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.