Recurrent termination of pregnancy, etiology and prophylaxis before conception.
E. L. SMYTHE, M.D., BREMERTON, WASH.
The causes of abortion are many and varied. Much has been written on the subject and yet there is ample room for discussion. The purpose of this article is not to deal with all types, but only with the type that occurs spontaneously. Criminal abortion has no place here, but in passing it may be mentioned that after all literature has been exhausted on the subject the prophylaxis resolves itself into three heads, viz., better economic conditions (politically, financially and socially), better legislation and better education.
Regardless of cause all cases should have the attention and services of a physician, but the spontaneous recurrent type demands more from a prophylactic standpoint, perhaps, especially from the patient who desires an offspring. The patient placing herself under the physician's care, gives the history of a first abortion or miscarriage following an injury, a fall, railway journey, or perhaps no cause can be ascertained as far as the patient's knowledge is concerned. This in general is the history.
Before any treatment is outlined the cause, if possible, should be found. The patient's history, a physical examination and, in some cases, a laboratory test is required before the physician can arrive at a definite conclusion as to diagnosis.
A chronic pathological condition of the endometrium with all its signs and symptoms is a cause that ranks first as to spontaneous abortion and miscarriage, occurring at regular or irregular intervals. Conservative treatment may be tried and, if successful, a thorough curettage is necessary to remove all the diseased decidua. Lacerations of the cervix is not as common a cause as some writers would have us believe, but the condition may be the primary cause to an existing endometritis. Trachelorrhaphy may be done, especially if the laceration extends to the perimetrium, but if the lacerations are small and there is no disease of the endometrium, direct the search to other sources.
Adhesions resulting from inflammatory deposits in the pelvis may cause the enlarging uterus to expel its contents. Generally there is a history of a pelvic cellulitis or peritonitis. Pain is a symptom to be expected from the onset in the early pregnancy of this type. On examination, the uterus is in malposition, fixed or limited in motion. Celiotomy is to be advised, the adhesions ligated and sectioned, and the uterus restored to its normal position. Malpositions of the uterus may be a factor to be reckoned with; here again the abortion may be the result of an endometritis secondary to the malposition. If the condition does not yield to medical and simple treatment, operation by one of the various methods on the ligaments, to hold the uterus in normal position, is the best procedure. Malformation of the uterus may be a baffling condition to combat. Some of these deformities can be corrected surgically. History of these cases are reported with good results after the deformity had been wholly or partially removed.
Tumors of the pelvis, whether internal or external to the uterus, may cause irritation by pressure and set up muscular contractions in the pregnant organ. These conditions are all generally indicative of surgery.
When in doubt as to diagnosis a Wassermann test, both paternal and maternal, should be made when the cause is held in the background. "When in doubt play trump," and sometimes the anti-syphilitic treatment is the ace of trump. A physician should always be suspicious of syphilis when there is recurrent miscarriages without apparent cause. Constipation should not be overlooked as a causative factor. A hypersensitive uterus can be stimulated to contraction by straining at stool or by pressure from the accumulation of fecal matter in the lower colon. The bowels should be well regulated before conception and maintained throughout pregnancy.
Of late much stress has been placed on placental enzymes and the toxemias of pregnancy causing hyperemesis, eclampsia and often resulting in miscarriage, either spontaneous or induced physiologically, to prevent fatal results. Although the treatment of these conditions is applied to the pregnant state, much aid, from a prophylactic standpoint, can be given prior to conception by getting the emunctories in good working condition. Obese and anemic patients require treatment to suit the case. In obesity a restricted and regulated diet should be urged with exercise in the open air. In anemic patients the cause, if possible, should be removed, prescribe tonics with iron and a suitable diet until the constitution is brought to par.
An interval of at least nine months, in most cases, should be enjoined on the patient before another conception is permitted. This is not always practicable, but our patients must be warned if the precaution is not observed. Physiological rest aids the uterus to outlive its faulty condition or irritability. If possible, the patient should take a vacation from the environments of home where physiological and sexual rest is assured, especially the patient with endometritis or subinvolution, as neurasthenic symptoms are not uncommon in the chronic form. Uterine tonics and sedatives are given as the case indicates. In endometritis and subinvolution when the musculature or the mucous membrane of the uterus is at fault the tonics are valuable. When the uterus is hypersensitive, due to reflex causes or otherwise, the sedatives are given as demanded.
Overwork and exhaustion, prolonged exercises, long walks, standing, improper food, alcohol, stimulants, violent purgatives, and all excesses should be avoided during the course of treatment. Occupation plays an important part in the prophylaxis of some cases. Workers in lead, mercury, or badly ventilated workshops, should be advised to discontinue their work or change their occupation.