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Dr. Blakely on Obstetrics, 1933
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Management of the Early and the Mild Late Toxemias of Pregnancy

Management of the Early and the Mild Late Toxemias of Pregnancy

By Stuart B. Blakely, M.D.

Read at Syracuse, N.Y.

April 3, 1941

Profound anatomies and physiological changes in pregnancy. A dividing line between what is normal and abnormal is impossible to fix. When the pregnant women present evidence of perverted body function we usually say that she is "toxic" a highly indefinite term. In spite of a vast amount of research, "toxemia of pregnancy" still remains largely a hypothetical concept. While it may be justifiable to assume the presence in the women's body of some toxin or toxins (it is almost impossible to postulate only one), such pressure in the blood has never been demonstrated. The source and method of action are unknown. Any tissue may be involved, but especially the hepatic, renal, nervous and reticuloendothelial. There is a growing belief that endocrine disturbances and vitamin and mineral deficiencies play an important role. One writer says that vitamin deficiency may simulate toxemia. it may well be true that vitamin deficiency is the toxemia. But the ultimate cause eludes reaches. In general, we can only say that the symptoms of the toxicities of pregnancy are due to altered or abnormal maternal function, induced directly or indirectly by the products of conception.

As far as I know Dr. De Lee is the only textbook writer who has specifically considered what he calls the minor toxemias of pregnancy. He allows two pages to the subject. The symptoms are very varied and often obscure and may stem from any material tissues or organ. A few may be of great significance, but most of them are not serious, and many may be considered as, and are minor discomforts of pregnancy. Some may be really toxic, many are metabolic or endocrine in origin, a number simply mechanical. The possibilities and possible combinations are almost endless. I shall not try to define or unscramble or classify them but discuss some of the more common. I shall not stick too closely to my text. I hope that you will pardon the frequent use of the first person singular.

Gastro-intestinal

HEARTBURN- one of the most common, and to me, obscure and difficult to relieve. It has certainly never been demonstrated that it occurs exclusively or predominantly in those patients with increased gastric acidity. It is usually a rather late symptom if at all sever, and while possibly toxic is better considered as being in some way related to altered gastric motility. Reverse peristalsis has been offered. A better suggestion is that it is due to a relaxation of the cardio (all smooth muscle tubes relax and dilate in pregnancy) plus increased intraabdominal pressure which results in a regurgitation of acid gastric juice into the lower esophagus. Many remedies have been used, usually some combination of "antacids", such as sodium bicarbonate, magnesia, bismuth, other carbonates, often with the addition of aromatic. In my experience, milk of magnesia makes them worse. Many patients find relief in "tums". I have no experience with colloidal preparations, and little success with fresh cream, dilute HCL or finely chewed nuts. Occasionally the drinking of sparkling water benefits. Some are helped by the reduction of total food intake, especially if eating too much and of fats. Sleeping with the head elevated on a pillow or with the head of the bed raised often is of help. A few patients find relief in auto lavage. Most obstetricians have their own favorite prescription or method for the treatment of heartburn, thus proving the non-existence of any specific for the condition.

SORE TONGUE- glossitis in my own experience the exhibition of large doses of vitamin B complex with dilute HCl and iron has helped these cases quite definitely.

GINGIVITES- local treatment by a really good dentist is of great value, as the instruction of the patent in careful and persistent oral hygiene and the use of astringent mouthwashes. Attention should be directed toward the general health and the prescribing of iron and whatever "tonics" may be indicated. While vitamins A, B, and C have been suggested for this condition, I feel that I have had the best results with large doses of C a quart or more of orange juice a day.

PTYALISM- probably best considered and treated as one of the rarer complications of early nausea and vomiting of pregnancy. I have never thought that I have ever been able to do much for this annoying condition by any drug.

EARLY NAUSEA AND VOMITING- while this symptom group probably has a toxic basis and possibly an endocrine factor, I firmly believe that the psychic element is predominant. These patients suffer from a conflict of desires and/or fears that causes them to reject the pregnancy; occasionally their nausea and vomiting is a punishment of self or husband. why do I think so?

Its greatly lessened incidence in recent years due to a more sane and enlightened attitude toward pregnancy. An induced abortion for this condition is a rarity nowadays.

The weakening of the influence of old ideas how often do the young pregnant women say that she does not see how she can be pregnant when she is not "sick".

Cures by cervical treatments attempted or faked abortion and by all sorts of therapy, basically psychic.

The results of the modern treatment which is practically psychotherapy plus sedation and glucose. It is quite impossible to maintain the toxic theory in the face of the rapid and often dramatic and spectacular results so often obtained.

What do I do with early nausea and vomiting of pregnancy? I never mention the possibility to my patients. If they say that they are so troubled or I discover it by roundabout inquiry, the casual statement is made that it occurs in not over half of pregnant patients, it doesn't last very long and few women are much bothered with it anymore. If they do not want to eat, all right, but insist that they should have daily the equivalent of one good meal which is sufficient to maintain their health. Assure them that their baby is not in need of line or any particular food at this time. They can have ANYTHING they want I emphasize that often naming some crazy and impossible food combinations. If they have no particular choice, I suggest that they eat largely sugars and starches, mentioning several. It is better to eat a half dozen or more times a day if they wish they may "piece" all day long. I tell them to take their food dry, without soups and milk, etc., to drink little or nothing with their food. Often the taking of something before rising help, and one else's cooking. I have always felt that the insistence on diet lists for these patients, while possibly of merit, is largely psychotherapy. They are so busy keeping track of their diet, that they forget their troubles. These will usually get well anyway, for patients rarely come to the doctor earlier than six weeks and in another six weeks they are pretty well over their vomiting. Of the interne and his recommendations for afterpains. I often give them phenobarbital ½-1 grain 3-4 times a day. I think it helps. I also believe that the reading of a good book or booklet on prenatal care, commensurate with their intelligence, is valuable. Finally, I have a talk with them. Sometimes I tell them that they don't want their baby, which they will indignantly deny. Then I explain. I tell them that they possess an inescapable instinct for a baby which cannot be denied, but that various conflicting factors enter into the pictures, and so arise fears and anxieties. Often these will come out if a little patience and ingenuity are exercised. Get them to face whatever the situation may be, and to adopt a good or at least as good as possible philosophy toward it. If these vomiting patients cannot be controlled and made reasonable comfortable by these measures, I insist on hospitalization, under the charge of a nurse who knows how to manage them. If nausea and vomiting are not then speedily controlled, I believe that abortion should be induced. I have had very little experience with the use of adrenal cortex or other endocrine substances or of vitamin B or other vitamins in the treatment of early nausea and vomiting of pregnancy. I cannot deny their worth nor would I disparage their use. Finally, and emphatically, in spite of whatever I have said this afternoon, believe me, I have the greatest respect for nausea and vomiting of pregnancy.

Late vomiting of pregnancy suggests an infection, not infrequently a pyelitic; or latent toxemia; or a reflex or mechanical cause, like a gallbladder disturbance. The older practitioners believed and often quite rightly in the intestinal origin of illness, and often prescribed for these patients a cathartic, usually a dose of calomel. It still often works well.

Of course, in all discussion of this type, it is not to be forgotten that pregnant women are not immune to diseases and conditions that may affect the non-pregnant women.

Circulatory system

Extrasystoles occur frequently in pregnancy, are usually of no importance and the patient can be assured of their harmlessness. "Formes Frustes", or mild manifestations of hyperthyroidism, are common in pregnancy. I hope that, eventually, I can have a basal reading on every obstetric patient, for it might furnish a clue to many obscure symptoms. Besides, a lowered basal reading in early pregnancy is a factor in abortion, as well as the development of late toxemia.

Vertigo and fainting are evidence of vasomotor instability. It is said that if you see a young woman being helped out of church or the theatre, she is probably pregnant. For the fatigue, exhaustion, "no pep" symptom of early pregnancy, I suggest all the sleep and rest they can get or want, and the prescription of alcohol and strychnine, which the older doctors used to say should never be given together.

Varices are certainly not due to pressure. Some women can tell immediately when they are pregnant by their veins beginning to swell. Rest, elevation and support by adhesive, stocking or elastic bandage. Of the elastic bandages, the real rubber ones are best, though not always the most comfortable. With the injection treatment, which has staunch champions, I have had no experience. Possibly, like many of the older men, I am afraid of a radical quite so bad as often pictured. Hemorrhoids should generally be handled conservatively, except in the case of thrombosed external hemorrhoids where the complete removal of the clot under local anesthesia and strict asepsis gives great and welcome relief.

There has been a deal of discussion recently of anemia in pregnancy. The so-called physiological anemia of pregnancy is probably the result of hydremic, though may be toxic or result from the breakdown of the red cells to supply the fetus with iron. It seldom needs treatment unless the RBC drop below 3,500,000 and the hemoglobin below 70%. A pernicious type of anemia may occur, and the obstetric patient is not immune to a factor that produces secondary anemia. Hypochromic anemia is the most common form of severe anemia encountered in pregnancy, probably a manifestation of toxemia. Factors in its development seem to be the family tendency, gastric disturbance, and a diet deficient in meat and iron. It usually begins in the latter half of pregnancy with lowered HCL; RBC above 3,000,000; low Hgb, somewhat like chlorosis. The patient's complaints are usually sore tongue, brittle nails, and neuritis manifestations, as well as the symptoms referable to any anemia condition. Iron seems almost a specific but the dosage must be adequate. Dilute HCl, liver, and transfusions should be remembered. I wish that every obstetric patient could \have at least a red count and a Hgb, determination.

Nervous system

There are many toxic symptoms referable to the nervous system, such as psychic changes of pregnancy; headaches, which in all cases demand attention and are especially of importance if late, sudden, persistent and severe; pruritic; insomnia, usually late in pregnancy and which should not be dismissed lightly. Neuritis symptoms like numbness and neuralgias usually of the extremities are very common and most of them toxic. If in the sciatic region they are usually glibly ascribed to "pressure", while as a matter of fact they are rarely so caused, being either toxic or referred from the Sarco-iliac joints. Most toxic neuritis symptoms of pregnancy can be helped by iron, calcium and vitamin B complex in adequate doses. Heat often helps them, e.g. the therapeutic lamp and the wrapping of an arm in flannel at night. In this group can probably be classed the cramps in the calves, usually the right, that often waken the patients in the early morning hours. I believe that there is here often an associated circulatory element, else why in the legs? Besides the medicines mentioned above iron, calcium and vitamin B and D the following procedures often help elevation of the legs several times a day for periods of fifteen minutes or longer; elastic stockings or bandages; heat, especially at night, and cautious massage.

I would like to call your attention to a neuritis symptom complex that not infrequently occurs postpartum, apparently toxic. It is severe pain in the neck shoulder upper thorax area, or in that of the hip-thigh-pelvis. That is the upper extremity is usually ascribed to the draught from a window or door. Heat, counterirritation, aspirin and very large amounts of vitamin B seem to help them.

At this place it might not be amiss to briefly consider the daily amounts of vitamins and minerals required by the pregnant women since these have been so frequently mentioned up to now and are definitely of great importance to the pregnant women's metabolic processes, though probably in nowhere the degree usually claimed.

Vitamin requirements of the pregnant women daily probably twice as much as is required by the non-pregnant.

Vitamin A 10,000 international units

Vitamin B 800 international units

Vitamin C 100 mgs. Ascorbic acid

Vitamins D 800 international units

These figures are not to be considered final. If we can believe advertisements, three yeast tablets a day fills the bill. Mineral requirements in pregnancy.

Phosphorus usually adequate, if enough animal protein in the diet. Iron 15-20 mg. Daily

Calcium the most important; beat companied by Vitamin D. The usual daily adult calcium requirement is about o.6 mgs. The fetus deposits little calcium before the fifth month but in the latter part of pregnancy 20 30 grams, 60% of it in the last two months. In the latter part of pregnancy, pregnant women need about 1 gm. Of calcium daily.

One Quart of milk 1.5 mgs. Calcium The following medicaments contain calcium as follows;

Abbott- Bone Phosphates tablet 1.7 mgs. Calcium

Decal D. Wafer 3.5 " "

Decal D. Capsule 1.75 " "

Squibs Dicalphos. C Vicsterol wafer 3.5 " "

Calcium gluconate powder 8.9% calcium

Many writers believe that non-traumatic abruptic placentae are often one of the best examples of one type of pregnancy toxemia. Omitting all reference to its possible role in abortion and all use of progesterone, we shall confine the discussion to slight localized premature separation of the placenta in the latter part of pregnancy. Shute of Canada has studied and written much on this subject. He believes that the condition is characterized by the appearance of local areas of pain and tenderness (sometimes with rigidity) in the uterine wall, associated with sacral backache and often though not necessarily accompanied by uterine bleeding. He maintains that they are very common, and are always toxic in origins, that the toxemia is associated with (not the same as caused by) an increased estrogenic substance in the blood that causes the resistance of the serum to proteolytic ferment. He maintains that the condition can be controlled and cured by adequate doses of vitamin E which is antagonistic to the estrogenic substance. He used wheat germ oil for this purpose which must be kept under refrigeration where it retains its potency for about eight weeks. He gives 12 drams the first twenty-four hours and continues one dram a day, which had best be continued to term. Much larger doses have been given without harmful results, and the dose must be ADEQUATE. He claims that under the treatment one can observe the shrinking and disappearance of the areas described and the subsidence of the symptoms. I believe that he is, in the main, correct. Local pain and tenderness in the wall of the pregnant uterus (note that the round ligament is excluded) are due either to a fibroid or a hemorrhage.

It might be of interest to compare vitamin E products as to tocopherol (name of synthetic vitamin E) Content and approximate retail cost in Binghamton.

Wheat germ oil one dram 5mgs tocopherol 9 cents

Gerome E one cap. 4mgs " 6.5"

Roche Ephinal Acetate tablet 3mgs tocopherol 3.8 cents

Squibs Tocophorex cap. 24mgs. Tocopherol 7 "

Winthrop Tofaxin cap. 30mgs. " 9 "

Abbots Natopherol cap. 50 mgs. " 9 cents Plus

It is obvious that there is wheat germ oil and wheat germ oil, that vitamin E capsules are not all the same, and that tablets of tocopherol vary in strength.

A common obstetric experience is to be confronted by a patient in late (occasionally earlier) pregnancy with rising blood pressure, albuminuria, and evidence of water retention. These three are the cardinal symptoms late toxemia of pregnancy, though eye, cerebral, gastrointestinal and other disturbances may even then be present or may be added as the disease progresses. For our purposes, the first procedure is the determination of the type of toxemia, and the second, the management of the three symptoms named.

The nephropathies of late pregnancy are still unsolved. A disease of kidneys and blood vessels predisposes to toxemia. Pregnancy is a very delicate test of renal function and unmasks latent or aggravates already existing reno-vascular disease. It seems probable that pregnancy elaborates a toxin with a specific action on the kidneys and blood vessels.

Corwin and Herrick believe that there are two broad types of late toxemia of pregnancy.

Closely related to vascular renal disease, more commonly essential hypertension. It appears earlier with history or evidence of the pre-existence of these diseases. First, the blood pressure rises, and considerably later if at all, albuminuria and edema appear. HAs a good prognosis with rest, and rarely drifts into pre-eclampsia or eclampsia? Reacts to the cold pressor test, and not to intravenous Pitressin except as the normal women.

Has no apparent relation to vascular renal disease. Appears later with no history or evidence of such preexisting disease. Increased blood pressure is associated with, or preceded by, albuminuria and oedemic. Does not respond to rest, and drifts easily into preeclampsia and eclampsia. Does not react to the cold pressor test, but gives by .66 cc. pitressin response of 50mm. Or more for 15 minutes instead of the usual 45 or less. The idea is that this group the preeclampsia and eclampsia is the result of specific toxemia. However, the idea is growing that back of ALL pregnancies nephropathies stands renovascular disease. Preeclampsia and eclampsia are often followed by permanent essential hypertension rarely by chronic nephritis. The older the patient, the greater the parity, the higher the pressure and the longer the duration before delivery, the greater the probability of a permanent increase of the blood pressure.

The differentiation of these groups can usually be made, though some toxic cases must remain unclassified. The help of good internist in the treatment of these toxemias is very valuable.

Management of mild late toxemia of pregnancy. Very important is the appreciation of the danger inherent in the condition, not only present but potentially for the future, and of the need of thorough clinical and laboratory investigation of every case, and continuous observation. A very valuable but often neglected source of information is the eye grounds.

Management of the reno-vascular group except under most unusual circumstances I personally believe that a woman with proved chronic nephritis should not become pregnant, and if pregnant, her pregnancy should be terminated, preferably with sterilization. My own personal experience in trying to continue or prolong pregnancy in these cases has been unsatisfactory and sometimes disastrous. The mother's condition is usually worsened; the baby often dies and lengthening of its intrauterine life does not materially increase its chances for survival. I admit that there are exceptions. On the other hand, many cases of mild essential hypertension can be carried through pregnancy under a strict medical regime. Just when this should be done, is very difficult, at times, to decide. I feel that most of them are surely NOT improved by pregnancy, and I should hesitate to advise pregnancy for a woman with a blood pressure of 170 or over.

Management of preeclampsia and the three symptoms of increased blood pressure, albuminuria and edema.

Blood pressure in pregnancy. Low blood pressure in pregnancy, in my experience, is of a slight moment. With the patient reclining, it is not uncommon to have readings below 100 systolic, and many times I have not been able to definitely determine the diastolic. Normal blood pressure in pregnancy with the patient reclining is rarely over 120/80 often much lower. Surely any readings persistently over 140/90 are definitely abnormal, or any systolic rise of 40mm, or more. I have almost a rule though not quite that I induce labor in a preeclamptic patient whose systolic pressure passes 170, or diastolic 110, especially if the rise has been rapid and depending somewhat on her other symptoms. Rest and sedation are valuable in the treatment of hypertension.

Albuminuria or proteinuria. It is doubtful if albumin is ever present in the urine in normal pregnancy. The "albuminuria of pregnancy", "the kidney of pregnancy", the "low reserve kidney" probably represents a kidney with congenitally defective function, unable to stand the extra strain of pregnancy. It is characterized by an increase of blood pressure to say 150/90 in the last two months, small or very moderate amounts of albumin in the urine, normal blood chemistry, no other symptoms, disappears in the puerperium and though may recur, does not become worse in succeeding pregnancies. It is probably best to classify it as a manifestation of latent hypertension or mild preeclampsia and it represents about 35% of all late pregnancy toxemias. It has always been a puzzle to me what to do with the patient with a large amount of albumin in the urine, and nothing else demonstrably wrong. W. J. Dieckmann of the University of Chicago, who published a very good paper on the "Prevention and Treatment of Eclampsia" in the American Journal of Surgery of April 1940, says that the patient should be hospitalized and the pregnancy interrupted if the albumin is 3 plus or more than 5gms. In 24 hours. There is no specific treatment for the condition.

Weight increase and water retention in pregnancy. a woman gains, on the average, between 20-25 pounds over her usual weight during pregnancy. Rarely should she gain more? About 15 pounds of this is a fetus, placenta, amniotic fluid, and the increase in fat and water. The weight gain is roughly distributed as follows first three months, little or nothing; second trimester, one-half pound a week; In the last two weeks immediately before delivery, the normal patient often loses a pound or more, and this has been suggested as a possible indication of the imminence of labor. I insist that my patients keep their weight gain within reasonably normal limits; on many days, the topic of our conversation seems to be pounds and food and diet. I tell them that they will put less strain on their gastrointestinal and cardiovascular-renal system and that many of the minor discomforts will be less in evidence or even disappear. They feel better, look better, and do not have to struggle to lose fat afterward. Some are hard to convince that they do not have to eat for two. If a patient is definitely over weight at the beginning of pregnancy there is no reason why she should not lose some, or at least not gain, during her nine months.

Practically, an excessive gain of weight during pregnancy, not the result of hypothyroidism or too much food and drink, must be due to water retention. Some water retention is normal in pregnancy, especially late. Of, the women's smoothed face and her swollen face and hands so often complained of in the morning. It is associated with sodium retention, and the pituitary and adrenals are implicated, clinically water retention is determined by the gain of weight and edema, remembering that 8-10 pints or pounds of fluid may be stored up in the body tissues before any edema may be noted. An excessive or sudden gain of weight always suggests a disturbance of water balance, as a quarter pound in one day, two pounds in one week or over five pounds in one month. A moderate amount of edema below the knees is normal in pregnancy, but any edema higher in the body is definitely abnormal.

Abnormal water retention is an important sign of pregnancy toxicosis, and its secretion can be aided and the toxemia often relieved by the following. 1. Limitation of fluid intake. Dr. Arnold had his patients keep an intake output chart of them with the intake kept below output. 2. Limitation of sodium salts, by the avoidance of salty foods (name them) and the use of salt in cooking and at the table. The daily average salt intake is to be reduced from 10-20 mgs to three or less. In this connection is it well to remember that the use of large quantities of baking soda for heartburn may not be entirely innocuous. The rational of a skim milk diet in the treatment of preeclampsia is that it contains little sodium but is high in calcium and potassium. 3. Adequate consumption of animal protein. Though this has been disputed it does no harm even in the presence of albuminuria rather the reverse. 4. Iron for any anemia. 5. Certain saline laxatives. 6. Intravenous glucose. In eclamptic toxemia, abnormal water retention may occur before rising of blood pressure or albuminuria, and a pair of scales is an important instrument. Persistent or progressively increasing generalized edema, not greatly or permanently influenced by treatment, is an indication for the interruption of pregnancy.

This discussion of the minor toxemias of pregnancy has been sketchy, incomplete, not very scientific, and highly personal. I feel very humble in the presence of any pregnancy. Eventually, someone is going to tell us all about the toxemias of pregnancy. I fear that no one in this room will live to see it.

 

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