Am J Surgery 1952 V-84

HE woman about to become a mother or with a new-born infant upon her bosom, should T be the object of trembhng care and sympathy wherever she bears her tender burden, or stretches her aching Iimbs. The very outcast of the streets has pity upon her sister in degradation, when the seal of promised maternity is impressed upon her. The remorseIess vengeance of the law brought down upon its victims by a machinery as sure as destiny, is arrested in its faI1 at a word which reveals her transient claim for mercy. The solemn prayer of the Iiturgy singles out her sor- rows from the muItipIied triaIs of Iife, to pIead for her in her hour of peri1. God forbid that any mem- ber of the profession to which she trusts her life, doubIy precious at that eventful period, should hazard it negIigentIy, unadvisedly or selfishly. OLIVER WENDELL HOLMES

11th of the Series

ABRUPT10 PLACENTAE*

CHARLES A. GORDON, M.D. Professor Emeritus of Obstetrics and Gynecology, State University of New York, College of Medicine (New York City)

ALEXANDER H. ROSENTHAL, M.D. AND JAMES L. O’LEARY, M.D. Associate Professor of Clinical Obstetrics and Associate Obstetrician and Gynecol- Gynecology, State University of New York, ogist, St. Catherine’s Hospital College of Medicine (New York City) Brooklyn, New York

NE of the greatest hazards of chiIdbirth was performed about five hours after admission. for both mother and baby is abruptio Examination of the abdomen reveaIed a tender, 0 pIacentae. The major determinants of board-like uterus characteristic of compIete mortality associated with separation of the separation of the placenta. No feta1 heart placenta are stiI1 hemorrhage and shock even sounds were heard. though the avaiIabiIity and earIy administra- At operation under IocaI anesthesia the tion of sufficient amounts of bIood have re- uterus was enlarged to the xiphoid process and suIted in some Iowering of the death rate. New of a dark purpIish hue with ecchymotic areas probIems have arisen. Although hemorrhage in the broad Iigaments. A smaI1 amount of and shock are adequateIy treated, death may oc- bIoody peritonea1 fluid was present. A low cur from acute renaI faiIure or afibrinogenemia. vertica1 incision was made and a dead fetus CASE I. A twenty-seven year oId.primipara deIivered. The pIacenta was found compIeteIy with vagina1 bIeeding in the eighth month of separated with numerous Iarge retroplacental pregnancy was admitted to the hospital in blood clots. BIeeding was not unusual. shock. Her antepartum course had been un- The patient’s condition was fair at the end eventful except for miId toxemia. Immediate of operation. Her bIood pressure was go/50 and shock treatment consisted of morphine, intra- her puIse 130. Another 500 cc. of bIood with venous glucose and TrendeIenburg position. glucose infusions were given but shock became After considerabIe deIay she was given I ,000 cc. deeper and death occurred six hours Iater. of blood and she recovered from shock. Surgery CASE II. A multipara with miId toxemia

* Cases are from the Committee on MaternaI Welfare of the MedicaI Society of the County of Kings, Brooklyn, N. Y. The text of the case reports is essentiaIIy as submitted to the Committee. The views expressed are those of the authors.

October, 1952 459

history-of-obgyn.com 460 Gordon et aI.-Abruptio PIacentae was admitted to the Jlospital after sharp bIeed- The symptoms of abruptio pIacentae vary ing during the seventh month of pregnancy. with the degree of separation. In the mild Her bIood pressure was 142/‘87. The uterus was forms the onIy finding may be a somewhat of normal size, the feta1 heart sounds were good increased broody show as Iabor progresses. and the cervix undilated. Vagina1 spotting Variation in feta1 heart rate wiJ1 be noticeable occurred for a few days. Cystogram was nega- only when Iarger areas of the placenta separate. tive for placenta previa, so the diagnosis was A history of toxemia is often eIicited, or the separation of the pIacenta and observation was blood pressure elevation and proteinuria char- continued. acteristic of toxemia may be observed at the One week later the patient had occasiona time of bIeeding. The greater the separation pain and passed a few blood clots. She was then the easier the diagnosis. The board-like rigidity taken to the operating room which was pre- of the uterus with areas of tenderness is pared for cesarean section and examined pathognomonic; absence of the feta1 heart tones vaginaIIy. When the cervix was found 3 cm. is confirmatory. Vagina1 bIeeding usuaIIy occurs dilated and the presentation vertex, the mem- and may be so profuse as to suggest pIacenta branes were ruptured. Labor progressed rapidly previa. The amount of externa1 bleeding, how- with deIivery of a 4 pound fetus within two ever, is no index of the severity of separation. hours. The pIacenta with about 1,000 cc. of CompIete separation with massive bIeeding bIood promptIy folIowed. Intravenous ergotrate may have occurred and yet hemorrhage be controIIed hemorrhage but the patient was in conceaIed. shock. She was given 500 cc. of blood which Concealed hemorrhage is more often than had been cross matched before deIivery, and not associated with hypertension and protein- 2 units of pIasma were administered whiIe uria. These patients are so often in shock that awaiting more bIood. There was no further materna1 hazards are greatIy increased. It is in bIeeding but death occurred one hour Iater. the management of these patients that there Examination of the pIacenta reveaIed a dark are differences of opinion. blood cIot covering about one-haIf the materna1 The etioIogy of abruptio pJacentae is still surface. obscure. It is quite likely that there is a link to toxemia. There may be a history of repeated Questions. (I) How common is abruptio episodes of premature separation of the pIa- pIacentae? (2) What are the symptoms? (3) centa in successive pregnancies. There is IittIe How is it produced? (4) Is the diagnosis diffl- doubt that the precipitating cause of sepa- cuIt? What is the differentia1 diagnosis? ration is degenerative changes in the materna1 Answers. The incidence of premature sepa- vesseJs at the pIacenta1 site. ration of the normaIIy impIanted pIacenta is Traction on a short cord and external trauma not known. Reports show a varying incidence have Iong been mentioned as causes of abruptio of from I : 80 to I : 250. Discrepancies depend pIacentae. Their occurrence seems improbable upon the different criteria accepted for diag- or at best quite rare. nosis. The degree of abruptio pIacehtae may In both of the aforementioned cases placentaI range from the simpIe evidence of a cIot found separation occurred prior to the onset of labor. upon the placenta at deIivery to compIete BIood pressure determinations are misIeading; separation resuIting in the death of the fetus. once separation begins and internal bIeeding Classification of cases by the severity of the occurs, bIood pressure evidence of hypertension maternal symptoms serves us best in outlining may no Ionger be present. MaternaJ mortality treatment, Patients with a Iigneous uterus, is high in this type of case. absent feta1 heart sounds and some evidence of In differentiaJ diagnosis pIacenta previa is shock may be classified as having severe con- most often confused with abruptio pIacentae. ditions; the remainder are either miId or ObviousIy there will be no difficulty when the moderate depending upon the amount of bleed- uterus is hard and tender and feta1 heart tones ing and degree of fetal embarrassment. It is are absent. When most of the bIeeding appears clear that abruptio placentae is not a we11 de- externaIIy, there will be no tenderness or fined entity Iike pIacenta previa. In miId cases spasticity of the uterine muscIe. On vaginal the frequency of diagnosis wiI1 depend to a examination pIacenta1 tissue will not be found great extent upon the obstetrician. and the diagnosis of separation becomes more American Journal of Surgery

history-of-obgyn.com Gordon et al.-Abruptio Placentae 461 apparent. Cystograms are of very little clinical prenatal care from the early months of preg- value. Rupture of the marginal sinus of the nancy. Her course had been uneventful except placenta cannot be differentiated from partial for mild toxemia during the last month. separation of the placenta until after delivery, She was admitted to the hospital at term and even then with difficulty; bleeding is with nausea, vomiting, pain in the lower usually not profuse and in either case treatment abdomen and scant vaginal bleeding. The is the same. Vasa previa, fortunately a rare pain was not severe but was persistent. Her complication, may be confused with separation blood pressure was I 10/70 and pulse varied of the pIacenta; only postpartum examination from 80 to I IO. The uterus was in a state of of the placenta and membranes will make this tonic contraction. No areas of tenderness were diagnosis. Spontaneous rupture of the uterus, noted and no fetal heart sounds were heard. which is very rare, should present no problem The patient’s blood was immediately typed in diagnosis. but blood was not on hand so blood plasma was * * * * administered. When rectal examination showed the cervix to be 3 cm. dilated, a tight abdominal CASE III. The patient was a quadripara binder was applied and pituitrin given in ? 4 whose first pregnancy had been complicated minim doses. Seven hours later the patient by severe toxemia ten years before. Her blood was delivered by low forceps under general pressure had remained elevated. When regis- anesthesia. Delivery was effected easily and tered in the clinic during the eighth month of the placenta followed immediately with about pregnancy she had proteinuria and her blood 2,000 cc. of bIood, mostly in the form of old pressure was 180/110. Hospitalization was re- clots. The fundus contracted down well and jected by the patient. She was placed on a salt- there was no further bleeding until twenty poor diet, given sedation and advised as to minutes later when the uterus relaxed. A necessity for rest. During the next month she uterine pack was then inserted with apparent was observed at weekly intervals. Her blood control of bleeding. Following this the blood pressure dropped to 160/ 100 and proteinuria pressure was I 10/66 and the pulse 150. An- diminished. A few days after her last prenatal other 500 cc. of blood and a second unit of visit she was admitted to the hospital with plasma were then given. The patient became severe abdominal pain and scant vaginal bleed- very restless, shock deepened and death ing. Her blood pressure was 80/40; pallor was occurred two hours later. Bleeding had con- marked with some cyanosis. The uterus was tinued in spite of the uterine pack. described as ligneous with definite areas of tenderness. No fetal heart sounds could be Questions. (I) Is the primipara or multipara heard. Shock treatment consisted of morphine, more likely to develop premature separation oxygen and transfusion of 1,000 cc. of blood. of the placenta? (2) How is abruptio placentae Five hours later she recovered from shock, best managed? so the membranes were ruptured and a Voor- Answers. It is not surprising that abruptio hees bag introduced. Pituitrin was administered placentae is more frequentIy observed in the m $6 minim doses at thirty-minute intervals. muItiparous patient. With few exceptions, After the third dose she went into active labor notably pre-eclampsia, repeated childbirth is and delivered spontaneously two hours later. associated with an increased number of ob- Her condition during labor was fair, the blood stetric complications. Multiparity and hyper- pressure being loo/ 130 and the pulse 80. tensive vascular disease occur more often in the Following delivery of a stillborn fetus the older age groups as does premature separation placenta was expressed with numerous large of the placenta. blood clots. Bleeding was so brisk for several Proper management of abruptio placentae minutes that the patient lost another 800 cc. is a real challenge today. Death rates for of blood. Bleeding was controlled by intra- mother and baby are stil1 high despite avail- venous ergotrate and uterine massage. The ability of blood and improved operative and patient relapsed into shock. Her blood pressure anesthetic technics. was not obtainable and death occurred two Prevention is not feasible inasmuch as the hours later. underlying cause is not known; nor can the CASE IV. A young primipara received good solution be found in better prenatal care, as the

October, 1952

history-of-obgyn.com 462 Gordon et aI.-Abruptio PIacentae incidence of abruptio pIacentae seems to vary examined vaginaIIy in bed, the membranes IittIe whether prenata1 care has been good or ruptured and the ripeness of the cervix deter- otherwise. Earlier induction of Iabor in some mined. This can best be discovered by vagina1 patients with chronic hypertensive disease examination. Recta1 examination may be mis- compIicated by toxemia may be indicated. Ieading. Has the cervix been so conditioned by If our resuIts are to improve, we must direct hormona1 and vascular changes, and Braxton our attention to better management of the Hicks contractions that one can anticipate patient once separation has occurred. Most that the uterine contractions of Iabor wiIl separations which occur during Iabor are miId resuIt in a rapid progressive dilatation of the or moderate in type and the prognosis for cervix? The compieteIy effaced, soft and mother and baby is good. In these cases diIatabIe cervix is obviously ripe, just as the mechanica factors probably pIay a large role, cIosed, firm and Iong cervix is obviously such as traction on the pIacenta1 edge by intact unripe. However, in most cases the degree of membranes or rupture of materna1 decidua1 ripeness of the cervix wiI1 be somewhere vesseIs secondary to uterine contractions. EarIy between these two extremes. Just as the recognition is important from the standpoint experienced housewife chooses the ripe meIon of fetal saIvage. Routine amniotomy shouId be by paIpation, so does the obstetrician recog- performed whenever separation is suspected nize the cervix which Iends itself to vagina1 during Iabor. The feta1 heart tones shouId be deIiverabiIity. checked more frequentIy and pitocin stimuIa- The ripe cervix wiII be recognized by a tion of Iabor wiI1 be indicated if uterine inertia certain softness which invoIves the entire is present. In this type of case we are concerned organ, the so-cahed “diIatable feeI.” The primariIy with the weIfare of the baby. An amount of diIatation is not important, yet occasiona indication for cesarean section may this type of cervix wiI1 aIways admit one finger arise in the presence of persistent or increasing with ease. In the primigravida effacement wiI1 evidence of feta1 distress. Good judgment wiI1 aImost aIways be compIete and the cervica1 be necessary. It is principahy in the conceaIed cana wiI1 be short. In the multipara effacement hemorrhage or so-caIIed toxic group that the is neither necessary or common. The cervix mortality is so high, being cIose to IO per cent may be ripe yet a good inch in Iength. The for the mother and IOO per cent for the fetus. shape of the cervica1 cana1, however, is im- Cases III and IV illustrate we11 the usua1 portant. If the interna OS is closed and the symptoms and course of the toxic type of cervica1 canal cone-shaped, the cervix is not abruptio placentae. Onset of symptoms began ripe no matter how soft it may be. It is diffrcuIt prior to the onset of Iabor and consisted of to describe the cervix which is fuIIy prepared abdomina1 pain, tenderness and spasticity of for the onset of labor. Actually there is no the uterus, absent feta1 heart tones and substitute for experience. evidence of shock. Vagina1 bleeding was scant Following vagina1 examination conservative or absent at the onset and shock was out of all treatment is continued or the patient is pre- proportion to the amount of externa1 bleeding. pared for cesarean section. Occasionahy a Shock therapy was deIayed or ineffectua1 due patient wiI1 deIiver or so progress in Iabor that to inadequate amounts of bIood given too Iate. delivery wiI1 become imminent whiIe the oper- Usually no less than 1,500 cc. of blood and ating room is being prepared. An impressive sometimes greater amounts are required to combat feature of abruptio pIacentae is the rapidity initial shock. GIucose solutions shouId be ad- with which deIivery is compIeted in the major- ministered whiIe awaiting bIood. A venocIysis ity of cases. It wouId appear as though nature, should be functioning at al1 times with a needIe reaIizing the error of her ways, attempts to save no smaller than 17 or 18 gauge. face. Treatment is instituted as soon as the An important compIication of abruptio patient is admitted to the hospital. One does placentae is the oIiguria and anuria which not procrastinate whiIe waiting for transfusion resuIt from renaI spasm and ischemia. The to be completed or for operating rooms to be obstetrician may be so busy combating shock set up. Intravenous pitocin, 5 minims in 500 cc. and acceIerating delivery that no attention is of gIucose, is given by sIow intravenous drip. paid to urinary output. We may rescue the If the diagnosis is clear, the patient may be patient from hemorrhage and shock yet permit American Journal of Surgery

history-of-obgyn.com Gordon et aI.-Abruptio PIacentae 463

her kidneys to die. A retention catheter shouId During the lirst tweIve hours postpartum be pIaced in the bladder at the time of vaginal the patient did not void and but 4 cc. of bloody examination and the urinary output checked urine were obtained by catheter. Treatment at so-minute intervals. Persistence of anuria consisted of hot packs over the Iumbar area, or marked ohguria despite adequate shock hot enemas, potassium citrate, fluids by mouth therapy and fluid replacement indicates severe and 300 cc. of IO per cent gIucose by vein. renal spasm. BIood pressures should be deter- OIiguria persisted. Continuous high spina anes- mined at haIf-hour intervals. Of themselves, thesia for tweIve hours did not increase urinary however, they may not be reIied upon, for output. No improvement in urinary output apparently normal readings may be shock folIowed decapsulation of both kidneys. The levels for patients previousIy hypertensive. patient’s hemoglobin was now found to be Proteinuria is secondary to shock and renal 36 per cent and the non-protein nitrogen 104 ischemia. It may not be due to toxemia. mg. A bIood transfusion of 500 cc. was ad- Dilating bags have no pIace in treatment; ministered. The bIood pressure fluctuated be- nor is there any good reason for the cervical tween 1soj70 and 180/70. Vomiting, dyspnea pack which may further traumatize an already and pulmonary edema foIlowed and the patient shocked patient and interfere with observation died on the fourth postpartum day. Autopsy on the progress of labor. It serves little purpose. showed pulmonary edema and cortica1 necrosis The time-honored abdomina1 binder and of both kidneys. Spanish windIass is condemned on mechanical CASE VI. A gravida II, para I reported to and physioIogic grounds. It may injure an her obstetrician when about eight weeks preg- already edematous and perhaps hemorrhagic nant. Total weight gain during pregnancy was uterine wall. The binder cannot limit placenta1 24 pounds and the patient’s blood pressure was site bIeeding and it interferes with respiratory 130/80. In the fortieth week of pregnancy she movements, increasing anoxia. Most important, entered the hospital with profuse vaginal it severeIy harrasses an already acutely ill bIeeding. Her bIood pressure then was rgojgo. patient. The uterus was hard and in tonic contraction The essentials of treatment are: (I) morphine and no feta1 heart sounds were heard. Vaginal for pain, (2) oxygen to combat anoxia, (3) bleeding continued and one hour after ad- earIy and vigorous shock therapy, (4) carefu1 mission the patient was in shock. She was given check of bIood pressure and urinary output, (5) plasma and morphine sulfate whiIe awaiting rupture of membranes and stimuIation of Iabor bIood. Three hours Iater she was examined in a11 cases and (6) cesarean section for some vaginaIIy. The cervix was found 3 cm. diIated patients. and the vertex engaged. The membranes were * * * * then ruptured and the patient was given CASE v. A twenty-six year old gravida II, 4 minims of pituitrin. Spontaneous delivery para I entered the hospita1 with a history of occurred within three hours. The lirst bIood severe Iower abdomina1 pain and scant vagina1 transfusion had been given just prior to de- bleeding. Her antenatal course had been nor- Iivery. The pIacenta showed evidence of retro- mal as had her previous pregnancy and de- pIacenta1 hemorrhage. livery. The uterus was tender and firm and no The next day the patient’s general condition fetal heart sound could be heard. Her bIood appeared to be good. Her temperature was pressure was I 18/60 and urinaIysis showed normal, the pulse 80 and the blood pressure proteinuria. On vagina1 examination the cervix r5o/go. Only 40 cc. of urine were passed after was found I cm. diIated; the vertex was above delivery and this showed heavy proteinuria and the brim. The membranes were then ruptured many casts. Another 500 cc. of bIood and and I minim of pituitrin administered. After 1,000 cc. of sodium lactate solution were then three hours of active Iabor a stillborn fetus was administered. delivered. During Iabor the patient’s bIood Oliguria persisted and but IO cc. of urine pressure rose to r6o/go foIlowing bIood trans- were passed on the second day. Urinary output fusion. The pIacenta was promptly expressed from the third to the ninth postpartum days with about 1,000 cc. of old bIood and clots; the varied from 125 to 300 cc. For a rather uterus contracted we11 and there was no further marked anemia, brood transfusion of 1,000 cc. bleeding. was administered on the fourth postpartum day October, I 952

history-of-obgyn.com 464 Gordon et al.-Abruptio Placentae

and goo cc. of blood on the sixth and seventh serious cases of premature placental separation. days. On the eighth day the hemoglobin was In Brooklyn nephron nephroses and cortical 8.2 gm. Non-protein nitrogen, urea and creati- necroses are responsible for an increasing per- nine were rising. The CO2 combining power of centage of the maternal deaths due to abruptio the blood was 67 per cent. Ffuid intake by pfacentae. Prompt treatment and greater mouth was estimated at 2,000 cc. daily. On the availability of bfood have reduced the immedi- ninth day the patient became comatose and ate mortafity due to hemorrhage and shock. died during a convulsion. Autopsy showed Shock associated with abruptio placentae is pufmonary edema and fower nephron nephrosis. even more important than was previously CASE VII. A primipara in the eighth month realized. It is now believed that the kidney of pregnancy was admitted to the hospitaf with lesions are the result of anoxia resulting from abdominaf pain and vaginal bleeding. Abdomi- renaf spasm. The type of lesion and its extent nal pain was severe and continuous, paffor was wifl depend upon the amount of vascular spasm marked and she compfained of blurred vision. and, what is more significant, its duration. A The blood pressure was 156/130, and her pufse continued low blood pressure means increasing regular and of good quahty. There was no tissue anoxia with the ever present possibility edema. The uterus was tender and tense. No of irreversible changes in the kidneys. Pro- fetal heart sounds were heard. On rectal exami- longed or exiensive renal spasm wiff result in nation the vertex was at the spines, the cervix cortical necrosis. Less extensive spasm causes a I cm. dilated and the membranes intact. No fesion more commonfy known as fower nephron urine was obtained on catheterization. nephrosis. In many cases, however, the entire Blood was transfused and cesarean section nephron is involved. Frequentfy patchy lesions performed. The peritoneal cavity contained of both types will be found in the same kidney free blood. The uterine serosa was covered with due to the varying degrees of arterial spasm. large scattered purplish areas. After removaf of From the standpoint of therapy the signifi- placenta and large dark bfood cfots the uterus cant factor is the duration of ischemia. The contracted well and was not removed. The onset of renaf spasm appears to coincide with patient did wef1. On the second postpartum day the onset of the abruptio placentae, or occurs the hemoglobin was 48 per cent. Repeated shortly afterward. Fortunately in most cases, blood transfusions with washed erythrocytes regardfess of treatment, spasm fasts but a short were administered. time and resufts only in temporary proteinuria During the first forty-eight hours but fifteen and ofiguria. drops of urine were obtained. On the second day, Abruptio placentae is a grave obstetric emer- after consuftation with the anesthesia depart- gency in which the patient’s lije depends as much ment, epidural block anesthesia was given for upon tbe speed with which treatment is initiated twenty-four hours without success. There was as upon the adequacy of that treatment. Every no restriction of fluids and 35 mofar factate effort must be made to shorten the period of sofution was administered by vein. The blood ischemia. As we have pointed out, the ob- pressure was 165,/90. On the third day the stetrician treating a patient dangerously ill of kidney pefves were irrigated with saline and shock and hemorrhage may easify lose sight of 15 cc. of bfoody urine obtained. On the fourth anuria. Frequently no consideration is given day the patient had loose, watery stools. Efforts to renal ischemia until the patient has suffered were made to induce diaphoresis. The temper- severe or irreparable damage to her kidneys. ature ranged between 99’ and 101.8%. Anuria BIood repfacement in these cases was inade- was finaffy compfete. On the sixth day after two quate. It may be truly said of abruptio pfa- convuIsions the patient died. centae that one cannot appreciate the amount of hemorrhage by the bIood that escapes from Questions. (I) Are kidney complications the vagina. Blood pressure determinations may common sequefae of abruptio placentae? (2) give a fafse sense of security. Bfood repface- What is the cause of acute renaf failure? How ment of fess than 1,500 cc. is usuaffy insuffr- is it best managed? cient. If shock therapy is adequate and oIiguria Answers. Acute renal faiIure as a cause of shoufd persist, relief of arteriaf spasm may be death is definitely on the increase. It is esti- attempted with fow spinal anesthesia. To be mated to occur in 6 to IO per cent of the more successful it must of course be done before American Journal of Surgery

history-of-obgyn.com Gordon et al.-Abruptio Placentae 465 ischemia has resulted in necrosis. When used heart sounds were reguIar and strong. The twenty-four and forty-eight hours postpartum uterus was somewhat tense but this was results are bound to be unsatisfactory. thought to be due to irritabiIity associated Confronted with the problem of oliguria or with the onset of Iabor. Her antenata1 course anuria, many are seized with an uncontrollable had been normal except for excessive weight urge to stimuIate kidney function. AI1 of the gain. Her blood pressure was 130/80. folIowing methods were used, and as might be Six hours later the patient complained of expected, to no avai1: hot packs, hot enemas, severe backache but did not appear to have frequent bIood transfusions (too Iate), irriga- labor pains. Her bIood pressure was I 10,/70 tion of kidney peIves, Iumbar diathermy, and the pulse 80. Rectal examination showed diuretics, renal decapsuIation and, lastly, no change so an enema was ordered, pIus two forcing of fluids. The horse which is being doses of quinine to be given at hourIy intervals. whipped is not onIy tired but also graveIy ill. Two hours Iater she had a hemorrhage of about Rational treatment must be based on the 500 cc. She grew paIe and her puIse was rapid. knowIedge that persistent oliguria foIlowing FetaI heart sounds could not be heard. She abruptio pIacentae means either cortica1 necro- was given morphine suIfate, I ,000 cc. of gIucose sis or nephron nephrosis. DifferentiaI cIinica1 and then 500 cc. of pIasma whiIe blood was diagnosis is not possibIe aIthough occurrence being cross matched. of frank hematuria points to the more serious When the cervix was found to be fully cortica1 necrosis. If renal failure shouId be due diIated, the membranes were ruptured and a to the more common nephron reversibIe Iesion, stiIIborn fetus deIivered by Iow forceps. The carefu1 contro1 of the patient during the first placenta and Iarge cIots immediateIy foIIowed eight to tweIve days wiI1 lower mortaIity. birth of the baby. Ergotrate was given intra- Attempts to stimulate renal function will be futile venousIy and pituitrin intramuscularly, and a and may result in jurther damage. blood transfusion of 500 cc. was begun at this FIuid baIance must be maintained in order time. When bIeeding continued, the uterus and to prevent puImonary edema which occurred vagina were packed. The patient was in pro- in these three cases. Intake of fluids shouId found shock when a second transfusion was never exceed the insensible Ioss pIus the equiva- begun. One hour later blood was seeping lent of the previous day’s urinary output. through the packing. WhiIe preparing for Anemia is best treated by the use of packed red hysterectomy shock deepened and death oc- ceIIs rather than whoIe bIood. Sodium chloride curred two hours postpartum. is contraindicated because of renaI inabiIity to CASE IX. A thirty-three year oId woman excrete saIt, the risk of edema and necrotizing whose first pregnancy had been interrupted for arteriolitis. Azotemia appears early but is not to toxemia was admitted to the hospita1 in the be feared; blood urea and non-protein nitrogen eighth month of her second pregnancy, com- levels rise markedly but they have little bearing pIaining of severe abdomina1 pain and scant upon the outcome. Acidosis is important. High vagina1 bIeeding. During the previous month carbohydrate diet is advised as Iiver damage her systolic bIood pressure had risen from 130 may occur. If the patient is successfuIIy carried to 170. The uterus was very hard and tender through the oliguric stage of eight to twelve and fetal heart sounds were not heard. days, regeneration of tubuIar epithelium can The membranes were ruptured, pituitrin take place and marked diuresis begin. Adminis- was administered and spontaneous delivery tration of Iarge amounts of fluid and salt wiII of a stilIborn fetus quickly followed. LocaI then be indicated. CarefuI daily determination anesthesia was used during repair of the peri- of the volume and saIt content of urine are neum. Many bIood cIots were extruded with necessary in estimating repIacement. the pIacenta. While bIeeding continued, the vagina was packed then repacked and blood * * * * transfusion of 1,000 cc. administered. It was CASE VIII. A thirty-six year oId multipara noted that the bIood showed no tendency to was admitted to the hospita1 at term with a clot. heavy bloody show and irregular uterine con- Four hours after deIivery a supravaginal tractions. The cervix was found to be z cm. hysterectomy was performed without difficulty diIated and the vertex at the spines. The feta1 but al1 cut surfaces bled freely and good

October, 1952

history-of-obgyn.com Gordon et aI.-Abruptio Placentae

hemostasis couId not be obtained. FolIowing tion of the hemorrhagic tendency. Fresh bank operation the patient continued to bIeed from blood because of its increased clotting abiIity the vagina and the abdomina1 incision. Prota- should be administered in Iarge amounts. It mine sulfate, vitamin K and thromboplastin shouId be routine to order this type of bIood were given without effect. Vagina1 bIeeding for a11 patients with abruptio placentae continued for ten hours after hysterectomy. whether afibrinogenemia is suspected or not; AI1 toId, 6 pints of bIood were administered, ordinary bank bIood should of course be ad- yet the patient graduaIIy sank deeper into ministered in the meantime. shock and expired. When conservative treatment is carried on, a 5 cc. sample of the patient’s blood should be Questions. (I) Is postpartum hemorrhage taken at hourIy intervaIs, IabeIed and aIIowed common in abruptio pIacentae? (2) May the to stand at room temperature. The formation blood-cIotting mechanism be disturbed? (3) of a poor cIot or subsequent dissoIution of the If so, how may this be diagnosed and treated? cIot shouId point to a disturbed cIotting (4) How may the high feta1 mortaIity be mechanism; and unIess deIivery is imminent, Iowered? cesarean section may be indicated to Iessen Answers. Contrary to what might be ex- the hazards of further fibrinogen depIetion. pected, postpartum hemorrhage folIowing ab- It goes without saying that adequate bIood ruptio pIacentae is not commonIy encountered. repIacement must be avaiIabIe before attempt- If genera1 anesthesia is avoided, prompt and ing deIivery, abdomina1 or otherwise. It is adequate treatment instituted, postpartum hoped that in the near future virus-free fibrino- hemorrhage as a cause of death shouId be gen for intravenous use wiI1 become com- eliminated. True enough third stage bIeeding merciaIIy available for treatment. will occur more often than in uncompIicated Recent advances in obstetrics have resuIted delivery and preparations shouId be made for in marked Iowering of cesarean section mortaI- its control. As stressed repeatedly in these ity rates, thus broadening indications for the Obstetric CIinics, too much emphasis cannot operation. PureIy feta1 indications are now be pIaced upon the vaIue of a functioning being accepted as vaIid reasons for cesarean venoclysis through a Iarge bore needle with section. In fact, even impIied fetal risk such as cross matched bIood avaiIabIe. Where bIood may be associated with breech presentation must be given rapidIy, the addition of smaI1 in the primipara, or toxemia, has been accepted amounts of procaine wiI1 overcome venous as sufficient reason for cesarean section in we11 spasm and faciIitate administration. Increased chosen cases. CertainIy in abruptio placentae pressure by the use of high IeveIs of the bIood the risk is more than impIied; and if we are container or the addition of a hand pressure to lower its exceedingIy high fetal mortaIity, bulb are also advised. we must concern ourseIves not only with early In some severe cases of abruptio a grave diagnosis but aIso with earIier cesarean section. but fortunateIy rare disturbance in the blood- In evaIuating treatment and the feta1 prog- clotting mechanism is observed. As the resuIt nosis, the presence or absence of associated of the absorption of a pIacenta1 or decidua1 toxemia may be of more importance than the substance, probabIy thromboplastin, a rapid amount of bleeding. Often in toxemia the and disseminated intravascuIar coaguIation pIacenta1 reserve has been so diminished that occurs invoIving chiefly the arterioIes and the Ioss of a smaI1 additional part of its effective capiIIaries. This may account for the liver and area of exchange may resuIt in fetal death. pituitary necrosis occasionally associated with The immediate management of the baby abruptio. during its first minutes of Iife is of prime im- When this intravascular clotting process is portance. More often than not, and rightIy so, extensive, afibrinogenemia results, i.e., hemor- this care wiI1 be delegated to the obstetrician rhagic diathesis develops and bIeeding becomes rather than the pediatrician. Anoxia and shock uncontroIIabIe from the uterus or cervica1 must be combated. Resuscitation procedures stump, vaginal waIIs, episiotomy or other body for the treatment of anoxia, i.e., the main- tissues. This hemorrhage is characterized by tenance of an adequate airway with the admin- the absence or marked paucity of cIots. Hope istration of oxygen, are we11 known; yet shock for these patients rests upon the early detec- is rareIy recognized and Iess often adequately American Journal of Surgery

history-of-obgyn.com Gordon et aI.-Abruptio Placentae 467 treated. FaiIure to recognize shock in the new- fetus, placenta and large quantities of cIots. born is probabIy due to our inability to obtain Postpartum bIeeding was profuse for a few bIood pressure determinations or observe minutes but was controIIed by ergotrate and changes in puIse voIume. These observations, pituitrin. Shortly after returning to bed the however, are not necessary for diagnosis since patient again bled profuseIy and shock fol- asphyxia pallida of itself means shock and Iowed. Vagina1 packing and counterpressure demands immediate antishock measures. Proper over the fundus did not contro1 bleeding. The management of the cord and pIacenta is im- patient was then taken to the operating room portant. Immediate cIamping of the cord and the vagina1 packing removed, and the shouId never be practiced. If possibIe the uterus and vagina packed. Soon bIeeding oc- pIacenta shouId be delivered with the cord curred through this packing. The patient’s con- uncut and then hung by a cIamp on its mem- dition was fair, as 1,000 cc. ‘of bIood had been branes or wrapped in a towel severa inches administered. above the baby, who is warmIy wrapped in a Under ether anesthesia supravaginal hyster- crib or incubator. The additiona 40 to 80 cc. ectomy was now performed whiIe transfusion of bIood which these babies receive in this continued. The uterus showed many areas of manner wiI1 be important in combating shock. subserosal hemorrhage and the broad Iigaments If after the five to ten minutes necessary to were i&Itrated with bIood. The patient’s post- drain the pIacenta have eIapsed evidence of operative condition remained fair. Two hours shock is stiI1 present, immediate transfusion later, however, vagina1 bIeeding recurred and of 30 to 80 cc. of bIood shouId be administered the patient died in profound shock. PathoIogic via the umbiIica1 vein. This is a reIativeIy report on the uterus showed extensive sub- simpIe procedure requiring onIy a syringe and serosa1 and myometria1 hemorrhage. a smaI1 catheter which is threaded into the CASE XI. A young primipara in her eighth umbiIica1 vein. If the mother is Rh positive, month of pregnancy compIained of mild irregu- her bIood may be used or Rh negative type 0 Iar abdomina1 pains associated with bIoody bIood shouId be given. Cross matching is not show. Her bIood pressure was ISO,~IOO. The necessary. If this type of bIood is not immedi- uterus was very large, tense and tender, and ateIy avaiIabIe, plasma may be substituted. no fetal heart sounds were heard. UrinaIysis Subsequent bIood examinations wiI1 indicate showed heavy proteinuria and the hemogIobin the further course of treatment. was 37 per cent. The diagnosis was pre- With marked Iowering of materna1 mortaIity, ecIampsia compIicated by poIyhydramnios and interest shouId be focused on simiIar Iowering secondary anemia. Twelve hours later several of feta1 and neonata1 mortality. smaI1 bIood cIots were passed. Since uterine tenderness was stiI1 present, partia1 separation * * * * of the pIacenta was suspected and the mem- CASE x. A thirty-nine year oId gravida IX branes were ruptured with escape of about para VI attended prenata1 cIinic reguIarIy from 1,300 cc. of cIear Auid. She then received 1,000 the fourth month of pregnancy. Her past cc. of bIood. Five hours afterward regular history was irreIevant and her antepartum strong uterine contractions began and con- course normaI. tinued for six hours, at which time caput ap- At term the membranes ruptured. Recta1 peared. Low forceps deIivery of a stilIborn examination showed the cervix to be 2 cm. fetus under saddle bIock anesthesia was fol- diIated, rather thick, and the presenting part Iowed by profuse vagina1 bIeeding, so the pIa- was unengaged vertex. No feta1 heart sounds centa was deIivered manuaIIy together with couId be heard. Since uterine contractions were severa oId cIots. Ergotrate and pituitrin faiIed weak and irreguIar, no therapy was instituted. to contro1 hemorrhage, so the uterus and Three hours Iater the patient bIed profuseIy vagina were tightIy packed. The patient was and was examined vaginaIIy. A No. 6 Voorhees now in profound shock and in no condition for bag was inserted into the Iower uterine segment hysterectomy. With another bIood transfusion and the vagina tightIy packed. GIucose was the patient graduaIIy recovered from shock. given intravenously folIowed by goo cc. of Four hours after delivery she had received bIood. Two hours Iater the packing and bag 2,500 cc. of bIood and 2,000 cc. of pIasma, it were expeIIed and foIIowed very shortIy by having been estimated that she had Iost at

OCtOh, 1952

history-of-obgyn.com 468 Gordon et al.-Abruptio PIacentae least 3,000 cc. of blood. It was then seen that a11 Iayers. The degree of muscuIar dissociation she was bIeeding activeIy through the pack. resulting from hemorrhagic infltration cannot Hysterectomy was decided upon and a supra- be determined by the gross appearance of the vagina1 hysterectomy performed under IocaI uterus. Hysterectomy is indicated onIy when anesthesia. The uterus was found to have been persistent bIeeding results from uterine atony. we11 packed but was flabby and showed numer- No uterus should be removed because it has a ous areas of subserosa1 hemorrhage. Death Couvelaire appearance. Hysterectomy not onIy occurred two hours following the operation. adds to the risk of section but aIso may tip the The pathoIogist reported subserosa1 and myo- scaIes adverseIy for a woman who is aIready metrial hemorrhage with edema invoIving graveIy III. Cesarean section may be success- chiefly the outer third of the muscuIar Iayer. fuIIy compIeted under IocaI anesthesia; but if hysterectomy is added, a genera1 anesthesia Questions. (I) How may the diagnosis of w:ith its additiona risks wiI1 become necessary. Couvelaire uterus be made? (2) What is the Lower segment cesarean section with horizonta1 treatment? (3) When is hysterectomy indi- eIIiptic incision wiI1 avoid the hemorrhagic and cated? (4) What type of anesthesia is best? friable muscle of the upper segment. If atony (3) Of what value are the uterine and vagina1 and hemorrhage shouId foIIow, IittIe time wiI1 packs? be Iost in Iigating the uterine vesseIs which wiII Answers. The diagnosis of CouveIaire uterus, easily be found at the Iateral edges of the or “apopIexie utero-pjacentaire” as it was uterine incision. If the resuIting ischemia pro- designated by that French obstetrician in I 9 I I, duces firm uterine contraction, the uterus may is certainly not diffrcuIt once the abdomen has be safeIy left; if not, IittIe time has been Iost been opened. The uterus has a characteristic and hysterectomy may be compIeted. deepIy purpIed mottling due to subserosa1 LocaI shouId be the anesthesia of choice hemorrhages involving the fundus and occa- whether deIivery be by the abdomina1 or sionally the broad Iigaments. Areas of hemor- vagina1 route. When cesarean section is indi- rhage are more numerous over the pIacenta1 site. cated and oIiguria has persisted in spite of ErroneousIy the impression exists that the successfu1 shock therapy, continuous spina “CouveIaire uterus” demands hysterectomy. anesthesia shouId be used in an attempt to In Couvelaire’s origina papers he stated that reIieve renaI spasm providing a quaIified phy- uterine contraction may be prompt and vigor- sician anesthetist is avaiIabIe. ous with no postpartum hemorrhage despite As stated in our clinic on postpartum hemor- the presence of uteropIacenta1 apoplexy. Little rhage, we do not use vagina1 or uterine packs. has been contributed to our knowIedge of the That they concea1 rather than prevent hemor- pathology of this compIication since his descrip- rhage is likely. The faIse sense of security they tion. Extensive hemorrhage invoIves chiefly Iend leads to further loss of both bIood and the serosa1 and outer third of the uterine time. Packing may concea1 bleeding until it is muscle, occasionally the middle third and rareIy too late to use better methods.

American Journal of Surgery

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