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The relationship between the early and late toxemias of pregnancy
I
N ()RI)l+:R to establish whether there is any relationship of clinical significance between the tosemias of early and late pregnancy, a pareI’ul study has been eondwtetl in one ot’ the prenatal clinics at the Kensington Hospital for Women, ot’ 272 patients who were registered and later delivered during the twenty-month period, heginning Jan. 1, 1932, and ending Sept. 1, 193S. Included in the series arc 127 primiparas and l-45 maltiparas. The ages ranged from fift.een years to thirty-five years, and with two exceptions all were white patients. The stimulus to rnakt, such a study was furnished hy the differences of opinion expressed 1)~ men of wide experience in the field of obstetrics on this question of relationship. Some held that the development of toxic2 manifestations in the first trimester in no way prognosticated troublr in the last thrw months of l)l’egn;ln(~~. Others contended that experience had taught them that ;I toxemia of greater or lesser concern developing in the last trimester was to he expected if there WiiS a histoq 01’;I tosic first three months. All of the l);ltients studied were person;~lly interviewed by the author on e;lcdhvisit to the I)rtwatal viinie. The majority registered some time during the first halt’ of l)regnanq-, and at the first visit mere questioned very carefully for an;\- synptoms of toxemia wewring during the first three months. Tn addition the p:lticbnt ‘s weight just before prepnancy. either known or estimated by her, was noted. ()n cB;ichsubsequent visit, the c;Ireful search for tosiy symI)toms was wntinued, emphasis being I)lac~ed011the complaints matle dllriiig thtb last three months. Blood pressure readings were made iit each visit and the patient’s weight on her last visit to the clinic l)eI’ore the onset of liil)(>r was taken as her final weight, assuming, of vouwc, that all these 1)aticnts were regular in their ;Itteiidanrc. The primiparas atld multilwas have bee11groupetl separately. Both of these groups h;l\e heen divided into Four classifiwtions or schedules WIWII
;tt
rllwtini:
of
the,
Ohst~t~~ical
Socit,ty
of
I’t~iI;lllt~l~)lli;~,
October
,T. 19:1::.
PRIMII’I\RAS
Thirty-eight per cent 01’ the primiparas were symptom-free in the first trimester, while 62 per cent manifested some degree of toxemia, varying in severity from physiologic nallsea itlId vomiting to hyperemesis gravidarum. ln the series of 4X cases representing the 3X per cent who were negative in the first trimester, 75 per cent had uneventful third trimesters, while 25 per cent had definite evidences of late toxemia. In the series of 69 cases represent.ing 5-k per cent 01’ t,he primiparns studied, who were physiologically toxic in the first trimester, 49 per cent were negative in the last trimester, while 51 l)er caent were regarded as toxic. In the toxic mothers at term the average weight, was slightl;\ But the average infant weight was above t,hat in the nontoxic mothers. definitely lower than the infant avcragr in healthy mothers. The mildly pathologic toxemias OF early pregnancy rlumbered 7 or 5.5 per cent of the total. Forty-three per cent were negative in the last trimester, while 57 per cent were toxic. In 3 cases of hyperemesis gravidarum. there were no evidences of Jt, should he noted that the toxemia developing in the Iiist trimester. average weight gain for the 3 mothers was 10 pounds, no doubt due to a The baby considerable weight loas during t,he stormy first trimester. weight a.verage for these women was 7 pounds 7 ounces.
MI~l.l’ll’AH.\S
Forty per cent of t,he multiparas were symptomless in the first trimester of their pregnancies, while 60 per cent experienced pathologic first trimest,ers from the standpoint of toxic manifestations. In the series of 5X cases representin; 1’ the 40 per cent who were negative in the first trimester, 70.6 per cent had uneventful third trimesters. The remaining 29.4 per cent were found to present definite evidence of toxemia in the last trimester. There were 68 cases, or 16.2 ~KV cent ot’ iI11 the multiparas studied, with physiologic mornin g iiiii~sea and vomiting. 01’ this group 5X.5 l)el c*ent oi’ t,he patients were without wmplicat ions in the last trimester, while 41.5 per writ of the [)atients demonstrated signs or late toxemia. Sixteen cases, or 11 per cent, were mildly pathologic in the first, trimester, with frequent attacks of llausea and vomiting. Despite the hectic first trimester experienced by this group, 13.7 per cent were nontoxic in the last trimester. The remaining 56.4 per cent of this series became toxic in the last trimester. Three mult,iparas, or 2 per cent, of the total, tlrreloped hyperemesis gravidarum in the first trimester. However, all 3 went t,hrough t,he remainder of their pregnancy without the slightest evidence of a late t,oxemia. The loss in weight esperiqced in the first trimester by these mothers was barely regained during the following six months. The nverage maternal weight gain in this series was 2 pounds. This did not influence the ultimate weight average of the babic>s, which was 7 pounds 2
0u11cw. CONCI,TTSIONS
1. The incidence of toxemia in early pregnanc,v is comparatively the In our series, 62 per cent of same for both primiparas and multiparas. the primiparas and 60 l)er cent oi’ the multiparas were toxic in the first trimester. 2. In primiparas wit,11 negative first trimesters, 25 per vent hare toxic third trimesters. The margin of safety is slightly lower in multiparws, No conclusion can be 29.4 per cent being tosic in the last trimester. reached on the character of the late toxemia these positive cases are likely to experience, since the percentages are well distributed among the three possibilities, namely, (1 ) on elevated blood pressure illOlle; (2) toxic> symptoms alone ; and (3 ) toxic symptoms and elevated blootl pressure combined. 3. The incidence of late tosemia is definitely increased in cases prosenting the physiologic nausea and vomiting of the first trimester, 41 per cent of multigaras and 51 l)er cent of primiparas experiencing this form of early t.osemia mere t,oxic in the last trimester. Here again the types of tosic manifestations in the last trimesters are fairly evenly distributed.
N ()RI)l+:R to establish whether there is any relationship of clinical significance between the tosemias of early and late pregnancy, a pareI’ul study has been eondwtetl in one ot’ the prenatal clinics at the Kensington Hospital for Women, ot’ 272 patients who were registered and later delivered during the twenty-month period, heginning Jan. 1, 1932, and ending Sept. 1, 193S. Included in the series arc 127 primiparas and l-45 maltiparas. The ages ranged from fift.een years to thirty-five years, and with two exceptions all were white patients. The stimulus to rnakt, such a study was furnished hy the differences of opinion expressed 1)~ men of wide experience in the field of obstetrics on this question of relationship. Some held that the development of toxic2 manifestations in the first trimester in no way prognosticated troublr in the last thrw months of l)l’egn;ln(~~. Others contended that experience had taught them that ;I toxemia of greater or lesser concern developing in the last trimester was to he expected if there WiiS a histoq 01’;I tosic first three months. All of the l);ltients studied were person;~lly interviewed by the author on e;lcdhvisit to the I)rtwatal viinie. The majority registered some time during the first halt’ of l)regnanq-, and at the first visit mere questioned very carefully for an;\- synptoms of toxemia wewring during the first three months. Tn addition the p:lticbnt ‘s weight just before prepnancy. either known or estimated by her, was noted. ()n cB;ichsubsequent visit, the c;Ireful search for tosiy symI)toms was wntinued, emphasis being I)lac~ed011the complaints matle dllriiig thtb last three months. Blood pressure readings were made iit each visit and the patient’s weight on her last visit to the clinic l)eI’ore the onset of liil)(>r was taken as her final weight, assuming, of vouwc, that all these 1)aticnts were regular in their ;Itteiidanrc. The primiparas atld multilwas have bee11groupetl separately. Both of these groups h;l\e heen divided into Four classifiwtions or schedules WIWII
;tt
rllwtini:
of
the,
Ohst~t~~ical
Socit,ty
of
I’t~iI;lllt~l~)lli;~,
October
,T. 19:1::.
PRIMII’I\RAS
Thirty-eight per cent 01’ the primiparas were symptom-free in the first trimester, while 62 per cent manifested some degree of toxemia, varying in severity from physiologic nallsea itlId vomiting to hyperemesis gravidarum. ln the series of 4X cases representing the 3X per cent who were negative in the first trimester, 75 per cent had uneventful third trimesters, while 25 per cent had definite evidences of late toxemia. In the series of 69 cases represent.ing 5-k per cent 01’ t,he primiparns studied, who were physiologically toxic in the first trimester, 49 per cent were negative in the last trimester, while 51 l)er caent were regarded as toxic. In the toxic mothers at term the average weight, was slightl;\ But the average infant weight was above t,hat in the nontoxic mothers. definitely lower than the infant avcragr in healthy mothers. The mildly pathologic toxemias OF early pregnancy rlumbered 7 or 5.5 per cent of the total. Forty-three per cent were negative in the last trimester, while 57 per cent were toxic. In 3 cases of hyperemesis gravidarum. there were no evidences of Jt, should he noted that the toxemia developing in the Iiist trimester. average weight gain for the 3 mothers was 10 pounds, no doubt due to a The baby considerable weight loas during t,he stormy first trimester. weight a.verage for these women was 7 pounds 7 ounces.
MI~l.l’ll’AH.\S
Forty per cent of t,he multiparas were symptomless in the first trimester of their pregnancies, while 60 per cent experienced pathologic first trimest,ers from the standpoint of toxic manifestations. In the series of 5X cases representin; 1’ the 40 per cent who were negative in the first trimester, 70.6 per cent had uneventful third trimesters. The remaining 29.4 per cent were found to present definite evidence of toxemia in the last trimester. There were 68 cases, or 16.2 ~KV cent ot’ iI11 the multiparas studied, with physiologic mornin g iiiii~sea and vomiting. 01’ this group 5X.5 l)el c*ent oi’ t,he patients were without wmplicat ions in the last trimester, while 41.5 per writ of the [)atients demonstrated signs or late toxemia. Sixteen cases, or 11 per cent, were mildly pathologic in the first, trimester, with frequent attacks of llausea and vomiting. Despite the hectic first trimester experienced by this group, 13.7 per cent were nontoxic in the last trimester. The remaining 56.4 per cent of this series became toxic in the last trimester. Three mult,iparas, or 2 per cent, of the total, tlrreloped hyperemesis gravidarum in the first trimester. However, all 3 went t,hrough t,he remainder of their pregnancy without the slightest evidence of a late t,oxemia. The loss in weight esperiqced in the first trimester by these mothers was barely regained during the following six months. The nverage maternal weight gain in this series was 2 pounds. This did not influence the ultimate weight average of the babic>s, which was 7 pounds 2
0u11cw. CONCI,TTSIONS
1. The incidence of toxemia in early pregnanc,v is comparatively the In our series, 62 per cent of same for both primiparas and multiparas. the primiparas and 60 l)er cent oi’ the multiparas were toxic in the first trimester. 2. In primiparas wit,11 negative first trimesters, 25 per vent hare toxic third trimesters. The margin of safety is slightly lower in multiparws, No conclusion can be 29.4 per cent being tosic in the last trimester. reached on the character of the late toxemia these positive cases are likely to experience, since the percentages are well distributed among the three possibilities, namely, (1 ) on elevated blood pressure illOlle; (2) toxic> symptoms alone ; and (3 ) toxic symptoms and elevated blootl pressure combined. 3. The incidence of late tosemia is definitely increased in cases prosenting the physiologic nausea and vomiting of the first trimester, 41 per cent of multigaras and 51 l)er cent of primiparas experiencing this form of early t.osemia mere t,oxic in the last trimester. Here again the types of tosic manifestations in the last trimesters are fairly evenly distributed.