gestation the stomach may become unable to retain
food, and there is notable loss of appetite; the condition is then
grave. There may be retching at the sight of food, at any change of
position, or at the entrance of a person into the room. The emesis
may recur so often at night as to cause exhaustion from insomnia.
Hiccough, thirst, pain in the stomach, and soreness of the thoracic
muscles are frequent and troublesome symptoms. In some cases there is
salivation.
The vomitus is food, mucus, and some bile at first; later mucus and
bile; finally it contains blood. The blood may come from the mouth,
pharynx, or stomach, and it is serious if it is gastric. The urine is
scanty, and shows nephritic irritation. At times it contains blood,
bile, acetone, diacetic acid, indican, and rarely sugar.
In the second stage of the disease all symptoms are aggravated,
and the stomach will not retain anything. There is extreme thirst;
the patient faints often, and loses weight rapidly. In chronic
cases there is much emaciation. The mouth is like that in a case of
typhoid. Sometimes there is a low fever; again, the temperature is
subnormal, with a rise before death. The pulse is rapid and weak, and
the post-mortem heart shows fatty degeneration as in a fatal sepsis.
In the third stage the mind is affected, there is delirium, stupor,
and coma; the vomiting ceases, the pulse grows more rapid and
feebler, and the weakness becomes more and more overwhelming until
the patient dies. This third stage is commonly short. In these
conditions it is too late to empty the uterus, and any attempt to do
so then only hastens death.
In some cases the fetus is apparently not affected; in toxic cases it
is affected, and then there may be miscarriage. If the fetus dies the
vomiting ceases, as a rule.
The liver enlarges in the first stage and later diminishes. There
may be a general hemorrhagic hepatitis and acute yellow atrophy, or
partial fatty degeneration around the central lobular veins. Necrosis
also occurs. Acute parenchymatous nephritis and hemorrhages into the
kidneys are often observed.
Neurotic and hysteric women are more liable to this disease than the
nervously stable. There is a direct communication by the sympathetic
and vagus nerves between the stomach and the uterus and its adnexa,
and thus reflex irritations readily pass to the stomach. Through this
path vomiting is caused by any unusual distention of the uterus,
as when the fetus grows too rapidly; or when the size of the ovum
is larger than normal, as in twin pregnancies; or in irritations
like hydramnios, displacement of the uterus, acute anteversions,
retroversions, or flexions which pinch and stretch the nerves.
Inflammations, as metritis, endrometritis, and cervicitis; tumors
of the uterus; diseases of the adnexa or of the pelvic connective
tissue or peritoneum are other sources of reflex vomiting. The proof
that such are causes is that the vomit ceases when the conditions
mentioned are cured. Such conditions exist, however, in women who are
not pregnant without causing vomit; there is therefore some special
disposition in the pregnant.
Diseases which in themselves have vomiting as a symptom will in
pregnancy make the vomit pernicious. Such are chronic gastritis,
gastric ulcer, enteritis, cancer, helminthiasis, large fecal
concretions, enteroptosis, tubercular peritonitis, and gall-stones.
What is apparently pernicious vomiting in pregnancy may be the
beginning of acute miliary tuberculosis. Diseases of the air
passages--hypertrophied turbinates, septal spurs, laryngeal and
apical tuberculosis--seem to cause the vomiting or to dispose to it.
When vomit is associated with uremia, this occurs, as a rule, in the
last months of pregnancy.
The cause, again, may be in the nervous system, from either a
demonstrable lesion or a functional imbalance--paresis, locomotor
ataxia, tumors or tubercle of the brain, meningitis, polyneuritis.
Even when the nervous system is not directly the cause of the emesis,
the remote irritant may work through the nervous system. A bad
neurotic inheritance, as from alcoholic, insane, or weak parents,
disposes to neurotic hyperemesis.
Toxins from the fetal syncytium appear to be another cause of the
vomit. The syncytium is a mass of protoplasm without cell demarkation
but with nuclei scattered throughout the substance. Sometimes this
embryological cellular material starts to grow after the manner of
a cancer, and then it is very malignant (_syncytioma malignum_),
but its connection with the pernicious vomit of pregnancy is more
theoretical than established. In physiological conditions the toxins
in the blood are neutralized by the secretions of the ductless
glands of the body, and in pregnancy probably these same glands by
intensified activity effect the same result. Injection of blood
serum taken from healthy pregnant women has cured cases of toxemic
pernicious vomit, and this makes the theory much more probable.
To diagnose the etiology of pernicious vomiting is not always easy.
We must decide first whether the emesis is really pernicious or
not; secondly, we have to determine whether or not it is due to the
presence of the fetus; thirdly, we are to differentiate the primary
and adjuvant causes for intelligent treatment. The age of the fetus
must be known to determine whether we may licitly interfere so as to
remove the fetus from the uterus if necessary, in medical opinion, to
do so.
Trousseau emptied the uterus of a woman to stop her pernicious
vomit, but she died, and at the autopsy he found a cancer of the
stomach. Caseaux discovered tubercular peritonitis in a woman who had
died after a diagnosis of hyperemesis gravidarum; Beau, tubercular
meningitis in a like case. Williams of Johns Hopkins University
stopped a very grave case of pernicious vomiting in a neurotic woman
merely by telling her of the dangers of artificial abortion.
There is no settled mortality percentage in hyperemesis gravidarum
because so much depends on diagnosis and treatment. Braun, in 150,000
obstetrical cases, never had a death from pernicious vomit; others
have a mortality of 40 per cent.
The treatment is technical, and is given in detail in books like
De Lee's _Principles and Practice of Obstetrics_.[136] Suggestion
and the environment are important elements in the treatment. Local
anesthetics, mechanical drugs like cerium oxalate and bismuth,
depressomotors, external applications, and gastric lavage are
indicated in the early stages of the disease, but are rather harmful
than useful in later stages. Adrenalin, ten drops of a 1:1000
solution by mouth, or three drops hypodermically as doses, often
cures. Sergent and Lian reported six such cases in one paper in
1913. Hypodermic injection of the extract of corpus luteum in 1
c.c. doses has been effective in some cases. So has the injection
of defibrinated serum from a healthy pregnant woman. Curtis
describes the technic in the _Journal of the American Medical
Association_, February 28, 1914. The gynecologist must adjust
uterine displacements and heal cervical erosions. The oculist,
laryngologist, and otologist are to remedy refractive errors and
remove irritants in the air passages and the ear.
[136] Philadelphia, 1913.
The treatment of last resort is to empty the uterus. This will cure
all cases of neurotic and reflex origin if done early enough. In
these cases, if the therapeutic abortion is deferred until very late,
the patient will die of exhaustion. Toxemic cases do not react well
after therapeutic abortion because of the damage previously done by
the circulating poison, especially in the liver. A positive diagnosis
of toxemia cannot always be made, and many patients in whom the
diagnosis has been made correctly recover without abortion. Apart
from moral considerations, it is very difficult to determine the
proper time to empty the uterus. A test is made of the glycolytic
power of the liver by giving two ounces of levulose internally;
and if sugar shows in the urine, this means that the liver is
unable to act normally, that it has been attacked and disabled by
the toxin, and therefore the therapeutic abortion should be done.
Again, a marked concentration of the blood, shown by erythrocytosis
and leucocytosis, indicates starvation. Some obstetricians perform
abortion when the pulse remains above 100, at the appearance of
fever, blood from the stomach, jaundice, albuminuria, mellituria,
acetonuria, indicanuria, or marked loss of weight. Polyneuritis, with
icterus and bile in the urine, is another indication for abortion;
a patient may die from polyneuritis alone after the hyperemesis has
ceased. Not one but all these facts must be considered, together with
one's own clinical experience.
In hyperemesis gravidarum, as elsewhere, therapeutic abortion is
never permissible, under any circumstances, if the child is not
viable. If the mother cannot be saved without emptying the uterus,
the mother must die; there is no way out of the difficulty. The proof
that this doctrine is correct has been given in the introductory
chapter on Homicide and when considering abortion in general.