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Ligation of the Uterine Arteries for Control of Hemorrhage in Placenta Previa
OF THE UTERINE ARTERIES FOR CONTROI.. OF HEMORRHAGE IN PLACENTA PREVIA •
r~IGATION
BY WILLIAM KERWIN,
M.D., F.A.C.S.,
ST.
Lours, Mo.
(From the Department of Gynecology, St. Louis Unwersity Sch
St. Mary's Hospital)
to both mother and child in pla-
ever-present high mortality THE centa previa is a source of great worry to obstetricians, and those
who have had mishaps, will no doubt welcome a treatment which is reliable in the control of hemorrhage, especially the protracted bleeding following delivery of the child and placenta. The method occurred to me while handling a case of placenta previa centralis in March, 1925, at which time I was unfamiliar with the work of Harold Miller who had done the same operation in 1907 and reported eleven cases. The operation was apparently not generally adopted or fell into disuse as no further reports appear in the literature sinee that time. The method deals with the ligation of the uterine arteries through the vagina. The technic is as follows: A vaginal retractor placed anteriorly holds the bladder up, while a lateral retractor exposes the right lateral vaginal fornix; the cervix is grasped with tenacula and pulled downward, backward, and to the left; with a large curved needle threaded with plain catgut a ligature is thrown around the main trunk of the right uterine artery and tied. This can be accomplished by inserting the point of the needle in the upper part of the right vaginal vault just anterior to the midplane and carrying the needle inward and as high as possible so as to include all the lateral parametrium. The needle follows a course upward and inward toward the uterus and emerges through the vaginal wall about an inch posterior to its entrance. On the dial of the clock the entrance would correspond to ten and the exit to eight with nine representing the position of the uterine artery. 'fhe same procedure is carried out on the left side and when this ligature is tied all bleeding stops. No denudation of the vaginal wall is made and the operation can be completed in a few minutes. (Fig. 1.) My first patient was in her fourth pregnancy which had been stormy owing to bleeding spells during the last two months caused by placenta previa centralis. Delivery of the child and placenta was followed by severe bleeding for which uterine packs and oxytoxics were used. The bleeding continued and a transfusion of 500 c.c. of blood was done. The uterus was repacked and more oxytoxics given but *Presented before the joint meeting of the St. Socie.ties at Chicago, December. 1926. ]8!}
Lout~
and the Chicago Gynecological
190
THE AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
bleeding continued. There was good tone in the uterus but in this patient as is so often the case the lower uterine segment and the cervix continued bleeding and the patient rapidly became exanguinated. Manual compression and two more transfusions failed and the patient became pulseless. Ligation of both uterine arteries was done and another transfusion given. The bleeding stopped and did not recur. Both mother and child are living and another child has been born recently with no complications. In a second case the ligation was done, as a prophylactic measure, after delivery. A third patient. seen in consultation was practically
Fig. 1.-Method of ligating the uterine artery.
pulseless from hemorrhage which was not under control. Ligation stopped the bleeding, transfusion was done, and the patient survived. It is my Qpinion that in the first and third cases the patients were saved from death by the operation. No unusual changes occurred in the uterus because of the ligation and the puerperium was normal. The lochia became serosanguinous on the second or third days. The method can be used prophylactically before delivery in placenta previa but would be somewhat difficult of execution if the head were low down and fixed, which it rarely is in placenta previa. Two questions to answer are : ( 1) Is the ureter in danger of injury? (2) Is it possible to ligate the artery without first exposing it Y
KERWIN:
LIGATION OF THE UTERIXE ARTERIES
191
The answers will be found in Fig. 2, which is a drawing of a specimen removed after doing the operation on a fresh postpartum cadaver. It will be seen that the ureter is about one inch from the ligature which completely compresses the main trunk of the uterine artery. 'l'he safety of the ureter is assured by upward retraction of the bladder and downward pull on the cervix which tend to establish a ''safety zone'' which is about one inch wide. The only requisites for doing the operation are the few instruments carried in the regular obstetric kit and a knowledge of the relative anatomy. It is presupposed that good obstetric judgment is used, Henkle has advised the use of clamps for the purpose, but the type of clamp u~ed to compress the parametrium is not at one's disposal
Fig. 2.-Cadavcr specimen with uterine attery tied.
when needed and is more injurious to the tissues than a simple ligature. Should one include the ureter with a ligature of plain catgut no great harm would come, for the ligature would either be free in a few days or could be removed. The ligatures were not removed in my cases. The operation should materially lessen the necessity for doing cesarean· section in placenta previa and save many women who were heretofore doomed to death by hemorrhage. SUMMARY
1. Ligation of the uterine arteries in placenta previa completely controls hemorrhage.
1U2
'l'HE Al\IERIC.\N JOCH~AJ, 01•' OBHTETHH'i'i A~D flY~l::COLUUY
2. The method is simple and can be done in a few minutes by any qualified obstetrician either in a hospital or at home. 3. Cesarean section may not be necessary in the treatment of placenta previa. 4. Hysterectomy for bleeding after delivery is unnecessary. 5. Maternal mortality from hemorrhage should be greatly lessened. REFERENCES
(1) Miller, Harold: Am. Jour. Burg., 1909, uiii, 12. Deutsch. med. Wchnschr., 1925, xxviii, 1139.
(2) Henkel, Max:
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'l'HE
CORD~'
SIDDALL, M.D., DETROIT, MICHIGAN
(From the Obstetri.cal Department, Henry Fora Hospital)
I
NFLAMMATORY changes of the umbilical cord have long been considered of more or less value in the diagnosis of fetal syphilis. Most importance has been ascribed to leucocytic and small round-cell infiltration of the vessel walls and adjacent connective tissue. Certain authors have also emphasized other changes such as thickening of the intima, with secondary vascular stenosis, edema with dissociation and even degeneration of muscle and elastic fibers, calcification, and gumma-like areas. Macroscopic findings have been considered of little value. Bondi found changes in fifteen cords from thirty-one definitely a11d four probably syphilitic children, No cord from one hundred nonsyphilitic children showed inftammation, although there occurred such maternal complications as pneumonia, typhus fever, rheumatism, intrapartum and postpartum infection, and nephritis. He be· iieved that positive findings were pathognomonic of syphilis but that negative findings were without significance. Seitz found the condition in syphilis only and believed it to be strong evidence of that disease. Ziegler was of the same opinion. Chiarabba saw inflammation in four instances of syphilis and believed gumma of the vein wall to be a specific lesion. Gargano mentioned small round-cell inftltrat,ion but stressed thickening and then destruction of the intima, dissociation of muscle fibers in the media, etc., as being the important syphilitic changes in the umbilical cord. Dominici found spirochetes where there were no gummata and believed that they could lead to the ordinary type of inflammatory exudate. Mohn found the changes in sixteen of twenty-four cords from syphilitic children. He believed that positive findings indicated a high probability of syphilis but were not absolutely characteristic. Thomsen, though finding one instance of inflamma· tion in fifty-nine probably nonsyphilitic umbilical cords, concluded later from studies done with Boas that for practical purposes inflammation was diagnostic of syphilis. Livon thought that the changes in the umbilical cord were not specific for syphilis *Read be!or\) t)le Detroit Obstetrical and Gynecological Society, February 7, 1927.
r~IGATION
BY WILLIAM KERWIN,
M.D., F.A.C.S.,
ST.
Lours, Mo.
(From the Department of Gynecology, St. Louis Unwersity Sch
St. Mary's Hospital)
to both mother and child in pla-
ever-present high mortality THE centa previa is a source of great worry to obstetricians, and those
who have had mishaps, will no doubt welcome a treatment which is reliable in the control of hemorrhage, especially the protracted bleeding following delivery of the child and placenta. The method occurred to me while handling a case of placenta previa centralis in March, 1925, at which time I was unfamiliar with the work of Harold Miller who had done the same operation in 1907 and reported eleven cases. The operation was apparently not generally adopted or fell into disuse as no further reports appear in the literature sinee that time. The method deals with the ligation of the uterine arteries through the vagina. The technic is as follows: A vaginal retractor placed anteriorly holds the bladder up, while a lateral retractor exposes the right lateral vaginal fornix; the cervix is grasped with tenacula and pulled downward, backward, and to the left; with a large curved needle threaded with plain catgut a ligature is thrown around the main trunk of the right uterine artery and tied. This can be accomplished by inserting the point of the needle in the upper part of the right vaginal vault just anterior to the midplane and carrying the needle inward and as high as possible so as to include all the lateral parametrium. The needle follows a course upward and inward toward the uterus and emerges through the vaginal wall about an inch posterior to its entrance. On the dial of the clock the entrance would correspond to ten and the exit to eight with nine representing the position of the uterine artery. 'fhe same procedure is carried out on the left side and when this ligature is tied all bleeding stops. No denudation of the vaginal wall is made and the operation can be completed in a few minutes. (Fig. 1.) My first patient was in her fourth pregnancy which had been stormy owing to bleeding spells during the last two months caused by placenta previa centralis. Delivery of the child and placenta was followed by severe bleeding for which uterine packs and oxytoxics were used. The bleeding continued and a transfusion of 500 c.c. of blood was done. The uterus was repacked and more oxytoxics given but *Presented before the joint meeting of the St. Socie.ties at Chicago, December. 1926. ]8!}
Lout~
and the Chicago Gynecological
190
THE AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
bleeding continued. There was good tone in the uterus but in this patient as is so often the case the lower uterine segment and the cervix continued bleeding and the patient rapidly became exanguinated. Manual compression and two more transfusions failed and the patient became pulseless. Ligation of both uterine arteries was done and another transfusion given. The bleeding stopped and did not recur. Both mother and child are living and another child has been born recently with no complications. In a second case the ligation was done, as a prophylactic measure, after delivery. A third patient. seen in consultation was practically
Fig. 1.-Method of ligating the uterine artery.
pulseless from hemorrhage which was not under control. Ligation stopped the bleeding, transfusion was done, and the patient survived. It is my Qpinion that in the first and third cases the patients were saved from death by the operation. No unusual changes occurred in the uterus because of the ligation and the puerperium was normal. The lochia became serosanguinous on the second or third days. The method can be used prophylactically before delivery in placenta previa but would be somewhat difficult of execution if the head were low down and fixed, which it rarely is in placenta previa. Two questions to answer are : ( 1) Is the ureter in danger of injury? (2) Is it possible to ligate the artery without first exposing it Y
KERWIN:
LIGATION OF THE UTERIXE ARTERIES
191
The answers will be found in Fig. 2, which is a drawing of a specimen removed after doing the operation on a fresh postpartum cadaver. It will be seen that the ureter is about one inch from the ligature which completely compresses the main trunk of the uterine artery. 'l'he safety of the ureter is assured by upward retraction of the bladder and downward pull on the cervix which tend to establish a ''safety zone'' which is about one inch wide. The only requisites for doing the operation are the few instruments carried in the regular obstetric kit and a knowledge of the relative anatomy. It is presupposed that good obstetric judgment is used, Henkle has advised the use of clamps for the purpose, but the type of clamp u~ed to compress the parametrium is not at one's disposal
Fig. 2.-Cadavcr specimen with uterine attery tied.
when needed and is more injurious to the tissues than a simple ligature. Should one include the ureter with a ligature of plain catgut no great harm would come, for the ligature would either be free in a few days or could be removed. The ligatures were not removed in my cases. The operation should materially lessen the necessity for doing cesarean· section in placenta previa and save many women who were heretofore doomed to death by hemorrhage. SUMMARY
1. Ligation of the uterine arteries in placenta previa completely controls hemorrhage.
1U2
'l'HE Al\IERIC.\N JOCH~AJ, 01•' OBHTETHH'i'i A~D flY~l::COLUUY
2. The method is simple and can be done in a few minutes by any qualified obstetrician either in a hospital or at home. 3. Cesarean section may not be necessary in the treatment of placenta previa. 4. Hysterectomy for bleeding after delivery is unnecessary. 5. Maternal mortality from hemorrhage should be greatly lessened. REFERENCES
(1) Miller, Harold: Am. Jour. Burg., 1909, uiii, 12. Deutsch. med. Wchnschr., 1925, xxviii, 1139.
(2) Henkel, Max:
LISTER BUILDING.
'l'IIJ£
~::UGNll;1JCANCE
OF
INll'I.~AMl\:lA'l'ION
UMBILICAL BY
R.
s.
Qli'
'l'HE
CORD~'
SIDDALL, M.D., DETROIT, MICHIGAN
(From the Obstetri.cal Department, Henry Fora Hospital)
I
NFLAMMATORY changes of the umbilical cord have long been considered of more or less value in the diagnosis of fetal syphilis. Most importance has been ascribed to leucocytic and small round-cell infiltration of the vessel walls and adjacent connective tissue. Certain authors have also emphasized other changes such as thickening of the intima, with secondary vascular stenosis, edema with dissociation and even degeneration of muscle and elastic fibers, calcification, and gumma-like areas. Macroscopic findings have been considered of little value. Bondi found changes in fifteen cords from thirty-one definitely a11d four probably syphilitic children, No cord from one hundred nonsyphilitic children showed inftammation, although there occurred such maternal complications as pneumonia, typhus fever, rheumatism, intrapartum and postpartum infection, and nephritis. He be· iieved that positive findings were pathognomonic of syphilis but that negative findings were without significance. Seitz found the condition in syphilis only and believed it to be strong evidence of that disease. Ziegler was of the same opinion. Chiarabba saw inflammation in four instances of syphilis and believed gumma of the vein wall to be a specific lesion. Gargano mentioned small round-cell inftltrat,ion but stressed thickening and then destruction of the intima, dissociation of muscle fibers in the media, etc., as being the important syphilitic changes in the umbilical cord. Dominici found spirochetes where there were no gummata and believed that they could lead to the ordinary type of inflammatory exudate. Mohn found the changes in sixteen of twenty-four cords from syphilitic children. He believed that positive findings indicated a high probability of syphilis but were not absolutely characteristic. Thomsen, though finding one instance of inflamma· tion in fifty-nine probably nonsyphilitic umbilical cords, concluded later from studies done with Boas that for practical purposes inflammation was diagnostic of syphilis. Livon thought that the changes in the umbilical cord were not specific for syphilis *Read be!or\) t)le Detroit Obstetrical and Gynecological Society, February 7, 1927.