INFECTIOUS DISEASES IN PREGNANCY
Any of the acute infections, as typhoid, typhus, smallpox, measles,
scarlatina, and the others, attacks a pregnant woman as readily
as one who is not pregnant. Pregnancy, as a rule, lessens the
resistance to the infection, and the infection is likely to cause
abortion. The toxin of the infection is added to the physiological
toxins of pregnancy, the kidneys often are overwhelmed, and there
is a tendency to hemorrhage. After the exhaustion from the disease,
delivery, whether premature or at term, is liable to end in collapse,
especially if the heart or lungs have been injured. Puerperal sepsis,
either general or local, is a common effect of these bacterial
diseases. In smallpox there is infection from the pustules and the
virus itself; in typhoid the typhoid bacillus and the streptococci
in Peyer's patches get into the blood; in influenza, pneumonia,
erysipelas, and diphtheria the bacteria directly cause sepsis, and in
scarlatina the pus organisms from the throat are found in the septic
foci.
In these infections the fetus may be killed by the high temperature;
it may die from asphyxia brought on by feeble maternal blood-pressure
and consequent stagnation of the circulation in the uterine sinuses;
it may be overwhelmed by maternal hemorrhage; by deoxidation of the
maternal blood, as in pneumonia; by a hemorrhage in the placenta, and
a consequent separation of the placenta itself from the uterine wall;
by fatty degeneration of the fetal villi, which renders respiration
of gases impossible. Again, the child may be infected by the disease
of the mother, or it may be killed by the toxins in the maternal
circulation.
The communication between the fetal and the maternal blood systems
is as indirect as that between the air in a man's lungs and his
blood. The communication between mother and fetus is by osmosis, but
certain toxins, drugs, and bacteria may also pass from the maternal
to the fetal circulation through the placenta. Strychnia injected
directly into the embryos of animals by Savory and Gussarow killed
the mother after passing to her through the placenta. There is no
direct communication (except by osmosis) between the fetal chorionic
villi and the maternal intervillous blood spaces. In the first half
of pregnancy fetal and maternal blood are separated by the syncytium,
Langhan's layer of cells, the stroma of the villi, and the walls of
the fetal capillaries; in the second half of gestation Langhan's
layer gradually disappears. In the fetal blood-vessels are found
many nucleated red corpuscles, but these are lacking in the maternal
intervillous spaces. Sänger also discovered that in pernicious
leucemia the leucocytes of the mother are not present in the fetal
circulation.
That gaseous substances pass through the fetal barrier of tissues
was proved by Zweifel, Cohnstein, and Zuntz. Zweifel showed that
chloroform administered to the mother rapidly reaches the fetus. As
early as 1817, Mayer proved the passage of cyanide of potassium.
Since then we have been made certain of the transmission of iodide
and ferrocyanide of potassium, salicylic acid, bichloride of mercury,
methylene blue, and many other substances. Krönig and Futh, in 1901,
determined that the maternal and the fetal blood freeze at the same
temperature, which indicates that they possess equal osmotic power,
and that osmosis may occur in either direction.
Some bacteria do not get through to the fetus, but a few do get in.
Tubercle bacilli were found in the fetus by Birch-Hirschfeld[139]
in 1891, and Schmorl[140] demonstrated them in 50 per cent. of the
placentas in one series of examinations. Bar and Renon[141] found
them in the blood of the umbilical cord in two of five cases. Actual
congenital tuberculosis is possible, though very exceptional: the
bacteria either pass through the wall between mother and fetus,
or destroy this wall and then get in. Smallpox, measles, and
scarlatina, the causes of which have not yet been demonstrated;
typhoid, cholera Asiatica, pneumonia, bubonic plague, erysipelas,
pus infection, anthrax, syphilis, febris recurrens, and malaria
have already been demonstrated in the fetus. Lynch of Johns Hopkins
collected sixteen cases of typhoid in the fetus. I found the typhoid
bacillus in the liver and kidneys of a still-born fetus whose mother
was ill with typhoid fever; this case was not among those collected
by Lynch.
[139] _Arbeiten d. pathologisch. Instit. zu Leipsig._ Jena, 1891.
[140] _Münchener medizinische Wochenschrift_, 1904, vol. li, p.
1676.
[141] _L'Obstétrique_, vol. i, p. 69.
The majority of writers give unfavorable prognoses for typhoid in
pregnancy. Abortion or premature labor is extremely common, with
great danger to the mother's life. When labor begins in these cases
the last sacraments should be administered early. Therapeutic
abortion in typhoid is very likely to cause death, yet a number of
women recover after abortion. As regards the woman's life, cases
of premature labor have a worse prognosis than early abortion. The
greatest danger is while the fever is high, and abortion is commoner
in the first week of fever than in the second or third. In protracted
typhoid abortion is likely to occur in the fourth week or later.
After defervescence the prognosis is better, but there is always
danger. Different physicians have markedly varying results. There is
no medical condition where skill in the physician counts more than
in typhoid; it is the supreme test of the therapeutist. Sacquin[142]
collected from various sources the statistics of 233 cases of
pregnancy during typhoid, and abortion or premature labor occurred
in 150 of these, with death in 16 per cent. Many skilful men have
a mortality as low as 3 per cent. in typhoid not complicated with
pregnancy.
[142] _Thèse._ Nancy, 1885.
The subject of typhoid is too vast for complete treatment here:
the article on Typhoid in the American edition of Nothnagel's
_Encyclopedia of Practical Medicine_ covers 472 large octavo pages.
A very important point is not to mistake typhoid for a septicemia
in its early stage. A Widal reaction should be made in apparently
septic cases to exclude typhoid. Sometimes, however, a streptococcic
infection will give a positive Widal, and there may be a mixed
typhoid and streptococcic infection.
Smallpox in pregnancy causes abortion or premature labor in the
majority of cases, and the child usually dies. The child may be born
in the eruptive stage, or pockmarked. Franklin reported a case where
a vaccinated woman was delivered of a child while her husband was in
the house ill with smallpox. The mother did not take the infection,
but the child was born dead of smallpox: the contagion had passed
to the child through the unaffected mother. Vaccinated women at
times bear children which are after birth immune to vaccinia and
smallpox--vaccinia, in the commonly held opinion at present, is an
attenuated smallpox. Pregnant women should be vaccinated, when there
is smallpox in their neighborhood, to protect themselves and their
children, unless they have been successfully vaccinated within four
or five years.
Vaccination prevents smallpox in more than 90 per cent. of the
exposures to the disease. The death-rate was 58 per cent. in
the unvaccinated cases and 16 per cent. in the vaccinated in a
group of 5000 cases of smallpox studied by Welch in 1894. During
the eighteenth century, according to Bernouilli's calculation,
one-twelfth of all the children born succumbed to this disease. In
1707, in Iceland, 18,000 of the entire population of 50,000 died
of smallpox. As late as 1885, 3164 persons died of the disease in
Montreal in one epidemic brought on at a time when vaccination had
been neglected. In Prussia, from 1851 to 1860, without compulsory
vaccination for civilians, there were 36,577 deaths from smallpox; in
the Prussian army during the same time, with compulsory vaccination,
there were only fourteen deaths. During the war of 1870 the French
armies, without vaccination, lost 23,469 men from smallpox; the
German armies lost only 459 men and there was a great epidemic of the
disease in Germany at the time.
The efficiency and necessity of vaccination against smallpox, which
is as virulent now as it ever was, is so certainly established
that a parent or guardian who neglects or refuses to have children
vaccinated when exposed to the disease is guilty of homicide through
neglect if an unvaccinated child under his care dies of smallpox.
Revaccination is necessary every eighth year if smallpox reappears.
Agitation against vaccination is not mere ignorance: it is a
dangerous crime, exactly like loosing a mad dog; and it is combined
with the insolence of ignorance. Persons who have seen smallpox
are very much afraid of it, because it is one of the most dreadful
afflictions humanity is exposed to; those who have not seen it, yet
say they are not afraid of it, are mere fools.
A pregnant woman who is infected with smallpox should receive the
last sacraments as soon as possible. If she aborts she may die very
quickly in collapse. If she is evidently in _articulo mortis_ and the
fetal heart can be heard, her cervix should be forcibly dilated, the
child turned, and delivered for baptism. If the physician waits for
death, the child will be dead also, and sectional delivery will be
too late for any good.
Pneumonia in pregnancy is a rare but very dangerous disease.
In one series of 13,611 pregnancies there were 120 cases of
pneumonia--eight-tenths of one per cent.; in another series of 1842
pregnancies two and three-tenths had pneumonia. Wallich,[143] in
a study of the mortality of this condition, found that pneumonia
causes abortion in one-third of the cases that occur during the
first six months of gestation, and in two-thirds of the cases that
happen between the sixth month and term. On the third day of the
pneumonia the abortions are most likely to occur. The maternal
mortality varies between 50 and 100 per cent. in the groups studied,
and the fetal mortality is 80 per cent. in general, but about 40 per
cent. for viable fetuses. The large size of the uterus in the last
months of pregnancy interferes with the descent of the diaphragm
in respiration, and the heart is likely to fail. The more advanced
the pregnancy, the greater the danger to both mother and child
from pneumonia. Among the dangers to the child is the imperfect
oxygenation of its blood, and in a few cases the pneumococci reach
the fetus.
[143] _Annales de Gynécologie._ June, 1889
Randall, in a study of 190 pregnant women who had pneumonia,
found a somewhat lower mortality than that observed by Wallich.
In Randall's series 70 died (36.7 per cent.); of 118 who did
not abort, only 12 died (10.7 per cent.). In a second group of
352 cases abortion happened in 58.8 per cent. Of 144 patients in
the first six months of gestation, 22.08 per cent. died, but of
those that aborted 52.08 per cent. died. Again, of 164 cases in
the last three months, 30.49 per cent. died, but 70.12 per cent.
died of those that aborted during these three months. Of 82 that
aborted, 87.8 per cent. died. The mortality in women under 25
years of age was 13.33 per cent.; in women from 25 to 35 years,
23.2 per cent.; over 35, 22 per cent.
Pneumonia in pregnancy is made worse by the mechanical
interference with respiration brought about by the enlargement
of the uterus, and the heart, which is overburdened in ordinary
pneumonia, is still more exhausted by the additional strain
of pregnancy in the pneumonia of gestation; moreover, the
lungs, which are obliged to do enhanced labor in pregnancy
in eliminating, are clogged by the pneumonia; it would seem,
then, that, if the fetus is viable, the womb should be emptied
to give the mother a better chance for recovery. Statistics,
however, are against therapeutic abortion. The evacuation of
the uterus determines blood to the inflamed lungs, which are
already overburdened. The exhaustion of labor weakens the
patient, and makes her liable to general septic infection.
Matton[144] found that in eighteen cases where pregnancy was
artificially interrupted, nine women died (50 per cent.); while
in twenty cases where no interference was attempted, only one
woman died. This comparison is not exact, perhaps, because we
do not know the gravity of the infection in each group, but
in any consideration the difference is remarkable. In a group
studied by Chatelain[145] the results in natural and artificial
delivery were virtually the same. Inasmuch as therapeutic
abortion at the best is no better than non-interference, there
is no justification for therapeutic abortion, unless in unusual
circumstances.
[144] _Jour. de Méd. de Bruxelles_, 1872, p. 412.
[145] _Ibid._, 1870, vol. l, pp. 430, 516, and vol. li, p. 11.
Pneumonia is an infectious disease, and a pregnant woman should,
for her own sake and the sake of the fetus, avoid exposure to
infection. When the disease is present the last sacraments should not
be deferred, as it may be impossible to make a confession when near
death.
Influenza in pregnancy is more severe than it is in the non-gravid
state. By the laity, and sometimes even by physicians, influenza
is confused with la grippe, but there is an influenza vera and an
influenza nostras, or la grippe, and this latter is not nearly
so serious a disease. The real influenza is caused by a specific
bacillus; it appears in epidemics which have a tendency to become
pandemic, and then the disease disappears for a generation. La grippe
is a bronchitis or coryza with some fever and muscle-soreness. True
influenza (the name is Italian, _influenza di freddo_) is very
infectious. The pandemic of 1889-90 started in Turkestan in June,
1889, and by October, 1890, influenza had gone westward and encircled
the earth along the trade routes. The preceding pandemic occurred in
1847-48.
There is no clear proof that pregnant women are especially liable
to infection by influenza, but there is always a notable fall in
the birth-rate after marked epidemics of the disease. This has been
observed in France, Germany, and Switzerland. When it does occur in
pregnancy it is likely to cause abortion. Pasquier, as early as 1410,
noticed this fact. The disease is likely to cause hemorrhage from
the uterus in non-gravid women, especially in those who are past the
climacteric, and menorrhagia in younger women who are not pregnant.
Moeller[146] found abortion or premature labor in 28.3 per cent. of
twenty-one severe cases. In severe influenza where there is diffuse
capillary bronchitis, pleuropneumonia, or spasmodic cough, abortion
is most likely to occur, and such abortion is always dangerous. The
hemorrhages in abortions from influenza are often alarmingly profuse.
[146] _Deutsch. med. Wochensch._, 1900, No. 28.
In threatened respiratory or cardiac failure in influenza
complicating pregnancy there may be question of therapeutic abortion,
but in such an event great care must be taken to avoid exhaustion and
shock. The child should be extracted; the woman should not be made to
labor. One of the important moral considerations in this matter of
influenza and pregnancy is that the woman commits grave sin if she
needlessly exposes herself to infection, because of the danger to
the child's life and the risk of its loss without baptism, and also
because of the danger to her own life.
Scarlatina (Italian _scarlattina_, Low Latin _febris scarlatina_),
or Scarlet Fever, is very rare in pregnancy. Popularly, scarlatina
is used for a light form of scarlet fever, as varioloid is used
for a light attack of smallpox; but physicians do not make this
distinction between scarlatina and scarlet fever: they use the terms
synonymously. In Nothnagel's _Encyclopedia of Practical Medicine_
Juergensen has an elaborate discussion on the differentiation between
genuine scarlet fever in the puerperium and the relatively frequent
septic erythema found in that state, but the received opinion now is
that real scarlet fever is very rare in pregnancy. Those who report
large numbers of scarlet fever cases in pregnancy err in diagnosis.
The mortality in the scarlatina of pregnancy may be very high--52 per
cent. in some epidemics; and if the infection happens immediately
after delivery, the mortality is still higher. A septic rash is
sometimes mistaken for scarlatina, but where the genuine disease is
present the pregnant woman is gravely obliged to avoid exposure to
it, both for her own sake and for that of the fetus. In the early
months of gestation scarlatina commonly causes abortion.
Measles in pregnancy is also very rare, but when it does occur it
is a serious disease. Gestation is interrupted in 55 per cent. of
the cases, and the mortality is 15 per cent. for the women. The same
moral and related conditions that obtain in scarlatina are found in
measles. There is a marked tendency to hemorrhage and pneumonia. Of
eleven cases reported by Klotz,[147] nine aborted.
[147] _Archiv. f. Gyn._, vol. xxix, p. 448.
In epidemics of Asiatic cholera the mortality among pregnant women
is extremely high. In the Hamburg epidemic of 1897, fifty-seven per
cent. of the pregnant women affected died. Abortion is very frequent
because of the hemorrhagic endometritis. The mortality for all
patients in Asiatic cholera is very great--almost 50 per cent. at
the beginning of the epidemic.
Typhus fever is the ship or famine fever of 1847. It is very rare
now. When it does occur it is about three times as fatal as typhoid.
It is a disease of poverty and war, and is spread largely by the
body-louse, as happened in Serbia in 1915. Skilled hygiene, however,
soon gains control of the epidemic.
Erysipelas in pregnancy is rare, but not infrequent after delivery.
In the puerperium it appears commonly as a septic infection in
abrasions about the parturient canal. When it starts on the face,
scalp, or breast the prognosis is relatively favorable, but even then
it causes death; when it starts on the genitalia it has a mortality
of 43 per cent. Erysipelas causes abortion. As it begins from pus
bacteria, it is not seen so frequently now as formerly, owing to
greater attention to asepsis. In the puerperium it is often an
infection brought on by dirty midwives or physicians.
Malaria, if severe, may interrupt gestation through fever or
cachexia. During labor in such cases the uterine action is feeble,
and hemorrhages are common after delivery. By proper treatment during
pregnancy these evils can be averted. The infection is spread from
one malaria patient to another by a mosquito (_Anopheles_), as yellow
fever is spread by another mosquito (_Stegomyia fasciata_).
Pulmonary tuberculosis in pregnancy is somewhat frequent; the
estimate is that about 32,000 tubercular women become pregnant
annually in the United States; and obstetricians incline to the
opinion that pregnancy commonly, though not always, makes the
tuberculosis worse. Nearly all agree that the combined effect of
pregnancy, the puerperium, and lactation is a grave burden on the
consumptive and lowers the power of resistance.
Trembley of the Saranac Lake Sanitarium reported that 63 per cent.
of 240 tubercular married women under his observation gave a history
which showed that the disease was first recognized during pregnancy
or the puerperium. Schauta's clinic found such origins in 29 per
cent. Fisberg, Funk, Jacob, Panwitz, and other observers, in a series
of 1100 cases, said 39 per cent. of these women thought the disease
began during pregnancy or the puerperium.
Some tubercular women during pregnancy give no clinical evidence
of an aggravation of the pulmonary disease, but these cases are
exceptional. Tubercular women who apparently improve during pregnancy
are likely to have a subsequent detrimental reaction. As tubercular
cases, however, are prone to show exacerbations even if not pregnant,
it is not possible to say that pregnancy is the sole cause of
the progressive lesions in particular instances. Where there are
no wide or deep areas of infection, there may be no recognizable
damage from pregnancy, but advanced and active tuberculosis, with
fever or cavity formation, does badly, especially if the throat is
involved. The pressure of the enlarged uterus causes dyspnoea; the
cough and fever may bring on miscarriage. Miscarriage, however,
is rare in tuberculosis; it is more common in cardiac and renal
diseases. Bernheim, in a series of 315 tubercular pregnancies, found
that abortion occurred in 23 per cent. The later in gestation the
tuberculosis becomes florid, the more likely it is that abortion will
happen. Conception may take place at any stage of the tuberculosis,
although women in the final stage are commonly sterile. Sometimes
a woman will give birth to a sound child and die herself of
tuberculosis a few days after the parturition.
Pregnancy in consumptive women is not necessarily detrimental to
each particular patient, nor is it, as a rule, a justification
for emptying the uterus of even the viable fetus. Even when the
tubercular condition grows worse during pregnancy it is not always
possible to prove that the pregnancy itself is the cause of the
deterioration. If the woman conceives in the final stage of pulmonary
tuberculosis she will die, whether she goes on to term or not.
Bonney[148] describes three cases of advanced pulmonary tuberculosis
which were cured during pregnancy, by the bodily changes peculiar to
that condition, but such results are altogether exceptional.
[148] _Pulmonary Tuberculosis_, p. 550. Philadelphia, 1908.
Artificially induced premature labor sometimes causes more damage
than normal parturition at term. Much depends upon the methods
used for the induction of the abortion. The insertion of bougies,
catheters, or sounds is always contraindicated in advanced
tuberculosis. Hirst of the University of Pennsylvania[149] thinks
the notion that tubercular women improve in pregnancy is "a
superstition," and that such women should neither marry nor have
children. De Lee[150] holds that tubercular women should not marry
because the woman is likely to infect her husband and children. He
thinks the disease grows worse in pregnancy, and that hemorrhage is
frequent except in chronic ulcerative tuberculosis. In this last
condition pregnancy does not ordinarily aggravate the condition.
In tubercular laryngitis complicating pregnancy, Küttner found the
mortality to be 90 per cent. Such laryngitis is usually fatal,
whether pregnancy is present or not. When there is a miscarriage
in tuberculosis, the infection often becomes florid and resembles
pneumonia. Advanced cases have a tedious and dangerous labor, with
dyspnoea and occasionally hemorrhage or cardiac exhaustion. Edema of
the lungs is not infrequent.
[149] _A Text-book of Obstetrics_, p. 427. Philadelphia, 1912.
[150] _The Principles and Practice of Obstetrics_, p. 480.
Philadelphia, 1913.
Williams of Johns Hopkins University, in the 1903 edition of his
_Obstetrics_, tells of a woman who died of tuberculous peritonitis a
short time after parturition. The uterus was studded with tubercles
and its interior was covered with tuberculous ulcers. The tubercle
bacillus had been found in cultures taken from the interior of the
uterus during life. Her child was born perfectly healthy and remained
so. Williams says in the same place that the induction of premature
labor because of tuberculosis is justifiable only in the interests
of the child, and this only in those rare cases in which the woman
is so ill that she probably will die before term. Norris[151] of
Philadelphia agrees with Williams that induction of premature labor
is useless, and he says all authorities unite in this opinion.
[151] _Pennsylvania Medical Journal_, February, 1916.
A tubercular woman should not nurse her infant because she will
infect it and exhaust herself. Infants are very susceptible to
tuberculosis. Birch-Hirschfeld, in 1891, first demonstrated
tuberculosis in the fetus, and Schmorl found it in the placenta in
50 per cent. of a series of cases that he examined. Infection of the
child _in utero_, however, is extremely rare even by the placental
way. There is a high death-rate from tuberculosis among infants,
but the infection is postnatal. Dietrich of Berlin found that the
death-rate from tuberculosis among children in Prussia is higher
during the first year of life than in any other year.
The moral conclusion is that artificial abortion in pregnancy
complicated with tuberculosis is never indicated except when the good
of the child is at stake in the last stage of gestation.