Antepartum hemorrhage

Vol. 78, No.6 December, 1959

OBSTETR ICS AND GYNECO LOGY Obstetrics ANTEPARTUM HEMORRHAGE* A Review of 383 Cases of Abruptio Placentae and 169 Cases of Placenta Previa Treated During the Years 1944 to 1957 RoBERT

A.

KIMBROUGH,

M.D.,

PHILADELPHIA, PA.

(From the Philadelphia Lying-In Division of the Pennsylvania Hospital)

HE management of hemorrhage during the last trimester of pregnancy constitutes one of our most important and controversial obstetrical probl
T

Pa·rt I. Abruptio Placentae During the 14 year period from 1944 through 1957 there were 41,919 Lleliveries; among these, 383 patients had premature separation of the normally situated placenta after the twenty-eighth week of pregnancy, representing an incidence of one such complication in 109 deliveries (Table I). This period of time was chosen as it more clearly represents our current management than would a study extending further into the past. TABLE

I.

INCIDENCE OF PREMATURE SEPARATION OF THE PLACENTA

Total No. of deliveries No. of cases of abruptio placentae Incidence of abruptio placentae

41,919 383 1 in 109

This study is based upon cases in which there was clinical evidence of separation; minor degrees of separation "\7olhich vvere discovered only after •Presented as the Ninth Annual Joseph L. Baer Lecture before the Chicago Gynecological

Society, Oct. 17, 1958.

1161

KTMRR01THH

1162

Arn.

I. Ob11t. & (Jyuer · Det'ember, 1Q;t:1

,lelivery of tlw pla<:,,~nta by th(• JH'e:wne;• o[ minut<> retroplaeental dots ol' small organized areas of separated plaeental tisstw han• not been in<·lnd;>d. '['ABLE

Unknown

ll.

ETIOLOGICAL J<'ACTOkR IN PREMA1'llkE i"\EPAkA1'JP:\

pregnaney

While hyrwrtensive toxemia of pr·egnaney and hypNtensivP c~anliovas<·n­ lar disease wer·e found in only 8.8 per eent of our· patients (Table II), in many of those in whom thrrP was no devation of blood pressm·p or- Jll'oh·inuria, abnormal gain in weight and edema Htnmgly suggt"st<•d the pl'<'iH'Tl<'(' of tox;•mia. A pn•-existing hypet·t<•nsion in otht•rs tnay hav<· h<•t•n JwtskPtl by a fall in blood pressure incident to hemorrhage. Dieckmann, 1 in r·ontrast, found that 69 p<>r cent of his pati<>nts with abruptio placentae~ had l'\'it1ell<'<> of toxemia. Hertig/ too, holds that toxic separation of the placwntu is a form of "uterine eclampsia" since fatal caS<'S have ht•pati<' h•sions whi<•h a l'<· not distinguishable from thost> of ordinat·y eclampsia. Direct trauma to the uterus as from a blow on tht' abdomen may pro
Symptomatology The constitutional symptoms of the mother usually wer<; in direct pr·oportion to the amount of hemorrhage. The cases of severe hemorrhage most often occurred before the onset of labor and the bleeding was more fn~qlwntly concealed for a comparatively long period. The mild cases uccurred usually in the course of labor and in these the bleeding was largely extcmal. Fibrinogenopenia is associated with abruptio placentae in a :mfficirnt number of cases to require determination of the level of fibrinogPn in each suspicious case. Presumably, absorption of thromboplastin from the retrnplacental area produces first intravascular coagulation of fibrin and !at('!' a critical fall in available fibrinogen; this results in absence OJ' deficienq of clot formation. Weiner, Reid, and Roby:' have stated that rupture of the membranes, reducing intracavitary pressure, often will reduce the absorption of thromboplastin; this mechanism, however, cannot be anticipated with certainty. Prompt replacement of fibrinogen in pure form is impe1·ative if the level is found to be low. Fibrinogenopenia of sufficient degree to be of clinical importance was found in only 4 of our patients during the past 5 years. Three of thesp were delivered spontaneously and one required cesarean section. Three of the 4 mothers recovered; the other died, presumably of amniotic fluid em holism. Three of the babies died in utero as a result of massive placental separation. Fibrinogen was administered to each patient after it was determined that a deficient level existed. In addition to excessive bleeding during labor, one of these patients presented a bizarre neurological picture which was thought to be due to cerebral lodgement of fibrin emboli incident to intravascular clotting. Sh<• recovered completely within 48 hours after delivery. Fortunately, three-fifths of the separations occurred during labor and did not, therefore, constitute the greatest hazard (Table III).

Voh1me 78

ANTEPARTUM HEMORRHAGE

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TABLE III.

1163

TIME OF OCCURRENCE OF ABRUPTIO PLACENTAE

Before labor During labor

157 226

'l'otal

383

41.0 59.0 100.0

The mild cases were those occurring, almost without exception, during labor, and they were manifested by somewhat more than usual bleeding some inceease in uterine tension, and, occasionally, evidence of slight or mo~1erate fetal distress. The severe instances were those in which there was evidence nf a large concealed or frank ('xternal hemo1-rhagf> (Table IV). 'l'ABLE

lV.

SEVERITY OF CASES 0~' ABRUPTIO PLACENTAE

Mild. Moderate Severe

199 100 84

-------------Totiif______ _

383

Management Our choice of management is dependent upon the severity of the symptoms, the presence or absence of good clot formation, the condition of the fetus, whether or not the patient is in labor, and, most important of all, the degree of cervical effacement and dilatation. In those instances in which the separation occmred in the course of labor, the condition of the mother and fetus usually remained satisfactory. Most often little more was necessary than the administration of oxygen and increased caution on the part of the obstetrician. As seen in Table V, more than two-thirds of our patients were deliverell vaginally.

TABLE

V.

METHOD OF DELIVERY IN CASES OF ABRUPTIO PLACENTAl;

Vaginal delivery Forc::eps Spontaneous Podalic. version Breech extraction

177 68 1

23 113

114

29.8

In the more severe examples, particularly those in which the separation occurs before the onset of labor, cesarean section is more often our method of delivery. Not until the uterus is empty can firm contraction of the uterus close the bleeding sinuses at the placental site. Among 222 patients in whom placental separation occurred during labor, more than 90 per e!C'nt were delivered vaginally. Of the 161 instances occurring before the onset of labor, three-fifths were managed by cesarean section (Table VI). In the more urgent cases, cesarean section occasionally is done in the interest of the mother even though the child is known to be dead. Before

Am. ]. Obst. & Gynec. December, 1959

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1164

instituting any procedure for delivery, the patient must be treated for shock, and lost blood must be replaced. ·while the necessary preparations for cesarean section are awaited, thE> membranes are ruptured to decrease absorption of thromboplastin and to hastE>n labor. l:'"ndcr these eircurnstances rapid dilatation of the cervix often obviates the need for cesarean section. If there is a disturbance of the dotting mechanism, fibrinogen must be administered in adequate amounts. A fine point o:f judgment is required in determining how long to postpone operative measures while reaction from shock is awaited. No arbitrary rules can be stated since each patient must he considered ac<:ording to prevailing circumstanc<"s. TABLE YI.

.METHOD OF DELIVERY ACCORDING TO TIME 0~' ();<.;SET (W SYMP'fOMS AS RELATE!> TO LABOR

%

<'ASES

Abruptio placentae during labor Cesarean section Vaginal delivery

17 :!05

Abruptio placentae before labor section.

97 64

222 7/i

92.3

161

60.2 39.8

Removal of the uterus was deemed advisable for only one of the patients who were managed by cesarean section. \Ve do not remove the uterus simply because of its darkened and contused appearance from extravasation of blood, but only jf it fails to contract after its evacuation. Following delivery precaution must be taken against postpartum hemorrhage. Many of these uteri fail to remain firmly contracted and a small amount of additional bleeding will be tolerated poorly by the patient who already has suffered a considerable loss of blood. The administration of oxytocin in dilute solution intravenously following delivery has lessened the incidence of hemorrhage.

Maternal Mortality The patient who died (Tables VII and VIII) was a gravida i, para o, at term. She was admitted '"'rith an excessive bloody show, in labor, and there was some undue tenderness o:f the uterus. A presumptive diagnosis of partial premature separation of the placenta was made. The membranes were ruptured artificially and good labor ensued. There was no further bleeding or evidence of fetal distress. The patient was delivered easily of a living male infant after 3 hours of labor. Follo\\-ing delivery, although the uterus was firmly contracted, bleeding continued. The uterine cavity was explored TABLE

VII.

MATERNAL MORTALITY FROM ABRUPTIO PLACENTAE

No. of cases of abruptio placentae

No. of maternal deaths from abruptio placentae TABLE

VIII.

NO.

%

383 1

0.26

MATERNAL MoRTALITY ACCORDING TO METHOD OF DELIVERY

0

1

114 383

0.00 0.26

ANTEPARTUM HEMORRHAGE

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and neither tear nor placental tissue was found. The blood failed to coagulate; whole blood and 1 Gm. of fibrinogen were given_ A total hysterectomy was performed. As the procedure was being completed the patient stopped breathing; despite cardiac massage, she died. Necropsy was not permitted. The uterine veins were filled with amniotic fluid. The cause of death was thought to be amniotic fluid embolism.

Fetal Mortality Since many of the babies were dead in utero at the time of admission to the hospital and since 40 of the babies weighed less than 4 pounds, the uncorrected mortality rate of 24.6 per cent is less than had been anticipated (Tables IX and X). There is little doubt, however, that even this could be reduced by more prompt recognition of the significance of the symptoms by both patient and physician. TABLE

IX.

GROSS FETAL MORTALITY FROM ABRUPTIO PLACENTAE

eases Total No, of fetal deaths Total uncorrected fetal mortalityt Stillborn Neonatal deaths Corrected fetal mortality

49

4i

24.6% 14.3%

*Includes 7 sets of twins. tForty of the 96 dead ba.bies weighed less than 4 pounds. TABLE

X.

FETAL MORTALITY ACCO!l.DING TO METHOD OF DELIVERY IN CASES OF ABRUPTIO PLACENTAE

Review of these cases of premature separation of the placenta will establish, we believe, the following principles concerning this complication: 1. If the case be one of mild degree, the conduct of labor should be unaltered except :for the administration of oxygen and increased vigilance on the part of the obstetrician. 2. In the more severe instances, the best interests of both mother and baby are served by as prompt evacuation of the uterus as is compatible with safety, particularly in those cases in which there is an associated fibrinogenopenia. 3. Treatment for shock and replacement of blood before measures for delivery are instituted decrease the operative risk 4. Replacement of blood following delivery is essential. 5. Precaution must be taken against postpartum hemorrhage. Part II. Placenta Previa During the same 14 year period there were 169 cases of placenta previa on our service in the Pennsylvania Hospital. Included are only those cases which occurred beyond the twenty-eighth week of pregnancy and in which the diagnosis was established by palpation of the placenta through the cervix, its visualization by roentgen studies, or by confirming its low attachment

KlMBROlJOH

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,\m. l Obst. & Grnec

[)eeember, 1959

at the time of cesarean section. By observanc(' of tlws0 criteria. many instances of mild painless bleeding were eliminated from tlw study ~Yen though it is likely that low implantation of the plal·<·uta was JH'eS<'llt m some. 11 may well be that the bleeding in some of thPSP patients was du!:' to l'Uptt;n· o£ the marginal sinus, a diagnosis which w<· havt• not IW<'Il able to rnak<· w1th any degree of certainty prior· to tlelivery. rrhe l'(~COI'l1Pd ineidet1CI' of plae<•llta (>l't•Yi!l Val'i('S With thf' Stl·idll<'SS of the et'iteria for· its diagnosis. ln our JnateJ·ial. Iimit<'d to pr·oved \'HS<'S, tiH· incid<•JJ('<' was on<· in 24~ tlt>livrt·il;s (1'ahlP X I).

Total No. of dP!iveries No. of cases of placenta prt'via Inciden<'f' of plac~>nta. prtwia

-t1,9Hl 16$) 1 in :2JR

Low implantation without actual encroachment on the intt>t'nal os wa;;; the degree most commonly t>ncountereu (Table XU). :\t>xt in or·dpr of frPquency were the total and partial val'ieties.

Total Partial Low implantation Not stated

Management of Placenta Previa Our choice of treatment in placenta previa is dt>pendent upon the severity of hemorrhage, the degree of shock, th<> likely viability of the child, the location of the placenta, the presentation, and the amount of cer·vical dilatation. In formet· years the diagnosis of or even a strong suspicion of plact>nta previa was considered an indication for immediatE> delivery. This attitude was attended by a high pereentage of prematurt> deliveries with an inevitably high rate of fetal mortality. Following the work of MacAfee, Herman .fohnson, and the late Tiffany Williams, we adoptt>d the so-ealled expectant treatment of placenta previa. Patients who present this complication prior to thl' thirty-eighth week of pregnancy are treated expectantly unless the bleeding is alarming in amount or duration. In most instances the first bleeding will cease spontaneously if the patient is kept in b!'(I. Vaginal examination except by speculum is avoided prior to the thirty-eighth week because of th<• danger that digital dislodgment or perforation of the placenta may force the necessity of premature delivery. Because of the tendency of subsequent ht•morrhages to be increasingly profuse, expectantly managed patients should remain in the hospital until delivered. If the bleeding occurs during labor, if the placenta is marginal or latet'al. and if the presentation is polar, rupture of the membranes often will allow the presenting part to make sufficient pressure on the partly separated and traumatized placenta to control the blc:eding. Traction on the scalp occasionally is advisable. In such instances labor is allowed to proceed to spontaneous or low forceps delivery. If the C<'rvix is completely dilated and if the baby is small, version and extraction on rare occasions may be the

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pr-ocedure of choice except in the presence of central implantation. Because of the danger that deep laceration of the cer-vix may extend into the placental :,;ite, manual dilatation of the cervix is strictly contraindicated. By following these principles, we were able to deliver 51 (30.1 per (•ent) of our patiNlts by the vaginal route (Table XIII). TABLE

XIII.

METHODS OF DELIVERY IN PLACENTA PREVIA

Vaginal Forceps

Spontaneous Version and extraction Breech extraction Braxton Hicks vf'rsion Cesarean section Total No. o:f ca1
2 1

1

118

69.9 100.0

169

In 118 (69.9 per cent) of our cases, cesarean section was performed. If the bleeding is profuse and the cet·vix is closed, we believe that the best interests of hoth mother and child are served by thifS procedure. Regardless of the amount of cervical dilatation, c<:>sarean section is done in every case of central placenta previa and in most instances of malpresentation. Maternal Mortality There was no deaths among the 51 patients in whom the amount of eervical dilatation and other favorable factors permitted vaginal delivery. Unfortunately, a relatively small number were found amenable to such simple management. No maternal mortality attended the 118 cesarean sections (Table XIV). TABLE

XIV.

MA'l'ERNAL MoRTALITY FROM PLACENTA PREviA

169

Cases of placenta previa Maternal deaths from placenta previa

0 (0.0%)

Fetal Mortality Intrauterine asphyxia presumably was responsible for most of the fetal deaths and was no doubt, a contributor-y cause in all of them (Table XV). Prematurity w~s the next most frequent factor as 11 of the 19 babies who died weighed less than 4 pounds. TABLE

XV.

GROSS FETAL MORTALITY AccoRDING TO METHOD OF DELIVERY

Ge13ar•ean section :fetal mortalityt Corrected fetal mortality •Included 2 seta ot twins.

11

19

120* 171

9.2 11.1 4 ,,

tl
Our experience has resulted in adoption of tb e following principles in the management of placenta previa:

KIMBROUGH

1168

\m.

J.

Obst & Gynec December, I q .I 9

1. Accurate diagnosis of the cause of bleeding is desirable. A cautiously performed vaginal examination, preferably with a speculum only, may reveal that the bleeding is due to a cervical polyp, an erosion, or, rarely. a cervical carcinoma rather than to placenta previa. Examination, however·, (•ntails the danger of sudden profuse bleeding as well as the risk of infection. :-:\o patient suspected of having placenta previa should br <'Xamined until sh<' is in an operating room which is ready for both vaginal and abdominal delivery. Rectal examination has no place in thr management of this complication; it is attended by great likelihood of producing hemonhage and g·ives less act~urate information than one can obtain by vaginal ('Xamination. X-ray studies hy the "soft tissue" technique have been valuable in loealization of the placenta. By this method the normally situated plac<'nta is visualized in practically all eases; the low-lying placenta is hidden by the pelvic bones. Failuee to find the placental shadow high in the utt•rus is definite evidence that the placenta is located probably, but not necessar·ily. in the lower uterine segment. The techniqu<' is deprndabl€', therefor't', only in ruling out, rather than positively diagnosing, placenta previa. 'rhis method of study is applicable. obviously, only in those patients in whom bleeding- haf; subsided. 2. Treatment of shock and replacement of blood ar<> essential befon' procedures for delivery ar·e instituted. 3. Expectant management of patients with placenta previa in the hope of hr·inging the child to gTeater viability is advisable provided thr patient rt•mains in the hospital throughout the remaindrr of the pregnancy. 4. If the cervix is dilated and the placenta pr·evia is only partial or· marginal, rupture of the membranes often will allow the presenting pHI't to make sufficient pressUl'e on the placenta to stop the bleeding. 5. BPcause of the danger of profuse hemorrhage from the vessels of tlw placental site and the added risk of infection, manual dilatation of the cervix and forcible vaginal delivery have no placr in the treatment of this condition. 6. The hydrostatic bag has no place in the management of placenta previa; the hazard of hemorrhage incident to its insertion and several instances of continuing, concealed intrauterine bleeding- following its insertion havr resulted in our giving up its use. 7. In all cases in which the cervix is not dilated, in all instanees of central placenta pr<'via regardless of the degree of cervical dilatation. and in those of malpresentation of the fetus, cesarean section is the safest and therefore the most conservative form of treatment The fetus, as well as the mother. may lose blood through the separated and damaged placenta. Incision through the placenta may produce additional fetal hemorrhage. Pnr these reasons classical cesarean section is preferred to the low eervical operation. 8. The use of oxytocin in dilute solution intJ•avenousiy by continnou~ chip immediately after delivery lessens the danger of postpartum hemonhage.

References 1. Dieckmann, W, .J.: AM. J. 0BST. & GYNEC. 31: 734, 1936. 2. Hertig, A. T.: Clinics 4: 602, 1945. (Cited by Greenhill.) 3. Weiner, A. E., Reid, D. E., and Roby, C. C.: AM. J. OBST. & 80i

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