CHAPTER XXII THE DIAGNOSIS OF UTERINE PREGNANCY, ABORTION, (Part 3)

is greatly increased, and this so-called " ammonia coefficient," instead of being 4 or 5 per cent as in normal pregnancy, may rise to 20, 30, or 40 per cent. Moreover, the proportion of amido-acids is increased, and sometimes the acetone content is abnormally large. In making a differential diagnosis between the three varieties it is essential to eliminate the toxemic form by a careful urinary 436 ABORTION analysis. If the ammonia coefficient exceeds 10 per cent the diagnosis of toxemic vomiting should be made. If the ammonia coefficient is approximately normal the probability of a serious toxemic condition can be eliminated and the diagnosis will be between the reflex and the neurotic varieties. Some manifest lesion in the generative tract makes the diagnosis reflex vomiting. The suggestion has been put forward by F. P. Underhill and R. F. Rand (Archiv. of Internal Medicine, Jan. 15, 1910, Vol. 5, p. 61), that the changes observed in the urine in pernicious vomiting of pregnancy are induced by the inanition which accompanies the severe grades of the disease and that the urine shows nothing characteristic until a stage of great prostration has been reached. They think that the supply of carbohydrates to the system is the factor which determines the relative output of urea and ammonia and claim good results in the treatment of pernicious vomiting by the administration by enema of dextrose in solution. THE DIAGNOSIS OF ABORTION Definitions. — An abortion is the expulsion from the uterus of the products of conception before the placenta is formed, that is, during the first three months; a miscarriage is the emptying of the uterus of the fetus, the placenta and its membranes, from the begining of the fourth month until the child is viable, at the end of six and three-fourths months; and a premature labor is the delivery of the child after it is viable, or between six and three- fourths months and term. The word abortion is so frequently used to mean the expulsion of the products of conception at any time from the beginning of pregnancy up to the time of viability that it is convenient to so use it in this chapter. A complete abortion is one in which the fetus and its membranes are cast off entire ; an incomplete abortion is one in which the fetus is born, but the membranes and the placenta, if formed, remain behind; a concealed or missed abortion is one in which the embryo has perished but is not expelled; spontaneous abortions are those which occur without known cause; induced abortions are those which are caused artificially and intentionally, whether by the ETIOLOGY 437 administration of drugs or by the use of intruments, and habitual abortions are abortions repeated in successive pregnancies. Frequency. — Obviously exact figures as to the frequency of abortions are difficult to obtain. Without doubt many occur during the first six weeks of pregnancy without attracting much attention, and many patients who have abortions are not under a physician's care. J. Clifton Edgar found 635 cases of interruption of pregnancy — abortion, miscarriage, or premature delivery — among 10,000 cases of labor treated in a dispensary service in New York City, or one in every 15.7. Some authors give the frequency of abortions as once in every five or six cases of labor. Abortion proper is more apt to occur in multiparas, while mis- carriages and premature labors are found more commonly in primiparse. This seems to be due to the frequency of uterine disease in multipara?, so that with an increasing number of preg- nancies the uterus becomes progressively less tolerant and expels its contents earlier with each successive pregnancy. Etiology. — The causes of abortion may be grouped in three classes in the order of their frequency: (1) maternal, (2) fetal, and (3) paternal. 1. The maternal causes are (a) constitutional and (b) local. a. Constitutional. Under this heading are to be classed the in- fectious diseases, as typhoid fever, pneumonia, smallpox, scarla- tina, cholera, especially if accompanied by high fever suddenly developed, and tuberculosis and syphilis. Syphilis in the mother is a very frequent cause of abortion, some authors going so far as to claim that it causes a quarter of all abortions. Other causes of abortion are cardiac diseases, the toxemia of chronic nephritis, diabetes mellitus, lead or arsenic poisoning, anemia from sudden loss of blood, the use of oxytoxic drugs, as ergot, cotton-root bark, quinine, aloes, and tansy, b. Local causes are all those conditions that cause pelvic congestion, such as malpositions of the uterus, especially retrodisplacements, chronic endometritis, lacerations of the cervix, and excessive sexual inter- course. 2. The causes in the ovum and embryo are, anything that interferes with the nutrition or produces the death of the fetus. Many of them are secondary to pathological conditions in the mother's tissues. They are syphilis of the decidua or placenta, and low 438 ABORTION situations of the placenta, also, less frequently, anomalies of the deciclua and the other fetal envelopes or of the fetus itself, pro- ducing injury or death. Introducing foreign bodies into the uterus, such as catheters or hatpins, must be reckoned as local causes. When the fetus is dead it acts like a foreign body and the uterus expels it. In exceptional instances the fetus may be retained in the uterus as long as two weeks after its death. 3. The causes due to the father are chiefly syphilis transmitted by the spermatozoa. Sometimes there are syphilitic changes in the placenta and fetus where the mother shows no sign of the disease. Other causes are debility in the father, perhaps due to tuberculosis, perhaps to excessive indulgence in sexual intercourse. A French author has cited the instance of thirty cows who were served by the same bull within a short period of time. The fifteen that were served first went to full term, while the last fifteen aborted without an exception. Symptoms. — In abortion during the first six weeks there are seldom any prodromal symptoms. The woman may think she has a delayed and profuse menstruation, and may not realize that she is pregnant. Much blood is lost and clots are passed, and there may be pains in the region of the uterus. If she thinks she is pregnant and observes the clots she will think that she has seen the fetus in the " fleshy mass" that she has passed. The ovum, as a matter of fact, is generally passed first of all and is lost with the blood and clots. In the case of a complete abortion all of the embryo and its envelopes are passed at once and there is very little hemorrhage, the process lasting from twenty-four to forty- eight hours from the first hemorrhage or pain until all symptoms cease. Abortions are more apt to be incomplete, portions of decidua being left behind, and, in this event, hemorrhage continues. In abortion from the sixth to the twelfth week there are apt to be prodromal symptoms of fullness and weight in the pelvis and backache, indicating pelvic congestion. At this time uterine pains and hemorrhage are more severe and constitutional symptoms such as nausea, pallor, rigors, nervousness, and apprehension are often marked. After the third month the symptoms of abortion are more like those of labor at term. The three stages of labor can be distinguished, the uterine contractions are more marked, and there are strong involuntary bearing-down efforts. DIAGNOSIS 439 Diagnosis. — The diagnosis of abortion depends on the deter- mination that the patient is pregnant; on the character of the pain, indicating uterine contractions; on the amount and character of the hemorrhage ; on dilatation of the cervix ; and on the descent of the products of conception into or through the os uteri. Practically we are called on to distinguish between threatened abortion, in- evitable abortion, and an abortion partially or wholly completed. The Diagnosis of Threatened Abortion. — First we get the history to determine the probability of the existence of pregnancy. If it can be learned that the patient has missed a catamenia twice or even once, if she has been exposed to impregnation, if she has experienced any disorders of digestion, or will tell of swelling of the breasts, or frequency of micturition, we may get valuable clews. Pain, if it indicates uterine contractions, is of a rhythmical char- acter, beginning in the flanks and extending to the pubic region. The distinct character of the pain is more clearly marked in mis- carriages than in abortions proper and in the threatened abortion there is little or no pain. Hemorrhage is moderate in amount, bright in color, free from clots, and intermittent. Examination shows breast changes (see section on normal uterine pregnancy, p. 421), purplish discoloration of the vagina and cervix, the cervix soft, the os somewhat dilated. The uterus is enlarged, the fundus is bulging forward, the lower uterine segment is compressible, and uterine contractions are infrequent. If, after a series of hours, the symptoms abate and the cervical canal does not dilate, the ovum does not descend, and uterine con- tractions are still of infrequent occurrence, the case may be said to be in the category of a threatened abortion. The Diagnosis of Inevitable Abortion. — If, on the other hand, the hemorrhage increases in amount, is persistent, and contains clots and fragments of fetal structures, pain is considerable and increas- ing in severity, and local examination shows that the ovum has moved down in the uterus, as attested by the elimination of the angle of anteflexion between the large anterior fundus and the cervix, while the ovum can be felt by the tip of the examining finger through the dilated os as a soft bag, uterine contractions being frequent, the case is one of inevitable abortion. An ovum may be differentiated from a blood clot by noting that it increases in size during a uterine contraction, becomes 440 ABORTION smooth and tense, and advances, while the blood clot is not tense and does not advance; also, the ovum presents a convex surface and is elastic, while the blood clot is cone-shaped with its apex down- ward and is not elastic. All clots or tissue passed should be floated out in water and examined with a magnifying glass for decidua, fringe-like chorionic tissue, or bits of placenta, the tissue being examined subsequently under the microscope. The Diagnosis of Abortion Partially or Wholly Completed. — To determine whether all or a part of the contents of the uterus have been expelled it is necessary to have everything which has been passed from the vulva preserved for careful inspection. To this end the napkins worn by the patient should be saved, and, before emptying the bladder or bowels she should sit on a chamber and strain so that the contents of the vagina may be expelled into the chamber for preservation. The ovum, being small and sus- pended in the liquor amnii, is usually lost when the membranes are ruptured early in the course of an abortion, being passed from the vagina at stool. Parts of the decidua are more often left in the uterus than not. In very early abortions the pieces of tissue can be felt with the tip of the uterine sound palpating the uterine cavity. When there is any foreign substance in the uterus the cervical canal will be found open. In pregnancy exceeding three months' duration the finger can be passed into the uterine cavity and will feel the bits of fetal membranes or portions of placenta still ad- herent to the walls. The Emmett curette forceps will bring away tissue for examination. If the tissues appear to be in any respect abnormal they should be sent to the pathologist for examination. The finding of an intact ovum settles the question of a complete abortion. The disappearance of the secretion of the breasts is an important sign that an abortion is complete. If the abortion is completed the uterus will be found contracted and the uterine canal closed. In missed abortion the dead fetus may be retained in the uterus for some time; there are no pain and no hemorrhage, but the cervix remains soft and the os patulous. The Diagnosis of Miscarriage. — The diagnosis of miscarriage is generally easier than that of abortion because the signs of pregnancy are definite and pronounced and the same may be said of the symptoms (see the diagnosis of normal uterine pregnancy, page 426). Differential Diagnosis.— Abortion must be differentiated from HYDATIDIFORM MOLE 441 extra-uterine pregnancy and from menorrhagia, metrorrhagia, and dysmenorrhea. In abortion the hemorrhage is generally greater in amount and the clots are more frequently passed than in early extra-uterine pregnancy after rupture; the pain is much less severe in abortion and is of the uterine contracture variety, that is, beginning as an aching in the flanks and radiating to the hypogastrium, whereas in extra-uterine pregnancy the pain is severe, agonizing, and in the beginning is unilateral. The changes in the uterus are more marked in abortion than in extra-uterine pregnancy, and in the latter some tumor of the adnexa can be determined. It is to be remembered that a uterine decidua is formed in the case of extra-uterine pregnancy and this is apt to be passed early. Menorrhagia and metrorrhagia are excluded by the history, which excludes pregnancy, and by the absence of the symptoms and signs of pregnancy, also by determining some cause for the increased flowing, such as a fibroid tumor, endometritis, or cancer. Dysmenorrhea is excluded by the past history of pain occurring at some definite interval of time before, after, or during the flow, and by the absence of the symptoms and signs of pregnancy. THE DIAGNOSIS OF HYDATIDIFORM MOLE Hyclatidiform mole, also called vesicular or cystic mole, is a dis- ease of the chorion consisting of a cystic formation at the ends of the villi, producing a mass that resembles a bunch of grapes. It is a rare disease occurring once in about three thousand cases of preg- nancy and is found oftenest among multipara between the ages of twenty-five and forty. It is apt to be repeated in successive preg- nancies in the same patient. The mole generally develops before the fourth month and causes the death of the fetus. Pathology. — The cystic process which involves the chorion is, according to Marchand, an edematous degeneration in which the syncytium plays an important role. Large masses of syncy- tium and chorionic epithelium invade the decidua and the uterine walls just as in chorio-epithelioma, the process resembling this disease which follows hydatidiform mole in about half the cases. The translucent vesicles are similar in shape to the elements 442 HYDATIDIFORM MOLE of the chorion of the first two months, being fusiform, pyriform, or rounded, they contain a fluid that is similar to liquor amnii, and of the chorion of the first two months, being fusiform, pyriform, they range in size from a pin's head to a large grape. The mass of vesicles may grow to the size of a man's head, the myxomatous degeneration involving the entire surface of the chorion, or it may Fig. 182.— Hydatidiform Mole. (Bumm.) be a small tumor involving only the placental portion of the chorion. The mass is expelled by the uterus as a rule in the fourth or fifth month with labor pains and hemorrhage, but portions of the cystic mass are apt to be closely adherent to the uterine wall so that some is apt to be left behind, necessitating a curetting. The fetus may be destroyed in cases of extensive disease, or it may be pre- DIAGNOSIS 443 served in cases of minor involvement. It is generally killed early. Sometimes, when the uterine blood-vessels are eroded, the hemor- rhage from hydatidiform mole may be excessive. Symptoms. — In the first few weeks of pregnancy there is no means of distinguishing cystic disease of the chorion. As the pregnancy advances the uterus containing hydatidiform mole increases in size more rapidly than in the case of normal pregnancy, and hemorrhage occurs with a bloody, watery discharge, which is not unlike currant-juice in appearance. Diagnosis. — The diagnosis rests on the symptoms and on a doughy feeling of the uterus on bimanual palpation, this being demonstrable after the third month when the rapid growth of the uterus becomes apparent. If the cysts are found in the vaginal discharge the diagnosis is certain. No fetal movements or heart sounds are heard and there is no ballottement. The possibility of the development of chorio-epithelioma follow- ing hydatidiform mole should never be lost sight of, and every patient should be kept under close observation for at least a month after the expulsion of the mole.