Extrauterine Pregnancy.—This is a pregnancy which occurs outside the uterus, and while the event usually happens in the tube, cases have been reported where the egg developed in the ovary or abdomen.

The ovum, owing to some delay in passage to the uterus, is fertilized either in the ovary or in the tube, and by reason of a chronic inflammation of the tube or pelvis, or of overgrowth does not succeed in reaching the uterus at all.

As the ovum develops, the tube expands, but it does not possess the power of growing into a large organ like the uterus, hence a sudden jar, a strain, or a blow may cause it to rupture and discharge the egg into the abdomen (ruptured tubal pregnancy) or force it out through the end of the tube (tubal abortion).

This phenomenon may be accompanied by a severe or even fatal hÆmorrhage; or the prostration may pass off in a few days or weeks, and leave the patient well.

In the early stages the ovum is absorbed, but after the pregnancy becomes more advanced, it may remain as a tumor, or require an operation for its removal.

Infection may occur and the mass ulcerate its way into neighboring organs (rectum, vagina, or bladder) and discharge itself in a long, suppurative process.

Most cases of ectopic (extrauterine)gestation present definite and even dangerous symptoms between the second and fourth month. The symptoms are those of pregnancy, together with irregular hÆmorrhages from the uterus, which may result in the expulsion of pieces of tissue or of membrane. Besides this, there is a vomiting and acute irregular pain on one side, associated with a sense of fullness. Such symptoms should be brought to the attention of the physician, who will learn the true condition of the pelvis by internal examination, conducted as gently as possible so as not to produce rupture.

If rupture occurs, it will be ushered in by a sharp lancinating pain on one side, followed by faintness, nausea, vomiting, prostration, rapid pulse, sighing respiration, and collapse. The temperature is subnormal and death may occur in a few hours, unless an operation is done.

In cases of tubal abortion (where the ovum escapes through the end of the tube) the symptoms are very similar, but the patient soon rallies and gradual recovery takes place.

If the diagnosis is made before rupture or abortion the treatment is laparotomy. If rupture occurs, the laparotomy must be done immediately to check the hÆmorrhage, which threatens the life of the patient. In tubal abortion, if the diagnosis is certain, some delay may be permitted under extreme watchfulness of the nurse and physician. In such case, the nurse will keep the patient absolutely quiet and forbid exertion of any kind.

If operation is necessary, the utmost gentleness must be used in preparing the abdomen. The tincture of iodine application to the site of the incision is sufficient preparation, and, of course, an abundance of sterile gauze, cotton, and towels should be supplied, as in every case where laparotomy is done.

If the rupture occurs while the nurse is present, the doctor should be notified at once, and if not at home, another doctor should be summoned. Meanwhile, the nurse prepares the room, solutions and utensils for an abdominal operation. Immediate incision to check the hÆmorrhage and remove the mass offers the greatest safety.

The after-care is the same as for any laparotomy, with the additional duty of making up the lost blood as soon as possible by nourishing foods, normal saline solution by rectum, and, if necessary, by hypodermoclysis.

Acute fevers are a serious complication of pregnancy on account of the danger of abortion or premature labor, which may come on either from the associated high temperature or from the transmission of the disease to the ovum.

The following diseases are known to affect the foetus in utero: cholera, yellow fever, small pox, scarlet fever, typhoid, measles, erysipelas, meningitis and syphilis.

Tuberculosis does not affect fertility or the course of the pregnancy, but the progress of the disease is hastened, and the maternal death accelerated.

The question of artificial abortion in the early months must be seriously considered, and if the case goes on to term, the child must not be nursed or cared for by the mother.

Syphilis is the most frequent systemic cause of the interruption of pregnancy. It is a blood disease, due to an organism, called spirochÆta pallida, and it appears in three distinct stages. The first is the primary stage, wherein a hard, nodular ulcer appears on some part of the body, as the vulva, lips, gums, tonsils, or hand. It is not always venereal in origin. The second stage begins six or eight weeks after the sore, and is marked by a general eruption of red spots, chronic sore throat, falling hair, and rheumatic pains in the joints. The third stage is the name given to the later conditions of the disease which affect the bones, blood vessels, and nervous system.

Infection of the ovum may usually be traced to the father, who may transmit syphilis at any stage of the disease. In the third stage, the child alone will be infected; the mother escapes.

The mother may or may not transmit the disease, depending on the period of pregnancy wherein her infection occurs. If she gets the disease at, before, or just about, the time of conception, she will abort three times out of four, and the ovum will show definite lesions. If infected later, abortion occurs less frequently; and if the disease is contracted late in pregnancy, the child may be born apparently free from infection.

Symptoms.—A child with congenital syphilis will show the eruption of coppery spots, blisters on palms and soles, deep cracks on the feet, snuffles, cracks and ulcers around the mouth and rectum, and the weakly, marasmic condition of the body.

The diagnosis in suspected cases can be rendered more certain by the Wassermann reaction. This is a laboratory test of the blood which should always be made before a wet nurse is allowed to nurse a child, or before a suspected child is nursed by a clean woman. In all cases of transfusion of blood, it is imperative.

Treatment.—Antisyphilitic treatment of an infected mother or child by salvarsan, mercury, and potassium iodide must be carried out vigorously in all cases.

The syphilitic patient must be prevented from spreading the infection by having dishes and utensils of her own, which are kept sterile. Discharges are collected and burned, and the nurse in charge of these cases must carefully cover her hands with rubber gloves, and see that all cracks and fissures are properly protected from contact with sources of infection.

Gonorrhoea is an acute or chronic disease of the mucous membranes due to a germ called the gonococcus.

Beginning with a sharp inflammatory disturbance of the urethra or vagina, it may pass slowly up through the genital passage and produce chronic and permanent disabilities, such as sterility, pus tubes, and pelvic peritonitis.

The symptoms are painful urination, painful inflammation of the vagina, with a purulent discharge. During pregnancy all these symptoms are intensified, and warty growths (condylomata) may appear on the vulva.

If infection occurs after pregnancy has begun, the course of the gestation is rarely affected, as the uterus is closed to germ invasion. During delivery, however, there is a serious danger of infection of mouth or eyes of the child if they come in contact with the discharge.

Prophylaxis.—The eyes at birth must be immediately instilled with a drop or two of 1 per cent solution of silver nitrate in water. This is not neutralized by normal saline. Great care must be used that the discharge does not come in contact with the eyes of the mother or attendants, lest infection follow.

Treatment.—Scrupulous cleanliness must be observed. Douches of potassium permanganate, 1:5000, or painting the vagina with iodine or solution of silver nitrate, or suppositories of argyrol or protargol furnish the best means of treatment before labor.

Neither syphilis nor gonorrhea is necessarily caused by venereal infection. They may be spread by barbers, dentists, physicians, and nurses,—by anyone who is unclean; and may be acquired innocently everywhere.

These diseases should not be discussed by the nurse or physician except with the patient. Certainly nothing from the sick room should be repeated elsewhere.

The valves of the heart are not uncommonly found to be diseased in pregnancy, the mitral being the most often affected, either as an insufficiency or as a stenosis (a narrowing of the mitral opening). Mitral stenosis is the most serious of all heart complications of pregnancy, and where this is present, a woman should be advised to avoid conception.

In other mitral lesions, many pregnancies may be successfully passed, if compensation is maintained; but every one brings further damage to the already weakened heart, and reduces its reserve of force. If the heart breaks down early in pregnancy, and does not respond to medication, abortion should be induced. In the second half of pregnancy, the mother should be given the prior chance, but the child should be saved, if possible.

Renal diseases, such as nephritis, may not only induce abortion by destroying the foetus, but the kidney lesion may be greatly aggravated by the pregnancy. The most careful observation of the patient’s condition, the regular examination of the urine, and the scientific management of the diet is necessary to relieve the work on the kidneys and keep the patient in a moderate degree of health.

It is the duty of the nurse to protect her patient against fatigue and chill, and to see that the proper diet is followed; but other symptoms, such as headache and disturbance of vision and developing edema, must be noted and reported to the physician at once.

Diseases of Liver.—Acute yellow atrophy is a rare condition, which, for reasons unknown, is promoted by pregnancy.

The symptoms are intense headache and pain in the abdomen, possibly accompanied by vomiting and purging, which are soon followed by coma. There is generally a certain amount of jaundice. The urine is diminished in amount and contains albumin, casts, and sometimes blood. There is no known treatment, and the end is death.

Diabetes is seldom found associated with pregnancy. Its presence is unfavorable to conception and to gestation. Mother and child are both less secure. Abortion or premature labor is the rule.

The hÆmorrhages of pregnancy in the first half generally mean abortion, and in the last half, either placenta prÆvia or premature detachment of the normally implanted placenta (see p. 228).

Abortion is the expulsion of the ovum before the foetus is viable, that is, before it is capable of maintaining life after birth. This means the twenty-eighth week, or the seventh month. Subsequent to the seventh month, the interruption is called premature labor. Abortion is a miniature labor, consisting of a stage of dilatation, a stage of expulsion, and a stage of involution.

The interruption of the pregnancy may occur spontaneously or be induced. In spontaneous cases the causes may be sought in diseases of the ovum, or in the mother, in injuries to the uterus or its contents, and such systemic affections as syphilis, Bright’s disease, alcoholism, lead poisoning, etc.

Abortions happen about once in every five or six pregnancies, and more frequently at the third month than at any other time.

The symptoms are hÆmorrhage and pain. The dangers are hÆmorrhage and infection.

Infection is most common and most serious in abortions that are brought about mechanically.

HÆmorrhage, in some degree, is an invariable symptom, which has its origin in the separation of the ovum from the uterine wall. HÆmorrhage from the uterus is serious at whatever stage of pregnancy it appears.

The duty of the nurse is to put the patient in a cool, dark room, on her back, elevate the foot of the bed, put ice bags on the lower abdomen, and summon the attending physician, with the hope that an abortion can be averted. Bromides and opium are the drugs most to be relied upon. Opium may be given in suppository, 1 grain night and morning.

If the hÆmorrhage is alarmingly profuse and the nurse is skillful and clean, under exceptional circumstances she may pack the vagina with sterile cotton while waiting for the doctor. Then the room should be set for operation.

Dead Ovum.—The ovum may be discharged in pieces or in a single complete mass.

The egg may die at any period of the pregnancy, and be discharged in a few hours, or it may not be expelled for weeks, if at all. Foetal death in the uterus may have its cause on the paternal side in a father too old or too young, or affected with such diseases as diabetes, nephritis, tuberculosis, syphilis, or chronic lead poisoning; on the maternal side, the same diseases, plus cancer, anÆmia, insufficient food, and inflammation of the uterus; on the part of the embryo, syphilis or any transmitted or primary disease of the ovum.

The results of retention of the dead ovum vary with the case. Infection of the ovum is rare, except where the membranes have ruptured and an open channel exists. No harm follows the death of the foetus, except in the presence of infections, all other changes are benign. The embryo in the first and second months may be absorbed, but at later periods, it becomes macerated petrified, or otherwise altered.

Among the signs of foetal death are prolonged cessation of foetal movements after being definitely observed, chilliness, languor and malaise of the mother, sense of weight in abdomen, and possibly a bad taste in the mouth. Furthermore, the uterus does not correspond to the period of pregnancy, and may have become smaller. Retrogressive changes take place in the breasts.

The diagnosis is only certain when the heart tones are persistently absent, or the macerated head of the foetus is felt through the partly dilated os as a flabby bag of bones.

Treatment in noninfective cases is expectant. Spontaneous expulsion will occur sooner or later and there is no necessitous indication for interference. Local signs of putrefaction, however, make the immediate emptying of the uterus necessary.