CHAPTER XXII THE DIAGNOSIS OF UTERINE PREGNANCY, ABORTION, (Part 1)

CHAPTER XXII THE DIAGNOSIS OF UTERINE PREGNANCY, ABORTION, AND HYDATIDIFORM MOLE Diagnosis of normal uterine pregnancy, p. 417: During the first three months, p. 418; History, p. 418, Amenorrhea, p, 419, Nausea and vomit- ing, p. 419, Salivation and minor digestive disturbances, p. 420, Breasts, p. 420, Leucorrhea, p. 420, Bladder disturbances, p. 420; Inspection and palpation, p. 420, Breasts, p. 421, Areola, p. 421, Inspection of the vulva and vagina, p. 421, Bimanual touch, p. 423. During the last six months, p. 426; History, p. 426, Quickening, p. 426; Inspection and palpation, p. 426, Gait, p. 426, Figure, p. 426, Breasts, p. 426, Secondary areola, p. 426, Vulva, p. 427, Bimanual touch, p. 427, Internal ballottement, p. 429, Abdomen, p. 427; Auscultation, p. 429, Tabular statement of symptoms and signs of pregnancy by months, p. 430. Differential diagnosis of normal pregnancy, p. 431; During the first three months, p. 431, Anteflexion, p. 431, Chronic subin- volution, p. 431, Fibroid in the anterior wall, p. 431, Retroflexion, p. 431, Extra-uterine pregnancy, p. 431; During the last six months, p. 432. Diagnosis of abnormal uterine pregnancy, p. 432: Diagnosis of retro- flexion and incarceration of the pregnant uterus, p. 432. Diagnosis of interstitial pregnancy and of pregnancy in a rudimentary horn of a bicornute uterus, p. 433. Diagnosis that pregnancy has occurred previously, p. 433. Diagnosis of multiple pregnancy, p. 434. Diagnosis of pernicious vomiting of pregnancy, p. 434. Diagnosis of abortion, p. 436: Definitions, p. 436. Frequency, p. 437. Etiology, p. 437. Symptoms, p. 438. Diagnosis, p. 439; Diagnosis of threatened abortion, p. 439; Diagnosis of inevitable abortion, p. 439; Diagnosis of abortion partially or wholly completed, p. 440; Diagnosis of miscarriage, p. 440. Differential diagnosis, p. 440. Diagnosis of hydatidiform mole, p, 441: Pathology, p. 441. Symptoms, p. 443. Diagnosis, p. 443. THE DIAGNOSIS OF NORMAL UTERINE PREGNANCY The diagnosis of normal uterine pregnancy offers often many difficulties to the practising physician and is perhaps the most important department of diagnosis. Vander Veer collected seventy- seven instances of abdominal operations on supposedly pathological growths, some of the operators being men of note, where the pa- tient was pregnant in each instance. Hirst mentions the fact 27 417 418 NORMAL UTERINE PREGNANCY that a gynecologist on the staff of a large hospital has twice oper- ated for fibroid tumors of the womb, and only after the amputation of the uterus found that it was pregnant, and not the seat of a fibroid tumor at all. Both patients died. I have seen the same thing happen in the experience of a prominent surgeon to one of the largest hospitals, although the subsequent fate of the patient was unknown. I have also known of a surgeon of large experience operating for ovarian tumor on the wife of a noted obstetrician, the diagnosis being made by the apprehensive husband and by an internist, the operation proving that there was no ovarian tumor, the excessive abdominal enlargement being due to pregnancy and hydramnios. Mistakes are so frequent that no excuse is necessary for occupying space in describing a subject which, by a strict in- terpretation, belongs in the domain of obstetrics. The diagnosis of pregnancy depends on the history; on inspection of the face, neck, figure, breasts, abdomen, and vagina; on the bi- manual examination, and, in the later months, on auscultation of the abdomen. During the First Three Months of Pregnancy The diagnosis of pregnancy before the fetal heart sounds are heard or fetal movements felt in the fifth or sixth month is not an absolute certainty; still, the strongest sort of a probability may be expressed if all the facts are taken into consideration. The demonstration of the changes in the genital organs due to the in- creased blood supply and the growth of the ovum form the basis of a diagnosis; contributory facts are the alterations in the breasts, the body form and carriage, and the effects on the nervous system. History To get the history of pregnancy is not always an easy matter, for patients not infrequently conceal the facts either because, in the case of the unmarried, they hope the physician may pass a sound into the uterus and cause abortion, or they are ashamed to acknowledge immorality, or, in the case of those pregnant for the first time, because of inaccurate observation. . Patients who have been pregnant previously can say sometimes that pregnancy began with a particular coitus when especially pleasurable sensations FIRST THREE MONTHS OF PREGNANCY 419 were experienced, also morbid cravings for special sorts of food or disturbances of digestion have been the same as with former preg- nancies. Amenorrhea. — Absence of menstruation is one of the chief symp- toms of pregnancy. In questioning the patient the exact date of the beginning of the last menstruation should be obtained and also how long it lasted, and whether it was in all respects similar to the usual menstrual periods. Did coitus occur soon after this period? The end of the last catamenia is the date from which the beginning of pregnancy is usually reckoned. If the patient has been always regular in her menstruation, amenorrhea of two months is a most suspicious circumstance; if, on the other hand, she has been habitually irregular or if she is nursing a baby, so much importance can not be attached to it. Cases are on record where menstruation has occurred at irregular intervals during the entire pregnancy; in fact, one or two shows of blood during the first few months are by no means uncommon. About half of all nursing women men- struate during lactation, and as the number of pregnancies in- crease the tendency to menstruate while nursing increases also, therefore amenorrhea during lactation is not a constant sign. Baudelocque, Deventer, and others have reported instances of regular menstruation occurring only during gestation, but such cases are rare. Amenorrhea may occur in chlorosis, maldevelop- ment of the uterus, or the beginning of the menopause, in tuber- culosis, obesity, acute constitutional diseases, prolonged lactation, chronic poisonings, particularly lead, or from change of climate, or profound mental disturbance. Amenorrhea is common in girls who have immigrated from a foreign country. A majority of the Irish girls seen in the out-patient clinics of Boston have amen- orrhea for several months after arriving in this country. Acro- megaly, occurring as it generally does in young subjects, is apt to have complete amenorrhea as one of its first symptoms, and tu- mors of the base of the brain, especially those involving the hy- pophysis cerebri, as pointed out by Harvey Cushing, have amen- orrhea as a prominent symptom. Nausea and Vomiting. — The morning sickness of pregnancy is a fairly common but by no means an invariable accompaniment of gestation. It varies from an occasional qualm to active nausea and vomiting occurring when first assuming the erect posture in 420 NORMAL UTERINE PREGNANCY the morning. Some patients can not brush their teeth without being nauseated. The symptom does not manifest itself as a rule until the fourth or fifth week, but may begin as soon as ten days after conception. It occurs also in BrigmVs disease, gastritis, and chlorosis. These diseases must be ruled out, and if there has been a previous pregnancy, nausea and vomiting will probably have occurred with it. The symptom must be regarded as due to the enlargement and stretching of the uterine muscle fibers and nerves. The nausea may occur at other times than in the morning and may persist throughout pregnancy, although it generally ceases after the third month. Salivation and Minor Digestive Disturbances. — An excessive flow of saliva, heartburn, eructations, and abnormalities in appetite such as longings for strange or unusual articles of food, are not unusual accompaniments of pregnancy. Occasionally patients are seen who enjoy better digestion and even better general health while they are pregnant than at any other time. The Breasts. — A sensation of weight and fullness in the breasts, often accompanied by tingling sensations, is common to pregnancy, and patients who are observant note greater prominence of the nipples, and enlargement of the follicles in the darkened areolae. Leucorrhea. — There is a marked increase in vaginal discharge during pregnancy. This is noted early with the occurrence of the engorgement of the genitals; but, of course, leucorrhea may be due to other causes. It is seldom that the increase in the discharge in early pregnancy is enough to attract the patient's attention. Bladder Disturbances. — Increased frequency of micturition is a most common accompaniment of early pregnancy, probably due to congestion of the vesical trigone coincident with the physiological hyperemia of the uterine organs. Inspection and Palpation Since the days of Hippocrates and Democritus certain changes in the face and neck have been observed in pregnant women. The eyes seem to be deeper set, and may have bluish circles under them; there are brownish-yellow blotches upon the skin of the cheeks, which are fuller than usual, and the neck seems larger than when the woman is not pregnant. Too much importance is not to FIRST THREE MONTHS OF PREGNANCY 421 be attached to these signs, which may be entirely absent. Still, one or more of the changes will be found not infrequently if oppor- tunity is afforded for careful observation of the patient both before and during pregnancy. The Breasts. — Enlargement. — The breast enlargement of preg- nancy presents a firm, irregular feeling on palpation, and not the smooth, soft swelling due to increase of fatty tissue. The hard, knotty sensation is due to the increase in the size and number of the lobules of the mammary gland. In the early months this change is to be distinguished most clearly at the outer edges of the gland. The veins of the entire breast are enlarged, forming a blue tra- cery under the skin, most marked in the neighborhood of or in the areola. They show better in persons with white, thin skins. The Areola. — The circular area upon which the nipple stands in the non-pregnant woman, of a pinkish or somewhat pigmented color according to the type of the individual, darker in brunettes and lighter in blondes, under the influence of gestation becomes darker in color. Even in the light blonde the customary pink color is deepened; in the brunette the areola becomes the color of the skin of a quadroon. In fair women the areola may be elevated above the surrounding skin; this feature is brought into prominence by stretching the skin of the rest of the breast. When stimulated by a touch of the finger tip the surface of the areola will wrinkle up or pucker. The wrinkling brings into prominence the enlarged se- baceous follicles, some twelve to twenty in number, which project about a sixteenth of an inch above the surface of the areola. The value of the mammary signs is greater in first pregnancies because many of the characteristics, such as enlargement and the appearances of the areola, persist after the termination of the first pregnancy. One must rule out previously existing uterine or ovarian disorders, or masturbation, because in these conditions the breast appearances are often the same as in pregnancy. The mammary signs are among the earliest of the indications of preg- nancy and are especially valuable as indicative of the probable condition in the case of the unmarried where it is necessary for the physician to proceed with caution. A physical examination of the chest gives opportunity to inspect the breasts, and their showing sometimes warrants further investigation. Inspection of the Vulva and Vagina. — On separating the labia the 422 NORMAL UTERINE PREGNANCY vagina will be found to be abnormally moist and covered with whitish shreds of desquamated epithelium, and the anterior vag- inal wall just under the urethra shows a dusky, purplish discolora- tion sometimes called Jacquemin's sign because first noted by this author in 1837. The discoloration is to be seen first in the bottoms of the furrows of the mucous membrane, therefore it is well to put the anterior vaginal wall on the stretch. This sign may be apparent as early as the end of the first month and is present in over half of Fig. 177.— Diagrammatic Side View of the Pregnant Uterus of the Sixth Week, during Relaxation. (After Dickinson.) all cases by the end of the third month. It is more distinct in mul- tipara) and is more apt to be absent in primiparse. Speculum examination of the upper vagina shows the cervix to be of a purplish color, soft to the feel, and in primiparse the os tincsc becomes rounder. Erosions arc of a deeper purple color than the surrounding tissues. Many observers consider the discoloration of the cervix an earlier and more constant sign than Jacquemin's sign. As congestion of vagina and cervix may be found in pelvic disease, such as large ovarian and uterine tumors obstructing the venous circulation, and in certain constitutional diseases, as heart FIRST THREE MONTHS OF PREGNANCY 423 disease and cirrhosis, the physician must be on his guard. The typical discoloration of pregnancy is, however, limited to the lower anterior vaginal wall, about the lower urethra, and to the cervix; whereas in pelvic disease and constitutional disorders the con- gestion is general. The Bimanual Touch. — This is practised wTith the patient in the customary dorsal position (see page 33). The finger notes a soft cervix. It is to be remembered that softening of the cervix is Fig. 177a. — The same, during Contraction. found also in septic conditions of the uterus, as in septic endome- tritis, so that a soft cervix is not pathognomonic of pregnancy. The uterus itself is a little lower in the pelvis than normal, and is enlarged by the growing ovum, which is usually attached to the endometrium in the neighborhood of the orifices of the tubes. The uterus grows faster than the ovum at first, and the ovum with its envelopes does not fill the uterine cavity until the end of the third month, when the decidua reflexa joins the decidua vera. The first change in shape noted in the gravid uterus consists in a slight enlargement of its transverse diameter; then it becomes lengthened and fatter as the ovum increases in size, especially in 424 NORMAL UTERINE PREGNANCY the anterior part of the body of the uterus; this anterior bulging being quite characteristic in many cases. Asymmetry is caused by the development of the ovum in one cornu, a not uncommon happening. Uterine enlargement may be detected by the practised hand as early as the sixth week; in the third month there can be no doubt about it, even to the tyro. The softening of the uterus varies in different individuals and at different times in the same individual. It is less in primiparse than in multipara, but under Fig. 178. — Six-weeks' Pregnant Uterus with Elongation of Cervix, Showing Extent to which its Cavity Is Occupied by the Ovum. O.E., external os; 0.1. , internal os; D.V., decidua vera; D.S., decidua serotina; D.R., decidua reflexa; Emb., embryo; P., placenta. (Williams.) the influence of pregnancy there is always an increase in elasticity of the organ. Even as early as the first weeks the rhythmical contrac- tions which go on throughout pregnancy may be felt by patient bimanual palpation. They involve the entire uterus and are ex- cited by any manipulation of the organ, therefore the bimanual examination should last from five to ten minutes so that sufficient time may be afforded for contractions to take place. Ellice Mc- Donald (Amer. Jour. Obstet., LVIL, 1908) observed intermittent FIRST THREE MONTHS OF PREGNANCY 425 contractions in 88 out of 100 cases of early pregnancy examined with reference to diagnosis. The lower uterine segment is the portion of the uterus where the softening is most manifest. The softening at this point is called Hegar's sign and can be determined only during uterine relaxation. The upper portion of the uterus, being occupied by the ovum, is tense and elastic ; below the ovum the soft uterine tissues may be compressed between the ringer in Fig. 179.— Bimanual Palpation of Early Pregnancy for Hegar's Sign. (Williams.) the vagina and the fingers of the abdominal hand brought down either in front of the uterus or behind it, generally the latter. (See Fig. 179.) Very early in pregnancy palpation with the abdominal hand in front of the body of the uterus and the vaginal finger behind the cervix is sometimes available, especially in cases of retroversion; later in pregnancy, when the uterus has become longer and more 426 NORMAL UTERINE PREGNANCY anteflexecl, the fingers of the abdominal hand are brought down behind the fundus, while the finger in the vagina is placed in front of the cervix. The softening of the tissues of the lower uterine segment makes this portion of the uterus more flexible than in the unimpregnated state. Downward pressure by the abdominal hand on the top of the fundus during a period of relaxation, while the vaginal finger under the crown of the cervix makes upward pressure, causes the uterus to bend in the weakest part, the softened area. McDonald found this increased flexibility in ninety-seven out of his one hundred cases. During the Last Six Months of Pregnancy History The history is the same, except that nausea and vomiting and digestive disturbances cease after the third month, and the bladder symptoms are apt to be less. Abdominal enlargement is noticeable now, and the patient has to let out her dresses. Quickening, or the sensation caused by the fetal movements, is felt from the sixteenth to the eighteenth week of gestation, some women detecting it earlier than others. Inspection and Palpation The Gait. — In the later months the pregnant woman walks with a backward pose, the abdomen, more or less enlarged, being prom- inent in front. Ask her to walk up and down the office and note her gait. Also, the