The PROGNOSIS and TREATMENT, so far as the mother is concerned, are the same as in the non-pregnant state. In view of the possible causative relation between simple and malignant icterus, and the injurious effect upon the foetus, medical treatment should be instituted at once. Restricted diet, mercurials or ipecacuanha, followed by saline cathartics, are the more important measures. Artificial abortion or the induction of premature labor has no effect upon the condition. This operative procedure is indicated in the interest of the child, however, when the icterus is intensive, of long duration, the foetus living and viable, the frequency of the foetal heart-beats diminished, and there is reason to fear its death. Carl Braun recognizes very distinctly the force of this indication.
Malignant Icterus.—Malignant icterus, due to the acute yellow atrophy of the liver of the pregnant woman (Rokitansky), is a very rare disease. Carl Braun has observed the condition only once in twenty-eight thousand cases from 1857 to 1863.
ETIOLOGY AND PATHOLOGY.—Very little is known as to the causes of acute yellow atrophy of the liver. Virchow ascribes one case coming under his own observation to compression of the lower half of the liver and gall-bladder by the growing uterus. The rarity of the affection and its occurrence irrespective of the time of pregnancy prove the limited operation of this etiological factor. It is in a high degree probable that the disease may have its starting-point in simple catarrhal icterus.
The liver is ochre-colored, shrunken to one half its volume, and flaccid. On section no signs of lobular structure are visible. Microscopical examination reveals total destruction of the acini and hepatic cells. In the place of the glandular elements, fat-globules, fine granular detritus, crystals of leucin and tyrosin are noted. The spleen is enlarged and the kidneys show acute inflammatory changes. Extensive ecchymoses are observed under the skin, pericardium, and gastric mucous membrane.
SYMPTOMS.—The prodromal symptoms of acute yellow atrophy of the liver are usually overlooked. A trivial jaundice with slight elevation of temperature may precede by several days the development of cerebral symptoms. Difficulty in speech, headache, disorders of the senses followed by delirium, convulsions (cholæmic eclampsia), and coma are the more important symptoms of cerebral origin. The pulse is remarkably frequent and small. The temperature is at first elevated several degrees, but becomes subnormal prior to death. The urine is sparingly secreted, highly colored by the bile-pigments, and contains albumen, tube-casts, leucin, tyrosin, and cholesterin. Urea, uric acid, and the urates are diminished. The combination of symptoms points to the retention within the system of the waste products usually excreted by the liver and kidneys. Ultimately, a condition of complete hepatic and renal insufficiency obtains.
DIAGNOSIS.—The dull yellow color of the skin and conjunctivæ, with fever and cerebral symptoms, is a sign of greatest diagnostic value. Physical exploration reveals tenderness on pressure over the hepatic region, and rapidly diminishing area of hepatic dulness on percussion. Care must be taken to exclude acute phosphorus-poisoning—a toxæmia simulating very closely acute yellow atrophy, and repeatedly confounded with that affection.
PROGNOSIS.—No case of recovery has been recorded up to the present time. The disease pursues a rapidly fatal course, terminating within a few days after the development of the icterus.
TREATMENT.—Therapeutic measures must be addressed to prophylaxis. It is necessary to regard simple icterus as a possible prodrome of the malignant form of the disorder.
DIABETES MELLITUS.
The most superficial discussion of the disorders of pregnancy would not be complete without some mention of diabetes. The existence of physiological glycosuria during pregnancy and lactation has been demonstrated. Bernard has shown that sugar appears in the placenta of calves at an early period, attains its maximum in the third or fourth month, and when the glycogenic function of the foetal liver is established entirely disappears. The relation between physiological glycosuria and that pathological exaggeration of a normal process, diabetes mellitus, is very obscure. It is, however, a clinical fact that diabetes mellitus occurs more frequently in the pregnant than in the non-gravid woman. Diabetic women are less apt to conceive. When conception does occur, pregnancy is liable to interruption from the death of the foetus. Under these circumstances glucose is found in the amniotic liquor and foetal urine. A case related by Bennewitz and cited by Matthews Duncan indicates that diabetes mellitus may be developed during successive pregnancies, and entirely disappear during the intervals. The influence of pregnancy in developing a latent diabetic tendency may be accepted as established. A clinical observation of some importance is that diabetic coma is seldom developed.