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Staff Meeting Bulletin I-Iospitalsofthe • · • University of .Minnesota I Staff Meeting Bulletin I-Iospitals of the •·• University of .Minnesota I I-Iemorrhage (Late in Pregnancy 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 placenta praevia. 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.
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