DIAGNOSIS OF PREGNANCY
The presence of pregnancy is naturally determined by the recognition of those changes in the maternal system which the growing ovum produces.
During the second half of the period the fœtus can be made out distinctly by palpation, or by its movements, and the heart tones observed by auscultation.
During the first half this is impossible and the diagnosis must be made from subjective symptoms elicited from the patient and upon physical signs observed by the physician.
It is of extreme practical importance to be able to recognize a pregnancy at all periods. The subjective symptoms of the first half are—amenorrhœa, morning sickness, irritability of the bladder, discomfort and swelling of the breasts, enlargement of the abdomen and quickening; but the appearance of any or all of these phenomena is not to be regarded as conclusive, but merely as a presumption that pregnancy exists. Either through ignorance, intent to deceive, or from pathological conditions, any or all of these symptoms may be present, but not until the tenth week are the changes in the uterus sufficiently definite to confirm a diagnosis unless the circumstances are especially favorable.
Amenorrhœa.—Cessation of the menses is practically invariable in pregnancy. One or two periods may occur after conception, but care must be used to exclude other causes of hæmorrhage. Sudden cessation of the periods in a healthy woman of regular habits who is not near the menopause, is strongly suggestive of pregnancy. Why a developing ovum causes an immediate arrest of menstruation is not understood.
Amenorrhœa may occur in consequence of chlorosis, heart disease, hysteria, tuberculosis, fright, grief, and some forms of insanity; a change from a low to a high altitude, or an ocean voyage not infrequently causes the flow to remain absent for one or more months. In addition to its value as a presumptive symptom, the amenorrhœa affords a common and convenient method of estimating the date of confinement. The method is fallacious but practical, and will be discussed later.
Morning Sickness.—This symptom is not invariable. It is most frequent in primiparas, but not so likely to occur in subsequent pregnancies. It usually appears about the second month, shortly after the first period missed. It varies in intensity. Some women have a little nausea on arising and no further trouble during the day, others are nauseated and vomit either on rising or after the first meal, and yet others after each meal; but the general health is not ordinarily affected and the tongue remains clean. Some cases are of extreme severity (hyperemesis) and will be discussed elsewhere.
The morning sickness is probably toxic in origin. It must be remembered that chronic alcoholism is accompanied by morning sickness, but with it the tongue is furred.
Irritability of bladder is shown by a frequency of urination. It is caused by the congestion and stretching of the tissues that lie between the uterus and bladder and hold them in relation to one another. After the third month an accommodation is established and the symptom does not reappear until late in pregnancy, when the pressure of the heavy uterus tends to keep the bladder empty. If especially annoying, this irritability may be much relieved by putting the patient in the knee-chest position night and morning.
Enlargement of the breasts is common in primiparas, but this, with changes in the areola, may occur at menstrual periods in nervous women. Tingling, pricking and shooting sensations may also be noted.
Enlargement of the abdomen is only noticeable toward the latter part of the first half, when the uterus rises out of the abdomen.
Quickening means “coming to life,” and refers to the first movements of the fœtus that are felt by the mother. It is described as similar to the flutter of a bird in the closed hand. It is sometimes accompanied by nausea and faintness. Quickening usually occurs about the seventeenth week of pregnancy, and continues to the end. Gas in the intestines will sometimes simulate quickening.
The movements are important in the second half as indicating that the child is alive.
Physical Signs.—During the first weeks no conclusive changes occur that can be detected by examination, and unless conditions are especially favorable, the earliest time for the definite diagnosis of pregnancy is the eighth week. Previous to this it is presumptive only.
At the eighth week, the breasts may show enlargement and tenderness, with some secretion. In the multipara, this sign has no significance. Secretion is present sometimes in the breast of nonpregnant women with uterine disease (fibroids).
Examination of the abdomen at this time is of little value, but changes in the uterus can be detected by careful bimanual examination. It is needless to say that all internal examinations should be made with the utmost care and gentleness.
Softening of the lips of the os (Goodell’s sign) may be found, but it must not be confused with erosions of the os. The os of a nonpregnant woman feels like the tip of the nose, and that of the pregnant woman like the lips.
Fig. 26.—Bimanual examination. (Edgar.)
The increased size and globular shape must also be considered as confirmatory.
Hegar’s Sign.—The upper part of the uterus is soft and distended by the ovum, the lower part is soft and not filled out by the ovum. Between the two is an isthmus that is compressible between the fingers of one hand in the vagina, and of the other upon the abdomen. When found, this sign is of great value.
At the eighth week, pregnancy can be regarded as highly probable by the conjunction of the following symptoms and signs: Amenorrhœa, morning sickness, irritability of bladder, slight breast changes in primiparas, lips of os externum softened, uterine body enlarged, softened, and nearly globular in shape, and Hegar’s sign.
Abderhalden’s test is a serum reaction based on the well established principle that the introduction into the blood of an organic foreign substance leads to the formation of a ferment to destroy it. Abderhalden’s plan was to discover whether the blood of a pregnant woman contained a ferment capable of destroying placental protein. It is a very complicated test, and subject to many inaccuracies and numerous sources of error. At the same time, the main features of this reaction have been confirmed, and when it is worked out, it will be of immense value not alone in early uterine pregnancies, but in extrauterine pregnancy. This view very properly demands that pregnancy be regarded as a parasitic disease. It is practicable as early as the sixth week to make a diagnosis, and it only fails in possibly ten per cent of the cases. The negative test is equally definite as eliminating pregnancy.
Sixteenth Week.—Morning sickness and urinary symptoms have disappeared but amenorrhœa remains. Enlargement of the breasts is noticeable, as well as the increased pigmentation. The uterus begins to rise above the symphysis as an elastic, somewhat ill-defined, boggy mass. The cervix is softer. The characteristic dull lavender coloration of the vulvar mucous membrane is now evident. It is due to the congestion and is called Jacquemins’ sign.
Two New Signs.—Irregular, painless contractions of the uterus (Braxton Hicks’ sign), and ballottement.
The contractions of Braxton Hicks now become more easily palpable.
Ballottement consists in the detection in the uterus of a movable solid body surrounded by fluid. In a standing position, the fœtus rests in the lower part of the uterus, just above the cervix. The woman stands with one foot on a low stool, and two fingers of one hand are pushed into the vagina until they touch the cervix, the other hand is placed on the fundus. A smart upward blow by the internal hand is transmitted to the fœtus, and it can be felt to leave the cervix, strike lightly the tissues underneath the external hand, and return to the cervix. It is simulated by so few things, and so rarely, that in practice it must be regarded as a positive sign.
During the second half, the subjective symptoms are of minor importance since unmistakable evidence is furnished by the physical signs. The symptoms of this period are mostly discomforts. Increased intraabdominal pressure brings on edema of the feet, cramps in the legs, varicose veins of the legs and vulva, dyspnœa, and palpitations.
Twenty-sixth Week.—About the twenty-sixth week, or, at the end of the sixth calendar month, the hypertrophy of the breasts, the presence of secretion, and the marked pigmentation are unmistakable. The abdominal protrusion is now clearly visible, and the fundus will be found at the level of the upper border of the umbilicus.
Spontaneous fœtal movements appear and may be felt by the palpating hand.
Auscultation reveals the uterine souffle and the fœtal heart sounds. The heart sounds and the fœtal movements, when obtained by the observer, are positive signs.
Uterine souffle is a soft, blowing murmur, synchronous with the mother’s pulse. It is best heard at the lower parts of the lateral borders of the uterus. It is due to the passage of blood through the greatly dilated uterine arteries. It may be heard also in cases of fibroid tumors of the uterus.
Fig. 27.—Abdominal enlargement at third, sixth, ninth, and tenth months of pregnancy. (Williams.)
Fig. 28.—Height of the uterus at various months of pregnancy. (Bumm.)
The fœtal heart sounds are the most anxiously sought for of all the signs of pregnancy. They are conclusive. They not only determine the diagnosis, but afford valuable information during labor, and nurse and student should lose no opportunity of becoming familiar with them. The heart tones can be heard as early as the twenty-sixth week, but they become more and more distinct as pregnancy advances. They vary from 140 to 160 beats to the minute at the twenty-sixth week, and at term, from 120 to 140. When they rise above 160 or sink below 120, some danger threatens the child. The fœtal heart tones have no significance as an indication of sex.
Funic souffle is the sound made by the passage of blood through the umbilical cord when a loop accidentally lies under the tip of the stethoscope. It is synchronous with the fœtal heart tones, but of no great practical importance when the heart tones can be obtained.
Determination of the period to which pregnancy has advanced is sometimes important. This can be approximated by a calculation of the time that has elapsed since the last period, or from the date on which quickening has occurred. Measurement of the height of the fundus and comparison with such scales as Spiegelberg’s, may be carried out, but it is not often required.
A method of estimation in gross, that is approximately correct, in many cases depends on the observation of the steady growth of the womb.
Thus, the uterus rises out of the pelvis at the fourth month, and may be found well above the symphysis pubis. At the fifth month the fundus is midway between the symphysis and the umbilicus. At the sixth month it reaches the umbilical level. At the eighth month it is a little more than midway between the umbilicus and the ensiform cartilage, which it attains in another month, the ninth. Then it usually sinks a little, especially in primiparas during the last two or three weeks. This is called lightening.
CHAPTER IV
HYGIENE OF NORMAL PREGNANCY
The time of confinement can never be accurately determined, because the onset of labor is purely an accident, dependent on many factors. Furthermore, conception does not take place necessarily at the time of intercourse, and we have no means of knowing whether conception occurred just after the last period present or just before the first period missed. So there is always a possible error of three weeks.
Pregnancy in the human family normally lasts from 275 to 280 days, and the approximate date of confinement can be obtained by the following convenient rules:
1. Take the first day of the last menstruation, count back three months and add seven days.
2. Or, assuming that quickening occurs at the seventeenth week, count ahead twenty-two weeks from the day on which quickening was observed.
3. Or, count two weeks from the day of lightening.
4. Or, with a pelvimeter, get the length of the fœtus by Ahlfeld’s rule (measure from symphysis to breech of child, subtract two cm. for thickness of abdominal wall and multiply by two. The result is the length of the child in centimeters) and compare with fifty centimeters, which is the average length of a mature child. After the seventh month, the child in utero grows at the rate of about 1 cm. a week (0.9 cm.).
5. Or, by the tape, according to Spiegelberg’s standard of growth, as previously mentioned.
The hygienic rules to be observed during pregnancy are founded on three basic principles: (1) To watch attentively the different organs and see that they functionate normally; (2) To eliminate all those conditions that favor the premature expulsion of the egg; and (3) To provide, so far as possible, for the normal gestation and the physiological delivery of the child. These factors will be taken up in detail.
The Diet.—The appetite is usually somewhat increased, but it is unnecessary to indulge the stomach on the ground that the mother “must eat for two.” Longings, however, should be gratified so far as the demand is not for unwholesome things. Food should be simple and plainly cooked. Meat is permitted in moderation unless some organic change exists to contraindicate it. Rich pastries and gravies should be avoided, but cereals, fruits and vegetables should be used in abundance. It may be better to eat four times a day instead of three. Fluids should be taken freely, from one to two quarts daily. Milk is especially valuable, and alkaline, natural and charged waters, such as Vichy and seltzer, are useful. Wine, beer and other alcohols should not be taken, or if the patient is habituated to their use, the amount should be restricted on account of danger to the pregnancy and danger to the child.
In contracted pelves it is sometimes desired to furnish a special diet, with the idea of controlling the size of the child (see Prochownick’s Diet, p. [332]) but this is an emergency. Certain books on maternity, designed for popular reading, advocate diets that are supposed, by depriving the child of lime salts, to keep its bones soft and make the labor easy. If it succeeds, the child will be injuriously affected. If it does not succeed, the claim is false.
Exercise.—Exercise should be taken, but it should not be violent, nor attended by risk. Golf, swimming, tennis, dancing, horseback or bicycle riding and fast driving in automobiles should be forbidden, lest abortion follow. General exhaustion must be avoided and all conditions that even approximate traumatism. Walking and slow driving are best, and housework is excellent up to a mild degree of fatigue. Travel should be restricted. If exercise is not feasible, massage will furnish the required stimulation to the circulation. The menstrual epochs are peculiarly favorable to abortive influences.
The Bowels.—Most women have a tendency to constipation during pregnancy. Many times this can be corrected by increasing the “roughening” in the food; more vegetables and fruits, bran bread and muffins, whole wheat bread, spinach, beans, carrots, turnips, peas and especially potatoes, baked and eaten, skin and all. Prunes, figs, and dates are valuable aids. Agar may be eaten three or four times daily. Russian oil (liquid petrolatum), taken in tablespoon doses three times daily, is an adjuvant, and finally, some form of cascara or aperient pill may be taken, if necessary.
Violent cathartics should not be used at all, and enemas as little as possible; only when quick results are necessary.
Heartburn.—Heartburn is a frequent complication, especially in the later months. It is due to an inordinate secretion of acid in the stomach. Soda mint tablets, bicarbonate of soda, and magnesia, in cake or as milk of magnesia, will relieve. The magnesia is also a laxative.
The kidneys require particular care during pregnancy, and in every case the urine should be examined monthly, up to the fifth month, and every two weeks thereafter, until the last six weeks, when a weekly test should be made.
The amount passed in twenty-four hours should be measured. Three pints is an average quantity. Albumin, sugar, and casts must be looked for and reported. Albumin may or may not be a serious symptom. Casts are significant of nephritis and indicate danger. Sugar may be lactose and be derived from the milk secreted in the breast. Edema of feet, hands and eyelids must always be investigated, with the possibility in mind, of heart and kidney lesions. Blindness, dizzy spells, headaches and spots before the eyes are always alarming symptoms until their innocence is established.
Through constant watchfulness of the urine, many cases of eclampsia may be averted.
Bathing is more important in pregnancy than at other times. The more the skin secretes, the less the burden on the kidneys. The skin must be kept warm, clean, and active. Then again, during pregnancy the skin is often unusually sensitive and only the mildest soaps and blandest applications can be used. The water must be neither hot nor cold, but just a comfortable temperature. Cold bathing, whether shower, plunge, or sitz, must be denied. Sea bathing is also unwise. The warm tub bath of plain water or with bran answers all conditions until the expected labor is near, then the warm shower or sponge bath should be substituted, lest germs from the bath water enter the vagina.
If the kidneys need aid, a hot pack may be used; but in all cases, frequent rubbing of the skin with a coarse towel should follow the bath.
The dress must be warm, loose, simple and suspended from the shoulders. To prevent chilling, wool or silk, or a mixture of both, should be worn next to the skin,—light in summer and heavy in winter.
The patient must be sensibly clad in broad, loose, low-heeled shoes. There should be no constriction about chest or abdomen. Circular garters must not be worn. If a corset is insisted upon, it must support the abdomen from below and lift it up. No corset is admissible that pushes down on the abdomen. This is especially true if the woman has borne one or more children and has a pendulous abdomen. The breasts may get heavy and require the rest and ease supplied by a properly fitting bust supporter.
Fainting is an annoying symptom in some women. It may come when quickening is first perceived, or from the excitement of crowds, or from hysteria. It usually passes quickly. The pallor is not deep, the pulse is not affected, and consciousness is not lost. It does not affect the ovum. Heart trouble should be excluded, and the daily habits of dress, diet, and bowels investigated. Smelling salts will usually suffice for the attack.
The abdominal walls may be strengthened by appropriate exercise before and after gestation, so that the muscles will preserve their tone. After delivery nursing the child will help greatly in the preservation of the waist line and figure, by aiding involution.
About the seventh month in primiparas, the abdomen gets very tense and in places the skin is stretched until it gives way and forms striæ. This tightness can be relieved to a considerable degree by inunctions of cocoanut oil or albolene.
Pain in the abdomen at this time may be due to mechanical distention, to strain on the muscles, to stretching of operative adhesions, to gas, constipation, or appendicitis. The physician should be informed of it. In every case, constipation, swelling of feet, hands or eyelids, blurring of vision, ringing in the ears, vomiting, persistent backache, or the passage of blood, no matter how slight, should be reported to the doctor.
The Breasts.—There should be no pressure on the glands and they should be warmly covered. The nipples must be kept clean and soft by soap and water, and about a month before the labor is expected, the nipple should be anointed with albolene or cocoanut oil and rubbed and pulled for a few minutes every night. This removes the crusts and dried secretions that collect on the nipple and prepare it for the macerating action of the baby’s mouth. No alcohol or strongly astringent washes should be used. Injuries must be avoided. If the nipples become tender they may be protected from external irritation by the lead nipple shield or by a wooden shield with a hollow center, such as Williams recommends.
Leucorrhœa.—This is one of the commonest discomforts of pregnancy, and the sense of uncleanliness, if the discharge is excessive, as well as the resulting irritation, may demand attention. It must be kept in mind, however, that the normal vaginal discharge of a healthy pregnant woman is strongly germicidal and should not be douched away without definite indications.
Vaginal douches of warm boric acid solution will do for cleanliness, but the douche bag must not be higher than the waist. Stronger and more antiseptic solutions are potassium permanganate 1:5000, or chinosol 1:1000. A suppository may be used, consisting of extract belladonna, gr. ss; tannic acid, gr. v, and boroglyceride dr. ss.
Sexual intercourse is distasteful to most pregnant women, but sometimes the inclination is intensified.
Coitus often causes much pelvic discomfort and may be an influential factor in producing abortion. It should be forbidden during the early months, at all menstrual epochs, and for at least two weeks before labor. The uterus may be infected by germs beneath the foreskin and hæmorrhage may follow the act if the placenta is low. In healthy persons, at the instance of the female, intercourse in moderation is permissible.
The mental condition should be placid without either excitement or fatigue. Anxiety should be dissipated by cheerful company and surroundings. Judicious amusement is desirable and a congenial occupation, but neighbors who tell frightful tales of disaster in labor, or nurses who relate the details of their critical cases, are equally to be avoided.
Many women of neurotic temperament dread the labor desperately. They are sure that death impends and they dwell with tragic interest on the stories of complicated cases related by thoughtless or malicious neighbors. The nurse can do much to allay these apprehensions by cheerfulness, optimism, and gentleness. Her buoyant temperament will drive away the patient’s fears just as effectively as the assurances of the physician.
Great allowances must be made for attacks of irritability, for the changes going on in the woman’s pelvis keep her in a capricious and whimsical condition. A good book to read at this time is, the “Prospective Mother,” by Slemons.
The subject of maternal impressions is the cause of much anxiety during pregnancy. It is safe to assure the mother that it is nearly impossible to mark her child by emotional stress. There is no demonstrable nervous communication between mother and child, and most of the deformities that occur and are attributable to shock, etc., can be explained by our knowledge of intrauterine changes. Furthermore, the same deformities occur in lower animals, to which it is difficult to ascribe such high nervous organization.
Many of the birthmarks, supposedly due to shock, occur too late in the pregnancy to affect the child, even if it were possible, for the child is completely formed before the fourteenth week.
The Determination of Sex.—It is not possible to know in advance of delivery whether the child will be a male or a female. It is equally impossible to determine or even to influence the sex of the coming child. Many theories have been advanced, and much talent has been wasted in trying to solve this problem.
Reasoning by analogy from the facts obtained from lower animals, the sex of the child is unalterably decided the moment conception occurs. The responsibility for the decisions seems to lie with the male cell. All we really know is that the sexes appear in the ratio of 100 girls to 106 boys.
CHAPTER V
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.
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.
CHAPTER VI
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.
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.