ABNORMAL PREGNANCY
After the diagnosis of pregnancy has been satisfactorily established, no
further internal examinations are necessary in the absence of special
indications, until about the thirtieth week.
At this time a series of complete physical examinations may be required
to determine the presentation and position of the child, the presence
and rate of fœtal heart tones, the diameters of the head, the length and
approximate maturity of the child, as well as the condition of the bony
and soft passages of the mother.
It is thus that an appreciation of the obstetrical problem is secured
and a course laid out for its successful solution.
Pregnancy is not a disease, but a normal function; but the woman is
exposed, nevertheless, to many grave risks that are peculiar to her
condition and to many complications accidental or otherwise which are
more serious on account of her pregnancy.
=The Toxæmias.=—The growing ovum brings about changes in the maternal
metabolism that are manifested by characteristic symptoms which in other
better known conditions are recognized as due to toxæmia. Therefore,
while there is no positive proof as yet that these symptoms, arising
during pregnancy, are toxæmic in origin, the evidence goes to show that
they are; and, therefore, should be classified as toxic.
Postmortem findings in eclampsia and pernicious vomiting such as
extensive thromboses, cell necrosis, and interstitial hæmorrhages are
very suggestive.
Clinical findings in regard to the excretion of nitrogen (urea, ammonia,
uric acid, etc.), the occurrence of acidosis, elevation of blood
pressure, fever, diminished excretion, coma and convulsions, all point
to toxæmia.
It is the minor disturbances, however, that the nurse will come in
contact with most. They are nearly all toxæmic in origin, and a brief
description of them must be given, together with suggestions for their
management.
=Salivation or Ptyalism.=—In the majority of cases, saliva is not
especially noticeable; but at times the secretion shows an enormous
increase, and may even demand abortion. Patients will have saliva
running constantly from the mouth. The amount may reach a pint or a
quart a day, and the skin of the lower lip becomes greatly inflamed.
The only satisfactory _treatment_ is a rigorous milk diet on the theory
that the disturbance is an intoxication. In extreme cases abortion may
be indicated.
=Gingivitis.=—The gums may become inflamed, spongy and hæmorrhagic
during pregnancy, usually in patients of low vitality. If a generous
diet and astringent mouth washes do not relieve the condition, the milk
diet should be considered.
=Toothache and Dental Decay.=—The patient may be given hypophosphites,
and the teeth should be put in good condition by a dentist.
=Constipation= has already been referred to. Strong cathartics should be
avoided lest abortion follow.
=Condylomata of pregnancy= occur most frequently around the labia,
perineum, and anus. They are wart-like growths that develop slowly or
quickly and may remain discrete or cover the entire area with masses as
small as beans or as large as cauliflowers, which in appearance they
much resemble. The etiology is obscure, but they are generally
associated with irritating vaginal discharges, such as an old gonorrhœa.
_Treatment_ consists in stopping the discharge or neutralizing it, and
in keeping the growths dry with a salicylic acid dusting powder. (See
Therapeutic Index.)
=Pruritus= is often distressing. The itching may be limited to the
genitals or appear on other parts of the body. It may be due to the
irritation of local discharges or to a condition of the nervous system,
arising from toxæmia. Astringent douches and protective ointments will
relieve some cases.
Bromides and milk diet, bran or alkaline baths give good results, and
local applications of sedative lotions and ointments containing menthol,
carbolic acid or cocaine (cautiously) will aid. The woman in some
instances becomes almost frantic, and tears at the vulva with her nails
until it bleeds.
The iodine treatment of Hensler is simple and often effective. If no
skin changes are visible and but little leucorrhœa, the vulva is
thoroughly prepared as for a vaginal operation, dried and painted with a
10 per cent solution of tincture of iodine. Generally one application
suffices, but when the leucorrhœa is bad, it may be necessary to repeat
the treatment on the third and fifth day thereafter. Between treatments,
the vulvar surfaces and even the vaginal walls (by insufflation) are
kept dry with zinc oxide powder. If all measures fail and exhaustion is
imminent, emptying the uterus may be advisable.
=Herpes= is an inflammatory, superficial eruption, characterized by red
patches, blisters, or pustules. It is accompanied by burning, itching,
and nervous depression. The origin is probably toxic and the termination
may be fatal. Milk diet, soothing lotions, and, if necessary, abortion,
constitute the means of treatment.
=Areas of pigmentation= (the chloasmata) are not amenable to treatment.
They usually disappear after labor.
=Albuminuria of Pregnancy.=—Albuminuria is so common as to be almost
physiological when the amount of albumin is small. When the amount of
albumin in the urine is large, it may be due to pre-existing disease,
which is first discovered when the urinalysis is made during pregnancy.
(Chronic nephritis?).
If it makes its debut during gestation and continues as a mere trace
without casts, it is spoken of as the albuminuria of pregnancy, but the
patient must be watched with great care, since the albuminuria may be a
premonitory sign of eclampsia.
Albuminuria and eclampsia must be considered together, because, while
the two conditions may exist separately, they are most frequently
associated, and it is believed that they have a common causation. It is
true that most cases of albuminuria terminate favorably, yet the higher
the albumin content, the greater the danger of eclampsia.
Albumin appears in the urine in from three to five per cent of all
pregnancies. It is more common in the latter half of gestation and the
attacks differ greatly in severity.
_Symptoms._—In the early stages the urine shows an abundant, pale fluid
of low specific gravity.
The seriousness of the case is generally indicated by the amount of
albumin, although this is not a reliable guide as to the danger of
eclampsia. Casts and red and white blood corpuscles are occasionally
found. The output of urea usually remains normal, but diminution usually
occurs in connection with eclampsia. Anæmia and anasarca are common, but
it is a hopeful clinical sign that the cases of extensive edema rarely
develop eclampsia.
In albuminuria of pregnancy there is a large fœtal mortality which, to a
degree, is independent of eclampsia. The infant dies _in utero_ or is
born feeble, or prematurely.
=Eclampsia= is the sudden appearance of convulsions in the course of
pregnancy. It may precede, follow, or accompany albuminuria. It occurs
rarely in the absence of albuminuria in a woman who was apparently in
good health. The two phenomena are best explained as a consequence of
toxæmia due to poisons at present unidentified.
_Treatment_ of the albuminuria is treatment for impending eclampsia.
Regular examination of the urine is indispensable. The presence of
albumin suggests toxæmia. The daily output of urine and the output of
urea must be compared, for a fall in urea is a premonitory sign of
eclampsia. The bowels and the skin should be stimulated, respectively,
by saline cathartics, hot baths and packs. The digestive organs must be
spared as much work as possible, especially the liver. Water is given in
abundance, and milk is the staple diet. Koumiss, butter milk and ice
cream may be allowed. As the patient improves, vegetables are allowed.
The food should be salt-free; and alcohol, as well as rich, indigestible
things should be forbidden. In the milder cases boiled fish and a little
chicken may be permitted.
The course of the disease and the condition of the patient is determined
by frequent examinations of the urine, while in all serious cases an
examination of the fundus of the eye must be made to detect a possible
albuminuric retinitis.
The treatment of eclampsia will be considered under the complications of
labor, where the attack usually begins.
=Pyelitis of pregnancy= is an acute, and rarely, a chronic infection of
the pelvis of the kidney, due to the Bacillus coli. It usually appears
after the fourth month (fifth to eighth) and attacks by preference the
right side. Extension to the kidney substance, ureters, and bladder is
occasionally observed.
_Symptoms._—Sudden, acute abdominal pain, at first diffuse, but after a
few hours, becoming localized in the right side, and on this account is
often confused with appendicitis, especially as vomiting is not
infrequent. A chill may mark the onset and the temperature rise to 103°
F. or 104° F. The bowels are constipated, the tongue coated, and there
is tenderness over the kidney. The urine is scanty, turbid, slightly
albuminous and contains pus and epithelium in the urinary canal. A
culture reveals the bacillus which has obtained access to the kidney,
either by extension of the ureter from the bladder, by direct invasion
of the tissues from the adjacent colon, or through the circulation.
_Treatment._—The diet should be fluid and mostly milk, the bowels should
be moved freely and frequently. The urine is alkalinized with sodium
citrate, since the Bacillus coli lives only in an acid medium. As the
symptoms subside, urotropin may be administered. If the patient does not
improve within two weeks, abortion must be seriously considered.
Nephrotomy is not to be thought of unless abortion has failed.
=Hyperemesis Gravidarum.=—The nausea and vomiting of pregnancy is so
usual as to be regarded as normal. It usually ceases from the fourth to
the fifth month spontaneously; has no ill effect upon the ovum, and may
respond readily to treatment.
Hyperemesis comes on at the same period and exhibits all stages of
violence, from the mild form above described, to cases that end fatally.
Three classes of this serious disorder may be distinguished as
associated (Eden), neurotic, and toxæmic vomiting.
Associated vomiting is the vomiting that comes with gastric ulcer or
cancer, chronic gastritis, cirrhosis of the liver, and cerebral disease.
These conditions must be excluded in diagnosis.
Neurotic vomiting—severe and persistent nausea and retching—is common in
pregnant women of the nervous type. It does not lead to loss of flesh
ordinarily; the urine is somewhat diminished in quantity from the lack
of fluids, but the amount of nitrogen excreted remains normal. This is
important.
Toxæmic vomiting includes a small but very important class of cases, for
all are severe and intractable and some end in death.
_Clinical Features._—The normal nausea and vomiting may seem unusually
severe. It persists and gets worse. Then vomiting occurs when no food is
taken and nothing is held on the stomach. The vomit is stained with bile
or blood. The tongue remains clean, and the general condition is good.
Next, weight is lost and the pulse quickens. A persistent pulse of over
100 is serious. The tongue becomes coated, sordes develops,
sleeplessness and muscular twitching appear, and the patient complains
of epigastric pain. Abortion may now occur and the condition clear up.
In its final stage, the urine becomes scanty and albuminous, icterus may
appear and the temperature rise to 100° F. or more, though sometimes it
is subnormal. The pulse may go to 120. Delirium and coma supervene, and
emptying the uterus is of no value. Fifty per cent of these bad cases
die.
The especially prominent points to be noted are the urine, which shows
acetone, albumin and blood, either one or all, as well as an increased
amount of ammonia. A persistently rapid pulse, marked loss of flesh,
coated tongue, jaundice and delirium are regularly present.
_Treatment._—Organic disease must be excluded and a diagnosis of
pregnancy strongly evident.
For the neurotic type, the patient must be segregated from her friends,
and a competent, cheerful nurse put in charge. A cool, darkened room is
best. If the patient can be transferred to a hospital, the results are
more satisfactory. Here the isolation from external interests and
irritations can be made complete. The patient does not talk, even the
nurse comes with food, attends to the obvious necessities, and departs
in silence. Once a day a sedative bath is given (see Baths, p. 325) and
medication in kind and frequency as the conditions demand.
In any case, the patient should be put to bed and fed carefully every
two or three hours on milk, peptonized food or barley water. If this is
not retained, albumin water may be given for twenty-four hours at
regular intervals, or rectal alimentation may be tried after stopping
all foods by mouth. Iced champagne, seltzer or Vichy, either alone or
with milk, may be tried. A dry diet is sometimes effective, rusk, toast,
toasted shredded wheat biscuit, crackers, etc., taken early in the
morning, as one eats cheese. No exercise is permitted except such
muscular and nervous excitation as may be derived from massage or the
sedative bath.
Drugs are sometimes of great value—the bromides, in full doses, or 1 m.
doses of tincture of iodine, well diluted, every hour; or bismuth with
hydrocyanic acid; or cocaine or oxalate of cerium. Occasionally good
results are reported from a capsule of pepsin, 2 gr. and ¼ gr. silver
nitrate given just before meals; and adrenalin in 10 drop doses may be
considered. Extract of corpus lutea has been tried by Hirst with
favorable results.
Sinapisms to the epigastrium and ice bags to the spine have been found
useful, and washing out the stomach is efficient at times. In washing
out the stomach, be sure the stomach tube is _iced_ before it is
introduced.
When the case gets worse in spite of treatment and acidosis supervenes,
bicarbonate of soda may be given in sixty grain doses every four hours,
by rectum, if necessary, until the urine gives an alkaline reaction.
Glucose as a readily assimilable carbohydrate may be given in doses up
to 10 oz. of a 6 per cent solution (Eden) or sugar infusions by rectum,
1000 c.c. in twenty-four hours by drop method.
_The obstetric treatment_ is the emptying of the uterus. To be effective
the abortion must be done before the condition of the patient is
desperate. It is most favorable before the febrile stage. If the
vomiting persists in spite of treatment and is accompanied by
emaciation, a pulse of over 100, albumin in the urine, with an increase
of the ammonia output, the pregnancy should be terminated at once. If
the patient can not go to a hospital, the nurse should prepare the room
as described for operations.
After emptying the uterus, the vomiting usually ceases but much labor is
thrown upon the nurse in supplying nourishment and caring for an
exhausted and whimsical patient.
The back must be inspected daily for decubitus (bed sores) and her
position changed frequently. A daily rub with alcohol and water (50 per
cent) followed by an oil inunction will be valuable. The teeth and gums
should be cleaned with gauze, wrapped around the finger and dipped in
solution of boric acid. No brush should be used.
[Illustration: Fig. 29.—Twins. (Lenoir and Tarnier.)]
=Multiple Pregnancy.=—Twins occur about once in ninety labors, triplets,
once in seven thousand.
Heredity and multiparity seem to be the only recognized predisposing
factors. The more pregnancies a woman has, the more liable she is to
have twins.
Twins may occur through a division of the primitive cell through the
fertilization of two ova from the same or different ovaries, or by
fertilization of a single ovum having two nuclei. (See Fig. 13). The
former are called binovular twins, and may or may not be of the same
sex. The latter are called uniovular twins and are always of the same
sex. Twins are usually somewhat smaller than a single child, and
frequently associated with hydramnios. Binovular twins have separate
placentæ and uniovular twins have one placenta, with separate cords.
Twin pregnancies usually go into labor earlier than the single child,
possibly on account of the over-distention of the uterus.
_The diagnosis_ is occasionally difficult and at other times easy. Two
sets of heart tones must be distinguished and differentiated by their
variation in frequency, heard at the same time by different observers.
The presence of twins may be strongly suspected also when the external
measurements of child and uterus greatly exceed the average. In such
cases a systematic and persistent search must be made for the two fœtal
heart tones.
_The delivery_ is generally uncomplicated, unless the chins become
locked.
=Displacements of the Uterus.=—In most cases displacements of the uterus
are a consequence of conception in organs that are previously
retroflected or retroverted. They rarely produce symptoms until the end
of the third month, when the attention is directed to the bladder. There
may be absolute retention or a constant dribbling from a full bladder
(ischuria paradoxa), possibly associated with pain. If recognized early,
an attempt should be made to replace the uterus by posture (knee chest)
and when replaced, to hold it by pessary or tampon. The prone position
in bed will aid.
After retention has occurred, the patient should be put to bed and the
bladder catheterized regularly every eight or ten hours for three or
four days. As a rule, the organ will rise spontaneously into the
abdomen. If it does not, it is probably incarcerated under the
promontory, and the physician must try to replace the uterus by
manipulation or by continuous pressure, but in bad cases, he will empty
the uterus before the condition of the patient becomes too serious.
In multiparas with weak abdominal walls, or women with spinal curvature
or contracted pelves, the uterus may fall forward and, passing between
the recti muscles, continue to drop until the fundus lies lower than the
symphysis pubis.
_Management_, until labor occurs, may be made more effective by using a
strong, well-fitting abdominal bandage.
=Malformation of the uterus= may possess an obstetric interest at times.
The double uterus (uterus didelphys) and the uterus with a rudimentary
horn (uterus bicornis) are examples. These are congenital conditions,
due to imperfect development, and pregnancy may take place in one or
both sides. If in one side only, the other half will also exhibit the
softening and other changes as in normal cases. Binovular twins may be
the result of a pregnancy in each side.
=Pressure Symptoms.=—_Edema_ of legs and sometimes of the vulva occurs
during the last trimester. It is due to increased intraabdominal
pressure and to direct interference with the return circulation by the
pressure of the heavy uterus on the iliac veins at the brim of the
pelvis. The urine should be examined for albumin and the patient put in
the horizontal position if the edema is troublesome.
_Varicose veins_ of legs and vulva may cause much distress. The limbs
should be bound with flannel spirals or with rubber bandages in the
recumbent position, or elastic stockings may be obtained. Operation
during pregnancy is not to be considered. The vulva can only be relieved
by a double bandage, which is sewed at the point where it crosses the
vulva, and buckled or tied to a waistband above the hips, both before
and behind. This brings support to the vulva. If the veins rupture, the
part should be elevated and compressed with an aseptic pad.
_Hæmorrhoids_ may either appear or grow worse late in pregnancy. If they
protrude, they should be replaced. Ointments and iced applications may
be used and the bowels kept loose.
_Cramps_ may occur in the muscles of the legs, due sometimes to the
varicose veins and sometimes to pressure on the lumbosacral plexus.
=Moles.=—Mole is the name given to an ovum which is destroyed by disease
of its coverings during the early months of gestation. Two kinds are
known, the blood mole (carneous mole, fleshy mole, or hæmatoma mole) and
the hydatidiform mole (vesicular mole).
The blood mole results from progressive or recurrent slight hæmorrhages
during the first three months of pregnancy, but hæmorrhages insufficient
in quantity to produce an abortion. The blood forms a clot, which may be
retained for several months and become solidified.
Hydatidiform mole is a disease of the young chorionic villi,
characterized by the growth of an immense number of irregular clusters
and chains of grape-like cysts from the very minute to bodies
four-fifths of an inch in diameter. The causation is unknown.
Both forms occur in the first half of the pregnancy and are
characterized by undue enlargement of the uterus and hæmorrhagic
discharge.
=Diseases of the Membranes.=—_Hydramnios_, or polyhydramnios, is the
name applied to the condition where an excess of liquor amnii is formed.
The amount normally present varies, but anything in excess of four pints
could be called hydramnios. Six gallons have been reported. Since the
source of the liquor amnii is not positively known, the etiology of
hydramnios must be equally obscure.
It is occasionally associated with morbid conditions of the mother, such
as hepatic or cardiac dropsy, but more frequently with developmental
anomalies of the fœtus.
Since the mother is usually healthy and the fœtus frequently deformed,
the theory is advanced that the disease is fœtal in origin. It
frequently occurs with twin pregnancies, and in the first months it is
most plausible that the liquor amnii is in some way derived from the
fœtus.
The disease is more common in multiparas. It is generally slow in onset,
but it may be acute, and an immense amount of fluid may be formed in a
few weeks.
_The symptoms_ are those due to pressure from the extremely large
uterus.
_The treatment_, if interference with heart or lungs becomes pronounced,
is puncture of the membranes. The child need not be considered for it is
usually dead or deformed.
_Oligohydramnios_ is the condition where the liquor amnii is deficient
in amount. It gives no maternal symptoms, but it is the cause of many
birthmarks and fœtal deformities (club-foot, spinal curvature, wry-neck,
ankylosis of joints).
Amniotic adhesions are usually associated with oligohydranmios and cause
deformities by amputation of limbs, strangulation of cord, and
production of six fingers.
=The placenta= may show anomalies of size and shape. Thus, there may be
two lobes, or three. There may be the main placenta and a small
out-lying mass connected by membrane and vessels with the larger
segment. The cord may be inserted in the middle or at the edge and
yellowish-white masses called infarcts may be found in its substance.
Unusual size and weight of the placenta are suggestive of syphilis.
=Abnormal conditions of the fœtus= may arise from primary or transmitted
disease or from errors of development. The developmental errors may be
monsters, _hydrocephalus spina bifida_, etc., which may not influence
the pregnancy. The most commonly transmitted disease is syphilis, which
may produce abortion, premature labor, or a child born with syphilitic
skin changes on palms and soles, as well as internally.