There is no illness to which the pregnant woman is immune, unless it be some menstrual disorder. It is not within the scope or intent of this article to consider each major deviation from normal health and discuss its effects on the course of the pregnancy, or, in turn, pregnancy’s influence on the ordinary life cycle of every disease. Let us content ourselves with discussing some of the commoner major medical and surgical problems as they occur in a pregnant woman,
In the course of the last twenty-five years there has been a radical change in the physician’s attitude toward heart disease and childbearing, as well as in his treatment of this
POSSIBLE MEDICAL AND SURGICAL COMPLICATIONS complication. Today motherhood is denied only to women with the most severe degree of heart impairment. Previously it was not uncommon to perform therapeutic abortion in cases of only moderate severity.
This change in attitude arises from the magnificent results obtained through modern advances in the management of pregnancy and labor in the cardiac patient. Today such cases are carried on calorie-restricted, salt-poor diets so that weight gain is kept below that permitted normal pregnant women. Whenever there is evidence of retention of tissue fluid, kidney-stimulating drugs are promptly administered to promote urinary excretion. Rest and freedom from physical effort are demanded. Colds and other infections of the upper respiratory tract are treated with great respect in pregnant women with heart disease, and bed-rest and antibiotics are promptly prescribed. Heart drugs of the digitalis series are given whenever indicated. Physicians have learned that cardiac patients do infinitely better if they are allowed to go into labor spontaneously at term and deliver vaginally, than if their pregnancies are terminated four or five weeks prematurely by Cesarean section, as used to be done. Today antibiotic drugs are given routinely to such patients during labor and the first few days thereafter, since infection and fever may penalize the damaged heart. If the heart shows the slightest evidence of losing its ability to carry on its intended function, labor, and at times delivery, is conducted in an oxygen tent. Pain-relief agents and anesthetics are carefully chosen and carefully given. It is also important to relieve the pregnant cardiac woman of fear and anxiety, for they tend to make the pulse beat rapidly, which is bad for such a patient, particularly during labor. The best way to dissipate fear and anxiety is reassurance by frank discussion between the patient and doctor. Airing fears, in itself, helps dispel them. With such meticulous attention almost all women with heart disease may be allowed several children. However, the extent of the heart lesion and the socio-economic situation are potent factors influencing safe family size in the individual case.
Sometimes, in the exceptional instance, heart surgery is carried out in indicated cases during pregnancy. Ordinarily such procedures are performed before conception and in the intervals between pregnancies.
If I were asked to name one of the most exciting advances in obstetrics, I would nominate the diagnosis and treatment of tuberculosis. It has now become routine in most clinics and private offices to take a chest X-ray in the beginning of pregnancy. Such a simple procedure has virtually forestalled the appearance of unsuspected lung disease. If an old healed lesion is found on X-ray, the ‘wonder drug’ isoniazid is prescribed as a prophylactic measure during the last few months of gestation to prevent the tuberculosis from being made active by delivery and the early post-delivery period. On the other hand, if physical examination, sputum tests, or X-ray reveals an active tuberculous infection, pregnancy is allowed to continue, and in most cases the woman can be treated successfully at home by a combination of three drugs: isoniazid, streptomycin, and para-aminosalicylic acid. This is a far cry from the situation a few years ago, when a large proportion of the active cases of tuberculosis discovered in early pregnancy were therapeutically aborted and then sent to sanatoria for months or years.
Modern medicine has demonstrated that pregnancy offers no obstruction to the therapy and cure of tuberculosis. The patients are treated as though they were not pregnant; even lung surgery is performed if necessary.
Before the introduction of insulin, few diabetic women became pregnant and when they did catastrophe often resulted. The death rate for both mother and infant was alarmingly high. With the use of insulin, diabetics have become normally fertile, and when the disease is kept under intelligent medical control pregnancy no longer threatens health or life.
However, diabetes, even when properly controlled, still gives relatively unsatisfactory fetal results. Theratio rises over that of nondiabetic women and for not completely understood reasons the of the diabetic woman has a tendency to die before labor during the late weeks of pregnancy. Since such a risk is greatest during the last two or three weeks, most physicians terminate the pregnancy of the diabetic woman three or four weeks before the calculated term by either inducing labor or performing a Cesarean section. The best results are obtained if during pregnancy and delivery the patient is under the joint care of an expert in diabetes and an expert in obstetrics.
The baby of a diabetic mother, particularly the one born to a mother who has recently acquired diabetes, tends to be excessively large. Babies of diabetic mothers often have a difficult first forty-eight hours, but when this period has passed they do as well as any other newborns. At first they require vigilant care by expert nurses and physicians.
The performance of a routine blood test for the diagnosis of syphilis, usually termed a ‘Wassermann,’ is made obligatory during pregnancy by the laws of most states. A positive test is assumed to be caused by a syphilitic infection—unless, in the rare case, it is proved due to some other medical condition. Today’s treatment of syphilis with penicillin is wonderfully rapid and effective compared to previous therapy with arsenic, mercury, and bismuth.
Six to nine million units of long-acting penicillin are given in divided doses by intramuscular injection over a ten-day to two-week period. Treating the mother treats the baby in the uterus as well, since penicillin readily crosses the placental barrier, and the child is born totally free of any evidence of the disease. On the other hand, when syphilis in the mother remains undetected and untreated the child may die in the uterus, or, if born alive, will be gravely ill, showing the stigmata of congenital syphilis.
Gonorrhea rarely complicates pregnancy. In untreated cases its main effect on reproduction is to render some husbands or wives irreparably sterile. If, because of incomplete therapy or some other reason, the mother harbors the gonococcus, the causative organism, in the vagina or cervix, it may infect the eyes of the newborn during passage through the lower birth canal. Preventive measures usually are carried out within a few minutes of birth on every baby, whether it be born to a bishop’s wife or a prostitute.
Since the gonococcus and the spirocheta pallidum—the causative agent of syphilis—are very susceptible to penicillin, both diseases are decreasing in frequency, and it may not be a vain hope that they will disappear in fifty or a hundred years,
Infantile paralysis has recently been slightly more prevalent among pregnant women than among nonpregnant women of the same age group. To be sure, the heightened susceptibility has been only in the order of 50 per cent; yet it is sufficient to cause physicians to recommend Salk vaccine or Sabin oral immunization during pregnancy if not previously given. Even though the patient has had preventive treatment, a booster dose may be prudent. Preg- nancy itself is not affected by immunizations of any type. The pregnant woman responds in the normal manner to the injection of all immunizing ‘shots,’ without complications to herself or the fetus, despite popular belief to the contrary. Great experience has been amassed with typhoid inoculation and vaccination against smallpox, both of which are safe during pregnancy. No increase in the rate of abortion or in the incidence of congenital malformations among the infants of mothers immunized during any stage of pregnancy has yet been demonstrated.
German Measles (Rubella)
In 1941 an epidemic of German measles occurred in Australia and it was noted that a high proportion of the women who acquired the disease during the first three months of pregnancy delivered malformed infants; women who got Rubella later in pregnancy delivered normal babies. In subsequent years this problem has been under close medical scrutiny. Several observations have emerged. In the first place, an accurate diagnosis of German measles is difficult to make; manyare misdiagnosed as German measles. In the second place, either the Australian virus was very virulent or it was from a different strain than the American or European variety, because in recent series here and abroad perhaps less than 20 per cent of children born to mothers infected in the first twelve weeks of pregnancy are seriously affected; between the twelfth and sixteenth weeks the incidence of congenital deafness is increased. At a recent conference held at the New York Academy of Medicine, in which I participated, it was the sense of the meeting that in women who acquired Rubella during the first twelve weeks of pregnancy the likelihood of bearing a malformed infant was only four or five times that of women who did not get German measles during early pregnancy. The New York City Department of Health feels that even these odds are still too high.
The practical conclusions the reader may draw are: 1. Expose your female children to German measles between the ages of six and sixteen and hope they get it, since one cannot have true German measles twice. 2. If you are less than three months pregnant and some relative or friend gets German measles, be tough, isolate yourself from him and his recent contacts, particularly children. The value of protective gamma globulin in this situation is doubtful; however, consult your physician about it. 3. If you are a schoolteacher early in pregnancy and you
POSSIBLE MEDICAL AND SURGICAL COMPLICATIONS have not had German measles and there is an outbreak of the disease in your community, withdraw from classes until it is over. 4. If you think you have got German measles in early pregnancy, have a physician who is an expert in the disease —usually a pediatrician or a physician in the Health Department—see you at once to confirm or refute your self-diagnosis. In twenty-four hours the telltalemay have vanished. 5. If your suspicion is confirmed, consult the doctor who is to deliver you. His advice will be predicated on religious grounds, on his experience with the problem and that of his medical community, on your age, on the ease with which you conceive, and on current developments in the problem. It is possible that the figures for fetal involvement will fall so low that no one will recommend therapeutic abortion for this indication. However, I, with probably a minority of doctors, feel that in 1962 therapeutic abortion because of German measles acquired during the first eight weeks of pregnancy is wise. It is probably wise between the eighth and twelfth weeks, but not justified after the twelfth week. The weeks are counted from the beginning of the last menses.
True measles, chicken pox, mumps, scarlet fever, glandular fever (acute infectious mononucleosis), and whooping cough apparently do not affect the normality of the fetus, regardless of the week in pregnancy when the illness occurs. As a matter of fact, the only infectious disease under indictment in this respect is German measles, curiously the mildest of them all.
Immunization of the Fetus
Antibodies resulting from childhood diseases which the mother contracted previous to conception remain circulating in her blood for an indefinite period, and are transferred via the placenta to the fetus in each pregnancy. As a result, the infant is born with immunity to a disease to which the mother has become immune. The duration of this type of acquired immunity in the child is brief, lasting from three to six months. An exception to this general rule is whooping cough, for even though the mother has had the illness, most newborns are highly susceptible.
Surgical emergencies arising during pregnancy are usually treated as though the patient were not pregnant. If a surgeon feels that he would be compelled to operate if the woman were not pregnant, he will usually operate when she is pregnant. This generalization is particularly true for appendicitis, acute gall-bladder conditions, strangulated hernias, thrombosed hemorrhoids, etc. On the other hand, if the surgical problem presents no emergency, such as removal of tonsils, cure of hemorrhoids, repair of a simple, unstrangulated hernia, plastic operations on the vagina for loss of urinary control or descent of the pelvic structures, surgery is better postponed until three months or more after delivery.
Abdominal operations on the reproductive organs are sometimes necessary during pregnancy; the commonest is removal of aof the ovary, or a tumor attached to the uterus by a slim stalk about which it may twist. If possible, one postpones removing an ovarian cyst until after the twelfth week since the corpus luteum of pregnancy may be in the cystic ovary, and its removal very early in pregnancy causes abortion in a small percentage of cases. Removal of the ovary containing the corpus luteum (the gland formed at the site of the ruptured Graafian follicle) after the twelfth week is completely safe.
Otherwise operations during pregnancy do not cause abortion or premature labor, or affect the fetus in any way. The fetus tolerates amazingly well anesthetics which do not seriously reduce the oxygen in the maternal blood.
Dental extractions or fillings may be performed whenever indicated. Local anesthesia is preferred to general anesthesia. If the latter is necessary during pregnancy, most physicians prefer sodium pentothal, cyclopropane, or ether to plain nitrous oxide, the dentist’s ‘laughing gas.’
Emotional difficulties of varying intensity may first assert themselves during pregnancy, or existing emotional illness may be aggravated by pregnancy. Treatment is not affected by the fact that the woman is pregnant. A psychiatrist or a psychiatric clinic should be consulted and therapy followed as is advised. Tranquilizers, shock, or even hospitilization may be recommended just as though the patient were not pregnant.
It is rare to perform a therapeutic abortion for psychiatric indications today unless the threat of suicide seems likely to be implemented. Then the choice lies between protective incarceration and termination of pregnancy.