PROBLEMS IN EARLY PREGNANCY

One of the earliest predicaments to confront a woman who has missed one or two periods, involves this all absorbing question, “Am I pregnant?” There are several simple techniques to determine pregnancy with reasonable certainty, right within one’s own home. A suspicion arises when there is a miss of the normal menstrual period. If menses have been regular for several months, then the intuition heightens. Many women have months when they skip the cycle normally. Others have periods too scant to notice. Then the diagnosis of pregnancy becomes more difficult.
Symptoms of pregnancy may be present. You may experience a feeling of nausea, typically in the morning. This is occasionally associated with prolonged vomiting lasting throughout the day. The breasts may swell and become more tender than is usually associated with the premenstrual state. A slight change may occur in the vaginal discharge. Occasionally, a woman who has had previous children just “feels pregnant.” In pregnancy after three to four months, a “lump” may actually be felt above the pubic bone, located in the lower abdomen. This is probably the enlarging womb. By five months gestation it will usually reach to the navel, with an obvious rounded prominence in the lower abdomen. Fetal movements may be sensed at four to four and a half months, though they are sometimes detected earlier by experienced mothers carrying their second or third child.
In most pharmacies today, you can purchase a urine pregnancy test kit. This analysis very simply measures the amount of HCG (Human Chorionic Gonadotropin), a hormone secreted by the developing placenta. A positive test for pregnancy develops within three to six weeks after conception. Use a concentrated morning urine sample for best reliability. If performed according
to directions, these tests are quite dependable in confirming the suspicion of pregnancy.
Vague abdominal pains are sometimes felt in early pregnancy. Pelvic pain may occur from pressure on an enlarged ovary, or from a “tilted” uterus. As it enlarges, the organs become tighter in the pelvis, while the womb has not yet risen into the abdominal cavity. Pain could be related to constipation, or to cystitis. Usually, a bladder infection is characterized by burning combined with a frequent urge to urinate. Stretching of the ligaments that support the uterus may produce pain. In later months, the pressure of a fetal part on a pelvic nerve or a sudden shifting of the baby within the womb may give rise to such symptoms. Usually reassurance is all the patient needs. Severe pain or sudden changes in health status should be called to the attention of a physician immediately, however, since it could be an ectopic (tubal) pregnancy. If this goes unrecognized it could rupture, with internal hemorrhage and potential disaster. Appendicitis may occasionally be superimposed upon pregnancy, requiring early diagnosis and prompt surgical treatment as usual.
Vaginal bleeding sometimes occurs, even after pregnancy begins. Usually this appears scant and transient, but at times it may be profuse. When an actual hemorrhage develops after pregnancy has established, this constitutes an obvious threat of miscarriage. The presence of regular contractions and pelvic pain, combined with vaginal bleeding, should alert to this possibility. At times a miscarriage may occur with the complete passage of the placenta and the subsequent stoppage of bleeding. If incomplete expulsion of the placenta or fetal tissue occurs, a simple operation, called a D and C (dilation and curettage), should be performed, so the bleeding will stop and the uterus can return to its normal size. Fever in the presence of a miscarriage is a more ominous sign, as it probably indicates the presence of pelvic infection.
For treatment of threatened miscarriage, bed rest is always advisable. The absence of straining, standing, or moving about lessens the flow and usually decreases the likelihood of a miscarriage. Sexual intercourse should be avoided in early pregnancy, particularly near the times when a menstrual period would otherwise occur. Uterine cramping and the likelihood of miscarriage is greater at these cycles, for reasons yet unknown. Hormones are no longer given routinely to mothers threatened with miscarriage. They are powerless to stop the inevitable. Furthermore, progesterone concentrates may cause damage to the fetus, if it is carried to term. Scientists believe that many spontaneous miscarriages are the result of some chromosomal defect, which
otherwise would have led to congenital deformity. They are eliminated by nature before the pregnancy goes too far. This is of considerable consolation to parents, suddenly disappointed by the premature loss of a long-looked-for baby. Most couples can wait a few months, then try again.
One of the more troublesome conditions of early pregnancy, sometimes lasting for months, is an upset stomach. Called “morning sickness,” for obvious reasons, nausea and vomiting tends to herald the onset of pregnancy. Although only a few ladies find it incapacitating, these symptoms tend to hinder proper nourishment, so important in the early months of pregnancy. This nausea may last throughout the day. On the other hand, it may be relieved by eating some crackers or other form of dry food. Frequently, the appetite completely changes, and the “lady-in-waiting” craves foods that were formerly disliked. In extreme cases this so-called pica (abnormal craving) is manifested by the “clay eating” habit of southerners, or the strange love for “pickles and ice cream” that ordinarily seems like a repulsive combination.
Mothers need to be careful that their appetites are controlled by reason when such cravings become abnormal. Where vomiting in pregnancy becomes persistent, hospitalization may prove necessary. One or two days of intravenous feedings is normally sufficient to bring back a normal digestion once again. Emotional contributions to this gastric problem are frequent. These can be related to ambivalence about being pregnant, or an underlying temperament of nervousness manifested in an unusually sensitive stomach. Nevertheless, the physiologic and hormonal changes that occur are profound. Such endocrine considerations may well explain these early digestive symptoms. A tolerance for food usually emerges by the fourth month, enabling a normal digestive tone to continue for the remainder of pregnancy.
Adequate fluid intake is vitally important from the start. It is suspected that the common, insufficient intake of water is one principal cause of persistent nausea and vomiting. Drink at least six to eight glasses of water per day, at whatever temperature is best tolerated by the sensitive stomach. If the mother avoids soups and creamed mixtures, and chews thoroughly a rather dry meal of whole grain crackers, breakfast cereals, or raw vegetables, her food will stay down better and permit the best nutrition at this critical stage. Vaginal discharge is often troublesome during the latter months of pregnancy. This may be due to the parasite Trichomonas, but is more commonly caused by a buildup of yeast or Monilia (Candida albicans).
Hormone changes combined with increased perineal moisture and warmth, create an environment favorable to the growth of these organisms. Diabetes mellitus, particularly aggravates the tendency to develop yeast infections.
Administration of hormones such as the birth control pill may produce a diabetes-like state in non-pregnant women. However, pregnancy increases this trend. Nylon underwear, panty hose, and tight slacks tend to increase the propensity for vaginitis. This is because greater warmth and moisture are produced in the perineum when one wears those synthetic fabric materials. Air circulation around the body and “breathing” of the skin is impeded. Then it leads to the rapid multiplication of yeast germs with such unpleasant symptoms as discharge, burning, itching, and skin rash. Gentle vaginal douches, with a dilute vinegar solution (one tablespoon of white vinegar to one quart of warm water) can help decrease the discharge and restore normal acidity to the birth canal. Specific agents are available to help in acute stages (such as Massingill products). However, the intestinal tract always harbors these germs, so it is impossible to completely escape from them. Therefore,you will find it preferable to build up resistance and let improved health of the body create its own defense. Marital relations should be avoided, not only when discharge or infection is present, but during any time of spotting or uterine cramping. Moreover, for at least four to six weeks prior to the birth of the baby, intimate relations should likewise be curtailed, since a significantly increased risk of infection in the amniotic fluid surrounding the baby has been linked to intercourse at this stage. Sexual continence at this critical time will be rewarded with better health, as well as peace of mind.

Anesthesia

One of the oldest forms of medical treatment is described in Genesis 2:18, 21-23, where the Creator Himself “caused a deep sleep” to come upon Adam while He took out the rib, closed up the incision, and made a “help meet for him.” Relief of pain is intimately associated with the rendering of needful medical care. This is one of the physician’s cardinal responsibilities.
For certain patients, some forms of severe pain may be life threatening. However, in the case of most effective pain relieving medications, addiction can occur, with distortion of mental imagery to the point of serious impairment. Thus, it is wise to look for the simplest methods of relieving pain when attempting to perform surgery.
Probably the oldest form of pain relief is refrigeration anesthesia. Extremities can be rendered pain free with ice packs. This is particularly valuable in the case of vascular disease where cardiac and circulatory impairment makes general anesthesia risky. During the World War II, army medics discovered that troops suffering from frostbite might save their limbs if the extremity remained frozen until medical care could be secured. This observation influenced all currently accepted first aid for frostbite used in our country.
In order to properly administer refrigeration anesthesia, the extremity needs to be cooled to the point of numbness, while keeping the remainder of the body warm to avoid a general drop in emperature, chilling, or agitation. Ice packs or snow can be used to progressively cool an xtremity, either a hand or foot. If the surgery is to be localized to the arm or leg, place the pack
just above the site of amputation. This reduces blood loss and allows for a careful, meticulous dissection of the tissue. Broken bones can be set with refrigeration. In the case of a simple fracture of the hand or wrist, immerse the extremity in ice water for one-half hour or more. This will allow manipulation and bone setting to be done quite painlessly.
Refrigeration can also be used topically in the removal of warts, moles, and other skin lesions. Dry ice or liquid nitrogen can be applied with a cotton applicator to freeze a small area and render it numb to pin prick.
A second method of anesthesia is the application of gradual pressure on a nerve. The ulnar nerve at the elbow (funny bone) is quite amenable to pressure. Quite often in certain positions a foot or a hand has been known to “go to sleep” due to stretching or pressure on an affected nerve. nowledge of neuroanatomy can utilize this principle favorably for surgery to an extremity.
Counterirritation can also be applied with electric stimulation near the point of incision. This can utilize DC current, but it is more effective with a pulsed generator, such as rehabilitation centers employ in treatment of chronic pain. Desensitization can be obtained with liniments and ointments, mustard packs or plasters. Even animal surgery has been performed using
counterirritation, e.g., the “twitch” on the nose of horses. Finally, it is helpful to understand some of the common injectable anesthetics that are used locally for the relief of pain. These are used both in dental and surgical care. But they have some side effects and potential allergic reactions. Injectable narcotics should always be avoided, as they leave behind serious effects on the brain. They are not only difficult to metabolize, but because of their tendency to produce euphoria can become rapidly addicting. On rare occasions for major procedures, general anesthesia may be necessary. The gaseous agent used in these cases should be that which is most rapidly metabolized and least toxic to the system. Nitrous oxide and oxygen are commonly employed together to relieve mild pain. Although ether is quite flammable, it still remains the safest form of general anesthesia, due to its rapid clearing from the blood by the way of the lungs and relatively low toxicity to the liver and other organs. Open drop techniques in a well ventilated area can be used, but for safety reasons general anesthesia ideally should be performed in a hospital. Newer anesthetic agents (Halothane, Ethrane, etc.), although more likely to cause toxicity, are less dangerous to the heart and usually nonflammable. Regional blocks, local nerve blocks, and spinal anesthesia have their places in hospital settings but it is beyond the scope of this book to detail their applications.

Suturing

Considerable practice is required to suture incisions and lacerations quickly and accurately. Yet these skills are not beyond the reach of the average layman gifted with manual dexterity or an interest in mastering the art. If possible, practice your suturing techniques on a piece of sponge rubber, upholstery, or even a pillow. Some surgeons become skilled in knot tying, practicing on door handles or in the automobile while traveling. The accompanying diagrams, located on pages 178 to 189, help demonstrate the principles of the three basic methods of surgical knot tying. The one described as an “instrument tie” utilizes a hemostat or needle holder, while the others require only skillful fingers for proper use. I would suggest that a novice begin with the two-handed tie and instrument tie, adding more complex forms as skill is gained.
Avoid tying the sutures so tightly that insufficient blood flow to the skin edges results. This would cause delayed and incomplete healing of the wound.
“Approximate, don’t strangulate” is the watch word for closure of lacerations with sutures. Human bites, animal bites, and lacerations opened longer than 12 hours, or those grossly contaminated are not sutured, but allowed to granulate and heal by secondary intention.
The placement of sutures and selection of suture material will be described in the following sections, as the various types of lacerations and their special care are considered. In a home-like setting it is possible to make the appropriate needles, like bending a sewing needle, sharpening the point in a chisel fashion to better penetrate the skin. Silk or cotton can be boiled along with the needle, thus sterilizing it for use in suturing. Prepared packages, that come already sterile, are available from suture manufacturing companies and can be obtained in various sizes and needle styles. Remember to consult the suture use manual for aid in selecting the appropriate sutures.