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Pregnancy in the young primigravida
PREGNANCY IN THE YOUNG PRIMIGRAVIDA* SAMUEL
R.
POLIAKOFF,
M.D.,
ATLANTA, GA.
(From the Department of Obstetrics and Gynecology, Emory University School of Medicine and Grady Memorial Hospital)
DEFINITE trend toward childbearing at an earlier age has been indicated by the reports of the National Office of Vital Statistics. Relatively few studies of the complications of pregnancy and delivery in the young primigravida have been reported in recent years. The present study was undertaken to evaluate the problem in the light of current obstetric practice.
A
Material
The young primigravida is defined for this study as a woman who has her first delivery at 15 years of age or younger. The records of 299 young primigravidas were reviewed. They were delivered at Grady Memorial Hospital under the supervision of the Department of Obstetrics and Gynecology of the Emory University School of Medicine. Eighty-three of the patients were white (27.8 per cent) and 216 were Negro. The deliveries occurred between 1949 and 19G3. The young primigravidas constituted 1.2 per cent of the white patients and 2.5 per cent of the Negro patients delivered during the period of this study. All deliveries at Grady Memorial Hospital are service cases. The patients reported upon in this study are being followed so that in a later survey the complications which develop in subsequent pregnancies may be evaluated. The age distribution and marital status at delivery are shown in Table I. The percentage of the Negro women under 15 years of age was 33.8 and of the white 21.6. Seventy and four tenths per cent of the Negro patients and 15.7 per cent of the white patients stated that they were not married. TABLE
I.
AGE DISTRIBUTION AND MARITAL STATUS WHITE
-~~--·-~-
Age.-
NEGRO
--------- - - - - - - - - - - -
15 years 14 years 13 years 12 years
65 16
143 61
2
9 3
0
Mari.tal StatjlS.70
Married Single
13
64 152
Antepartal Care
Antepartal care was received by 265 patients ( 75 white and 190 Negro). Nineteen patients, all Negro, registered for antepartal care but did not return *Presented at the Twentieth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hollywood, Florida, Feb. 1 to 5, 1958.
746
PREGNANCY IN YOUNG PRIMICfRAVIDA
\·olume 76 ~umbt>r -l-
until labor had begun. Thus 53 patients (17.7 per cent) may be considered al' not having received antepartal care. Only 20 of the latter were married. The stage of gestation at which the patients were first seen and their marital status are shown in Table II. It should be noted that 67.9 per cent of HH· patients seen in the first trimester were married, while only 42.1 per cent and 40.3 per Cf~nt of those seen first in the second and third trimesters werP marric•(l Of those seen for the first time in labor, 70.6 per cent stated that they Wf'J'( single. TABLE
II.
STAGE OF PREGNANCY WHEN THE PATIEN'r WAS FIRST SEEN
:::~:~1 ~::~E- ~fAR-
I
MARI' i Sl'AGE OF PREGNANCY RIED SINGLE QUATE QUATE RlEll SINGLE --~F~i~rs~t~t~ri~n-le-s~te-r------~-2~3~~~1--~~2~2--~----.,,-----~l.-~"1··-~ 16
Second trimester Third trimester Labor
30 12 5
3 6 3
21 7 0
----=Tc--o-taf-----------------=7-=-0----1~3=-------c:50
1~ ____
:31 I:) :i
11 8
INAIJEQFATf:
,Ill
5!l
il4 21
0
10
3.1____ 6J - - --]52 ---9T-- -
The adequacy of antepartal care was appraised on the basis of: 1 1) tlw stage of pregnancy at which the patient was first seen, (2) the number of antPpartal visits made, and (3) the regularity with which the patients att<•ruled ihu clinics. The care was judged inadequate if the patient was not SPen until ilH' last month of pregnancy, if she made less than four visits, and if shP skipp<•d more than three appointments in succession. The antepartal care was considered adequate in 141 cases; 74 of thes<~ patients were married. The care was judged to be inaclequatf' in 1:)S <·a:-;e~: 98, or 62.0 per cent, of these patients were unmarriN1 (TahlP ITT). TABLE
CARE
Adequate
III.
ADEQUACY OF AN'I'EPARTAL CARE
_____w_H-.--IT_E_______ I----·---~F.(iR~------1 MARRIED SINGLE MARRIED I SI:-!GLE ___i __ 'j'~"AL
'------4-c-7~---'--------c-3----~----cc2~7---
Inadequate__________2__3_________1_0______ Total 70 13 TABLE
IV.
64
____ ss_ 152
37 64
TOXEMIA
WHITE
KEGRO
8
31 9 2 42
3 0 11
2!)!1
TOXEMIA
____R_A,-C_E_____ i_~IARITAI. ST~T_ll'~-~
Mild pre-eclampsia Severe pre-eclampsia Eclampsia Total
141
______2?~.
ANTEP~!-~J:.~':'_:R~.
' ; I ADE· i lNAllEI_~RRIED i_srNGL~- QUA~]._QP,\TE l.'l
2tl
t)
6
1
1
20
14 6 0 20
2:) ti
:!
Toxemia The acute toxemias of pregnancy were the most common major obstetrical complieation (Table IV). They occurred in 53 patients ( 17.7 per cent). The ineidencr of toxemia was 13.3 per cent among- the white patients and 19.4 p<'r
748
POLIAKO:B'J<'
,\m. j.
& (;yJlCl Octuber, 19~K
l)\J~t.
cent among the Negro. The marital status of the patients with toxemia was given as 20 married ( 37.7 per cent) and 33 single ( 62.3 per cent). The toxemia was classified as mild pre-eclampsia in 89, severe pre-eclampsia in 12, and eclampsia in 2. The 39 cases of mild pre-eclampsia included 25 patients who had received inadequate antepartal care. In only 5 cases were the patients admitted to the hospital and labor induced primarily because of mild pre-eclampsia. The other cases were first diagnosed at the time the patients were admitted in labor. Mild pre-eclampsia was diagnosed in 32 patients at term. Adequate antepartal care had been received by only 6 of the 12 patients with severe pre-eclampsia. Four of the 6 who received adequate care were admitted to the hospital for induction of lahor. The 2 cases of eclampsia occurred in Negro patients who had received no antepartal ca1·e. Both patients had their first convulsion at home and were in labor when admitted to the hospital. 'l'he pregnancy was at term in one case and at 30 weeks in the other. Both infants were stillborn. Other Complications
Syphilis.-This disease was diagnosed in 15 patients, none of whom were married. The syphilis was classified as early latent in 12, secondary in 1, and congenital in 2. Treatment was given to 14 of these patients during pregnancy. The disease was diagnosed at delivery in one patient who had not received antepartal care. There was a past record of syphilis in 4 other single Negro patients. All of these had received adequate therapy and did not show any evidence of disease. Rheumatic Heart Disease.-Rheumatic heart disease was diagnosed in 4 patients, none of whom gave a history of cardiac decompensation. From a cardiac standpoint, all did well in pregnancy, labor, and delivery. There was a history of rheumatic fever in 4 other patients who showed no signs of cardiac involvement. Abortions.-Abortion occurred in 12 patients, in the first trimester in 10 and in the second trimester in 2. All denird criminal induction of the abortion . .1:intepartal Bleeding.-There were 4 cases of antepartal bleeding. These were diagnosed as rupture of the marginal sinus in 2 cases and partial abruptio placentae in 2 cases. The abruptio placentae occurred at term in one case in association with eclampsia and at approximately 28 weeks in the other. MisceUaneous.-Nausea and vomiting was sufficiently severe to warrant hospitalization in only one case. Psychiatric treatment was given to one patient. This patient had received psychiatric therapy prior to her pregnancy and it was continued during and after the pregnancy. Only one patient was classified as mentally deficient. The other medical diseases complicating pregnancy were one case of inactive pulmonary tuberculosis, one case of juvenile diabetes, and one case of thyrotoxicosis. Treatment of the latter patient consisted of antithyroid drugs and subtotal thyroidectomy during pregnancy. There was one diagnosed case of acute gonorrhea and one case of gonorrheal arthritis. One patient suffered a poisonous snake bite; this case was complicated by thrombophlebitis of the involved extremity. One patient had a ruptured cornual pregnancy complicated by chorioadenoma destruens. The patient was alive and apparently well a years later.
\"u!ume 76 .'Jnmber ~
PREGNANCY IN YOUNG PRIMIGRAVIDA
Labor Labor was prolonged over 24 hours in 13 cases, an incidence of 4.4 per cent. Tlw second stage of labor was longer than 1 hour in 8 patients. Sedation was given as the cause of the prolonged sooond stage in ~ cases and the occiput pos-terior position in 6. One retained placenta was the only abnormality of tlw third stage. There were no cases of postpartum hemorrhage. Cephalic presentation occurred in 283 cases and breech presentation in 4. Of the latter, 3 were at term and one the second of premature twins. ThPrP was one transverse presentation. IJabor was induced in 9 patients. The indication in all cases was aeute toxemia, and all inductions were successful on the first attempt. Ther·e were i'i rlPliverieR hv inili~ateil low fm·~pns :mil 6 hv miilforcens. A posterior positi~~ ;~s the ~indicati~I;~ f~~~ 5 of th~ ~idfo~ceps· applic~tio~s and tramwerse arrest for one. Three cesarean sections of the low cervical type wer1· performed. The indication for one was diabetes and toxemia; the indication fol' the other 2 was a contracted pelvis.
Postpartum Morbidity An abnormal elevation of temperature was recorded in 19 cases, a postpartum morbidity rate of 6.4 per cent. Endometritis was the cause of the temperature elevation in 14 cases, breast abscess in one, and pyelonephritis in 4. A breakdown of the episiotomy occurred in one patient who also had endometritis.
Infants There were 288 infants delivered, including one set of twins. Of these, ~:38 weighed 2,500 grams or over and 50 (17.4 per cent) weighed less than 2,500 grams. There were 10 neonatal deaths (3.5 per cent) and 7 stillbirths (~.4 rwr· /71o-nt \
'--'-l~l./!1
'n1n.Y~to lit'tr a navino.+ol .L.LLV.LI.J(..li.L.Ll.IJ rri,-rinoo '-t..l-'V.L.L.L.LUI.JU•.L
o~l'J..L.Lf;
TABLE
Premature
41
Yl'!'lta.
-'-"l.l'-'
V.
!; Q n..f! V-'- "-'•"-'
ntl'T'
J:-''·"'""
( T!l hlt) 17-J ,..i'lY't • )' ,,,..,__.._._v '._._,_.,..._..._._,
lNFANTH
1
7 7
3
0 ~·
7
Nine of the white patients (11.4 per cent) had premature infants, as compared with 41 (19.6 per cent) of the Negro patients. There were no stillbirths and 3 neonatal deaths among the white patients, a perinatal mortality rate of 3.8 per cent, compared with 7 stillbirths and 7 neonatal deaths among the Negro patients, a perinatal mortality rate of 6.7 per cent. Six term infants died. Of these 2 were neonatal deaths and 4 stillbirths. Antepartal care was considered adequate in only one of these. There were no complicating factors in 4 (2 stillbirths and 2 neonatal death8). Eelampsia and abruptio placentae complicated one stillbirth. The other occurred with a transverse presentation. The weight distribution of the premature infants is shown in Table VI. It should be noted that 3:3 ( 6 white and 27 Negro) infants weighed between 2,000 and 2,499 grams. These were 66 per cent of all the prernatures. Only one white premature infant died. The mother had no antepartal care and suffered severe pre-eclampsia. Toxemia was associated with 4 prematun'
750
POLIAKOFJ!"
Am.
J.
llb
deaths among the Negroes. Labor was induced in all of these cases. Abruptio placentae was the cause of the stillbirth of one premature Negro infant. Another infant was stillborn whose mother had syphilis and had not received treatment. There were no complicating factors except prematurity in 4 of the pl~ri natal deaths of Negro infants. All the deaths of premature infants occurred in cases with inadequate antepartal care. TABLE
VI.
WEIGHT DISTRIBUTlON OF PREMATURE INFANTS
Comments The age distribution of the two groups shows a difference only in that 21.6 per cent of the white patients and 33.8 per cent of the Negroes were under 15 years of age. The marital status of the two was more significantly different in that 84.3 per cent of the white and only 29.6 per cent of the Negro patients were married, in comparison with the general obstetrical ratio at Grady Memorial Hospital of 96 per cent white and 78 per cent Negro patients married at the time of their delivery. The majority of both white and Negro patients sought care in the second trimester of pregnancy, as do most obstetrical patients at Grady Memorial Hospital. A significant fact was that although only 17.7 per cent of the patients were seen in the first trimester, 67.9 per cent of these were married. Even though white patients constituted 27.8 per cent of all patients, they accounted for 45.3 per cent of the patients seen in the first trimester. Only 47.2 per cent of the patients received adequate antepartal care, in spite of adequate and easily accessible facilities. It is significant that 52.5 per cent of those who received adequate care were married and that 60.2 per cent of the white patients received adequate care, while only 42.1 per cent of the Negro patients did. The incidence of acute toxemia was three times as great as that seen on the entire obstetrical service. It is well known that there is a higher incidence of toxemia among the Negroes in the South. This fact held true in this study with a 13.3 per cent incidence in the white and 19.4 per cent in the Negro. Only 37.7 per cent of the patients with toxemia were married and only 37.7 per cent received adequate care. Nineteen patients either had syphilis or had a past record of the disease. It is surprising to see such a high incidence among such young patients. It is significant that all of these patients were Negroes and that 17 were not married. The low incidence ( 4.0 per eent) of abortion may be explained by the fact that most patients who have abortions arc treated in the Outpatient Department at Grady Memorial Hospital. Labor and the puerperium presented no complications in the young primigravidas which could be attributed to the age of the patient. The operative rate compares favorably with that of the other obstetrical patients at Grady Memorial Hospital. The study showed a high incidence of prematurity (17.4 per cent) and a high perinatal mortality rate ( 5.9 per cent) among the young primigravidas.
Volume 76 Number 4
PREGNANCY IN YOUNG PRIMIGRAVIDA
7G1
'rhe rate for both was higher in the Negro patients. This holds true in t h(~ patients delivered at Grady Memorial Hospital. No completely satisfactory ('Xplanation can be given for the higher premature and perinatal mortality rates. The only correlating features are the lack of adequate nnt.epartal care and tlw high incidence of toxemia among these patients. · The two conspicuous features disclosed in this survey are the high rate of unmarried patients and the lack of adequate antepartal care. The two are parallel and appear in greater frequency in the Negro patients. The frequency of complications was also greatPr in the patients who W('l'P not married and who did not receive adequate care. · This Rtudy points to the great need for sex education and education for parenthood at a relatively early age. It would seem advisable that such instrm~ tion be included in the curriculum of the school, in ehnrch study groups, and certainly in the home. From the medical standpoint, it should be noted that the ages of some of these patients reach back into the years when they ar<: still under the eare of the pediatrician. The guidance of th(' parent and the patii·nt in sex education could be begun by the pediatric·.ian.
Summary A study of pregnancy and delivery has been made in 299 white and Negrn women Hi years of age and younger. F'ifteen and seven-tenths per cent of thr white patients and 70.4 per cent of the Negro patients stated that they \V(~rc no1 married. Antepartal care was considert>d adequate in only 47.2 per cent of tlw patients. Tlw acute toxemias of pregnancy, which occurred in 17.7 per cent of thP patients, were the most common major obstetrical complication. I_.abor and deIivery were not influenced by the age of the patient. The perinatal mortality Pate was fi.9 per cent and the prematurity rate 'vas 17.4 per cent. The frequency of complications was greatf•r in the patients who wrr(' not married and who did not receive adequate care. 'l'hP nred for sex education and education for parenthood at an early age is Rtrt>SS()d.
Discussion DR .fOHN M. NOKES, Charlottesville, Va.-Dr. Poliakoff hrings to our attentior• again a pitiful social welfare problem for which there is no ea~y solution. His article adds confirmatory evidence to the many fine studies published in the pa~t two r1ccadAs which, despite minor differences, are in general agreement that the young primigravida presents no unique problem from a strictly obstetric viewpoint. In fact, the weight of the data is to the contrary. The young primigravida appears to be in son1ewhat more favorable statistical circumstance than her older sister. Her labor tends to be a~ short or shorter, and freer from such complieations a~ eephalopelvic disproportion, abruptio· placentae, and, of course, placenta previa. Thus, there is an almost un~nimous reportin~ of a lower ceRarPan section rate in this group. Furthermore, as documented information has a<~.eurnulated, we have found that m 0 ~1 of the apprehensions formerly held concerning the young primigravida were without fa~.t. or foundation. The birth weight of her child is close to the average figure. She does rwt ~how an inen•ase in premature delivery, postpartum hemorrha{
Am . .l. Obst. & Gynec October, 1958
POLIAKOFF
752
In addition, the outcome for her baby is not only as favorable as that of the average primigravida, but actually more so, inasmuch as most series report a dt•crcased perinatal mortality in the young primigravida. The high incidence of syphilis (19 cases) among such young patients should serve as a challenge to the Public Health authorities of the State of Georgia. The young primigravida does differ from her older counterpart, although it is more a difference in degree than difference in kind. 8he tends to be unmarried and she tends to show an increase in toxemia, both in total incidence and in severity. The former is not usually taken to be within the province of the obstetrician while the latter is-yet they both undoubtedly have the same etiological background. It is almost antomatic to associate an increase in toxemia with a decrease in antepartum care, yet reference to Table I will point out the fallacy of that belief. Dr. Poliakoff reports that 4i per cent of his patients receiver! adequate prPnatal care and that these patients presentPd a l i per cent incidence of toxemia. Our paper reported an adequate prenatal program in only :n per cent of patients with an 18 per cent incidence of toxemia. On the other hand, Sinclair ( J. Obst. & Gynaec., Brit. Emp. 59:504, 195~), reported that 81 pt>r cent of his patients received adequate prenatal care, Schmitz and Towne (Surg., Gyncl'. & Obst. 84:962, 194i) reported 85 per cent, and .Marchetti allll .Menaker (AM. J. 0BS1'. & GYNF:C. 59: 1013, 1950) reported 95 per cent with reported incidences of toxemia of 16, 15, and 20 per cent, respectively. TABI.E I 1"1
"'<
~ r/1 z Pi1oo
r/1
1"1
P< z p..
g:
~8
AUTHOR
Smclau Hofmeister and Burgess Schmitz and Towne Marchetti and .Menaker Nokes and Thornton Poliakoff
;8
j
8 1"1 I'll"! ~
iOO
16
1"1 I>:
< H
r/1 p..
0
ril
<
<
1"1 ..:<
r/1
1"1 0: 0
<
O'Z
1"1
0
<
::s ..:<
1"1
16.0% 3.3%
15
11.7o/o
200
17
15.0%
634
16 20.0% 5.6% li 15
I
8<1
fi.l
p..
136
894 299
0
18.0o/o 3.0% 17.0%
<<-< p<
Pill"! AI>:
p..
z"'
I
~
2% 85% 95% 31% 47%
t, higher than average for entire service. same as average for entire service.
...<
z
~"~w "" < z I>:<~0: ;;; ... c._. ~"~o ll.liJi Zo \:!: 8!>1 ~ .... ro..o ::s 1"1 /':le!> 01"1 < 8 ... ~ 1"1 8 ~ .... 01<. co 000 r/11"1 r-11"1 ~~ ~< <"' ow ~:;: ~~ ..:< ..:< ~ ~Pi p..
~
81%
H
?< ...<1"1 ...,1"1 ..,P<"' Zi>: 8 Pi ~ p
t Sit.
-
s S
s s
s s
65% 72%
t
t
s
Sit. Sit .
1'
H
...<<
~w ~~ "",.:;
s ~
0
99%
0
s
~
s
L lower than average for entire service.
~
~
1' S.
So it cannot be the mere lack of prenatal care per se which is responsible for the increased toxemia rate in this group. It is well known that adolescents tend to di~regard instructions and restrictions, and what is prenatal care if not ''instructions and restrictions"~ The high incidence of toxemia in the young primigravida will certainly hinder us m our efforts further to reduce maternal deaths from this cause. The problem, therefore, of both toxemia and illegitimacy in this group can be reduced to the problem of education. Unfortunately, the development of emotional and intellectual maturity lags behind the development of biologic maturity. The problems of the young primigravida will not be solved by any advance in obstetric technique, but rather by an advance in our thinking and approach toward education in an effort to erase the clisparity between intellectual and physiologic maturity. DR. ARTHUR L. RIVERS, Charleston, S. C.-I would like to ask Dr. Poliakoff whether or not his group has had any success in using the relaxants in these patients with toxemia. I am ashamed to report that we had a case of eclampsia last week in a girl of 18 who had been in the office the previous Wednesday, and she had two convulsions on the
\'ol Llmc /I) '-'umber "1
PREGNANCY IN YOUNG PRIMIGRAVIDA
following Thursday. Her blood pressure was 135/85. Aft<>r shr hail had two eonvulsion~. the blood pressure was 160/120, and she had 3 plus albumin. The cervix was not a~ favorable as we would like for induction of labor, but we thought it was safe. The nwm" hranes were ruptured, and, after sedation and magnesium sulfates, we began intraveuou~ Pitocin and Cervilaxin. \Ve think we had some success in short<>ning- hl'r lahor hPr'aUSf' ~h<> was deliverPd perfectly normally 7 hours later the ~a me day after having had 1hr· I 'i'rvilaxin. DR. HERBER'!' E. SCHMITZ, Chicago, IlL-Several yt'ars ago we undertook a similar involving 200 unwPd youngsters. We have this material in St. Vincent's Infant an•l Maternity Hospital in Chicago, which is an institution for the rarr of unwed mothers. A.tl of our patients were single. ~tudy
We had <·omplrte control of this group because as soon as their problem is revealer\ to th1' social serviee department of the Catholic Charities of Chicago, they are sent to this home. }'rom then on their diet and their complete control is within the institution and th<>y havP no dutnc
toxt~mia.
I doubt that thu dif't. alone or the mstrk
We had no other complications. We had one cesarea11 ~eetion, which was for dispro· portion. In every instance labor was shortened in tlwse individuals, and we had an over· ~~II and uncorrected fetal loss of 4.5 per cent. Our conclusions were exactly the. same as those of Dr. Poliakoff, that these youngsters 1·an go into lahor, have very few complications and ovPr·all havP a much shorter and mueh i'asier labor than the average patient. DR. POLIAKOFF (elosing).-In answer to Dr. Rivers' question on the use of ro" laxing agents; tlH'Y were not used. In general, the patients wnre delivered rapidly r..ftrr the induction was b<>gun.
R.
POLIAKOFF,
M.D.,
ATLANTA, GA.
(From the Department of Obstetrics and Gynecology, Emory University School of Medicine and Grady Memorial Hospital)
DEFINITE trend toward childbearing at an earlier age has been indicated by the reports of the National Office of Vital Statistics. Relatively few studies of the complications of pregnancy and delivery in the young primigravida have been reported in recent years. The present study was undertaken to evaluate the problem in the light of current obstetric practice.
A
Material
The young primigravida is defined for this study as a woman who has her first delivery at 15 years of age or younger. The records of 299 young primigravidas were reviewed. They were delivered at Grady Memorial Hospital under the supervision of the Department of Obstetrics and Gynecology of the Emory University School of Medicine. Eighty-three of the patients were white (27.8 per cent) and 216 were Negro. The deliveries occurred between 1949 and 19G3. The young primigravidas constituted 1.2 per cent of the white patients and 2.5 per cent of the Negro patients delivered during the period of this study. All deliveries at Grady Memorial Hospital are service cases. The patients reported upon in this study are being followed so that in a later survey the complications which develop in subsequent pregnancies may be evaluated. The age distribution and marital status at delivery are shown in Table I. The percentage of the Negro women under 15 years of age was 33.8 and of the white 21.6. Seventy and four tenths per cent of the Negro patients and 15.7 per cent of the white patients stated that they were not married. TABLE
I.
AGE DISTRIBUTION AND MARITAL STATUS WHITE
-~~--·-~-
Age.-
NEGRO
--------- - - - - - - - - - - -
15 years 14 years 13 years 12 years
65 16
143 61
2
9 3
0
Mari.tal StatjlS.70
Married Single
13
64 152
Antepartal Care
Antepartal care was received by 265 patients ( 75 white and 190 Negro). Nineteen patients, all Negro, registered for antepartal care but did not return *Presented at the Twentieth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hollywood, Florida, Feb. 1 to 5, 1958.
746
PREGNANCY IN YOUNG PRIMICfRAVIDA
\·olume 76 ~umbt>r -l-
until labor had begun. Thus 53 patients (17.7 per cent) may be considered al' not having received antepartal care. Only 20 of the latter were married. The stage of gestation at which the patients were first seen and their marital status are shown in Table II. It should be noted that 67.9 per cent of HH· patients seen in the first trimester were married, while only 42.1 per cent and 40.3 per Cf~nt of those seen first in the second and third trimesters werP marric•(l Of those seen for the first time in labor, 70.6 per cent stated that they Wf'J'( single. TABLE
II.
STAGE OF PREGNANCY WHEN THE PATIEN'r WAS FIRST SEEN
:::~:~1 ~::~E- ~fAR-
I
MARI' i Sl'AGE OF PREGNANCY RIED SINGLE QUATE QUATE RlEll SINGLE --~F~i~rs~t~t~ri~n-le-s~te-r------~-2~3~~~1--~~2~2--~----.,,-----~l.-~"1··-~ 16
Second trimester Third trimester Labor
30 12 5
3 6 3
21 7 0
----=Tc--o-taf-----------------=7-=-0----1~3=-------c:50
1~ ____
:31 I:) :i
11 8
INAIJEQFATf:
,Ill
5!l
il4 21
0
10
3.1____ 6J - - --]52 ---9T-- -
The adequacy of antepartal care was appraised on the basis of: 1 1) tlw stage of pregnancy at which the patient was first seen, (2) the number of antPpartal visits made, and (3) the regularity with which the patients att<•ruled ihu clinics. The care was judged inadequate if the patient was not SPen until ilH' last month of pregnancy, if she made less than four visits, and if shP skipp<•d more than three appointments in succession. The antepartal care was considered adequate in 141 cases; 74 of thes<~ patients were married. The care was judged to be inaclequatf' in 1:)S <·a:-;e~: 98, or 62.0 per cent, of these patients were unmarriN1 (TahlP ITT). TABLE
CARE
Adequate
III.
ADEQUACY OF AN'I'EPARTAL CARE
_____w_H-.--IT_E_______ I----·---~F.(iR~------1 MARRIED SINGLE MARRIED I SI:-!GLE ___i __ 'j'~"AL
'------4-c-7~---'--------c-3----~----cc2~7---
Inadequate__________2__3_________1_0______ Total 70 13 TABLE
IV.
64
____ ss_ 152
37 64
TOXEMIA
WHITE
KEGRO
8
31 9 2 42
3 0 11
2!)!1
TOXEMIA
____R_A,-C_E_____ i_~IARITAI. ST~T_ll'~-~
Mild pre-eclampsia Severe pre-eclampsia Eclampsia Total
141
______2?~.
ANTEP~!-~J:.~':'_:R~.
' ; I ADE· i lNAllEI_~RRIED i_srNGL~- QUA~]._QP,\TE l.'l
2tl
t)
6
1
1
20
14 6 0 20
2:) ti
:!
Toxemia The acute toxemias of pregnancy were the most common major obstetrical complieation (Table IV). They occurred in 53 patients ( 17.7 per cent). The ineidencr of toxemia was 13.3 per cent among- the white patients and 19.4 p<'r
748
POLIAKO:B'J<'
,\m. j.
& (;yJlCl Octuber, 19~K
l)\J~t.
cent among the Negro. The marital status of the patients with toxemia was given as 20 married ( 37.7 per cent) and 33 single ( 62.3 per cent). The toxemia was classified as mild pre-eclampsia in 89, severe pre-eclampsia in 12, and eclampsia in 2. The 39 cases of mild pre-eclampsia included 25 patients who had received inadequate antepartal care. In only 5 cases were the patients admitted to the hospital and labor induced primarily because of mild pre-eclampsia. The other cases were first diagnosed at the time the patients were admitted in labor. Mild pre-eclampsia was diagnosed in 32 patients at term. Adequate antepartal care had been received by only 6 of the 12 patients with severe pre-eclampsia. Four of the 6 who received adequate care were admitted to the hospital for induction of lahor. The 2 cases of eclampsia occurred in Negro patients who had received no antepartal ca1·e. Both patients had their first convulsion at home and were in labor when admitted to the hospital. 'l'he pregnancy was at term in one case and at 30 weeks in the other. Both infants were stillborn. Other Complications
Syphilis.-This disease was diagnosed in 15 patients, none of whom were married. The syphilis was classified as early latent in 12, secondary in 1, and congenital in 2. Treatment was given to 14 of these patients during pregnancy. The disease was diagnosed at delivery in one patient who had not received antepartal care. There was a past record of syphilis in 4 other single Negro patients. All of these had received adequate therapy and did not show any evidence of disease. Rheumatic Heart Disease.-Rheumatic heart disease was diagnosed in 4 patients, none of whom gave a history of cardiac decompensation. From a cardiac standpoint, all did well in pregnancy, labor, and delivery. There was a history of rheumatic fever in 4 other patients who showed no signs of cardiac involvement. Abortions.-Abortion occurred in 12 patients, in the first trimester in 10 and in the second trimester in 2. All denird criminal induction of the abortion . .1:intepartal Bleeding.-There were 4 cases of antepartal bleeding. These were diagnosed as rupture of the marginal sinus in 2 cases and partial abruptio placentae in 2 cases. The abruptio placentae occurred at term in one case in association with eclampsia and at approximately 28 weeks in the other. MisceUaneous.-Nausea and vomiting was sufficiently severe to warrant hospitalization in only one case. Psychiatric treatment was given to one patient. This patient had received psychiatric therapy prior to her pregnancy and it was continued during and after the pregnancy. Only one patient was classified as mentally deficient. The other medical diseases complicating pregnancy were one case of inactive pulmonary tuberculosis, one case of juvenile diabetes, and one case of thyrotoxicosis. Treatment of the latter patient consisted of antithyroid drugs and subtotal thyroidectomy during pregnancy. There was one diagnosed case of acute gonorrhea and one case of gonorrheal arthritis. One patient suffered a poisonous snake bite; this case was complicated by thrombophlebitis of the involved extremity. One patient had a ruptured cornual pregnancy complicated by chorioadenoma destruens. The patient was alive and apparently well a years later.
\"u!ume 76 .'Jnmber ~
PREGNANCY IN YOUNG PRIMIGRAVIDA
Labor Labor was prolonged over 24 hours in 13 cases, an incidence of 4.4 per cent. Tlw second stage of labor was longer than 1 hour in 8 patients. Sedation was given as the cause of the prolonged sooond stage in ~ cases and the occiput pos-terior position in 6. One retained placenta was the only abnormality of tlw third stage. There were no cases of postpartum hemorrhage. Cephalic presentation occurred in 283 cases and breech presentation in 4. Of the latter, 3 were at term and one the second of premature twins. ThPrP was one transverse presentation. IJabor was induced in 9 patients. The indication in all cases was aeute toxemia, and all inductions were successful on the first attempt. Ther·e were i'i rlPliverieR hv inili~ateil low fm·~pns :mil 6 hv miilforcens. A posterior positi~~ ;~s the ~indicati~I;~ f~~~ 5 of th~ ~idfo~ceps· applic~tio~s and tramwerse arrest for one. Three cesarean sections of the low cervical type wer1· performed. The indication for one was diabetes and toxemia; the indication fol' the other 2 was a contracted pelvis.
Postpartum Morbidity An abnormal elevation of temperature was recorded in 19 cases, a postpartum morbidity rate of 6.4 per cent. Endometritis was the cause of the temperature elevation in 14 cases, breast abscess in one, and pyelonephritis in 4. A breakdown of the episiotomy occurred in one patient who also had endometritis.
Infants There were 288 infants delivered, including one set of twins. Of these, ~:38 weighed 2,500 grams or over and 50 (17.4 per cent) weighed less than 2,500 grams. There were 10 neonatal deaths (3.5 per cent) and 7 stillbirths (~.4 rwr· /71o-nt \
'--'-l~l./!1
'n1n.Y~to lit'tr a navino.+ol .L.LLV.LI.J(..li.L.Ll.IJ rri,-rinoo '-t..l-'V.L.L.L.LUI.JU•.L
o~l'J..L.Lf;
TABLE
Premature
41
Yl'!'lta.
-'-"l.l'-'
V.
!; Q n..f! V-'- "-'•"-'
ntl'T'
J:-''·"'""
( T!l hlt) 17-J ,..i'lY't • )' ,,,..,__.._._v '._._,_.,..._..._._,
lNFANTH
1
7 7
3
0 ~·
7
Nine of the white patients (11.4 per cent) had premature infants, as compared with 41 (19.6 per cent) of the Negro patients. There were no stillbirths and 3 neonatal deaths among the white patients, a perinatal mortality rate of 3.8 per cent, compared with 7 stillbirths and 7 neonatal deaths among the Negro patients, a perinatal mortality rate of 6.7 per cent. Six term infants died. Of these 2 were neonatal deaths and 4 stillbirths. Antepartal care was considered adequate in only one of these. There were no complicating factors in 4 (2 stillbirths and 2 neonatal death8). Eelampsia and abruptio placentae complicated one stillbirth. The other occurred with a transverse presentation. The weight distribution of the premature infants is shown in Table VI. It should be noted that 3:3 ( 6 white and 27 Negro) infants weighed between 2,000 and 2,499 grams. These were 66 per cent of all the prernatures. Only one white premature infant died. The mother had no antepartal care and suffered severe pre-eclampsia. Toxemia was associated with 4 prematun'
750
POLIAKOFJ!"
Am.
J.
llb
deaths among the Negroes. Labor was induced in all of these cases. Abruptio placentae was the cause of the stillbirth of one premature Negro infant. Another infant was stillborn whose mother had syphilis and had not received treatment. There were no complicating factors except prematurity in 4 of the pl~ri natal deaths of Negro infants. All the deaths of premature infants occurred in cases with inadequate antepartal care. TABLE
VI.
WEIGHT DISTRIBUTlON OF PREMATURE INFANTS
Comments The age distribution of the two groups shows a difference only in that 21.6 per cent of the white patients and 33.8 per cent of the Negroes were under 15 years of age. The marital status of the two was more significantly different in that 84.3 per cent of the white and only 29.6 per cent of the Negro patients were married, in comparison with the general obstetrical ratio at Grady Memorial Hospital of 96 per cent white and 78 per cent Negro patients married at the time of their delivery. The majority of both white and Negro patients sought care in the second trimester of pregnancy, as do most obstetrical patients at Grady Memorial Hospital. A significant fact was that although only 17.7 per cent of the patients were seen in the first trimester, 67.9 per cent of these were married. Even though white patients constituted 27.8 per cent of all patients, they accounted for 45.3 per cent of the patients seen in the first trimester. Only 47.2 per cent of the patients received adequate antepartal care, in spite of adequate and easily accessible facilities. It is significant that 52.5 per cent of those who received adequate care were married and that 60.2 per cent of the white patients received adequate care, while only 42.1 per cent of the Negro patients did. The incidence of acute toxemia was three times as great as that seen on the entire obstetrical service. It is well known that there is a higher incidence of toxemia among the Negroes in the South. This fact held true in this study with a 13.3 per cent incidence in the white and 19.4 per cent in the Negro. Only 37.7 per cent of the patients with toxemia were married and only 37.7 per cent received adequate care. Nineteen patients either had syphilis or had a past record of the disease. It is surprising to see such a high incidence among such young patients. It is significant that all of these patients were Negroes and that 17 were not married. The low incidence ( 4.0 per eent) of abortion may be explained by the fact that most patients who have abortions arc treated in the Outpatient Department at Grady Memorial Hospital. Labor and the puerperium presented no complications in the young primigravidas which could be attributed to the age of the patient. The operative rate compares favorably with that of the other obstetrical patients at Grady Memorial Hospital. The study showed a high incidence of prematurity (17.4 per cent) and a high perinatal mortality rate ( 5.9 per cent) among the young primigravidas.
Volume 76 Number 4
PREGNANCY IN YOUNG PRIMIGRAVIDA
7G1
'rhe rate for both was higher in the Negro patients. This holds true in t h(~ patients delivered at Grady Memorial Hospital. No completely satisfactory ('Xplanation can be given for the higher premature and perinatal mortality rates. The only correlating features are the lack of adequate nnt.epartal care and tlw high incidence of toxemia among these patients. · The two conspicuous features disclosed in this survey are the high rate of unmarried patients and the lack of adequate antepartal care. The two are parallel and appear in greater frequency in the Negro patients. The frequency of complications was also greatPr in the patients who W('l'P not married and who did not receive adequate care. · This Rtudy points to the great need for sex education and education for parenthood at a relatively early age. It would seem advisable that such instrm~ tion be included in the curriculum of the school, in ehnrch study groups, and certainly in the home. From the medical standpoint, it should be noted that the ages of some of these patients reach back into the years when they ar<: still under the eare of the pediatrician. The guidance of th(' parent and the patii·nt in sex education could be begun by the pediatric·.ian.
Summary A study of pregnancy and delivery has been made in 299 white and Negrn women Hi years of age and younger. F'ifteen and seven-tenths per cent of thr white patients and 70.4 per cent of the Negro patients stated that they \V(~rc no1 married. Antepartal care was considert>d adequate in only 47.2 per cent of tlw patients. Tlw acute toxemias of pregnancy, which occurred in 17.7 per cent of thP patients, were the most common major obstetrical complication. I_.abor and deIivery were not influenced by the age of the patient. The perinatal mortality Pate was fi.9 per cent and the prematurity rate 'vas 17.4 per cent. The frequency of complications was greatf•r in the patients who wrr(' not married and who did not receive adequate care. 'l'hP nred for sex education and education for parenthood at an early age is Rtrt>SS()d.
Discussion DR .fOHN M. NOKES, Charlottesville, Va.-Dr. Poliakoff hrings to our attentior• again a pitiful social welfare problem for which there is no ea~y solution. His article adds confirmatory evidence to the many fine studies published in the pa~t two r1ccadAs which, despite minor differences, are in general agreement that the young primigravida presents no unique problem from a strictly obstetric viewpoint. In fact, the weight of the data is to the contrary. The young primigravida appears to be in son1ewhat more favorable statistical circumstance than her older sister. Her labor tends to be a~ short or shorter, and freer from such complieations a~ eephalopelvic disproportion, abruptio· placentae, and, of course, placenta previa. Thus, there is an almost un~nimous reportin~ of a lower ceRarPan section rate in this group. Furthermore, as documented information has a<~.eurnulated, we have found that m 0 ~1 of the apprehensions formerly held concerning the young primigravida were without fa~.t. or foundation. The birth weight of her child is close to the average figure. She does rwt ~how an inen•ase in premature delivery, postpartum hemorrha{
Am . .l. Obst. & Gynec October, 1958
POLIAKOFF
752
In addition, the outcome for her baby is not only as favorable as that of the average primigravida, but actually more so, inasmuch as most series report a dt•crcased perinatal mortality in the young primigravida. The high incidence of syphilis (19 cases) among such young patients should serve as a challenge to the Public Health authorities of the State of Georgia. The young primigravida does differ from her older counterpart, although it is more a difference in degree than difference in kind. 8he tends to be unmarried and she tends to show an increase in toxemia, both in total incidence and in severity. The former is not usually taken to be within the province of the obstetrician while the latter is-yet they both undoubtedly have the same etiological background. It is almost antomatic to associate an increase in toxemia with a decrease in antepartum care, yet reference to Table I will point out the fallacy of that belief. Dr. Poliakoff reports that 4i per cent of his patients receiver! adequate prPnatal care and that these patients presentPd a l i per cent incidence of toxemia. Our paper reported an adequate prenatal program in only :n per cent of patients with an 18 per cent incidence of toxemia. On the other hand, Sinclair ( J. Obst. & Gynaec., Brit. Emp. 59:504, 195~), reported that 81 pt>r cent of his patients received adequate prenatal care, Schmitz and Towne (Surg., Gyncl'. & Obst. 84:962, 194i) reported 85 per cent, and .Marchetti allll .Menaker (AM. J. 0BS1'. & GYNF:C. 59: 1013, 1950) reported 95 per cent with reported incidences of toxemia of 16, 15, and 20 per cent, respectively. TABI.E I 1"1
"'<
~ r/1 z Pi
r/1
1"1
P< z p..
g:
~8
AUTHOR
Smclau Hofmeister and Burgess Schmitz and Towne Marchetti and .Menaker Nokes and Thornton Poliakoff
;8
j
8 1"1 I'll"! ~
iOO
16
1"1 I>:
< H
r/1 p..
0
ril
<
<
1"1 ..:<
r/1
1"1 0: 0
<
O'Z
1"1
0
<
::s ..:<
1"1
16.0% 3.3%
15
11.7o/o
200
17
15.0%
634
16 20.0% 5.6% li 15
I
8<1
fi.l
p..
136
894 299
0
18.0o/o 3.0% 17.0%
<<-< p<
Pill"! AI>:
p..
z"'
I
~
2% 85% 95% 31% 47%
t, higher than average for entire service. same as average for entire service.
...<
z
~"~w "" < z I>:<~0: ;;; ... c._. ~"~o ll.liJi Zo \:!: 8!>1 ~ .... ro..o ::s 1"1 /':le!> 01"1 < 8 ... ~ 1"1 8 ~ .... 01<. co 000 r/11"1 r-11"1 ~~ ~< <"' ow ~:;: ~~ ..:< ..:< ~ ~Pi p..
~
81%
H
?< ...<1"1 ...,1"1 ..,P<"' Zi>: 8 Pi ~ p
t Sit.
-
s S
s s
s s
65% 72%
t
t
s
Sit. Sit .
1'
H
...<<
~w ~~ "",.:;
s ~
0
99%
0
s
~
s
L lower than average for entire service.
~
~
1' S.
So it cannot be the mere lack of prenatal care per se which is responsible for the increased toxemia rate in this group. It is well known that adolescents tend to di~regard instructions and restrictions, and what is prenatal care if not ''instructions and restrictions"~ The high incidence of toxemia in the young primigravida will certainly hinder us m our efforts further to reduce maternal deaths from this cause. The problem, therefore, of both toxemia and illegitimacy in this group can be reduced to the problem of education. Unfortunately, the development of emotional and intellectual maturity lags behind the development of biologic maturity. The problems of the young primigravida will not be solved by any advance in obstetric technique, but rather by an advance in our thinking and approach toward education in an effort to erase the clisparity between intellectual and physiologic maturity. DR. ARTHUR L. RIVERS, Charleston, S. C.-I would like to ask Dr. Poliakoff whether or not his group has had any success in using the relaxants in these patients with toxemia. I am ashamed to report that we had a case of eclampsia last week in a girl of 18 who had been in the office the previous Wednesday, and she had two convulsions on the
\'ol Llmc /I) '-'umber "1
PREGNANCY IN YOUNG PRIMIGRAVIDA
following Thursday. Her blood pressure was 135/85. Aft<>r shr hail had two eonvulsion~. the blood pressure was 160/120, and she had 3 plus albumin. The cervix was not a~ favorable as we would like for induction of labor, but we thought it was safe. The nwm" hranes were ruptured, and, after sedation and magnesium sulfates, we began intraveuou~ Pitocin and Cervilaxin. \Ve think we had some success in short<>ning- hl'r lahor hPr'aUSf' ~h<> was deliverPd perfectly normally 7 hours later the ~a me day after having had 1hr· I 'i'rvilaxin. DR. HERBER'!' E. SCHMITZ, Chicago, IlL-Several yt'ars ago we undertook a similar involving 200 unwPd youngsters. We have this material in St. Vincent's Infant an•l Maternity Hospital in Chicago, which is an institution for the rarr of unwed mothers. A.tl of our patients were single. ~tudy
We had <·omplrte control of this group because as soon as their problem is revealer\ to th1' social serviee department of the Catholic Charities of Chicago, they are sent to this home. }'rom then on their diet and their complete control is within the institution and th<>y havP no dutnc
toxt~mia.
I doubt that thu dif't. alone or the mstrk
We had no other complications. We had one cesarea11 ~eetion, which was for dispro· portion. In every instance labor was shortened in tlwse individuals, and we had an over· ~~II and uncorrected fetal loss of 4.5 per cent. Our conclusions were exactly the. same as those of Dr. Poliakoff, that these youngsters 1·an go into lahor, have very few complications and ovPr·all havP a much shorter and mueh i'asier labor than the average patient. DR. POLIAKOFF (elosing).-In answer to Dr. Rivers' question on the use of ro" laxing agents; tlH'Y were not used. In general, the patients wnre delivered rapidly r..ftrr the induction was b<>gun.