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by Murder

  Besides this treatment being effective, it does not have the long-term problems associated with many of the psychotropic drugs used in the treatment of depression. These medications not only

  have significant side effects but also may interact with other medications and certain foods.

  What Are the Symptoms of a Miscarriage?

  Q: I'm working on a scene in the early 1900s with a female character falling ill, probably having a miscarriage. Can you help me get an idea of what a miscarriage would feel like? Severe cramps? Bleeding? Warning signs?

  A: A miscarriage occurs when a fetus is no longer viable and the uterus expels it. This may result from many causes. The fetus may be genetically defective so that its full-term survival was impossible from conception; the placenta may be poorly formed or function improperly, resulting in fetal death; the uterus may be scarred from old infections or trauma such as a previous dilatation and curettage (D and C) or abortion and may not be able to support the growing fetus; or a healthy fetus may be injured or killed by trauma or infection. The Hollywood staple is for the woman to fall or be pushed down some stairs or fall from a horse. These and many other types of blunt abdominal trauma may injure or kill the fetus and result in fetal loss.

  The symptoms of impending miscarriage include vague or cramping lower abdominal pain, nausea, diaphoresis (sweating), dizziness, and vaginal bleeding. The bleeding may be minimal and spotty, which may occur in pregnancy without impending miscarriage, or it may be brisk and profound. Ultimately, it will become significant and may be associated with "water breaking" if the pregnancy has progressed far enough for a significant amount of amniotic fluid to develop. This would be followed by passage of the fetal and placental tissues. Early on, in a pregnancy that is only a few weeks along, these tissues are amorphous and ragged, looking

  more like a large clot of blood. After two months or so a formed fetus may be expelled.

  A miscarriage may occur fairly suddenly or may stutter along for several weeks, depending on many factors. For example, the woman may experience severe lower abdominal pain, nausea, sweating, weakness, and the passage of blood and tissue over a period of an hour or two. Needless to say, fear and anxiety would accompany this, since this is a painful and potentially lethal event. On the other hand, she might experience several days or weeks of mild cramping and perhaps some spotting. Ultimately, the cramps would become more intense, followed by more significant bleeding and tissue passage.

  Afterwards she may bleed a little or a lot, even to the point of exsanguination (bleeding to death). She may develop an intrauterine infection with high fevers and shaking chills, from which she may or may not recover.

  One hundred years ago there was little that could be done, and survival depended on how severe the miscarriage was, the degree of blood loss, the occurrence of infections (for which there was no treatment), and luck. She would be put to bed, fed lightly, given warm tea, and sponged with water to relieve any fever. The family would gather, the priest would visit, and the doctor, if there was one, would be summoned, though there would be little he could do.

  What Complications of Pregnancy Would Lead to Hospital or Bed Confinement?

  Q: I am writing a story that revolves around the pregnancy of an unwed sixteen-year-old. Her pregnancy is difficult in that she experiences nausea, weight loss, and depression. For plot purposes I want her to be confined to bed for the last several weeks of her pregnancy. I

  know that several problems can lead to this recommendation by her doctor. What are some of the common ones I should consider?

  A: The four most likely would be premature labor, premature rupture of the membranes (water breaking), preeclampsia, and peripartum cardiomyopathy. Let's look at each of these.

  Premature labor is when the uterus begins to have contractions weeks or months before the expected delivery date. If these contractions continue, a premature birth could follow, putting the child's survival in question. Typically, the contractions begin as mild and intermittent lower abdominal discomfort, and progress in frequency and intensity over several days. The expectant mother may ignore or deny them at first, but if they progress, she will have to seek medical help. Mild bleeding or spotting may occur.

  For premature labor she would be given bed rest, though she would likely be able to get up for bathroom use, bathing, and eating. The major concern here is that she avoid as much activity as possible. If the contractions do not subside with these conservative measures, she would be hospitalized and given intravenous magnesium sulfate (mag sulfate, for short) in an attempt to stop the premature uterine contractions. If this is not successful, delivery, perhaps via cesarean section (c-section), might be done.

  Premature rupture of the membranes is when the water breaks weeks or months before the expected delivery date. This is more serious than premature labor. When the membranes break, amniotic fluid is lost, and the "cocoon" within which the fetus lives is breached. This often triggers full labor, followed by delivery, or allows a route for infection to enter the uterus. Occasionally, with proper treatment and good luck, the membranes heal, the amniotic fluid re-forms, and the pregnancy continues as planned.

  For premature rupture of the membranes she would be hospitalized and observed for signs of infection (fever, chills, vaginal discharge) or fetal distress (increase or decrease in the infant's heart rate or abnormal fetal movements). She would be put at strict bed rest and likely placed on intravenous antibiotics. If she was twenty-eight to thirty-six weeks along, her M.D. would try to buy time with this treatment. If she was thirty-six weeks or more, he might choose to induce labor. Either way, if signs of infection or fetal distress appear, delivery would follow in short order.

  Preeclampsia is a common but poorly understood entity. It is estimated that worldwide more than fifty thousand women die from this each year. It is a complex interaction between the mother and the fetus that likely involves the immune system. It is more common with first pregnancies and in women who have diabetes. It is also more common when either the mother or the father was a product of a preeclamptic pregnancy. Curiously, it is less common in women who smoke cigarettes.

  Symptoms and signs of preeclampsia include elevated blood pressure; edema (swelling) of the ankles, feet, and hands, and around the eyes; irritability; headache; lethargy; confusion; and protein in the urine. Untreated, it can evolve to eclampsia, which is marked by seizures, coma, severe elevation of blood pressure, and a high mortality rate.

  If your young lady developed preeclampsia, she would be hospitalized, put at strict bed rest, given intravenous mag sulfate, and placed on diuretics and other medications to control her blood pressure. Again, this treatment would be continued to buy time until the fetus was beyond thirty-six weeks, and then delivery would be performed.

  Another possibility is peripartum cardiomyopathy, a mouthful to say the least. Translation: "Peri" means around. "Partum" means the time of delivery. "Cardio" means heart. "Myo" means muscle. "Pathy" means disease. So peripartum cardiomyopathy means a disease of the heart muscle that occurs around the time of delivery. This is not so difficult after all.

  In cardiology there are several different types of cardiomyopathy. Most have in common a weakness of the heart muscle which leads to the heart's performing poorly as a pump—its main function. The term for this is "heart failure." The weakened heart no longer pumps the blood through the body as vigorously as it should, the blood pressure falls to low levels, pressure builds in the lungs, and the lungs fill with water and become congested—a condition known as "congestive heart failure." Major causes are hypertension (high blood pressure), coronary artery disease with heart attacks, toxins such as alcohol, and virus infections of the heart muscle.

  Peripartum cardiomyopathy is a special form of congestive heart failure. Its cause is unknown, but it occurs in one of every three thousand to four thousand pregnancies. For unknown reasons, during the last month of pregnancy and up to five months after delivery, the mother can develop a wea
kened heart muscle and slip into heart failure. The symptoms are shortness of breath, fatigue, and edema of the legs. The treatment is rest, salt restriction, and diuretics. Sometimes digitalis, which strengthens the heart muscle, is given.

  Typically, it begins in the last few weeks of pregnancy and resolves within a few days after delivery. It worsens with each subsequent pregnancy, and women who suffer this are usually advised against future pregnancies. There is no known way to either predict or prevent its occurrence.

  Over several days to a week your character could gradually become fatigued, gain several pounds in weight (as the body holds on to salt in water), become progressively short of breath, develop swollen ankles, and have to be admitted to the hospital for treatment.

  If you want your young lady to be at home, go with premature labor. If you want her in the hospital, any of these would work.

  What Medical Emergency Would Expose a Young Woman's Secret Pregnancy?

  Q: In my story a sixteen-year-old girl attempts to hide her pregnancy from her parents and is successful for several

  months. At that time I would like for her secret to be discovered in some way that would be dramatic and threatening to her life. I thought about a miscarriage, but could you suggest any other situations that would put her life in danger? I want her to survive but just be scared.

  A: Several situations come to mind.

  A miscarriage, as you suggested, would work well. It could occur in a single dramatic event or progress over several days in a stuttering fashion. She could suddenly develop severe lower abdominal cramping pain with bleeding and expulsion of fetal tissues. If she was several months along, a formed fetus would appear. She could collapse and sink into a state of shock, manifested by low blood pressure, a pale appearance with perhaps a bluish tinge to her fingers and toes and around her lips, and a cold, clammy sweat. She would be taken to the hospital emergency room, where IVs would be started and blood and fluids given, and then she would be taken to surgery for an emergency D and C. In this procedure the physician, likely a gynecologist, would remove any retained tissues from the uterus.

  Alternatively, she could develop episodic pains, with or without vaginal bleeding or spotting, which would progress until the miscarriage occurred. A visit to the hospital and a D and C would follow. In either circumstance, she would remain in the hospital for a few days but would likely recover completely without any long-term problems—at least, physical problems. Her psychological reactions could be long term and significant.

  Another possibility would be an ectopic pregnancy. During fertilization the egg leaves the ovary, finds its way to the mouth of the fallopian tube, and begins to descend toward the uterus. The sperm enter the cervical os (the opening at the end of the cervix) and swim through the cervix and into the uterus. They then migrate up the fallopian tube, where they meet the descending egg. One

  wins the race, and the actual fertilization takes place within the fallopian tube. The fertilized egg continues downward and into the uterus, where implantation in the endometrium, which lines the uterine wall, occurs and the pregnancy commences.

  Sometimes the fertilized egg gets hung up in the fallopian tube (Figure 10). The zygote (the ball of cells that will grow into the fetus) develops normally and continues to enlarge just as it would in the uterus. Early on, the mother's symptoms would be exactly the same as if she had a normal intrauterine (inside the uterus) pregnancy. She may suffer morning nausea, mood swings, breast tenderness, and all the other symptoms of pregnancy. Testing for pregnancy would be positive, and no one would know or suspect that anything was wrong. As the fetus develops and grows, however, the fallopian tube, unlike the uterus, cannot expand to accommodate the enlarging fetus. Ultimately, the fallopian tube ruptures. This may take six to twelve weeks.

  The symptoms are similar to a miscarriage except the abdominal pain may be more severe and in the right or left side of the lower abdomen, depending on which tube held the ectopic pregnancy, rather then centralized in the mid portion of the lower abdomen. Vaginal bleeding may be much less dramatic or may not occur at all, since the ruptured fallopian tube would bleed into the abdominal cavity and the uterine os would not likely open to allow passage of blood as it does in a miscarriage.

  An ectopic pregnancy typically causes abdominal pain on the right or left side for several days before it ruptures. It is often confused with appendicitis, since the symptoms are similar. A pelvic exam usually reveals a palpable mass in either the right or left lower abdomen in the area of the fallopian tubes and ovaries—an area called the adnexa. If she saw her gynecologist at this stage, he would determine that she had a positive pregnancy test and a tender adnexal mass, and would likely obtain an abdominal ultrasound (a picture of the abdominal contents using sound waves) and make

  the diagnosis of an ectopic pregnancy. Surgery would follow. The affected fallopian tube would be removed. She could still have future pregnancies since the other tube, the ovaries, and the uterus would remain intact.

  If she ignored or denied the abdominal pain, it would progressively become more severe and more frequent, but vaginal bleeding or spotting would be unlikely. Eventually, tubular rupture would occur.

  Another scenario is that her fear of discovery would lead her into the hands of an unlicensed and unscrupulous clinic where abortions are done, no questions asked—for a hefty fee, of course. Here an unqualified physician or nurse or someone with no medical training at all would perform a makeshift D and C using improper equipment and with poor, if any, sterile technique. The life-threatening complications that might follow are many and severe.

  She could continue to bleed from trauma that occurred during the procedure or from retained tissues, if the D and C was incomplete. Pain and bleeding would continue over several days, she would become progressively weaker and more anemic, and her secret would likely be discovered.

  She could suffer a perforation of the uterus, a common occurrence in the days of coat hanger abortions. Here, the instrument used to clean out the unwanted pregnancy pushes through the uterine wall and into the abdomen. The uterus is actually perforated quite easily, and physicians performing therapeutic abortions or D and C's are very cognizant of this fact and take great care to avoid this complication. This is a very painful event and leads to severe bleeding and shock. Death is common, since the uterus tends to bleed a great deal when damaged in this manner. Emergency surgery for repair or removal of the uterus would be lifesaving.

  She could survive the abortion only to develop an infection several days later. Infections within the uterus are particularly treacherous. The uterus has little capacity to contain infections, and, thus, any bacterial organisms introduced into the uterine cavity by improper sterile technique quickly enter the bloodstream and lead to septicemia (bloodstream infection) and septic shock. Septic shock occurs when the toxins of the bacteria cause severe derangements in the cardiovascular controls of blood pressure and the ability of the body's tissues to use oxygen. The symptoms and signs of septic shock include low blood pressure, high temperatures, shaking chills, confusion, disorientation, and ultimately death. This type of infection has a high mortality rate. Surgical removal of the uterus, high doses of antibiotics, intravenous steroids, and drugs to support the blood pressure are needed if survival is to be realized (dopamine, epinephrine, and Dobutamine are commonly used intravenous agents for this purpose).

  What Is the Gulf War Syndrome?

  Q: I need some information about the Gulf War Syndrome for a short story I am writing. Everything I've read is confusing, and there seems to be a great debate as to whether it is real or not. Is it? What causes it, and how does it affect the people who have it? Is there any treatment for it?

  A: Your confusion is justified. Even the experts argue over whether it is real and, if so, what its causes are. It is a broad and complex subject, and our understanding of the syndrome is in a state of evolution.

  The controversy began when many members of our military who ret
urned from the Persian Gulf War began to exhibit unusual symptoms. The most common were fatigue, headaches, memory loss, insomnia, various rashes, swelling and burning of the feet and hands, joint pain and swelling, chronic cough, muscular weakness, loss of coordination, numbness and tingling in their extremities, rectal bleeding, and cardiac arrhythmias with palpitations. This constellation of symptoms became known as the Gulf War Syndrome (GWS).

  In medicine the term "syndrome" refers to a group of signs and symptoms that occur together often enough to be recognized as a distinct entity but for which no causal or physiologic relationship has been established. If a man and a woman are walking down the street holding hands, it doesn't mean they are married. In a syndrome the signs and symptoms hold hands, but marriage or any other relationship between them has not been scientifically established. This is the case with GWS.

  The cause of GWS is unknown. Some feel it is entirely psychosomatic, while others suggest it is from chemical or biologic weapons

  used by the Iraqi military or it is the result of our destruction of their chemical weapons bunkers, which released the agents into the air and exposed our troops to the toxic vapors. Still others believe it is related to the vaccines against anthrax and botulinum that our soldiers received or perhaps to the pyridostigmine bromide pills that were given to counteract the effects of many known chemical weapon compounds. The most likely explanation may be a combination of all these. That is, the toxic symptoms may result from a mixture of vaccines and medicines that the soldiers were given and the chemical and/or biologic agents to which they were exposed.

  Toxic chemicals that the Iraqi military possessed at that time include sarin, Soman, Tabun, VX, hydrogen cyanide, cyanogen chloride, mustard gas, thiodiglycol (a precursor chemical of mustard gas), and Lewisite. Possible biologic agents include botulinus toxin and anthrax.