Staff Meeting Bulletin I-Iospitals of the •·• University of .Minnesota I

I-Iemorrhage (Late in

Volume VIII Thursday, January 14, 1937 Number 12 STAFF MEETING BULLE~IN HOSPITALS OF TP~ ••• UHl VEII-S1 TY UF 1.lINi.~ES01rl. Volume VIII Thursday. January 14. 1937 Number 12

INDEX

I. LAST VvEEK ••.•....•.•..••••..•.• " It 142

I I. MOVIB. ••••••••...••• • . • .• • •... • 142

I II. GUEST. ••••• • ••••••• • _. •••••••••• 142

IV. ABSTF..ACT & CASE REPuRTS. ••••••••••• •• •••• 142-153

Publishe1 for the Gen~ral Staff Meeting each week during the school year. October to May, incl~;_sive.

Financed by the Citizens Aid Society

William A. OIBri~n. M.D. 112

latter, of course, is one of the three major causes of maternal mortality. Date: January 7, 1937 Herewith is presented a summary of the Place: nurses' Hall present knowled:,,;e of gestetiom:l Recreation Room hemorrhag8 as rev8eled in recent period­ icelfl and current standcrd obstetrice.l Time: 12:15 to 1:20 P.M. works. Information gainAd from locLl experience is interspersed throughout Program: l'lovie: Steel the discourse. For obvious reasons, the deetn on ablatio placent2e and placent Abstract: Rheumatic Fever praevia are treated separately. present: 99 Out of 1,290 mothers delivered in the University of Minnesota Hospitals from Discussion: R. M. Amberg January 1, 1934 to January 1, 1937, 96 or P. F. Dwan 7.44% had a final diagnosis of either M. J. Shapiro ablatio placentae or plncenta preevia. L. G. Rigler In other words, 1 in every 13 cases hed I. Mc~rrie at least a history of bleeding in preg­ nancy. Of these 96 cases, 75 were called ablatio placentae and 21 .

II. MOVIE: Close scrutiny of the records, however, disclosed that nearly 4~ of the bleeding Title: The Solar Family diagnoses were unjustified in the light of any information appearing in the records; Released by: Erpi Film Corporation i.e., there has been a tendency to attach the term nblatio plncentF.'e to every case with a history of vaginal spotting in the third trimester, without adequate observa­ tion of the patient before and during labor and of the placenta after delivery. At least, if these observations were made, III. Gueqt: Alfred Washington Adson there is now no record of them. For this from Mayo Clinic will be reason, it was thought advisable to here next week. exclude the so-called unconfirmed ce.ses from this study. Thus, the true incidence of hemorrhage late in pregnancy becomes 4.65% or 1 in 21 cases. IV. ABS'l'RACT .AnD CASE REPORT S: A. ABLATIO PLACENTAE HElViORRHAGE LATE In PHEGNANCY Usual definition: Charles E. McLennan Uterine hemorrhe.gf' from premature With an analysis of 96 consecutive separation of a normally implanted cases from the University of Minnesota placenta. Rudolph, however, has report­ Hospitals during the three-year period, ed a case with anatomic evidence of January 1, 1934 to January I, 1937. ablatio placentae and placenta praevie marginalis in the same uterus, and With rare exceptions, hemorrhage suggests that ablatio placentae be de­ late in pregnancy is attributable fined merely as Ilpremature sepe.ration of either to ablatio placentae praevia. the placentall without reference to its Davis states that placenta praevia and situation in the uterus. ablatio placentae are responsible for the hemorrhage in over 53% of the fatal cases of obstetrical hemorrhage; the 143

Etiology:

Accidental hemorrhage (Eigby,1776), The primary cause of ablatio placen­ placental apoplexy (Lee, 1848), abruptio tae, if there be a single one, is imper­ pl~centae (DeLee, 1902), uteroplacental fectly understood. Some of the numerous apoplexy (Couvelaire, 1911), and pre­ suggested Causes are listed herewith. ma~ure detachment of the placenta. Holmes (1901) is credited with intro­ I. Predisposing causes: duction of the term ablatio placentae. Implication of trauma as an etiologic 1. Full-term pregnancy. factor is an objection to the term 2. lviul tiparity. Ilaccidental hemorrhage". Similarly, 3. Placental changes (inflammatory or abruptio placentae suggests sudden and degenerative). violent detachment, whereas in many cases the detachment and its symptoms II.Direct causes: develop insidiously. 1. Traumatic: Freguency: a. Direct external trmlIDa (rare). All cases of premature separation ~. Traction on short umbilical cord. of the placenta do not present symptoms. c. Injury by version. It is only by routine insppction of the d. Sudden uterine collapse in rup­ Placenta ~artum that one will find ture of hydramnion, birth of evidence of slight placental separation, first child of twins. with the typical retroplacental e. Interference with hemostatic hemorrhages. Holmes thinks that clinic­ contraction of uterus: ally importa.nt cases of ablatio (1) Tumor. placentae occur only once in about 500 (2) Dense adhesions. deliveries. Schumann finds separation (3) Second Twin. of the lower pole of the placenta, f. Torsion of uterus (Polak, 1924). particularly if the placental site is g. Maternal hypertension (Dieckmann) abnormally low, occurring about once in 200 labors, whereas severe cases occur 2. structural: in a ratio of less than one to 800 preg­ nancies. Many writers feel that sta­ Developmental weakness of decidua tistics covering the frequency of or of fastening villi. ablatio placentae are so variable that little importance can be attached to 3. Psychoneurotic: this point in practice. Davis and McGee, in reviewing 19 pnpers, found frequen­ Extreme emotional strain. cies varying from 1 in 94 to 1 in 555. Note the following figures: 4. Toxemic:

Incidence of Ablatio ?lacentae Davis and McGee report that 57~ of their cases showed evidence Reported by Total %of Once of toxemia of pregnancy. Reports by other investigators range from ---Cases Total in University of l,,;inn- 24 to 10~h. Tenney recently has esota Hospitals(1937) 1,290 3.17 32 studied the syncytium of placentae Irving (1936 ) 28,391 1.04 96 from cases of toxemia and ablatio Dorman (191~~) 0.87 115 placentae. He found definite syn­ Montgomery (1934) 4,246 0.75 130 cytial degeneration in all of the McCord (1936 ) 4,972 0.56 178 toxemias, 'out a normal picture in Colclough (1902) 0.48 207 cases of ablation uncomplicated by Essen-Moller (1913) 0.46 2113 signs or symptoms or toxemia. He Smith, P. H. (1935 ) 7,981 0.43 233 presents this as evidence for the Davis, M. E. (1931 ) 40.000 0.41 244 existence of non-toxic, non-trauma­ Dieckmann (1936 ) 11.922 0.37 270 tic placental separation. 144

5. Other less popular suggestions: arterial pressure is established, tearing of the spongy layer continues (1) until a. Histamine intoxication 'bleeding ceases through coagulation, (2) (Hofbauer). Bartholomew be­ until internal pressure falls to a point lieves that histamine is insufficient to Cause furtner tearing, elaborated during autolysis (3) until the entire placenta is d.etached, of acute infarcts on the or (4) until blood makes its esc[~pe through maternal placental surface. the cervical canal or into the amniotic caVity. b. Endometritis. In true toxic apoplexy (Couvelaire c. Increased venous pressure uterus) occurs a peculiar alteration of (relative oestruction of the uterine wall with mottling of the venous return) causing rup­ peritoneum and hemorrhagic infiltrntion ture of placental sinuses of the muscle bundles which mPkes a life­ (Harvey). less wall imparting the sensation of soaked sole leather. This process may in­ d. Abscess of placenta volve broad ligaments, tubes, ovaries. (Rosenfeld). Fortunately, the true Couvelaire uterus occurs infrequently. In 52 complete sepa­ Pathologic anato~y: rations, Davis and }fcGee found onl:,r 15 uteri of the Couvelc:ire type. Separation may be complete or in­ complete. In the latter the central Symptomatology: portion of the placenta may be separated, the periphGrJr adherent, or the margin This varies markedly from those casps alone detached. The higher the placental with violent onset ~nd course to those site upon the uterine wall, the more with such slight evidences of pathology characteristic the symptoms of ablatio. that placental separation is not even sus­ Hemorrhage is dependent not so much upon pected and is recognizHble only by post­ the amount of placental t~ssue separated partum inspection of the placent~. The as upon the size and number of the uter­ latter group includes most of those pomen ine sinuses exposed. Extensive throm­ who, during pregnancy, have repeated, in­ bosis of uterine sinuses may pave the consequential bleedings, occurring after way for a wide separation with minimEl.l unusual physical strain, coitus, fatigue, hemorrhage. etc., but ceasing after a few hours.

Hemorrhage may be absolutely con­ For descriptive purposes, CDses are cealed (internal) or relatively con­ designated es mild, moder2te, 8.nd. severe, cealed (external). In each case of true or a mild and fulmineting. :&')ch of these ablatio, there is a primary absolute con­ mcy be differentie.ted into those wi th ab­ cealment of the blood, but after a short solutely concenled hemorrhege and those time (minutes to hours) the blood serum with relatively concealed bleeding. or blood itself escapes. The one un­ varying pathognomonic sign of ablatio The signs are maternal and fetal: is expulsion of old clots and free blood with the placenta. Ie Mdernal:

As the subplacental hematoma spreads, 1. Acute anemil:'.• it may: (1) be confined to the li~its 2. Vertigo, syncope. of the placenta; (2) cleave the membranes 3. Escape of serum, old clots, dark almost wholly away frow the uterine wall: blood. (3) rarely rupture the membranes and. hem­ 4. Shock (perhaps out of proportion orrhage into the amniotic cavity; (4) to blood loss). cleave membranes down to internal as, 5. In uterus: through which blood escapes into the va­ a. Local pain and tenderness. gina. Once the cavity with blood under b. Distention, diffuse or local. 145

c. Firm consistency - wide vari­ concentration which predisposes to bleed­ ations. ing from mucous surfaces, incisions. and d. Loss of alternation between the uterus. A striking number of patients contraction and relaxation. have subnormal concentrations of fibrin.

II. Fetal t 3. Renal function is impaired in many cases, as shown by a N.P.N. of more 1. Sudden, violent fetal movements, than 40 mg.!lOO c.c. and urea clearance followed by arrest of same. of less than 50%, but it returns to normal after an interval of several months. 2. Changes in heart rate and qual­ ity. Richardson points out 4. Plasma cholesterol determinations that fetal heart tones present are within normal limits. the earliest indication of pre­ mature separation and are always prognosis: altered in so definite a manner as to direct suspicion positive­ For the mother - good; for the in­ ly toward placental detaChment. fant - poor. ravis and McGee s 19 au­ Fetal embarrassment first brings thors ranged from 2.6 to 66~ maternal' on compensatory acceleration of mortali ty, 59 to 10CY.b fetal mortality. the heart rate to the point of Other representative figures follow: maximum tolerance, then follows asphyxia with decreasing rate Mat. Fetal when some three-fourths of the Mort.a;; Mort.,% placenta has separated. Dieckmann Non-toxemic group o 44 Rudolph recently has suggested a Toxemic group o 70 rather academic classification of ablatio Richardson o 50 placentae as: (1) contractive type, char­ Smith, P. H. 3 62 acterized by sudden abruption with com­ Greenhill 4 pensatory contraction to arrest bleeding Univ.of Minn. Hospitals 4.9 30(approx' from placental site, ligneous uterus, sud­ Rotunda Hospital (Dublin) 7 den pain; (2) retractive type, in which McCord 7.1 64 abruption is followed by rapid retraction Davis, M.E.(40,000 of the upper and lower uterine segments, deliveries) 7.3 60 doughy uterus, less sudden onset of pain, Williams 8 no shock. Holmes, (200 cases,190l) 32 86 fortes 36 81 Dieckmann(U. of Chicago Clinics) Goodell (106 cases,1870) 51 9'4 separates his cases of ablation into (1) a vascular, hypertensive or toxemic type, Treatment: and (2) a nQn-toxemic type. In either group the separation may be partial or The initial step in the treatment of complete, the hemorrhage internal, exter- any hemorrhage late in pregnancy is the nal or combined, and the symptoms and signs immediate provision of compatible blood mild or severe. donors. Blood matching is started with or even before the examination and prep­ Laboratory: (from Dieckmann, 58 cases) aration of the patient. Equipment and personnel should be made immediately avai1~ 1. Hemoglobin, hematocrit and serum able and kept so for several hours after protein concentrations are lowered pro­ delivery. portionately to the hemorrhage. Deter­ mination on admission is not an exact in­ In Cases of minor severity before the dex of the patient 1 s hemoglobin because, 36th week, the patient is kept in bed and following hemorrhage, there is first a given sufficient morphine to control pain blood concentration and later a dilution. and uterine irritability.

2. Blood fibrin mey be reduced to a In severe cases at any stage, preg- 146 nancy must be terminated promptly. It death of . is essential th&t common sense judg­ ment be employed rather than adherence 7. Cesarean section: to any set of fixed rules. Choice of management hinges on 6 main points: The choice for all severe cases with uneffaced, undilated cervices. Follow 1. Stage of labor (dilation of cervix). with hysterectomy if true Couvelaire ­ 2. Expulsive efficiency of uterine uterus is found. However, it must be contractions. remembered that, even after section, 3. Stage of pregnancy. approximately 75% of uteri contract 4. Fetomaternal disproportion. rigorously enough to justify their re­ 5. Infection, actual (,r potentiaL tention (Stander). S. 0bstetric sl0:l1 of accoucheur. Folloning delivery from below,hes­ Available methods of treatment are: itancy in contraction of the uterus is ar. indice.tion for packing. Rerely, it is necessary to do a postpartum hysterectomy if bleeding continues through the pack. To be considered only when symp­ toms are extremely mild. Fortunately, placental separation frequently inaugurates immediate labor, 2. Rupture _~membrane5: and sufficient cervical obliteration obtains for rapid vaginal delivery ­ To expedite labor in mild cases. either spontaneously, or with the aid of forceps or version And extraction. In 3. Atdominal compression and vaginal 41 cases from this hospital, only two t ampo nade: were delivered by Cesarean section, and one of these was done pri~arily for con­ The so-called RO~lnda method, tracted pelVis. recommended by DeNormandie, Hefferman and others. Spanish windlass to abdo­ Case Reports on Ablatio Pl<:cer~ae: men, vaginal pac~ing and perineal T-binder. Holmes believes this method I. Ablatio placentae, complete; cesarean is irrational and mentions it only to section; uterus saved•. ~ _ condemn it. Reported results are not age 25, gravida i, para favorable. 0, 8 months gestation

4. Rubbc_r bag: Admitted 10-23-33: Vaginal spotting wi th cramps. Usually not advisable since it may mask the hemorrhage. Reserved for 10-25-33: Cystogram diagnosed borderline cases where diagnosis lies llplacenta praevia marginalis ll (L.R.). between placenta praevia lateralis and low implantation with premature sepa­ 10-27-33: Cystogram repeated; now ration. no praevia apparent. No bleeding.

5. Manual dnation: 10-29-33: AbdominAl cramps; pass­ ing old blood. ftIways dangerous in itself, but occasionally an invaluable aid. To be 10-30 to 11-4: No bleeding. Sent followed by immediate delivery by easi­ home. est method available (version or for­ ceps) • Readmitted 11-13-33: BackRche, cramps, minimal bleeding (25 c.c.). 6. Braxton Hicks version: Bruit over fundus. Fetel heart good. Uterus well relaxed, not tender. No Dangerous, since empty fundus may placenta palpable by rectal. Cervix fill with blood. Nearly always means 1 em. dilated, at 11 A.M. 147

Two h0urs later: 1 P.M. - No 9~30 A.H. - Supravaginal hys­ change in condition. terectomy. Findings: cyanotic peritoneum, 1,000 c.c. blood in abdominal cavity; 1:30 P.M. : Sudden continuous uterus soft, blue, friable, with muscle abdominal pain, tetanic uterus, bundles destroyed by hemorrhage. 1200 gm. no fetal heart audible, blood stillborn fetus. pressure 100/60. Uneventful recovery. Discharged in good 2:00 P.M.: Passed 500 c.c. dark condition on 16th postpartum day. blood from vagina; ligneous uterus, pallor, severe abdominal pain. Analysis of Minnesota Cases of Ablatio Cervix still only I em. dilated. Placenta, 1934 to 1937.

0:00 P.M.: Classical cesarean All cases diagnosed ablatio: section. Found Couvelaire type of 75 in 1,290, 6% or 1 in 17 uterus with complete separation of placenta. Fetus dead. 1500 c.c. Unconfirmed in records: of blood in uterine cavity. uterus 1934- 16 out of 30 or 53.4% contracted well after pituitrin, so 1935- 14 " II 26 or 53.8% was closed in layers. Transfusion 1936- 4 11 tl 19 or 81.1% given. R~rortrbl~ crsoo of cb12tio: Uneventful recovery. Discharged in 41 in 1,290, 3.2% or 1 in 32 good condition on 16th postpartum 1934- 14 in 425, 3.3:bor 1 in. 30 day. 1935- 12" 430, 2.8% or 1 in 36 1936- 15" 435, 3.5% or 1 in 29 II. Ablatio placehtae, complete; hys- terectomy. __ Average age 26.8 , age 40, gravida i, para 0, 6 months gestation, achon­ Average no. deliveries prior droplastic dwarf, myomatous uterus. to ablatio 1.8

5-18-35: Lower abdo~inal pains; Average duration of pregnancy, not reported to physician. weeks 35.2

5-19-35: Severe, crampy lower Average length of labor, hours 6.3 abdominal pain after auto ride. No bleeding. Uterus firm and Only 4 of 41 patients had previous irregular. Fetal heart good. . Rectal examination - no informa­ tion. Blood pressure 110/60. CystograIll: Done in 17 of 41 cases. Sent to hos~ital. Original im­ Only 2 diagnosed as placenta praevia. pressions: (1) threatened pre­ Error - 12Jb. mature labor, (2) ablatio placen­ tae with concealed hemorrhage, Infants: 22 males, 21 females. (3) torsion of myoma pedicle. 5 stillborn, 9 died within 24 hours; mortality 32.5% 5-20-35: 1:30 A.M. - No fetal 23 premature heart heard; less 'pain but very 13 of the 14 deaths were in tender abdomen. premature group

9:00 AM. - Uterus Type of deliverz: board-like, abdomen very tender, Spontaneous 33 upper abdominal distention, moder­ Forceps extraction 4 ate cyanosis of abdominal wall; Version and extraction 2 patient pallid, pulse up frOID 80 Cesarean section 2 to 120. Impression: Couvelaire uterus. Maternal deaths: 2 (1 puerperal sepsis, 1 postpartum hemorrhage). 148

B. Placenta prao~ia Etiology:

Snynonym: Unavoidable hemorrhage I. Indirect or contri_buting causes: (Rigby, 1776). l. Hultiparity. 2. Age of mother. Definition: A condition in which the 3. Twin placenta is attahhed to (two placentae). the dilating zone of the uterus, i. e •. 4. Previous uterine infection in which the placental site is more or (postabortal, postpartw~ less in the lower uterine segment. endometritis, etc.)

Varieties: II. Direct causes:

1. Simple low implantation: 1. Gravity: Ovum not arrested Lower border less than 10 em. above until it reaches dependent zone. the internal os, while bulk of the or­ gan is above the isthmus uteri. 2. Overgrowth. of placenta: When nidation occurs in the lower segment, 2. Lateral: Placental rim eL­ cotyledons cannot obt~in sufficient nutri­ croaches into the dilating zone but ment from vessels at the site, so spread does not reach the periphery of the out to acquire necessary blood supply internal os. (large, thin placenta praevia is common).

3. Marginal: Placental border 3. Reflexal placenta (Hofmeier approximately at edge of internal os. and Kaltenbach, 1888, and Jolly, 1911): Pert of laeve continues to grow 4. Partial: Placental edge OVer­ instead of UTldergoing involution early in lapping portion of dilated internal os. pregnancy, with result th~t part of the placenta develops in contDct with decidua 5. Complete: Internal as com­ capsulari s. pletely covered by placenta. Oentral placenta praevia implies that center Pathology: of placenta and internal os coincide; this occurs so infrequently that it When thA placenta is inserted cen­ is needless to employ the term. trally or partially so, it is evident that, as the formation of the 10TIer uter­ Frequ£~c~: Materially greater in ine segment and dilation of the internal a hospital service. Holmes thinks pla­ os progress, its attachments must in­ centa praevia is seen about onCe in evitably be torn through, the rupture 1,000 labors in general practice, while being followed by a hemorrhage from the Schumann estimates it at once in 700 maternal vessels. Bleeding is favored pregnancies. Frequency statistics by the fact that it is impossible for given by various authors are: the stretched fibers of the 10Ber uterine segment to compress the torn vessels. %of When the placent has developed in the Cases all 1 in capsularis, this thin tissue is devoid of Univ.of Minnesota all support where it bridges over the in­ Hospitals 1,290 1.47 68 ternal os, and consequently a slisht Irving (1936) 28,391 l.08 92 traum~ will open up the intervillous space. Binder (1934) 9,000 .93 108 Cragin 25,000 .89 112 Symptoms - objective signs: Daily (1934) .87 115 Smith (1935 ) 7,981 .75 133 l. Painless hemorrhage Wilson (1934) 16,310 .63 159 a. Usually during the second half Marr (1935 ) .36 278 of pregnancy, commonly after the 7th month. Ude & Urner(1935) 5,856 .29 346 Early praevia always confused with abor­ Muller (1877) .09 1078 tion. - - 149

b. First bleeding usually very never considered absolutely diagnostic ­ slight. Initial hemorrhage followed merely confirmatory. (Note results of by others at irregular intervals. cystograms in our recent bleeding cases).

c. Trauma may precipitate the Prognosis: hemorrhage. d. Usually spontaneous, at any The risk increases progressively as hour. the placenta occupies a place near, at or over the internal os. Maternal mortality 2. Cervix succulent (edematous), is increased by postpartum hemorrhage from patulous as a rule. adherent placenta and cervical lacerations (manual dilation and rapid extraction fol­ 3. Bogginess in lower uterine lowing version). Postpartum uterine in­ segment. ertia and postpartum infection are also common. The infants die from (1) pre­ 4. Placental bruit heard above maturity and (2) intrauterine asphyxia. pubes. Placenta praevia does not tend to repeat itself in subsequent pregnancies (Irving). 5. Mcl-position of fetus common Some of the more reliable mortality fig­ (tr~nsverse, breech, brow). ures range as follows: Feta1 Diagnosis: Total Os.of Mat. Mort. Cases Praevia 1'ort .% -L. 1. Absolute diagnosis is possible Adair (Chicago only through actual pnlpation of the Lying-in) III o placenta in the lover uterine segment. With caesarean section 12.3 With Braxton Hicks version 54.0 2. Hemorrhage without pain, shock With rupture of membranes 33.3 or clots is suggestive. With insertion of bag 50.0

3. Postpartum: marginal rupture Siegel (dely.by of the membranes is confirmatory evi­ cesarean section) 0.99 24.8 dence. Wilson 4. Amniogra-phy: Devised by Menees, (Brooklyn) 16,310 102 1.96 24.5 Miller and Holly in 1930. Strontium iodide or uroselectan are injected into Binder through abdominal wall; (Jersey City) 9,000 84 2.40 placenta then outlined in profile on Full-term infants 18.0 roentgenorgram. Unfortunately, this Prematures 66.0 procedure is nearly always followed by the onset of labor. We have had no ex­ Marr (N Y.Nurs.& perience with the method in this clinic. Child's·Hosp.) 40,588 146 4.70 53.0

5. Pneumoperitoneum: SUggested by Univ. of If,inn. Spiedel and Turner in 1924. Apparently Hospitals 1,290 19 5.26 31.6 never used extensively. Irving (Boston 6. Cystogram: Developed by Ude Lying-in) 28,391 308 7.00 20.0 and Urner at the Minneapolis General (net) Hospital. An iodide emulsion (25 to 40 c.c.) is used as contrast Kellogg medium to outline upper border of (1895-1919) 218 13.60 bladder in relation to the fetal head. Limitations of the method must be ade­ Treatment: quately understood. Our experience with it has been fairly satisfactory, although There is no one treatment for every the evidence gained from the procedure is patient. The diagnosis can be made, di- 150 rcctly or through elimination, only by mortality rate definitely increased by vaginal examination. This involves this method. the cerious risk of introduction of infection. Hence the time and place 6. Oesarean section: Reserved for for such examination must be care­ complete placenta praevia with uneffaced fully chosen, with the utmost· precau­ cervix, live fetus and non-infected genital tion as to asepsis. A suspected case tract. Section is justifiable, of course, of placenta prnevia is never examined where other primary indications exist. in the home if hospitalization is physically possible. Irving recently has advocated cesarean section followed by hysterectomy The diagnosis once made, termina­ with drainage on all potentially infected tion of pregnancy should be insisted cases, whatever may be the condition of upon if the patient refuses continuous the fetus. We cannot support this opinion. hospitalization and rest in bed. There is a considerable element of Available evidence, however, truth in Kello"g's statement: liThe im­ justifies the attempt to carry a provement in mortality statistics in doubtfully viable fetus to a safer placenta praevia ••• depends much more stage, basing the necessity for inter­ on the promptness with which the unpacked, vention upon the severity of the hemor­ unexamined, bleeding pregnant woman is rhage. hospitalized by the practitioner and de­ livered by an obstetrician, than on Before the vaginal examination is whether she is delivered through the begun, everything must be ready for natural passages conservatively or by immediate blood transfusion, version, cesarean section. II bag insertion, or cesarean section. Neglect of these precautions is often Gase Report on Placenta praevia: fatal. 1. 1 age 33, para iii, Common methods of treatment are: graVida vi.

1. Watchful expectancy: Only Last menstrual period 10-25-35, until definite Viability. due 8-1-36.

2. Vaginal tamponade: Merely a First slight vaginal bleeding temporary expedient during transporta­ (10 - 20 c.c.) on 6-15-36. tion to hospital. Should be avoided Patient advised by private phy­ wherever possible. sician to come to University of Minnesota Hospitals. at once, but 3. Rupture of membranes: Suit­ . did not arrive until two weeks able for lateral placenta praevia if later. the fetal position is favorable. Head acts as tampon. 7-1-36: First seen in out-patient Department; recurrence of slight 4. Bag insertion: Probably the bleeding. Admitted to hospital. most useful method for immediate con­ trol of bleeding. Inserted intra- or 7-2-36: Oystogram - very sugges­ extraovularly, or directly through tive of placenta praevia. placenta if necessary. At full dila­ tion, deliver by version or forceps, On bed rest until 7-9-30. ~o or allow spontaneous delivery to occur bleeding, no contractions. Patieni if bleeding is not marked. up and about, anxious to SO home 7-1C-36. J.C. Litzenberg advised 5. Braxton Hicks version: Useful vaginal examination before con­ when bags are not available, partic~ sidering discharge of patient. larly if child is not viable. Fetal 151

7-10-36: 1:45 P.M. - sterile TxPe of d81ivery~ vaginal examination revealed complete placenta praevia. Bag followed by version Brisk bleeding began at once, and extraction 8 lost 250 - 300 C.c. of blood Cesarean section 4 on way to operating room. Spontaneous 3 Outlet forceps ~ 2:00 P.M. - Classi­ Bag followed by forceps 1 cal cesarean section done; Version and extraction 1 living male infant, 3120 grams, 50 em. uterus packed. Patient Infants: 14 females, 9 males (4 multiple given intravenous glucose on pregnancies) operating table and transfusion 4 stillborn, 2 neonatal deaths; immediately afterward. mortality 31.6% 11 premature Uneventful recovery. rischarged 5 of the 6 deaths were in pre­ in good condition on 13th post­ mature group; death of the partum Qay. one term fetus occurred after insertion of bag directly ~alysis of Minnesota Cases of Placenta through placenta. praevia. 1934 to 1937 Mat ernal deaths: 1 - from bilateral All cases diagnosed bronchopneumonia on 3d praevia: 21 in 1290, 1.63% or 1 in 61 postpartum day; marginal praevia with bag insertion, version, uterine packing. Unconfirmed in records: 2 Maternal mortality rate; 5.310

Reportable iMidence: 19 in 1290, 1.47% or 1 in 68 SUlOf;ARY: 1934: 7 in 425, 1.64% or 1 in 61 1935: 6 in 430, 1.40% or 1 in 72 1. Ablatio placentae and placenta prae­ 1936 : 6 in 435, 1.3710 or 1 in 73 via are major factors in maternal mor­ tality. Average age, years 30.7 2. The incidence of hemorrhage late in Average number deliverie~ pregnancy appears to be from 4 to 15 prior to praevia 3.2 times greater in this clinic than in similar institutions throughout the Average duration of pregnancy, weeks 313.1 country.

Average length of la~or, hours 7.8 3. The severe, fulminating, typical textbook picture of ablatio placentae is Number of patients having an infrequent occurrenCe. previous 8 4. Little ~as been added to the knowledge Type of placenta praevia: of the etiology, pathology, symptoma­ Low implantation 4 tology of ablatio and placenta prae'ITia Lateral in the past 30 years; considerable im­ Marginal, partial 13 provement has been effected in the mater­ Complete 7 nal mortality, a lesser improveillent in fetal mortality. Cystogram: Done in 15 of 19 cases. 5. Certain principles of treatment are Diagnosed placenta praevia 10 outlined herewith. The method of choice No diagnosis possible 2 must be carefully considered for each and Negative for praevia 3 every case. Error 20% 152

6. The cystogram is a valuable ~iag­ 9. DeNormandie, n. L. nostic aid in placenta praevia, when Premature separation of the placenta used merely as confirmatory evidence in private practic~. and with full knowledge of its limita­ Am. J. Ob, and Gyn., 31 : 325-332, 1936. t ions. 10. Dieckmann, W. J. 7. The campai~n for hospitalization Blood chemistry and renal function in of all cases of bleeding late in preg­ abruptio placentae nancy must be continued and extended. Am. J. Ob, and Gyn., 31 : 734-745, 1836.

8. This study has disclosed certain 11. Harvey, H. E. deficiencies in our case records and premature separation of the placenta in the system of cataloging same. and circulatory collapse associated It is res~ectfully suggested that steps with pericardial effusion. be taken to eliminate these sources of Am. J. Ob, and Gyn., 31 : 803-805, 1936. error in our statistics. 12. Heffernan, R. J. AbClominal compression and vaginal tam­ BIBLIOGRAPHY: ponade in the treatment of a~ruptio placentae. 1. Bartholomew, R.A. New Eng. J. Mod., 214 : 370-373, 1936. Abruptio placentae following acute placental ir~arct. 13. Holmes, R. J.A.M.A., 102 : 676-677, 19~4. Chapter in Davis, C.H. Gyn. & Obst., vol. 1, Hagerstown, Md., 2. 3inder, J. W. F. Prior Co., 1933. An analysis of 84 cases of placenta praevia. 14. Irving, F. G. Am J. Ob, and Gyn., 28 : 92-96,1934. A study of 308 cases of placenta prae­ via 3. Burke, F.J. Am. J. Ob. & Gyn., 32 : 36-50, 1936. Aminography J. Ob, and Gyn. Brit. Emp., 15. Kellogg, F.S. 42 : 1096-1106, 1935. Placenta praevia A review of 437 cases from the Eoston 4. Cooke, W. R.: Lying-in Hospital Chapter in Curtis, A.H. New Eng. J. Med., 209 : 1201-1211, 193c. and GynecolosY, vol. 2, Phila., W.B.Saunders Co., 1934. IG. Marr, J. P. Analysis of 146 cases of placenta ~rae­ 5. Daily, E. F. via. Placenta praevia Am. J. nb. & Gyn., 29 : 454-457, 1935. S. G. & 0., 59 10h-109, 1934. 17. Mcntgo~ery. T. L. h. Davis, M. E. Pn;matllr.3 separation of the placenta, Hemorrhage late in pregnancy with special reference to the etiolog S. Clin. No. Amer., 15 : 737-755,1935. of placent21 lesions .Am. J. Ob. & Gyn., 28 : 33-39, 1934 7. :lavis, M.E. and W. B. McGee Abruptio placentae 18. Partes, L. S. G. & 0., 53: 768-779, 1931. A props de 1 'opoplflxie utbro-::'lacentair' Gyenec. et oost., 31 : SS5-i39'3, 1935. 8. reLee, J.B. Principles and practice of obstetrics 19. Richardson, G. C. Phila., W.B.Saunders Co .• 5th ed.~1928. The significance of fetal heart tones in ablatio placentae. Am. J. 00. & Gyn., 32: 429-444, 1936. 153

20. ~onsheim, J. 32. Wilson, h. A. ~~sults of treatment in placenta Placenta praevia. The results of praevia the treatment of Ie? cases occur­ Am. J. Ob. & Gyn., 32 : 139-143,1936 ring in 16,310. Am. J. Ob. and Gyn., 27 : 713-717, 21. ~osenfeld, S. S. 1934. Abscess of the placenta causing abruptio placentae J.A.M.A., 105 : 1113-1114, 1935.

22. Rudolph, L. Premature separation of the placenta Am. J. nb. & Gyn., 32 : 479-485,1936.

23. Schumann, E.A. A toxtbook of obstetrics Phila., W. B. Saunders Co., 1936.

24. Siegel, I.A. 0bservations on 101 cases of placenta praevia delivered by abdominal cesarian section Am. J. Ob. & Gyn., 27 : 889-893, 1934.

25. Smith, P. H. Hemorrhage in late pregnancy Am. J. ob. & Gyn., 30 : ~2-68, 1935.

26. Spiodel, E. & Turner, H. H. The roentgen-ray diagnosis of normal and abnormal pregnancies. Am. J. Ob. & Gyn., 7 : 697-702, 1924.

27. Stander, H. J. Williams obstetrics, 7th ed., N.Y., D. Appleton-Cent'lry Co., 19.31;.

28. Tenney, B. Sy~cytial degeneration in normal and pathologic placentas. Am. J. Ob. & Gyn., 31 : 1024-1028,1931;

29. Ude, W.H. & Urner, J.A. Roentge~ologic dia~nosis of placenta praevj,C', Am ..J. 00. & Gyn., :::9 : 0;i";7-E79, 1935.

30. 0de, W.H. & Urner, J.A. Roort~Cjr.ologic d,ie,R;nosis of placenta

9-11, 1935.

31. U'le, 'N.H., Weurn, T.W., and Uruer, J,A. ]oontgenol~gic diagnosis of placenta praevia Am. J. Roent. & Rad. Ther., 31 : 230-233, 19~~4.