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Problems During Pregnancy

Most young women in the childbearing age range enjoy good general health. They may develop minor annoyances such as hemorrhoids or heartburn during pregnancy, but serious complications are rare. There are, however, a few diseases, such as toxemia, which are peculiar to pregnancy, and, of course, any chronic illness, such as diabetes, may coincide with pregnancy. Although the main purpose of this article is to emphasize the normality of the pregnant state, some brief descriptions of the more common complications will be included. Through even a cursory understanding of them, you should be better equipped to appreciate the normal, to recognize the abnormal, to act in an emergency, and to assess the significance of any problem you might encounter.

Generally speaking, women who become pregnant for the first time after the age of thirty-five are slightly more prone to develop complications. Many women have completely normal, uneventful first pregnancies at thirty-six or thirty-nine or even forty-two, but in this age range they do have to be watched a little more carefully.

This might be a good place to insert a statement which needs more emphasis than you might imagine, namely, that no two pregnancies are alike. If you were terribly nauseated with your first pregnancy it does not follow that you will be nauseated with this one. That you gained thirty pounds without developing toxemia the first time does not assure you of such good fortune again. Nor will this fetus necessarily kick so much as the last one. Nor is your labor going to be the same. There are of course, general trends, such as the fact that some 'women tend to deliver prematurely, and varicose veins are apt to become worse with each pregnancy, and kidney infections are prone to recur. But by and large the course of each pregnancy may be quite different from the others of the same individual.

Miscarriages

The terms miscarriage and abortion are synonymous in medical parlance. These words are used to describe the termination of a pregnancy before the baby is big enough to survive. Miscarriages are very common. At least one out of every ten pregnancies terminates in this manner.

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Causes. It is usually impossible for a doctor to determine the exact cause of an individual miscarriage, but it is known that most of them result from the union of sperm with an imperfect egg or vice versa. No matter how healthy the man and wife, a certain number of his sperm and her eggs are bound to be faulty, the pregnancies which result from such a union are usually aborted. There is nothing whatever that can be done to prevent this, the commonest cause of miscarriage. Occasionally abortions are due to a maternal disease, such as hypothyroidism or diabetes, or a congenital deformity of the pelvic organs, the treatment of which may prevent future abortions. But usually miscarriages are unpreventable and of no particular significance in the over-all reproductive potential of a healthy young woman.

It is virtually impossible for any sort of body injury to cause a miscarriage. Likewise it stands to reason that if some such normal function as intercourse or douching or riding in a car seems to have precipitated a miscarriage, then such a pregnancy was certainly doomed from the start and the miscarriage would have occurred in this case sooner or later anyway. In short, if a miscarriage occurs, there is nothing to be gained by searching for an outside cause to feel guilty about. These things are beyond your control.

Time of Occurrence. Nine out of ten miscarriages occur during the first three months of pregnancy, so once you have reached this point you can pretty much dismiss this fear. And contrariwise, since so many pregnancies do end in early abortion, it is wise not to feel overly confident until you have passed the third month. It is probably for this reason that many women don't spread the happy news among their friends until they are a little further along.

Symptoms. The cardinal signs of miscarriage are pain and bleeding. The pain comes in the form of lower abdominal cramps, similar to menstrual cramps or early labor pains. The bleeding is usually bright red, sometimes brown; it may be scant or copious. If either of these symptoms occurs, go to bed and call your doctor, in that order. If you pass anything which looks like tissue save it and show it to your doctor. If the tissue includes the fetus or part of the placenta the abortion process has become irreversible.

Sometimes these symptoms appear briefly and then disappear on their own. At least one in five women bleed during the early months of pregnancy, but only half of these go on to abort. The other half stop bleeding and carry to term normally. By and large, however once bleeding occurs, abortion will or will not follow, regardless of what either you or your doctor does. Bed rest sedation and hormones are often prescribed after the 'bleeding 'has started, but there is no convincing evidence that any of these remedies has ever prevented an abortion. So by all means follow your doctor's instructions, but pray, too, that you are one of the lucky ones whose bleeding will spontaneously stop.

Treatment. The process of abortion is sometimes incomplete. Fragments of placental tissue may remain in the uterus and bleeding will continue until they are removed. For this reason it is necessary in some cases to perform a curettage (a “scraping”), thereby evacuating the uterine cavity completely. This is a minor operation which is performed in the hospital. In other cases the entire pregnancy may be aborted in toto and the administration of a drug such as Ergotrate, which will cause the uterus to contract, will suffice to prevent unnecessary blood loss. Late abortions (i.e., those occurring between the twelfth and twentieth weeks) are more hazardous and will therefore usually require hospitalization.

Recovery. Recovery from a miscarriage should be prompt and permanent if the blood loss was not excessive. And when it comes to interpreting this phrase, “excessive blood loss,” bear in mind the fact that it is not harmful for a healthy person to donate a pint of blood to the Red Cross. Many women erroneously feel that they are “hemorrhaging” when they lose less than half this amount. Tub baths, douches, and intercourse should be avoided for two weeks following a miscarriage, but other activities can be resumed promptly. The next menstrual period may appear m four to six weeks. There is no harm in trying to conceive again right away.

Recurrences. If you have been aborted before, it may occur to you that another miscarriage will signify there is something terribly wrong with you, that you will never be able to carry a pregnancy to term. Common sense will assure you that this deduction is illogical if you are in good general health. It's like tossing a coin; if you do it long enough, you can toss heads ten times in a row. So don't be discouraged by one, two, or even three miscarriages; or, if you must be discouraged, don’t give up.

Ectopic Pregnancies

Once in a while a fertilized egg will in its transit toward the womb, become lodged in the wall of the fallopian tube. This happens once in about 200 pregnancies and it produces an untenable situation. The tubes were not designed to harbor pregnancies. If a fertilized egg does become stuck in the tube it will continue to grow normally for a while; but sooner or later the tube (as opposed to the flexible muscular uterus) will be able to expand its delicate wall no further and it will burst. This invariably happens sooner rather than later - some time during the first three months. It will produce bleeding directly into the abdominal cavity which must be stopped by an abdominal operation to remove the tube.

Symptoms. Usually the pregnancy seems perfectly normal for a month or two or even three; there are the usual pregnancy symptoms. But there often is some vaginal bleeding, there may be episodes of weakness or actual fainting, and eventually there will be pain, usually on one side of the lower abdomen. These symptoms must be reported to your doctor at once. From here on the matter is in his hands. If he suspects an ectoptic pregnancy he will hospitalize you; if his suspicions are confirmed by laboratory tests he will operate immediately. Ectopic pregnancies are medical emergencies of the first order.

Cause. The cause of ectopic pregnancy is not always apparent, though it more often occurs in tubes which have been infected in the past. Many women with a history of ectopic pregnancy proceed to develop future pregnancies in the uterus where they belong.

Multiple Pregnancies

The natural incidence of twins is roughly 1 in 86 pregnancies, of triplets 1 in 86 times 86, of quadruplets 86X86X86, and so forth. Thus the likelihood of twins, triplets, quadruplets, and quintuplets is approximately 1 in 86; 7500; 650,000; and 55,000.000 respectively. These ratios have been altered in recent years by the use of drugs, in women who do not ovulate spontaneously which sometimes bring about the extrusion of more than one egg per month. Hence the headlines about quintuplets littering the land. For all practical purposes, however, our discussion can be limited to twins.

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Causes and Kinds. Identical twins constitute about one fourth of all twins; there is nothing “hereditary” about them. They occur as the result of splitting of the ovum very soon after its implantation in the uterus. The tendency to have fraternal twins is, on the other hand, to a slight degree inherited from either parent. Fraternal twins result from the simultaneous fertilization of two eggs. Except for being born on the same day, they are no more similar than any other pair of siblings. Twin pregnancies tend to occur more often in older women.

Detection. Most pregnant women wonder whether or not they are going to have twins. This is especially true during the second and subsequent pregnancies, when women feel that they are “so much bigger” because their abdominal musculature is weaker and the uterus therefore protrudes farther. This possibility is also constantly on the obstetrician's mind, and he has many ways of detecting twins before they are born. His first suspicion may be based, as early as the second month, on rapid enlargement of the womb. Later on he may be further convinced by feeling two fetuses or hearing two fetal heartbeats. Foolproof diagnosis can be made by X-ray or ultrasonogram. There is no reason to fear the effect of an X-ray taken for this purpose. As a matter of fact, it will not only satisfy your curiosity, but also help the doctor in his management of your pregnancy and delivery. In any case, most twins are not detected before the fifth month (when the fetus first becomes visible on X-ray) and sometimes not until after the first baby is delivered.

Care. Twin pregnancies require more meticulous obstetrical care, for complications of many varieties are more apt to develop. The prospective mother of twins will have to be more scrupulous in her diet and in her attention to all of the doctor's advice. She will probably feel doubly uncomfortable during the last few months and will need a great deal of rest. Labor usually occurs two to four weeks before term, but neither labor nor delivery should be unduly difficult.

One of the most important aspects of a twin pregnancy is preparation for twin motherhood. It is almost imperative, whether these are the first babies or not, to have help in the early rearing of them – as much help as you can get.

German Measles

A woman who develops German measles (rubella) during the first three months of pregnancy may deliver a deformed baby. This observation was first made in Australia in 1941 and it has been subsequently confirmed many times. The reason for this lies in the facts that the major body organs (the heart, the brain, the eyes, and so forth) are formed during the first few months of life, and the German' measles virus can reach the embryo and affect its development at this time. Cataracts, heart anomalies, deaf-mutism, and underdevelopment of the brain may result.

If German measles does occur during the first three months the odds of a deformity's developing are roughly one in five. During the fourth month the odds drop to about one in twelve. After this the chances of the infant's being affected are practically zero. There is, of course, no risk to the mother, and regular measles and other virus diseases are not known to cause fetal deformities at all.

During your first visit to the doctor, he probably took blood from your arm in order to determine your level of immunity to German measles. If this test shows that you are not immune (because you have never had the disease), you should be extra careful, during the first four months, to avoid exposure to an active case. If you are exposed, however, a second blood test will show whether or not you develop the disease. And if you do develop the disease you will want to discuss the situation thoroughly with your husband and your obstetrician. There should be no obstacle to your having an abortion in this circumstance if you want one.

X-ray Hazards

Since the first atom bomb explosion there has been a gradual fallout of facts and rumors about the hazards of all forms of radiation, including diagnostic X-ray. The pregnant woman has been a particular victim in this regard - so much so that an occasional obstetrical patient actually balks these days at her doctor's recommendation that she have X-rays taken to determine the adequacy of her pelvis (X-ray pelvimetry).

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Leukemia. It is thought by some investigators there may be a slightly greater risk of your baby's developing leukemia if your pelvis is X-rayed during pregnancy. Even if this is true the risk is very small – much smaller than the proven risk of injury to your baby if X-rays are not performed when some obstetrical difficulty is suspected.

Deformities. It is also rumored that X-rays during pregnancy can cause deformities of the fetus. Despite keen concern about this on the part of the medical profession, there is no proof of this. It is possible, if not probable, that excessive radiation during pregnancy may lead to a genetic disturbance which will become manifest by deformities in future generations, 50 or 150 years from now, but the likelihood of this is very small. Doctor's are generally ordering fewer X-rays nowadays on pregnant and non-pregnant patients alike, and radiologists are striving to develop more perfect techniques. But there are many sources of radiation other than diagnostic X-rays. The ground we walk on, the air we breathe, and the milk we drink all contain sources of radiation which are equally “dangerous.” X-rays comprise but a fraction of the radiation we receive during our lives.

Conclusion: If your doctor thinks that X-rays are necessary in your case, take his advice and don't worry about it.

Malformation Of The Baby

The most universal fear of pregnant women is that their babies will be abnormal; the most common question asked immediately after delivery is “Is it all right?” This is a perfectly normal attitude. The fear that nine months of waiting and planning will result in the birth of a deformed baby is certainly natural, as long as this fear is not excessive.

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Incidence. In actual fact, however, only one baby in a hundred is severely deformed. This is one statistic which should provide some comfort to the intelligent woman. Most abnormal pregnancies end in miscarriage in the early months. Almost all of the infants which show major degrees of deformity are stillborn - born dead. There are very few instances m which the baby is born alive but badly deformed. Included among these would be cases of neurological (e.g., hydrocephalus and meningomyelocele, intestinal (e.g., tracheo-esophageal fistula), and cardiac.; deformities. Again, if these organ systems are markedly affected the infant usually dies within a few days, although some newer operations have been devised to rectify the less extensive defects of this type.

An intermediate group may be born with afflictions which do not become manifest until later in life such as cerebral palsy, cystic kidneys, and some forms of congenital heart disease. These are also very rare and there is new hope in the prevention and treatment of many of these conditions.

The vast majority of congenital abnormalities are relatively minor and correctable. The plastic surgeon can work miracles in reconstructing harelips and cleft palates. Clubfeet can usually be treated successfully without surgery. Undescended testicles umbilical hernias and extra digits are among the most common deformities and among the easiest to fix.

Prenatal Diagnosis. New techniques have been developed to detect, before birth, the presence of certain diseases m the fetus. In general this entails inserting a needle through the abdominal wall and into the uterine cavity (amniocentesis), removing some of the amniotic fluid, and examining the fetal cells in this fluid for evidence of chromosomal or biochemical abnormalities. It is important to realize that this procedure is not so totally harmless that it should be done without good reason, that there are as yet few laboratories in the country equipped and staffed to conduct these examinations accurately, and that only a few of the known genetic defects can be diagnosed in this way.

These tests may be performed when there is reason to suspect mongolism, muscular dystrophy, and other fetal abnormalities. And this suspicion arises in these three circumstances:

(1) there is a history of such a defect in the mother's or the father's family;

(2) the woman has previously given birth to a defective child; and

(3) the pregnant woman is over forty, when the incidence of genetic defects (particularly mongolism) goes up.

If you find yourself in any of these circumstances you will want to talk with your doctor about the desirability of amniocentesis. Usually the test cannot be done before the sixteenth week and it takes an additional two or three weeks to get a report. If the report shows that your baby will be abnormal, you may want to consider having an abortion.

Death Of The Fetus

About one pregnancy in a hundred is complicated by death of the fetus between the fifth month and the onset of labor. This situation may be suspected by the absence of fetal movement for forty-eight hours or more. It can then be confirmed or disproved by the obstetrician's auscultation of the fetal heartbeat and X-rays of the abdomen. The absence of fetal activity for several hours or even a day is not uncommon; there is no need to report this to your doctor until you are reasonably sure that there has been no movement for forty-eight hours.

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Causes. The cause of fetal death is unknown in one quarter of these cases. Another quarter can be traced to toxemia of pregnancy. In the remaining cases the deaths are due to congenital abnormalities, Rh incompatibility, and various maternal diseases. You can see that, except for some of the cases of toxemia, these deaths are unpreventable.

Management. Almost all of these deaths occur during the last two months of pregnancy. No matter when or why they occur, however, no harm will befall the mother and nothing should be done to terminate the pregnancy. Eventually labor will begin spontaneously, usually at about the time that it would have started if the fetus had remained alive.

The RH Factor

In 1940 a new substance was discovered in the red blood cells of rhesus monkeys. As a tribute to this species of monkey this substance was named the Rh factor. In the course of testing human beings for the presence of the Rh factor, it was learned that 85 per cent of us have it and 15 per cent do not. Those who have this Rh factor in their red blood cells are called Rh-positive; those who do not are referred to as Rh-negative.

Mechanism of Trouble. If the red blood cells of an Rh-positive person are introduced into the blood stream of an Rh-negative person, they will cause the formation of substances known as antibodies which, in turn, will destroy these alien Rh-positive cells. When this happens - i.e., when Rh antibodies form in the blood stream – that person is said to be “sensitized” to the Rh factor. The introduction of Rh-positive blood cells into the blood stream of an Rh-negative individual can be effected in two ways: blood transfusion or pregnancy. Prior to the administration of a blood transfusion nowadays, the blood cells of both donor and recipient are tested for the Rh factor, and Rh-positive blood is never given to an Rh-negative patient. But in the case of some pregnancies this admixture of Rh-positive and Rh-negative blood is unpreventable. Here is what happens:

In 87 per cent of marriages either both partners are Rh-negative, both are Rh-positive, or the wife is positive and the husband negative; no sort of Rh trouble can ever result from any of these combinations. In 13 per cent of marriages, however, the wife is Rh-negative and the husband is rh-positive; it is this small group which we are about to discuss, for it is in this group that Rh trouble may develop. In order to understand how it develops, it is important to remember that in all of these cases in which the mother is negative and the father positive (or, for that matter, in the event that either or both of the parents are Rh-positive) the child will be Rh-positive.

And in these cases the red blood cells of the baby may, at the time of delivery, enter the blood stream of the Rh-negative woman and cause the formation of antibodies. The mother is then said to be “sensitized” to the Rh factor. The risk of sensitization is about 15 per cent each time such a mother gives birth to an Rh-positive child. When sensitization occurs, the mother's antibodies may then leak into the blood stream of her babies during subsequent pregnancies, where they can destroy the babies' red blood cells. The first Rh-positive baby in such a setup is invariably unaffected, since sensitization of the mother occurs after she delivers. It is important to realize that the mother, whose red cells are Rh-negative, cannot be harmed by these antibodies, which attack only Rh-positive cells.

Prediction of Trouble. On your first visit to the obstetrician he will take a specimen of your blood in order to determine whether you are Rh-positive or negative. If you are positive, you have nothing to worry about. If you are negative he will then take a sample of your husband's blood, and if it is also negative you have nothing to worry about. But if your marriage is one of the 13 per cent which consists of an Rh-negative woman and an Rh-positive man, it is known in the medical world as an “Rh-incompatible” marriage. In these cases your obstetrician will be alert to the possibility of Rh trouble.

The Prevention of Trouble. Until 1965 there was no way of preventing Rh trouble from developing in a certain percentage of Rh-incompatible couples. Nowadays, Rh sensitization can almost always be prevented by the administration of a sort of anti-antibody drug. Usually known as Rhogam, when given to a woman within a few days after delivery it will prevent the formation of antibodies which might otherwise affect her next child. This injection must then be repeated after each pregnancy in order to perpetuate this protection.

If you are Rh-negative and your husband Rh-positive I would like to offer this perhaps strange but potentially significant piece of advice: Remind your doctor of this fact after you deliver, so that he will be sure to give you Rhogam. Although it is not generally advocated for patients' telling their doctor what to do, doctors' memories are not infallible and in this instance a tactful reminder might prevent a serious problem for you.

It is important to remember, incidentally, that Rh sensitization may occur after an induced abortion or a miscarriage as well as after a delivery, and that Rhogam must therefore be given in all of these circumstances.

Treatment of Trouble. If you were sensitized to the Rh factor before Rhogam became available, there is no way of destroying the Rh antibodies that have already formed in your blood stream and thereby preventing future trouble. The doctor can detect the intensity of this sensitization process, which tends to increase with each succeeding pregnancy, by testing the concentration of antibodies in your blood and, if necessary, in your amniotic fluid (by amniocentesis). And if this antibody level becomes dangerously high he may advise induction of labor three or four weeks before term.

Effect upon the Baby. The disease with which these infants may be afflicted is known as erythroblastosis fetalis It can take several forms. In the milder cases the baby may become a little jaundiced for several days after birth without any lasting effects. If this jaundice deepens, however, it may indicate that a greater number of the baby's blood cells are being destroyed by antibodies, and in such cases the pediatrician may perform what is known as an exchange transfusion, by which the baby's blood is actually replaced with blood which is free of antibodies. A rather remarkable degree of success can now be claimed for this therapy of a disease process which, in days prior to this technique was often fatal. In the occasional extremely severe case the baby is born dead. If the baby is born alive and properly treated it will probably have no lasting ill effects.

ABO Incompatibility. Erythroblastosis may also be due to incompatibility between the infant's and the mother's major blood types. In these cases the baby's blood group is usually A or B, the mother's group O. The mechanism of trouble developing is the same as with Rh trouble: maternal antibodies enter the fetal circulation and destroy its red blood cells. Although as common as erythroblastosis due to the Rh factor, this type of erythroblastosis has been publicized far less. The reason for this is that the effect upon the infant is rarely serious or permanent, and so this condition is less to be feared. In contrast to Rh trouble, ABO trouble may develop in a first pregnancy. The treatment is the same as that described for erythroblastosis due to Rh incompatibility.

Toxemia Of Pregnancy

Signs and Symptoms. Toxemia is a disease specific to pregnancy which affects primarily the health of the mother, secondarily that of the fetus. It is a disease which occurs only in the last three months of pregnancy and is characterized chiefly by edema (puffiness of the skin, most noticeable around the ankles, hands, and face), high blood pressure, and albumin in the urine. Notice that edema is the only one of these cardinal criteria which can be recognized by the patient herself, and of course many women have swollen ankles without having toxemia. This fact serves to emphasize one of the most significant features of this disease: namely, that its onset is insidious and it may develop without the patient's suspecting that anything is wrong. There are other symptoms, such as dizziness, double vision, abdominal pain, headaches, and spots before the eyes, but these are not invariable and not always indicative of toxemia.

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Detection. The detection of toxemia obviously then must depend upon the findings of your doctor at the time of your office visits. This is indeed one of the most important reasons for these visits and it explains why the blood pressure, urine, and weight are checked every time. This is why you are asked to report to your doctor any severe headaches, any sudden gain in weight, and any swelling of the hands or feet. For toxemia develops slowly and, like so many other diseases, it can be treated with optimal results if the treatment is instituted before the process has become advanced. If, for example, a woman's blood pressure increases from 120 to 140, the toxemia can usually be corrected; if this early rise goes undetected until the blood pressure reaches 180 or 200, however, the disease process becomes more difficult to reverse and the health of the mother and fetus is in jeopardy.

Causes. The cause of this disease is unknown. Dietary, hormonal, and psychological factors have been implicated. It is known that toxemia occurs more often in women with hypertension, with diabetes, and with twin pregnancies. And, perhaps most important, we know that it occurs much less often among intelligent, cooperative women who have adequate obstetrical care. In some of our southern states, for example, where prenatal care is often lacking, the incidence of toxemia is several times its incidence in other states where care is more uniformly available.

Implications. And what are the implications of toxemia once it develops? In general the gravity of the situation is directly proportional to the severity of the disease. The type of toxemia described thus far is known as pre-eclampsia; it almost never has any lasting effect upon the mother, but it may occasionally kill the fetus. And if pre-eclampsia progresses far enough it becomes eclampsia, which is characterized by all of the above symptoms plus convulsions, coma, and/or death of the mother and a high mortality rate among the babies. Fortunately eclampsia is exceedingly rare among obstetrical cases which are sensibly supervised.

Salt Restriction. It is known that pre-eclampsia is usually characterized by the retention of salt by the pregnant patient. This knowledge is the sole reason that pregnant women are asked to reduce their intake of salt during the last few months. This salt retention produces the edema of toxemia. It is known that women who gain excessive amounts of weight during pregnancy are somewhat more likely to develop toxemia. Hence the importance of diet during pregnancy. You can appreciate the extent to which the prevention of toxemia is emphasized in American obstetrics now that you realize that much of the rationale for dietary regulation, salt restriction, and antepartum office visits is predicated upon this issue.

Treatment. The treatment of toxemia is largely empirical. Bed rest, sedatives, salt deprivation diuretics and drugs which lower the blood pressure may be used. The only sure cure is delivery of the baby. But let me repeat once more that the most effective form of treatment is prevention, and much of this prevention depends upon you.

Maternal Diseases

Women are no more or less inclined to become ill during pregnancy than they were before pregnancy. Various longstanding and acute illnesses may precede pregnancy, coincide with pregnancy, recur during pregnancy, or develop during pregnancy. Most chronic conditions such as heart disease and diabetes have an adverse effect upon pregnancy and vice versa. For this reason it is imperative that women with such afflictions seek the most competent obstetrical care they can find as soon as they suspect that they are pregnant.

Urinary Tract Infection. The most common site of infection during pregnancy is the urinary tract - the bladder and kidneys. Characterized chiefly by fever, discomfort in the flanks, and a burning sensation upon voiding, these infections can be recurrent, especially in women who have had episodes of kidney or bladder trouble in the past. It may sound like a trivial piece of advice but many of these infections could probably be prevented by better toilet hygiene. After a bowel movement it is advisable to wipe the anal area in a front-to-back direction, for bacteria can be propelled toward the bladder by the opposite motion.

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Anemia. Anemia is so common among pregnant women that a certain degree of it is to be expected. The hemoglobin values in pregnancy rarely exceed 80 percent of the normal non-pregnant level. But this type of anemia is, in a sense, more apparent than real. That is to say, the standard tests for hemoglobin reveal low values during pregnancy because of the dilution of the blood by increased retention of body fluids. Whatever actual reduction there is in body hemoglobin may be due to the use of maternal iron by the fetus, but this can be counteracted by the adequate ingestion of iron through the diet and prenatal capsules. Cases of pathological anemia, such as pernicious anemia, are rare in pregnancy.

Fibroids. Pregnancy is sometimes complicated by benign fibroid tumors of the uterus. They arise in clusters from the wall of the womb and are composed of the same mixture of muscle and fibrous tissue. They may be as small as millet seeds or as large as grapefruits. During pregnancy they are often responsible for abdominal pain. Although rarely incapacitating in severity, this pain may come and go throughout the nine months and nothing definite can be done about it. Aspirin, ice bags, and rest are helpful. Surgical removal of tumors must await delivery of the baby.

Maternal Deaths

This might be a good place to say a word about maternal deaths. Fifty years ago in the U.S.A. the maternal mortality rate was about 70 per 10,000 live births. Now it is about 3 per 10,000. This dramatic improvement has been wrought by:

(1) the greater specialization of doctors,

(2) the modem emphasis on good antepartum care,

(3) the increase in proportion of hospital deliveries, and

(4) the advances in medicine such as antibiotics, blood banks, and better anesthesia.

Of these 3 deaths per 10,000, roughly one third are due to non-obstetrical factors; that is, they are due to diseases such as cancer and heart trouble which antedated the pregnancy. Another third are associated with inadequate obstetrical care. The remainder can be attributed to pregnancy itself. If you are in reasonably good health, therefore, and if you receive good obstetrical care, your chance of dying during pregnancy or delivery is about one in 10,000. This is much smaller than your chance of being killed on the highway during a long trip. One might almost conclude that your chances of surviving the nine months of pregnancy, if properly cared for, are better than your chance of surviving any other nine month period in your life, for you are constantly under medical supervision.

Even now obstetricians are sometimes cautioned by expectant fathers to “save my wife and disregard the baby” if a crisis arises. There is no need for such advice these days. This sort of crisis no longer arises. And if it did, doctors would instinctively do their utmost to save their patient.

Surgery During Pregnancy

Conditions which require surgery, such as appendicitis and gallstones, may occur in the pregnant as well as the non-pregnant individual. Most of these conditions are more common in older women, but it would nevertheless be well for you to be aware of the fact that surgery can be performed during pregnancy, just in case.

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Acute Appendicitis. Only one woman among 2,000 develops appendicitis during pregnancy. Appendectomy must be performed as soon as the diagnosis is made. Nausea, vomiting, and pain on the right side of the abdomen are the characteristic symptoms. If you have any severe abdominal pain, call your doctor; don't take any medicine on your own - especially not a laxative. If your appendix must be removed, there will be a slightly increased risk of miscarriage or premature labor during the week following the operation, but the vast majority of pregnancies will be completely unharmed.

Ovarian Cysts. Cysts of the ovary are sometimes discovered during the initial pelvic examination performed at the first office visit. It is a normal phenomenon for small cysts to develop on the ovaries of pregnant and non-pregnant women; they are usually of no medical significance and they disappear spontaneously. With cysts the size of an orange or larger, the story is different. These cysts are prone to cause trouble during pregnancy and must be removed. If possible it is best to perform this type of surgery during the middle trimester, when complications are least likely to occur. The risk of abortion following this type of operation is not great.

Other Operations. Most other surgical conditions are too rare to warrant individual discussion, but suffice it to say that almost any type of surgery can be performed during pregnancy. Even cardiac surgery is being done. Thyroid operations are sometimes performed. Gallstones and kidney stones are rare, but they can be removed if necessary.

Induced Abortion

It is not likely that many of you will want to have an abortion. Unfortunately however, some of you will have to consider this alternative if you are faced with the possibility of giving birth to a defective child. For this reason I have decided to include a brief description of the methods used to terminate a pregnancy.

During the first twelve weeks an abortion can be done “from below” - by D and C (dilatation and curettage) or suction curettage. The cervix is dilated, with tapered metal rods, in order to permit the introduction of other instruments into the uterine cavity. The pregnancy is then removed with a spoon-shaped instrument called a curette or through a hollow plastic tube attached to a suction pump. These early abortions are simple and safe. They are usually performed under local anesthesia on an out-patient basis.

Another method, called hysterotomy, can be performed at any stage of pregnancy. It is simply a miniature cesarean section. Like a cesarean at term, it means an abdominal scar, spending about a week in the hospital, and having future babies by the abdominal route. For these reasons, and since there is a simpler method for late terminations, hysterotomy is rarely done except in conjunction with a sterilization procedure.

The simpler method for late abortions is called “salting out.” It is usually done between the sixteenth and twentieth weeks. A needle is inserted through the abdominal wall and into the uterine cavity (amniocentesis), some of the amniotic fluid is removed, and this fluid is replaced with a concentrated salt solution. This will cause a miscarriage in one to three days. The amniocentesis is associated with no significant discomfort; the miscarriage, however, may be moderately painful.

Sterilization

Sterilization is not a “complication of pregnancy”. Many of you will not ever want to be sterilized. Some of you will reject the idea now but consider it after having another baby or two. If you are among those who think that this pregnancy should be your last, however, you should at least weigh the pros and cons and discuss them with your husband and your doctor while you are still pregnant, for the best time for a woman to be sterilized is immediately after she gives birth.

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The Alternatives. If you and your husband are determined not to have any more children after this one, by far the most certain means of achieving this end is sterilization. But of course this can mean your sterilization or his. It may be argued that sterilizing the woman is more rational because it is the woman who gets pregnant. And it can be argued that it is more sensible to sterilize the man since the procedure to sterilize him is far simpler. The only alternatives to male and female sterilization, if you want no more children are abstinence and contraception until your change of life.

The Pros. The obvious advantages of sterilization, then, are that it is permanent and effective (about one failure in 200 cases) and that it is far simpler than taking the Pill or using a diaphragm for another ten or twenty years: When performed within forty-eight hours of delivery (the optimum time), the operation entails little additional discomfort or inconvenience. There are no subsequent side effects such as interference with menstruation or dimunition of libido.

The Cons. The very permanence of sterilization that is so eagerly sought by some women has proven to be its ultimate drawback. For it is often impossible to predict how one will feel about future childbearing. You may change your mind. One of your children may die. Your marriage may break up and you may want to have children by your second husband. All remote possibilities, but they warrant serious thought. Then, too, there are women who, although determined not to conceive again, want to retain this option - just in case. Perhaps it makes them feel more feminine to know that they can get pregnant even though they don't want to.

The Reasons. By far the most common reason for requesting sterilization is simply to limit the size of the family. Sometimes medical factors come into play. Women with diabetes, heart disease, hypertension, and other conditions affecting their health and that of their offspring may find it wise to stop after one or two children. And women whose babies are born by cesarean should usually be limited to two or three because of the repeated danger of rupture of the uterine scar.

The Methods. Female sterilization usually involves an abdominal operation and a two- or three-inch scar. A few doctors prefer the vaginal approach. Although most often performed within forty-eight hours of delivery, it can be done at any time. It is technically a little easier to do after birth and of course if it is done at this time it spares the patient another hospitalization.

Since the procedure is known colloquially as “tying the tubes,” I imagine that there are many misconceptions of what is done. Actually it is very simple. A one-inch segment of each tube is excised and the cut ends are tied with a catgut suture. Eventually these cut ends become scarred shut, so that the sperm and the egg cannot get together. Sterilization also results from removal of the uterus, tubes, and/or ovaries, but these operations are generally done to treat a specific disease.

There is another, brand-new technique of sterilizing women through a laparoscope - a metal tube inserted through the abdominal wall or the top of the vagina. Through this instrument the tubes are visualized and cauterized - that is, sealed shut by heat. The advantages are a smaller scar and a shorter hospital stay (sometimes less than twenty-four hours).

In the case of the man, the procedure is known as vasectomy, for it entails the excision of a small segment of each vas deferens - the tiny tube which carries sperm from the testicle. This can be done in the office, under local anesthesia. More and more men are now willing to undergo vasectomy.

Health | Reproduction | Pregnancy


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