Weight Estimates during Pregnancy and the Puerperium

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WEIGHT ESTIMATES PURING PR\llG~ANCY AND PUERPERIUM

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An in-dwelling catheter helps to maintain the patency of the urethral canal during the first few postoperative days, and the bladder should be catheterized occasionally thereafter. Otherwise residual urine may accumulate. REFERENCES

lDorland, W. A. N.: The .American Illustrated Medical Dictionary, Ed. 11, 1922, W. B. Saunders Co. 2Watkins, Thomas J.: Surgery, Gynecology, and Obstetrics, xl, No. 5, p. 687. SSti.ickel: Veit 's Handbuch fiir Gynlikologie, ii, 287. '.Ashton, William E:. Practice of Gynecology, Ed. 6, 1916, W. B. Saunders Co., p. 613. 580 PARK .AVENUE.

(For disoussion see pa.ge 522.)

WEIGHT ESTIMATES DURING PREGNANCY AND THE PUERPERIUM* BY WILLIAM KERWIN, M.D., F.A.C.S., ST. Louis, Mo .

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BSERVING the weight gain in the pregnant woman should no longer be a question for discussion among obstetricians, as its value has been definitely established by ~he work of several recent observers. The state of health coincides fairly accurately with the weight in the nonpregnant state, and in pregnancy this holds more or less true, although variations within physiologic limits occur. The patient's attitude towards prenatal care is determined by the interest which the obstetrician shows in her general state of health, and there is no better way to stimulate this interest than to observe, at regular intervals, the weight gain the patient is making. In the nonpregnant state, a woman gives considerable thought to her physique, but when pregnant, she slumps to a considerable degree and awakes with a much altered postnatal figure. The sagging breast, wrinkled bosom, bulging hips, pendulous abdomen, etc., are conditions to which pregnancy fat makes a liberal contribution. A too rapid gain in the late months may be a factor in the toxemia of pregnancy. Among those who have made a study of weights during pregnanQy are Gassner, Zangemeister, Lorenzen, Nebel, Baumm, Heil, Kruger, Momm, Kemper, Davis, Hannah, Smith, and Randall. Gassner was interested in showing that gain in weight throughout the terminal months of pregnancy is within physiologic limits. Zangemeister found that the weight increases progressively from the twenty-seventh week to the end of pregnancy, and states that "the average increase from the twenty-seventh to the fortieth week is 5.55 kilograms, 405 grams per week or 55 grams per day. The greatest weight is attained throe days previous to delivery, although some patients make ibis weight at an early date. During the last few days of pregnaney there is a decided decrease in weight in about 98 per cent of the cases, and this foretells the •Read at a meeting of the Gynecological Society, St. Louis, 1\:lo., December 11,

1925,

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<·nch increasrs. ''

The rl0rn·asr• in IYPight b causl'tl h,v prn<·r•ss.•s in ]ll'<'l/.llfllll',l" and in the oTgani:mJ, uot alone h,v thP loss of tlw ol'um and thP <':tUS(' hns not b0eu dPtrrminerl. An increase in <1im<•sis lws hrPn olJserwcl at this tinw. Intraut('Tine d('ath of the frtus enusrs ·tl two days hefono rJelivrry. HP ~tates, '' tlwre are threr typt•s at tlw Pntl. of prl'gnanry: (1) Bod~· wright inneasrs up to the rntl of prrgnanry withont an,Y 1t•rminal den('ase. (:.l) '\V1~ight. attains grcatPst !wight shortly hdor1• hil'th and •h'errasr··~, (a) rontinuono;ly np to '1rlivrry or (h) n•mains ~Ulll<'. (:1) \Vt•ight innf'as••s np to thrre aJt. Multiparae innra~r 11101'(' thau pnnuparae. Davis givf'~ an avernge \Wight h'KK of fiftec>n ponntls following delivrry. liP eon· ~iders a weight gain of sevrn ftm1 n l1nlf ponmls prr month during tllP last thrN' month!' as exrPRSiY(', and the WC'ight should hf' conhollrd. ..\ rnpirl~ wPight gain i>
a forPJ'Uilllf'l' of

rt·lampsia.

Hmnmh di(•ts patiPnts tu <'t•ntrol w tinJP of labor, cluP to insufficient foods grratly inrrcasf'S thr prr eent of stillhirths and premature births; greatly de('reases the ai'Pragl' wright of full-term babies at hirth; definitely inereases the postnatal infantile mortality; has little if any dfe0t on the progres~ of babies
It ha~ interested us to watch the increase in weight during the different trimesters and the decrease that takes place during the first two weeks following delivery and the decrease that occurs dnring the normal puerperium. Several hundred recordA of cases coming to the Cass Avenue Prenatal Clinic were reviewed to obtain the following data: The average gain from the md of twelve weeks to the end of twentyfour weekR in 260 cases was eight and one-half pounds. The avera.ge gain from the twenty-fourth week to the end of pregnancy in 127 cases was seven and one-half poundR. The average gain from the third month of pregnancy to the end in 147 eases was sixteen and one-half pounds. The average loss during the six weeks following delivery in 152 cases was sixteen and one-third pounds. 'rhese weights were taken from records of patients of all nationalities, most of whom belong to the laboring class. The average loss in weight

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during the two weeks following delivery in 73 hospital cases of the more leisure class was twenty pounds. These weights were taken at St. Mary's Hospital at the onset of labor and again two weeks later when the patient was discharged. The figures indicate that the loss for the first two weeks following delivery is greater than during the six weeks following delivery; in other words, the patient regains some of the weight loss which must be attributed to the inactivity of the body while at rest in bed. There are no figures to cover the change in weight during the laetation period, but this, needless to say, would be greatly influenced by the diet, the· activity, and the environment of the patient and the vigor of the ehild. The greatest weight gain from the twelfth to the twenty-fourth week was twenty pounds in a patient weighing 139 pounds at the end of the twelfth week, attaining a weight of 159 pounds at the end of twentyfour weeks. The smallest gain during that period was one pound in a patient weighing 193 pounds at the end of twelve weeks and 194 pounds at the end of twenty-four weeks. ThiR patient was on a diet low in fats and sugars. In the series between the twenty-fourth week and the end of pregnancy the greatest weight gain was 26 pounds in a patient who weighed 152 pounds at the end of twenty-four weeks, and 178 at the end of pregnancy. One patient in this series, weighing 230 pounds at the end of six months, weighed 231 pounds at the end of pregnancy. This patient was subjected to a diet low in fats and sugars. The greatest gain from the twelfth week to the end of pregnancy was 38 pounds in a patient weighing 142 pounds at twelve weeks and 180 pounds at the end. The smallest gain during that period was six pounds in a patient weighing 109 pounds at twelve weeks and 115 pounch> at the end. When the weight was excessive for the height of the patient, diet was instituted with the hope of controlling the gain as far as possible. In private practice with the patient under better control this could be accomplished in practically all cases. It was apparent that the patient felt decidedly better if the weight gain was kept low, providing the initial weight was above par. The greatest loss during the first two weeks following delivery was 36 pounds in a patient who weighed 176 pounds at the end of labor and 140 pounds two weeks later. The smallest loss was 7 pounds in a patient weighing 125 pounds at the onset of labor and 118 pounds two weeks later. One patient weighing 182 pounds at the onset, however, weighed 174 pounds two weeks later, a loss of 8 pounds, so that the weight of the body and the size of the ovum do not necessarily determine the amount of weight loss. During six weeks of the puerperium the greatest loss was 31 pounds, in a patient weighing 183 pounds at the end of pregnancy and 152 pounds six weeks later. One patient weighed 113 pounds at the end of pregnancy and weighed the same six weeks later,

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while another weighing 168 pounds weighed 166 pounds at the end of six weeks. It would be rather difficult to chart the individual ca:;es showing small losses and great losses, but the series show that certain facts are apparently true, namely: '!'hat the loss in weight during the puerperium is not solely influenced by the weight of the ovum, by lactation, or by the weight of the body at the onset of labor. It therefore must be a combination of these factors, with environment, diet, and exercise playing important roles. The gain in weight is not effected in all cases by the growth of the ovum, as it can be definitely controlled through diet, exercise, etc. Edema no doubt plays a very important role. Needless to say, the patient who has lost considerable weight during the early months as a result of nausea and vomiting, will regain weight rapidly after these conditions have passed, and this she should be permitted to do. It is not advisable so to restrict the diet that the fetus is deprived of ingredients necessary for its development, although there is some doubt as to whether these products are procured through the diet of the mother, or can be obtained in sufficient quantity from the mother's tissues. Figures compiled during the starvation period of the war suggest that the fetus is capable of normal development regardless of the mother's diet. A summary of the above facts and the work of others force the following conclusions : 1. Obesity is pathologic in pregnancy as well as in the nonpregnant state. C) It can and should be controlled through diet and exercise. 3. Excessive weight gain is detrimental to both mother and child. 4. The weight gain is about equal in the second and in the third trimesters. (rl'he rapid gain in the second trimester is probably due to the fact that the patient enters the second trimester with a weight below normal, brought about by the disturbance in digestion which frequently exists in the first trimester.) 5. The weight loss for the puerperium about equals the weight gain made during pregnancy. 6. The greatest loss occurs during the lying-in period, and this loss is not due solely to the loss of the ovum. 7. More consideration should be given to the future health and physique of the pregnant woman. Improvement in these conditions ean be obtained through the control of pregnancy fat. REFERENCES

Baumm: Diss. Miinchen, 1887, Ziit, Winkels Handbuch. Davis: AKER. JOUR. 0BST. AND GYNEC,, 1923, vi, 575-587. Gassner: Monatschr. f. Geburtsh., 1862, xix, 1. Hannah: Texas State Jour. of Med., 1923.

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INJURIES OF THE INFANT DURING DELIVERY

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Heil: .Arch. f. Gynak., 1896, li, 18. Kemper: Areh. f. Gyn.itk., 1924, 121·268. Kruger: Zentralbl. Gyn., 1807, xiii, 237. Lorenzen: Ztschr. f. Geburtsh. u. Gynak., 1921, lxxxiv, 426. Momm: ZentraJbl. f. Gynii.k., 1920, p. 233. Nebel: :Med. Kiin., 1922, xviii, 339. Smith: Lancet, London, 1916, cxci, 54. Zangeme:ister: Ztschr. f. Geburtsh. u. Gynak., 1919, Ixxxi, 491. LISTER BUILDING.

INJURIES OF THE INFANT DURING DELIVERY411 BY P. BROOKE BLAND, M.D., PHILADELPHIA, PA. (From the Department of Obstetrics, Jefferson Medi.oal College.)

N ANALYZING the theme assigned to me, I was carried in retrospect to the winter of 1907. It was my good fortune to spend several hours of each day with Dr. Stork, one of the pathologists in the Allgemeines Krankenhaus, in Vienna. Here it was not uncommon to witness from ten to fifteen or more autopsies almost every day. Adult autopsy material was always abundant, it being the rule that all patients dying in the institution be subject to postmortem investigation. Daily I observed large numbers of bodies of newborn babies in the morbid anatomy room, but in these, routine postmortem studies were not made. Naturally, I was led to speculate as to the cause of fetal death. The question arose as to whether all were inevitable and whether some, at least, were not preventable. In recent years, the question of fetal injury and fetal death has been receiving more and more the long deferred attention it justly deserves. Noteworthy strides have been made in maternity work, but the high plane on which practical obstetrics should stand has not been attained. In this country, there is something woefully wrong, since from the standpoint of obstetric mortality, we stand fourteenth in the sixteen leading nations of the world. In New York City, according to Polak, "one baby out of every twenty-one is born dead and one out of twenty-six dies before it is one month old, while one mother in every two hundred and fifty deliveries dies from infection or as an indirect cause of it.'' This author further claims that more than 61 per cent of all gynecologic surgery is a result of poor obstetric practice. Dr. Barton Cooke Hirst, five years ago, in a paper entitled : "The Obstetrical Department of a Modern Medical School," drew attention to the defects in the teaching and practice of obstetrics in America. In Pennsylvania, the maternal mortality has not changed in the past seventeen years. The mortality was 6.1 per cent per thousand in 1906, and it was precisely the same in 1923. Twelve hundred and fifty-one mothers died in confinement in 1922, and the toll in 1923 was 1,373.

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*Read at a meeting of the Philadelphia Obstetrical Society, November 10, 1925.