ABNORMAL PREGNANCY (Cont’d)
=Extrauterine Pregnancy.=—This is a pregnancy which occurs outside the
uterus, and while the event usually happens in the tube, cases have been
reported where the egg developed in the ovary or abdomen.
The ovum, owing to some delay in passage to the uterus, is fertilized
either in the ovary or in the tube, and by reason of a chronic
inflammation of the tube or pelvis, or of overgrowth does not succeed in
reaching the uterus at all.
As the ovum develops, the tube expands, but it does not possess the
power of growing into a large organ like the uterus, hence a sudden jar,
a strain, or a blow may cause it to rupture and discharge the egg into
the abdomen (ruptured tubal pregnancy) or force it out through the end
of the tube (tubal abortion).
This phenomenon may be accompanied by a severe or even fatal hæmorrhage;
or the prostration may pass off in a few days or weeks, and leave the
patient well.
In the early stages the ovum is absorbed, but after the pregnancy
becomes more advanced, it may remain as a tumor, or require an operation
for its removal.
Infection may occur and the mass ulcerate its way into neighboring
organs (rectum, vagina, or bladder) and discharge itself in a long,
suppurative process.
Most cases of ectopic (extrauterine)gestation present definite and even
dangerous symptoms between the second and fourth month. The _symptoms_
are those of pregnancy, together with irregular hæmorrhages from the
uterus, which may result in the expulsion of pieces of tissue or of
membrane. Besides this, there is a vomiting and acute irregular pain on
one side, associated with a sense of fullness. Such symptoms should be
brought to the attention of the physician, who will learn the true
condition of the pelvis by internal examination, conducted as gently as
possible so as not to produce rupture.
If rupture occurs, it will be ushered in by a sharp lancinating pain on
one side, followed by faintness, nausea, vomiting, prostration, rapid
pulse, sighing respiration, and collapse. The temperature is subnormal
and death may occur in a few hours, unless an operation is done.
[Illustration: Fig. 30.—Diagram representing the sites for the various
forms of tubal pregnancy. 1, interstitial pregnancy; 2, isthmial
pregnancy; 3, ampullar pregnancy; 4, infundibular pregnancy; 5,
tubo-ovarian pregnancy. (Gilliam.)]
In cases of tubal abortion (where the ovum escapes through the end of
the tube) the symptoms are very similar, but the patient soon rallies
and gradual recovery takes place.
If the diagnosis is made before rupture or abortion the _treatment_ is
laparotomy. If rupture occurs, the laparotomy must be done immediately
to check the hæmorrhage, which threatens the life of the patient. In
tubal abortion, if the diagnosis is certain, some delay may be permitted
under extreme watchfulness of the nurse and physician. In such case, the
nurse will keep the patient absolutely quiet and forbid exertion of any
kind.
If operation is necessary, the utmost gentleness must be used in
preparing the abdomen. The tincture of iodine application to the site of
the incision is sufficient preparation, and, of course, an abundance of
sterile gauze, cotton, and towels should be supplied, as in every case
where laparotomy is done.
If the rupture occurs while the nurse is present, the doctor should be
notified at once, and if not at home, another doctor should be summoned.
Meanwhile, the nurse prepares the room, solutions and utensils for an
abdominal operation. Immediate incision to check the hæmorrhage and
remove the mass offers the greatest safety.
The after-care is the same as for any laparotomy, with the additional
duty of making up the lost blood as soon as possible by nourishing
foods, normal saline solution by rectum, and, if necessary, by
hypodermoclysis.
=Acute fevers= are a serious complication of pregnancy on account of the
danger of abortion or premature labor, which may come on either from the
associated high temperature or from the transmission of the disease to
the ovum.
The following diseases are known to affect the fœtus _in utero_:
cholera, yellow fever, small pox, scarlet fever, typhoid, measles,
erysipelas, meningitis and syphilis.
CHRONIC INFECTIONS
=Tuberculosis= does not affect fertility or the course of the pregnancy,
but the progress of the disease is hastened, and the maternal death
accelerated.
The question of artificial abortion in the early months must be
seriously considered, and if the case goes on to term, the child must
not be nursed or cared for by the mother.
=Syphilis= is the most frequent systemic cause of the interruption of
pregnancy. It is a blood disease, due to an organism, called spirochæta
pallida, and it appears in three distinct stages. The first is the
primary stage, wherein a hard, nodular ulcer appears on some part of the
body, as the vulva, lips, gums, tonsils, or hand. It is _not always_
venereal in origin. The second stage begins six or eight weeks after the
sore, and is marked by a general eruption of red spots, chronic sore
throat, falling hair, and rheumatic pains in the joints. The third stage
is the name given to the later conditions of the disease which affect
the bones, blood vessels, and nervous system.
Infection of the ovum may usually be traced to the father, who may
transmit syphilis at any stage of the disease. In the third stage, the
child alone will be infected; the mother escapes.
The mother may or may not transmit the disease, depending on the period
of pregnancy wherein her infection occurs. If she gets the disease at,
before, or just about, the time of conception, she will abort three
times out of four, and the ovum will show definite lesions. If infected
later, abortion occurs less frequently; and if the disease is contracted
late in pregnancy, the child may be born apparently free from infection.
_Symptoms._—A child with congenital syphilis will show the eruption of
coppery spots, blisters on palms and soles, deep cracks on the feet,
snuffles, cracks and ulcers around the mouth and rectum, and the weakly,
marasmic condition of the body.
The diagnosis in suspected cases can be rendered more certain by the
Wassermann reaction. This is a laboratory test of the blood which should
always be made before a wet nurse is allowed to nurse a child, or before
a suspected child is nursed by a clean woman. In all cases of
transfusion of blood, it is imperative.
_Treatment._—Antisyphilitic treatment of an infected mother or child by
salvarsan, mercury, and potassium iodide must be carried out vigorously
in all cases.
The syphilitic patient must be prevented from spreading the infection by
having dishes and utensils of her own, which are kept sterile.
Discharges are collected and burned, and the nurse in charge of these
cases must carefully cover her hands with rubber gloves, and see that
all cracks and fissures are properly protected from contact with sources
of infection.
=Gonorrhœa= is an acute or chronic disease of the mucous membranes due
to a germ called the gonococcus.
Beginning with a sharp inflammatory disturbance of the urethra or
vagina, it may pass slowly up through the genital passage and produce
chronic and permanent disabilities, such as sterility, pus tubes, and
pelvic peritonitis.
_The symptoms_ are painful urination, painful inflammation of the
vagina, with a purulent discharge. During pregnancy all these symptoms
are intensified, and warty growths (condylomata) may appear on the
vulva.
If infection occurs after pregnancy has begun, the course of the
gestation is rarely affected, as the uterus is closed to germ invasion.
During delivery, however, there is a serious danger of infection of
mouth or eyes of the child if they come in contact with the discharge.
_Prophylaxis._—The eyes at birth must be immediately instilled with a
drop or two of 1 per cent solution of silver nitrate in water. This is
_not neutralized_ by normal saline. Great care must be used that the
discharge does not come in contact with the eyes of the mother or
attendants, lest infection follow.
_Treatment._—Scrupulous cleanliness must be observed. Douches of
potassium permanganate, 1:5000, or painting the vagina with iodine or
solution of silver nitrate, or suppositories of argyrol or protargol
furnish the best means of treatment before labor.
Neither syphilis nor gonorrhea is _necessarily_ caused by venereal
infection. They may be spread by barbers, dentists, physicians, and
nurses,—by anyone who is unclean; and may be acquired innocently
everywhere.
These diseases should not be discussed by the nurse or physician except
with the patient. Certainly nothing from the sick room should be
repeated elsewhere.
=The valves of the heart= are not uncommonly found to be diseased in
pregnancy, the mitral being the most often affected, either as an
insufficiency or as a stenosis (a narrowing of the mitral opening).
Mitral stenosis is the most serious of all heart complications of
pregnancy, and where this is present, a woman should be advised to avoid
conception.
In other mitral lesions, many pregnancies may be successfully passed, if
compensation is maintained; but every one brings further damage to the
already weakened heart, and reduces its reserve of force. If the heart
breaks down early in pregnancy, and does not respond to medication,
abortion should be induced. In the second half of pregnancy, the mother
should be given the prior chance, but the child should be saved, if
possible.
=Renal diseases=, such as nephritis, may not only induce abortion by
destroying the fœtus, but the kidney lesion may be greatly aggravated by
the pregnancy. The most careful observation of the patient’s condition,
the regular examination of the urine, and the scientific management of
the diet is necessary to relieve the work on the kidneys and keep the
patient in a moderate degree of health.
It is the duty of the nurse to protect her patient against fatigue and
chill, and to see that the proper diet is followed; but other symptoms,
such as headache and disturbance of vision and developing edema, must be
noted and reported to the physician at once.
=Diseases of Liver.=—Acute yellow atrophy is a rare condition, which,
for reasons unknown, is promoted by pregnancy.
_The symptoms_ are intense headache and pain in the abdomen, possibly
accompanied by vomiting and purging, which are soon followed by coma.
There is generally a certain amount of jaundice. The urine is diminished
in amount and contains albumin, casts, and sometimes blood. There is no
known treatment, and the end is death.
=Diabetes= is seldom found associated with pregnancy. Its presence is
unfavorable to conception and to gestation. Mother and child are both
less secure. Abortion or premature labor is the rule.
=The hæmorrhages= of pregnancy in the first half generally mean
abortion, and in the last half, either placenta prævia or premature
detachment of the normally implanted placenta (see p. 228).
=Abortion= is the expulsion of the ovum before the fœtus is viable, that
is, before it is capable of maintaining life after birth. This means the
twenty-eighth week, or the seventh month. Subsequent to the seventh
month, the interruption is called premature labor. Abortion is a
miniature labor, consisting of a stage of dilatation, a stage of
expulsion, and a stage of involution.
The interruption of the pregnancy may occur spontaneously or be induced.
In spontaneous cases the causes may be sought in diseases of the ovum,
or in the mother, in injuries to the uterus or its contents, and such
systemic affections as syphilis, Bright’s disease, alcoholism, lead
poisoning, etc.
Abortions happen about once in every five or six pregnancies, and more
frequently at the third month than at any other time.
_The symptoms_ are hæmorrhage and pain. The _dangers_ are hæmorrhage and
infection.
Infection is most common and most serious in abortions that are brought
about mechanically.
Hæmorrhage, in some degree, is an invariable symptom, which has its
origin in the separation of the ovum from the uterine wall. Hæmorrhage
from the uterus is serious at whatever stage of pregnancy it appears.
The duty of the nurse is to put the patient in a cool, dark room, on her
back, elevate the foot of the bed, put ice bags on the lower abdomen,
and summon the attending physician, with the hope that an abortion can
be averted. Bromides and opium are the drugs most to be relied upon.
Opium may be given in suppository, 1 grain night and morning.
If the hæmorrhage is alarmingly profuse and the nurse is skillful and
clean, under exceptional circumstances she may pack the vagina with
sterile cotton while waiting for the doctor. Then the room should be set
for operation.
=Dead Ovum.=—The ovum may be discharged in pieces or in a single
complete mass.
The egg may die at any period of the pregnancy, and be discharged in a
few hours, or it may not be expelled for weeks, if at all. Fœtal death
in the uterus may have its cause on the paternal side in a father too
old or too young, or affected with such diseases as diabetes, nephritis,
tuberculosis, syphilis, or chronic lead poisoning; on the maternal side,
the same diseases, plus cancer, anæmia, insufficient food, and
inflammation of the uterus; on the part of the embryo, syphilis or any
transmitted or primary disease of the ovum.
The results of retention of the dead ovum vary with the case. Infection
of the ovum is rare, except where the membranes have ruptured and an
open channel exists. No harm follows the death of the fœtus, except in
the presence of infections, all other changes are benign. The embryo in
the first and second months may be absorbed, but at later periods, it
becomes macerated petrified, or otherwise altered.
Among the _signs_ of fœtal death are prolonged cessation of fœtal
movements after being definitely observed, chilliness, languor and
malaise of the mother, sense of weight in abdomen, and possibly a bad
taste in the mouth. Furthermore, the uterus does not correspond to the
period of pregnancy, and may have become smaller. Retrogressive changes
take place in the breasts.
The diagnosis is only certain when the heart tones are persistently
absent, or the macerated head of the fœtus is felt through the partly
dilated os as a flabby bag of bones.
_Treatment_ in noninfective cases is expectant. Spontaneous expulsion
will occur sooner or later and there is no necessitous indication for
interference. Local signs of putrefaction, however, make the immediate
emptying of the uterus necessary.