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.
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.
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.
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.
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.
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.
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.
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.
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.
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.