Postgrad Med J: first published as 10.1136/pgmj.38.438.254 on 1 April 1962. Downloaded from POSTGRAD. MED. J. (I962), 38, 254 PRAEVIA C. H. G. MACAFEE, C.B.E., HoN.D.Sc.(Leeds), F.R.C.S., F.R.C.O.G. Professor of Midwifery and Gyn&ecology, The Queen's University, Belfast

THE subject of placenta pravia has been so widely will be dealt with later. On examination of the discussed that it is difficult to find a new approach abdomen the fretus in the majority of cases is for the postgraduate student. It is important, lying in the longitudinal axis with the vertex however, for any student to remember some of presenting, but may be presenting as a breech or the basic facts which are liable to be overlooked lying in the transverse . when dealing with the wider aspects of this In a series of patients with placenta praevia subject. recently reviewed in Belfast the baby presented as a vertex in 68%, as a breech in 12.6% and was lying oblique or transverse in approximately 20% Haemorrhage is of course the symptom that of cases. most frequently draws attention to the presence Even in a polar presentation the presenting part of a placenta praevia. It is usually of sudden onset lies high except in those patients with a minor and may occur when the patient is asleep in bed degree of placenta pravia. If the placenta lies or carrying out her normal household duties. The anteriorly the presenting part may be partially amount lost varies considerably but is usually obscured and can only be recognized on palpation greater in the multipara than in the primigravida. when approached by the palpating hands from The lost is usually bright red and may be each side as in the pelvic grip. When lying associated with the passage of large clots. In the posteriorly, as between 60 to 70% do, by copyright. the majority of cases the is painless. presenting part is displaced forwards and may even Where the patient complains of pain two things appear to overlap the symphysis. In a multiple must be considered. First, has the patient had an if the presenting part of the first baby accidental haemorrhage either alone or in associa- is not well engaged after 30 to 34 weeks, the tion with a placenta praevia? Second, has she presence of a placenta praevia should be suspected started in labour? The presence of an accidental even in the absence of haemorrhage. haemorrhage in association with a placenta pravia Although antepartum hamorrhage is the most is nearly always accompanied by abdominal pain common warning symptom of placenta praevia it and uterine tenderness, particularly if the placenta has been found, in the series of Belfast caseshttp://pmj.bmj.com/ should lie anteriorly. mentioned above, that in approximately I5% of The diagnosis of accidental haemorrhage in patients this symptom was absent. In these association with placenta prxevia can be difficult, patients the low-lying placenta is discovered especially if one has accurately confirmed the accidentally when dealing with some other presence of the placenta pravia. The association occurring in that particular preg- may not be suspected unless there is albuminuria, nancy, for example, when doing a Cesarean which has increased following the hemorrhage, section for diabetes mellitus, or when examining on September 30, 2021 by guest. Protected and hypertension. An accidental hemorrhage due a patient before rupturing membranes in the to separation of the portion of placenta implanted treatment of toxaemia of pregnancy or Rhesus in the upper uterine segment is more liable to incompatibility. The possibility of a placenta cause some disturbance of the foetal heart than pravia being present must always be considered haemorrhage from the portion of placenta in the in any patient with a high free head at or near lower uterine segment. term, and emphasizes the necessity for careful The onset of labour as a cause for the pain is as abdominal and vaginal examination in the a rule easily diagnosed by observing the patient appropriate surroundings. for a few minutes, and also by the persistence of the uterine bleeding. In many cases by the time Diagnosis the doctor or midwife arrives with the patient the Many of the points inl the clinical diagnosis of serious bleeding has ceased and may not recur for placenta praevia have already been made, but the weeks. If the uterine bleeding does persist in the diagnosis can only be confirmed on vaginal absence of pain, even in small amount, one must examination. Some teachers criticize and do not think of some local cause for the symptom. This practise this method of examination, but its Postgrad Med J: first published as 10.1136/pgmj.38.438.254 on 1 April 1962. Downloaded from April I962 MACAFEE: Placenta Prcevia 255 omission leads to many unnecessary Caesarean made. Observance of this essential part of the sections. To make the diagnosis it is unnecessary treatment can reduce both maternal and foetal to explore the lower uterine segment, and indeed mortality. Unfortunately there are still doctors this can be dangerous, but if the degree of placenta and nurses who do not follow this basic rule and, praevia is any but the most minor the placenta can according to the Report on Confidential Enquiries be felt intervening between the head and the into Maternal Deaths in England and Wales, in examining finger in one or more fornices. If the some cases failure to do so has resulted in the os is dilated the maternal surface of a major patient's death. degree of placenta praevia can be gently palpated At times it may be difficult to convince the at the internal os without causing any bleeding. patient of the necessity for her further stay in Except in major degrees of placenta previa, hospital once her bleeding has stopped. One palpation of the placenta against the soft breech appreciates the many difficulties with which these is more difficult than in head presentations. Much mothers have to contend, especially if they have is claimed for placentography in cases where the left young children at home, but if the consultant presenting part has remained high and a warning in charge will take the time and trouble to have a haemorrhage has not occurred. However, there is personal talk with the patient, and seek the aid of a difference of opinion among radiologists as to an almoner, he is unlikely to fail to convince her whether one or four exposures are necessary to of the wisdom of his advice. This advice must be demonstrate the situation of the placenta, and given by the most senior member of the team, not some even state that the use of X-rays for this by a house officer or ward sister, although the purpose should be abolished. It must be re- latter can be of the greatest assistance. membered that the majority of obstetricians, Active treatment depends on the period of particularly those in the underdeveloped parts of at which the patient is admitted. If the the world, must depend on clinical methods as a patient has reached 37 to 40 weeks, and especially reliable radiological opinion is not available. if she is a multipara, arrangements should be A vaginal examination to confirm the presence made for active treatment. This entails a careful of a placenta praevia must not be carried out until general examination, abdominal palpation to by copyright. as near full-term as possible so as to avoid the determine the points already mentioned, blood complication of prematurity which plays such a grouping, haemoglobin estimation and a vaginal serious part in the perinatal fietal mortality. examination. The last should be done in an operating theatre with everything prepared for a The other common cause of antepartum . haemorrhage is of course accidental haemorrhage. If the period of gestation is between 30 and 36 In these cases the presenting part is usually weeks expectant treatment plays an important in part. If possible, one aims at postponing treatment engaged the pelvic brim, there may or may not http://pmj.bmj.com/ be associated and hypertension and until 37 or 38 weeks in the hope that the foetal the may be tender. The patient complains mortality resulting from prematurity may be of varying degrees of pain. Even where the reduced. While hoping for this one may be amount of haemorrhage has been small the fcetal forced to interfere at an earlier stage than one heart may be seriously disturbed, or even silent. wishes on account of persistence of the haemorr- Where there is no associated toxaemia or hyper- hage, or recurrence of bleeding of such a degree tension there is still a tendency to treat such that treatment is indicated. patients rather casually and perhaps allow them In either class of patient the type of treatment on September 30, 2021 by guest. Protected to return home if placentography shows that the really depends on the findings on vaginal examina- placenta is in the upper uterine segment. This is tion. Undoubtedly, where the patient has had a an attitude the writer cannot support but a prolonged spell of expectant treatment one is discussion on this is not relevant here. influenced in favour of a Caesarean section as the Local pathology in the vagina or cervix must be method of treatment most likely to result in a considered as a cause of the bleeding, therefore it living child. Caesarean section is indicated in all is essential that once the bleeding has ceased, or major degrees of placenta praevia, in posterior persists only as a blood-stained discharge, a placenta praevia of the second degree on account speculum should be passed and the cervix and of the risk of prolapsed cord, and where the baby walls presents as a breech or transverse irrespective of vaginal carefully inspected. the degree of praevia. Treatment The last indication will probably be seriously It has long been recognized that any patient questioned but emerges after investigating the with antepartum hemorrhage should be transferred results of over 400 cases of placenta previa. to hospital without any vaginal examination being Where a breech or transverse was delivered per Postgrad Med J: first published as 10.1136/pgmj.38.438.254 on 1 April 1962. Downloaded from 256 POSTGRADUATE MEDICAL JOURNAL April I962 vias naturales in even what appeared to be most at a much earlier stage than one would desire. favourable circumstances the foetal mortality was There may be social and medical reasons for not 42z3%- Those cases delivered by Caesarean using Caesarean section as a method of treatment section in similar presentations had a mortality of in such a high proportion of cases as has been only 5.7%. This mortality has not been the described. In such cases version with its associated result of mismanagement of the breech delivery, high ftetal mortality may still have to be used to but is due to the grave risk of interfering with the avoid leaving a scar in the uterus to be dealt with circulation in the . Eccentric or by inexperienced attendants at a subsequent velamentous insertions of the umbilical cord are confinement. well recognized anatomical features of placenta praevia and in many cases where the baby presents Improvements as a breech or transverse the umbilical cord is in In the 95 years between I844 to 1939 the fcetal close proximity to the internal os. In delivering mortality rate from placenta pravia remained at the baby as a breech the cord is compressed approximately 60%, while the maternal mortality resulting in a still birth. The advice to deliver by fell from 30 to 5%. Caesarean section does not of course hold when Since 1945 the reduction in both maternal and there is an intrauterine death at the time treatment foetal mortality has been gratifying, the maternal is instituted. mortality in certain series being reduced to nil and Quite apart from breech presentation, Caesarean the foetal mortality to about Io%. This improve- section in placenta previa is associated with the ment has been due to several factors of which the lowest foetal mortality. Of 163 Caesarean sections following may be regarded as the most important. performed for placenta praevia from 1953 to I960 Expectant therapy. The number of cases inclusive, only eight babies were lost, a perinatal suitable for this varies from hospital to hospital. mortality of 4.8%. Of those eight babies lost In Belfast we find that 49.6% in the last I6 years seven were in patients operated on between 28 to were treated within 72 hours of admission. Of weeks. The one lost out of Caesarean these were over weeks and 36 baby 107 71% 36 gestation by copyright. sections done after 36 weeks died in the neonatal therefore it was unnecessary to postpone treatment. period. Difficulties associated with Caesarean In approximately half the total patients, treatment section have been discussed in a recent article could be safely delayed thus improving the (Macafee, 1960). outlook for both mother and baby. Artificial rupture of the membranes is most Increased use of Ccesarean section. This feature suitable for the first degree and perhaps for a has already been discussed. second degree placenta praevia if the latter is Improved resuscitative measures. situated anteriorly. Improved pcediatric care. While one has been rather about the When we read the two recent on Con-

dogmatic reports http://pmj.bmj.com/ value of expectant therapy and the methods of fidential Enquiries into Maternal Deaths we active treatment, it is important to remember that cannot be complacent. In England and Wales 'every obstetrician must be alive to the environ- from 1942 to I949 inclusive 65 women died ment in which he is practising and the type of during pregnancy, and 330 during or after patients he is to treat' (Qureshi, I953). We in , from placenta praevia. In other words, the United Kingdom must remember that our 395 women died during those eight years from a hospitals, blood transfusion services etc., are complication which, if properly treated, should be never very far from the patient, while in other associated with a maternal mortality of almost nil. on September 30, 2021 by guest. Protected parts of the world the same facilities are not yet From the Report on Confidential Enquiries into available. Some readers who come from such maternal deaths we find that from 1952 to 1954 areas must recognize that treatment has to vary 29 women died, and in 55% of these cases there according to the environment and facilities were avoidable factors. In spite of all that has available. To get expectant treatment accepted been written and taught on the subject the years and to change the outlook toward Caesarean 1955 to I957 show little or no improvement as section, required time and the education not only 28 women died in those years, and in 43% there of doctors and nurses, but also patients. The same were avoidable factors. will apply to the underdeveloped areas. In such These final figures are my excuse for dealing areas it may still not be possible to adopt expectant with some basic facts of diagnosis and treatment treatment and the patient may have to be delivered which appear to have been overlooked. REFERENCES MACAFEE, C. H. G. (1960): Placenta Praevia, Lancet, i, 449. QURESHI, M. S. (1953): A Study of Maternal Mortality in 200 Cases of Placenta Previa, Medicus (Karachi), 6, 187. Report on Confidential Enquiries into Maternal Deaths in England and Wales, 1952-54. H.M.S.O. Report on Confidential Enquiries into Maternal Deaths in England and Wales, 1955-57. H.M.S.O.