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Abortion after grass pollen injection
ABORTION
AFTER
GRASS POLLEN
NATHAN
INJECTION
M.D. N. Y.
FRANCIS,
RQCHEXTER,
-RAMPLIKE pain in the lower abdomen with scant vaginal bleed’ ing associated with a constitutional allergic rea.ction was first reported by Cooke1 in 1922. He referred to two patients with immediat’e reactions, including asthma, coryza, urticaria, and menstrual flow coming three hours after injection and lasting one day. He strongly recommended caution in the treatment of pregnant women blecause of the possibility that abortion ma,y be induced. Kahn2 in 1928 reported a case of a woman in t,he first month of pregnancy who complained of excruciating pain in the lower abdomen twenty minutes a,fter receiving an injection of grass pollen. She described the pain as #similar to labor pains, but more steady. There was no bleeding, and the symptoms ,subsided by the following day. :Robinson3 in 1929 reported a patient with uterine pa,in as a part of a constitutional reaction in which there was no bleeding. Such constitutional reactions may end with abortion, a case of which is presented. (
CASE REPORT A white female, aged 34 years, was admitted to the Rochester General Hospital About two hours after receiving an with the chief complaint of vaginal bleeding. injection of grass pollen (Nov. 9, 1939) the patient began to have hay fever which was the most intense that she had ever experienced. Soon thereafter she began to have cramps in the lower abdomen with spotting. Moderate bleeding continued until three days later when she had a profuse vaginal hemorrhage and was admitted to the hospit,al. She had ha,d an appendectomy in 1933 and a dilatation and curettage in 1938 for irregular vaginal bleeding of 1.5 years’ duration. The pathologic report at that time was that of hypertrophic endometritis. Her menstrual history since then ha,d been normal,, with the last period in July, 1939. She had attended our allergy clinic since 1934 for treatment of grass poilenosis with good results from preseasonal injections until 1939 and perennial treatment thereafter. Her father has hay fever. The physical examination showed that the abdomen was tender in the left lower quadrant. The uterus was palpated 3 fingers above the symphysis pubis. The vulva. was covered with fresh and elotte,d blood. A fetus 9 em. long was present in the vagina. The patient began to shock. She was given dilatation and curettage discharge on the seventh -F’rom the Allergy Clinic Presented at the Annual
Condlitions, Atlantic
bleed into the uterus soon after entry atnd went into mild acacia, fluids, and 659 C.C. of whole blood. Emergency were done. The postoperative course W,BS uneventful with hospital day. of the Rochester General Hosoital. Meeting of the Society fo#r the-study
City, N. J., May 3, 1941. 559
of Asthma
and Allied
560
THE
JOURNAL
OF ALLERGY
We had no difficulty The patient was moderately sensitive to grass pollen antigen. in increasing the dose of injections to give her adequate protection. The maximum )dose was 0.60 C.C. of a 1:250 extract on June 29. Then the dose was decreased, as is our custom, during the sea,son through which the patient is treated, and it was again reduced in August because the patient remained away from the clinic for a period longer than four weeks. The patient had very few symptoms of hay fever during the season when she was expected to have them, and she told us that she had had as good a year as she had previously experienced. The abortion occurred on Nov. 9, 1939, with a dose of 0.35 C.C. of a 1:250 extract. This dose was definitely below her highest.
We make our own extsacts according to the method of Coca. Our stock solution is 1:50 which we prepare two or three times yearly. Grass solution contains equal parts of timothy, orchard grass, June grass, and red top. We use the perennial plan of treatment almost exclusively. The incidence of the constitutional reactidn in our experience has been less than 0.5 per cent. In 1940 we gave 3,106 injections with fewer than fifteen constitutional reactions. An interesting observation was the leucopenia because the patient was receiving no medication which is known to depress the leucocytes. The white counts on the second and fifth hospital days were 3,900 and 3,800. respectively. Widal and others regard the drop in the total white count as one of the most important changes in the blood which may occur in the course of allergic conditions. SUMMARY
1. Since the symptoms of severe bar fever came when no grass pollen was in the air, it was a,ssumed that the sudden ha,y fever was due to the rapid absorption of the injected grass pollen into the systemic circulation. 2. Since the cramps in the lower abdomen and vaginal bleeding came on the same day and were followed by abortion three days later, it is likely that the abortlion and the constitutional reaction were related. REFERENCES 1. Cooke, R. A.: 5. Immunol. 7: 119, 1922. 2. Kahn, I. 8.: J. A. %I. A. 90: 2101, 1928. M. Rec. 129: 139, 1929. 3. Robinson, E. M.: DISCUSSION DR. ALBERT VAKDER VEER, New York City-While I have seen possibly not more than one or two miscarriages following a constitutional reaction, I have observed a number of cases in which a woman has had abdominal and uterine cramps that, had she been pregnant, would undoubtedly have led to abortion. Therefore, we exercise extreme caution with a patient who is pregnant. Every case has to be treated individually. For instance, if the patient is one whom you have treated for several pears, you have some general idea of the amount of extract she can take. If she is a new patient, you may not know much about her normal dose. In any event, we try to
FRANCIS:
ARORTIOK AFTER GRASS POLLEN INJECTION
561
underdose the patient rather than give the regular amount. It depends somewhat on when the baby is expected. If, for instance, the patient has ra,gweed hay fever and expects a. baby in July, then it is fairly simple to give small doses until the baby is delivered, and then very rapidly increase the dose from the middle or end of July until the beginning of the sea,son. The doses may be increa,sed at short interva,ls so that by the tilme the season isi due the patient will have enough to protect her. Of course, you can refuse to treat a,t all, but, if the patient has hay fever complicated by asthma, then that in itself may bring on a8miscarriage. The treatment depends somewhat upon how many children the patient has had. If she is a. young woman with one or two, there is less need for worry than there would be if she were having her first pregnancy. One of my patients, a woman, 40 years old, has been married for eight years We have to be extremely careful in and is having her first pregnancy. a, case like that. I should say tha.t we try to underdose such a8patient, and, if we can get up to one-half of the regular dose, we can at least take the edge off the hay fever and prevent asthma. This may not be a very good result, but at least it will be on the safe side. There are two points I should like to make about the case presented. In. t.he first place, I believe that with perennial treatment we a.re more likely to get sudden unexplained constitutional rea.ctions than with weekly treatment. With the perennia 1 treatment frequently we see pattients who seem to become saturated and have a sudden constitutional reaction after a, dose no la.rger, sometimes smaller, than they ordinarily have carried. When we treat a patient weekly, we get a little idea from the local reaction and from the symptoms about whether a dangerous dose is being approached. In the second place, I noticed that this patient always received adrenalin along with the injections. The adrenalin slows up the absorption, and the constitutional reaction may come after the patient has left the o&e and the physician cannot do anything about it. I believe that we must be very cautious about pregnancy. In this particular case the patient was through her season before her baby was delivered. Personally, I would have stopped treatment since her hay fever was all right. Francis stated that the DR. SELIAN HEBALD, New York City.-Dr. grass extract used in his cli.nic was made two or three tilmes a year. How old was the extract t,hat produced the constitutional reaction2 DR. FRANCIS.-The
extract was about 4 or 5 months old.
DR. WARREN T. VAUGHAN, Richmond.-It seems to me that there are other factors to be taken into consideration in the protection of the pregnant woman. Dr. Vander Veer has outlined the specific points: as’far as pollen treatment is concerned, but often there are other allergic factors that should be taken care of as a matter of protection. The patient to whom I am referring was not pregnant, but such a. situation might arise. A woman was having perennial treatment and was receiving 0.20 cc. of 150 extract every two weeks. She was also allergic to chocolate and pork. Her husband was a physician. One night for the first time she broke her diet. She ate a hot dog and a cake of chocolate. One-half hour later her husband gave her exactly the #samedose he ha.d been giving
her every two weeks, and for the first time she had a constitutional reaction. Those additional factors that might play a part and might tip the balance would be well considered in the protection of a pregnant woman against possible abortion. DR. HOWARD OSGOOD, Buffalo.-1 should like to ask Dr. Francis and Dr. Vander Veer how many pregnant women they have carried through constitutional reactions without abortion. It does happen, as shown by the following experience several yea,rs ago. The ease was that of a young woman who was quite sensitive to grass pollen, had had preseasonal treatment, and felt very well. She was seven months pregnant. On one visit by misstake she was given several times the dose of grass extract that she should have had. She left the office and was back again in fifteen or twenty minutes with a constitutional reaction-severe generalized urticaria, and erythema and marked asthma. I gave her 0.5 cc. of adrenalin, applied a tourniquet proximal to the injection, and quieted her as well as I could psychologically. She came through perfectly all right and now has a fine baby. She also returned in the succeeding years’ for continued treatment. DR. GEORGE II. WALDBOTT, Detroit.-There are many questions which confront us when we treat pregnant allergic patients. The patients’ want to know not only whether or not the injections will interfere with pregnancy, but also if they a.re likely to harm the baby after birth. Is it safe to have an anesthetic during confinement, and which aaesthetic should be used? How should the patient be ma.naged if hay fever and a,sthma symptoms develop during confinement 1 Unfortunately, we cannot answer these questions but can discuss only the impre#ssion gained from clinical experience. We should be awa.re of the possibility of inducing spastic contraction of the uterus and subsequent abortion with overdoses of pollen extract. But if we proceed cautiously, I feel that #such accidents’ can be avoided. I do not consider pregnancy a contraindication to hay fever treatment. As far as the effect of hay fever treatment on the baby is concerned, I believe that it is equally as protective to the baby as to the mother. Hospitalization for confinement affords an excellent opportunity for rendering patients with hay fever or pollen asthma symptom free for the season by cautiously giving increasing doses of pollen extracts daily or even two to three times a day. We should be cautious about the choice of an anesthetic and the administration of drugs during confinement. I know of two patients who, shortly after confinement, developed rather severe shock which could not be explained by the obstetrician and which had the earmarks of allergic shock. It may ha.ve been caused by morphine or the anesthetic to which sensitivity existed. In one patient, the administration of aminophyllin controlled the situation very promptly. DR. H. Hun-En.-About thirty minutes after I gave one of my l&yearold patients a pollen extract treatment,. she ha.d a mild constitutional reaction accompanied by menstrual-like cramps and menstrual flow midway between her regular menstrual periods. She afterward reported that she had had menstrual-like paminsafter three or four previous treatments but had had no other symptoms. Another patient, aged 35 years,
FRAKCIS
:
AUOItTIOiV
dFTER
GRASS
I’OLLEN
ISJECTIOS
563
aborted a three months’ pregnancy about four days after having a, mild constitutional reaction consisting only of itching of the hands and feet. Since ha,ving these experiences, I have not knowingly given a pregnant patient a pollen treatment by intracutaneous or subcutaneous injection. In spite of a,11precautions with the regular or with l.ess intensive treatment, constitutional reactions may occur, and I do not believe that’one should take that chance with any pregnant patient. In 1934 I pointed out that about 40 per cent of pregnant patients will go through a pollen season with little or no symptoms without having any specific pollen treatment and that the majority of patients can be satisfactorily protected by applying pollens on the skin, as for scratch testing, once a week. Constitutional reactions from such a method are rare, and in my experience this method has been very satisfactory. A pa.per read at this meeting earlier in the day gives more evidence on the acquisition of immunity by a,pplications to the skin.
AFTER
GRASS POLLEN
NATHAN
INJECTION
M.D. N. Y.
FRANCIS,
RQCHEXTER,
-RAMPLIKE pain in the lower abdomen with scant vaginal bleed’ ing associated with a constitutional allergic rea.ction was first reported by Cooke1 in 1922. He referred to two patients with immediat’e reactions, including asthma, coryza, urticaria, and menstrual flow coming three hours after injection and lasting one day. He strongly recommended caution in the treatment of pregnant women blecause of the possibility that abortion ma,y be induced. Kahn2 in 1928 reported a case of a woman in t,he first month of pregnancy who complained of excruciating pain in the lower abdomen twenty minutes a,fter receiving an injection of grass pollen. She described the pain as #similar to labor pains, but more steady. There was no bleeding, and the symptoms ,subsided by the following day. :Robinson3 in 1929 reported a patient with uterine pa,in as a part of a constitutional reaction in which there was no bleeding. Such constitutional reactions may end with abortion, a case of which is presented. (
CASE REPORT A white female, aged 34 years, was admitted to the Rochester General Hospital About two hours after receiving an with the chief complaint of vaginal bleeding. injection of grass pollen (Nov. 9, 1939) the patient began to have hay fever which was the most intense that she had ever experienced. Soon thereafter she began to have cramps in the lower abdomen with spotting. Moderate bleeding continued until three days later when she had a profuse vaginal hemorrhage and was admitted to the hospit,al. She had ha,d an appendectomy in 1933 and a dilatation and curettage in 1938 for irregular vaginal bleeding of 1.5 years’ duration. The pathologic report at that time was that of hypertrophic endometritis. Her menstrual history since then ha,d been normal,, with the last period in July, 1939. She had attended our allergy clinic since 1934 for treatment of grass poilenosis with good results from preseasonal injections until 1939 and perennial treatment thereafter. Her father has hay fever. The physical examination showed that the abdomen was tender in the left lower quadrant. The uterus was palpated 3 fingers above the symphysis pubis. The vulva. was covered with fresh and elotte,d blood. A fetus 9 em. long was present in the vagina. The patient began to shock. She was given dilatation and curettage discharge on the seventh -F’rom the Allergy Clinic Presented at the Annual
Condlitions, Atlantic
bleed into the uterus soon after entry atnd went into mild acacia, fluids, and 659 C.C. of whole blood. Emergency were done. The postoperative course W,BS uneventful with hospital day. of the Rochester General Hosoital. Meeting of the Society fo#r the-study
City, N. J., May 3, 1941. 559
of Asthma
and Allied
560
THE
JOURNAL
OF ALLERGY
We had no difficulty The patient was moderately sensitive to grass pollen antigen. in increasing the dose of injections to give her adequate protection. The maximum )dose was 0.60 C.C. of a 1:250 extract on June 29. Then the dose was decreased, as is our custom, during the sea,son through which the patient is treated, and it was again reduced in August because the patient remained away from the clinic for a period longer than four weeks. The patient had very few symptoms of hay fever during the season when she was expected to have them, and she told us that she had had as good a year as she had previously experienced. The abortion occurred on Nov. 9, 1939, with a dose of 0.35 C.C. of a 1:250 extract. This dose was definitely below her highest.
We make our own extsacts according to the method of Coca. Our stock solution is 1:50 which we prepare two or three times yearly. Grass solution contains equal parts of timothy, orchard grass, June grass, and red top. We use the perennial plan of treatment almost exclusively. The incidence of the constitutional reactidn in our experience has been less than 0.5 per cent. In 1940 we gave 3,106 injections with fewer than fifteen constitutional reactions. An interesting observation was the leucopenia because the patient was receiving no medication which is known to depress the leucocytes. The white counts on the second and fifth hospital days were 3,900 and 3,800. respectively. Widal and others regard the drop in the total white count as one of the most important changes in the blood which may occur in the course of allergic conditions. SUMMARY
1. Since the symptoms of severe bar fever came when no grass pollen was in the air, it was a,ssumed that the sudden ha,y fever was due to the rapid absorption of the injected grass pollen into the systemic circulation. 2. Since the cramps in the lower abdomen and vaginal bleeding came on the same day and were followed by abortion three days later, it is likely that the abortlion and the constitutional reaction were related. REFERENCES 1. Cooke, R. A.: 5. Immunol. 7: 119, 1922. 2. Kahn, I. 8.: J. A. %I. A. 90: 2101, 1928. M. Rec. 129: 139, 1929. 3. Robinson, E. M.: DISCUSSION DR. ALBERT VAKDER VEER, New York City-While I have seen possibly not more than one or two miscarriages following a constitutional reaction, I have observed a number of cases in which a woman has had abdominal and uterine cramps that, had she been pregnant, would undoubtedly have led to abortion. Therefore, we exercise extreme caution with a patient who is pregnant. Every case has to be treated individually. For instance, if the patient is one whom you have treated for several pears, you have some general idea of the amount of extract she can take. If she is a new patient, you may not know much about her normal dose. In any event, we try to
FRANCIS:
ARORTIOK AFTER GRASS POLLEN INJECTION
561
underdose the patient rather than give the regular amount. It depends somewhat on when the baby is expected. If, for instance, the patient has ra,gweed hay fever and expects a. baby in July, then it is fairly simple to give small doses until the baby is delivered, and then very rapidly increase the dose from the middle or end of July until the beginning of the sea,son. The doses may be increa,sed at short interva,ls so that by the tilme the season isi due the patient will have enough to protect her. Of course, you can refuse to treat a,t all, but, if the patient has hay fever complicated by asthma, then that in itself may bring on a8miscarriage. The treatment depends somewhat upon how many children the patient has had. If she is a. young woman with one or two, there is less need for worry than there would be if she were having her first pregnancy. One of my patients, a woman, 40 years old, has been married for eight years We have to be extremely careful in and is having her first pregnancy. a, case like that. I should say tha.t we try to underdose such a8patient, and, if we can get up to one-half of the regular dose, we can at least take the edge off the hay fever and prevent asthma. This may not be a very good result, but at least it will be on the safe side. There are two points I should like to make about the case presented. In. t.he first place, I believe that with perennial treatment we a.re more likely to get sudden unexplained constitutional rea.ctions than with weekly treatment. With the perennia 1 treatment frequently we see pattients who seem to become saturated and have a sudden constitutional reaction after a, dose no la.rger, sometimes smaller, than they ordinarily have carried. When we treat a patient weekly, we get a little idea from the local reaction and from the symptoms about whether a dangerous dose is being approached. In the second place, I noticed that this patient always received adrenalin along with the injections. The adrenalin slows up the absorption, and the constitutional reaction may come after the patient has left the o&e and the physician cannot do anything about it. I believe that we must be very cautious about pregnancy. In this particular case the patient was through her season before her baby was delivered. Personally, I would have stopped treatment since her hay fever was all right. Francis stated that the DR. SELIAN HEBALD, New York City.-Dr. grass extract used in his cli.nic was made two or three tilmes a year. How old was the extract t,hat produced the constitutional reaction2 DR. FRANCIS.-The
extract was about 4 or 5 months old.
DR. WARREN T. VAUGHAN, Richmond.-It seems to me that there are other factors to be taken into consideration in the protection of the pregnant woman. Dr. Vander Veer has outlined the specific points: as’far as pollen treatment is concerned, but often there are other allergic factors that should be taken care of as a matter of protection. The patient to whom I am referring was not pregnant, but such a. situation might arise. A woman was having perennial treatment and was receiving 0.20 cc. of 150 extract every two weeks. She was also allergic to chocolate and pork. Her husband was a physician. One night for the first time she broke her diet. She ate a hot dog and a cake of chocolate. One-half hour later her husband gave her exactly the #samedose he ha.d been giving
her every two weeks, and for the first time she had a constitutional reaction. Those additional factors that might play a part and might tip the balance would be well considered in the protection of a pregnant woman against possible abortion. DR. HOWARD OSGOOD, Buffalo.-1 should like to ask Dr. Francis and Dr. Vander Veer how many pregnant women they have carried through constitutional reactions without abortion. It does happen, as shown by the following experience several yea,rs ago. The ease was that of a young woman who was quite sensitive to grass pollen, had had preseasonal treatment, and felt very well. She was seven months pregnant. On one visit by misstake she was given several times the dose of grass extract that she should have had. She left the office and was back again in fifteen or twenty minutes with a constitutional reaction-severe generalized urticaria, and erythema and marked asthma. I gave her 0.5 cc. of adrenalin, applied a tourniquet proximal to the injection, and quieted her as well as I could psychologically. She came through perfectly all right and now has a fine baby. She also returned in the succeeding years’ for continued treatment. DR. GEORGE II. WALDBOTT, Detroit.-There are many questions which confront us when we treat pregnant allergic patients. The patients’ want to know not only whether or not the injections will interfere with pregnancy, but also if they a.re likely to harm the baby after birth. Is it safe to have an anesthetic during confinement, and which aaesthetic should be used? How should the patient be ma.naged if hay fever and a,sthma symptoms develop during confinement 1 Unfortunately, we cannot answer these questions but can discuss only the impre#ssion gained from clinical experience. We should be awa.re of the possibility of inducing spastic contraction of the uterus and subsequent abortion with overdoses of pollen extract. But if we proceed cautiously, I feel that #such accidents’ can be avoided. I do not consider pregnancy a contraindication to hay fever treatment. As far as the effect of hay fever treatment on the baby is concerned, I believe that it is equally as protective to the baby as to the mother. Hospitalization for confinement affords an excellent opportunity for rendering patients with hay fever or pollen asthma symptom free for the season by cautiously giving increasing doses of pollen extracts daily or even two to three times a day. We should be cautious about the choice of an anesthetic and the administration of drugs during confinement. I know of two patients who, shortly after confinement, developed rather severe shock which could not be explained by the obstetrician and which had the earmarks of allergic shock. It may ha.ve been caused by morphine or the anesthetic to which sensitivity existed. In one patient, the administration of aminophyllin controlled the situation very promptly. DR. H. Hun-En.-About thirty minutes after I gave one of my l&yearold patients a pollen extract treatment,. she ha.d a mild constitutional reaction accompanied by menstrual-like cramps and menstrual flow midway between her regular menstrual periods. She afterward reported that she had had menstrual-like paminsafter three or four previous treatments but had had no other symptoms. Another patient, aged 35 years,
FRAKCIS
:
AUOItTIOiV
dFTER
GRASS
I’OLLEN
ISJECTIOS
563
aborted a three months’ pregnancy about four days after having a, mild constitutional reaction consisting only of itching of the hands and feet. Since ha,ving these experiences, I have not knowingly given a pregnant patient a pollen treatment by intracutaneous or subcutaneous injection. In spite of a,11precautions with the regular or with l.ess intensive treatment, constitutional reactions may occur, and I do not believe that’one should take that chance with any pregnant patient. In 1934 I pointed out that about 40 per cent of pregnant patients will go through a pollen season with little or no symptoms without having any specific pollen treatment and that the majority of patients can be satisfactorily protected by applying pollens on the skin, as for scratch testing, once a week. Constitutional reactions from such a method are rare, and in my experience this method has been very satisfactory. A pa.per read at this meeting earlier in the day gives more evidence on the acquisition of immunity by a,pplications to the skin.