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Management of Placenta Praevia
Medical Clinics of North America May, 1941. New York Number
CLINIC OF DR. GEORGE LOVERIDGE BOWEN FRENCH HOSPITAL MANAGEMENT OF PLACENTA PRAEVIA
PLACENTA praevia is generally classified as: (1) complete placenta praevia, in which the internal os of the uterine cervix is entirely covered by the placenta; (2) partial placenta praevia, in which the internal os is partly covered by the placenta, and (3) marginal placenta praevia, in which the placenta approximates the internal os but does not encroach upon it. Frequency.-In two large sefies of deliveries recently reviewed, placenta praevia occurred in a ratio of 1 to 105 in 26,116 Iabors,ll and 1 to 134 in 34,879 labors.4 The relative frequency of the three types of placenta praevia is reported in several large hospital series as follows: Complete, Partial, Marginal, Per Cent Per Cent Per Cent Bellevue Hospital, New York1.2. . 23 25 42 (10% unclassified) Charity Hospital, New Orleans'.... 3i 33 30 Chicago Lying-In3 . • . . . • • • • . • • • . 34 13 52 Maryland University and Baltimore City Hospitals". . . . . . . . . . . .. 2() 26 47
The variations in the frequency of the three grades may be clue to the difference in the amount of dilatation at the time vaginal examinations are made, making accurate diagnosis difficult. Etiology.-The etiology is unknown, although various theories have been advanced to explain the low implantation of the placenta. We do know that the condition occurs more frequently in multigravid than in primigravid women, and more frequently in white than in Negro women. Symptoms.-The cardinal symptom is painless bleeding. This is usually seen in the last trimester of pregnancy, although it may occur in the earlier months. Reports show that 40 to SO 649
GEORGE LOVERlDGE BOWEN
per cent of all women who experience this symptom in the last trimester have placenta praevia. Diagnosis.-Ev'en though the bleeding is slight the patient should be placed in a hospital for study and diagnosis. Transportation entails no great risk provided an internal examination is not done in the home. As the clotted blood provides good hemostasis it should not be dislodged, nor should any attempt be made to pack the vagina. Effective vaginal packing is difficult with ideal surroundings and equipment, and even when properly done it increases the risk of infection. It may be desirable to give the patient ~ grain of morphine before she. is moved. Immediately following admission to the hospital the blood is typed and, if time permits, a complete blood count and hemoglobin and cell volume de terminations are made. After the initial hemorrhage, the patient with sedation and bed rest may not bleed again for intervals varying from a few hours to several days. Therefore, if the bleeding stops, the patient may be kept in bed for four or five days before any vaginal examination is done. During this waiting period roentgenography may be helpful in making a diagnosis. Ude et al. 6 in 1934 reported filling the bladder with a radiopaque substance before taking x-ray pictures. This shows the relationship between the bladder and the lower uterine segment. When the placenta is implanted low on the anterior wall, its structure is interposed between the presenting part and the lower uterine segment and thereby decreases the proximity of the presenting part to the bladder. However, Carvalh0 7 obtained some false positives where factors other than a low implanted placenta were present which caused an upward displacement of the fetal head. In addition, the procedure was found of little value when the placenta was implanted low on the posterior wall. Brown and Dippel 8 have reported accurate determination of placental location by soft tissue roentgenography after distending the bladder with air. Further work along these lines may develop more practical and helpful aids. At present a sterile vaginal examination is our most satisfactory method of diagnosis. For this examination the patient must be taken to the delivery room, complete aseptic technic
MANAGEMENT OF PLACENTA PRAEVIA
651
is essential, and all equipment and personnel must be in readiness to institute any necessary procedure. In some clinics a team is scrubbed and the operating room is set up for a cesarean section before the vaginal examination is begun. The resulting decrease in maternal mortality, as shown by the reports from one clinic where this precaution is observed, well justifies it. If no placenta praevia is found a bivalve speculum should be inserted to inspect the cervix. If placenta praevia is found there may be further and profuse bleeding following the vaginal examination. A blood donor must be present as there is no substitute for blood to replace the loss from hemorrhage, and whole blood is indicated. TREATMENT
The only contribution which the physician can make to the prophylaxis of placenta praevia is to tell patients to notify their physicians when any bleeding is seen. The general principles which govern the active treatment are: hospitalization, control of hemorrhage, replacement of blood loss, and termination of pregnancy when the diagnosis is established. Choice of Method of Delivery.-Two methods of delivery are available, vaginal and abdominal. To decide which is preferable one must weigh several factors. The optimum method is the one which minimizes the following hazards: blood loss, trauma with ensuing shock, and infection. Most writers agree that in complete placenta praevia cesarean section is the procedure of choice. In marginal or partial placenta praevia, to decide the method of delivery one must consider the period of gestation, the viability and the size of the fetus, the parity of the patient, and the condition of the cervix. With a marginal placenta praevia, and occasionally with a partial placenta praevia, when the cervix is soft, partly dilated and favorable for labor, the baby may be delivered through the vagina. However, when the cervix is firm, unfavorable for labor and relatively closed, the abdominal route is preferred . . Vaginal Delivery of the Infant.-There are several methods to consider when one decides upon vaginal delivery: 1. Rupture of the Membranes.-This, the simplest method, allows the presenting part to fit against the placenta
GEORGE LOVERIDGE BOWEN
and control the bleeding. It may be combined with the use of the Willett 10 clamp on the baby's scalp to keep pressure against the low implanted placenta; or, in case of a breech, one foot may be brought down and used as a tampon. In some of these patients small amounts of pituitary extract, beginning with 1-minim doses, may be administered to start uterine contractions. The Willett forceps (Fig. 58) is a modification of the T-shaped de Martel scalp clamp, and was introduced in England in 1925. After rupturing the membranes this clamp is fastened to the baby's scalp and gentle traction is applied to keep it against the placenta and cervix. While this clamp has not been used in the clinics with which the writer is associated, Davis 3 reports favorably on its use at the Chicago Lying-In
Fig. 58.-WilIett scalp obstetrical forceps.
Hospital, and the reports in the contemporary English literature are most favorable. Davis states that the scalp injury may be disregarded. Sometimes by external version it is possible to convert a vertex to a breech before rupturing the membranes in order to provide a leg for a tampon. If either of these combinations is employed, it must be remembered that dilation of the cervix requires time, and neither undue pressure nor manual effort to hasten it may be used. Furthermore, delivery must not be attempted until the dilatation is complete. 2. Metreurysis.-Metreurysis is not as popular today as it was ten years ago.' However, the Voorhees bag is still used in some clinics when artificial rupture of the membranes fails to control the bleeding.
MANAGEMENT OF PLACENTA PRAEVIA
653
There are two methods of inserting a bag: Ca) For intraovular insertion the membranes are ruptured and the bag is placed against the fetal side of the placenta. The disadvantages of this method are infection of the amniotic sac, and increased fetal anoxemia from interference with the placental circulation. Cb) For extra-ovular insertion the bag is inserted into the lower uterine segment without rupturing the membranes. This method may cause premature separation of the low implanted placenta. The writer prefers the intra-ovular method. The bag must be perfectly filled and a light, steady weight of 250 to 500 gm. must be applied for traction; intermittent pulling should not be countenanced because of the risk of tearing the cervix. A No. 4 or No. 5 bag must be used. 3. Braxton Hicks Version.-This has been used less in recent years. It is a valuable method when the baby is small and its viability is in doubt. The disadvantages are the necessity for anesthesia, trauma to the baby, and fetal anoxemia from interference with placental circulation. After the leg has been brought down it may be held, but traction must never be made as severe laceration of the lower uterine segment may result. A review of the mortality statistics shows the dangers of this error. Methods which meet with disfavor are: tamponade, accouchement force, and expectant treatment. Tamponade to be effective must be done thoroughly; blood clots must be removed and in doing this more bleeding may follow. Furthermore, the danger of introducing infection is a serious one. Accouchement force, by manual or mechanical methods, is mentioned only to be condemned. Expectant treatment has no place in the care of patients with active bleeding. However, it may be used in the case of patients who have bled but once and stopped, and who have a baby of questionable viability. With such findings the patient must be in bed in the hospital, under the observation of a well trained staff, and with a blood bank or donor available. In managing the third stage of labor, again one should individualize. If the patient does not bleed it is well to wait for separation of the placenta and deliver it in the accustomed
GEORGE LOVERIDGE BOWEN
manner. However, if there is bleeding a manual removal of the placenta is imperative, followed by inspection of the cervix with adequate exposure and a good light. Right-angled retractors facilitate exposure of the cervix, and several sponge forceps are essential to grasp the cervical rim and thoroughly inspect it. Repair of any bleeding cervical laceration should be done at once. One must be aware constantly of the danger of shock and try to avoid it by a minimum of trauma, and by treating hemorrhage by adequate transfusions of whole blood. If the patient is bleeding from the placental site, the uterus and vagina should be packed completely with plain 2inch gauze. Part of this packing may be removed in twelve hours, and the remainder in twenty-four hours. The writer saw one patient with placenta praevia packed with iodoform gauze who died five days later from iodoform poisoning. As iodoform has little proved value except as a deodorant, plain gauze packing is recommended. Abdominal Delivery of the Infant.-As previously stated, when a central placenta praevia is found in the last trimester of pregnancy, delivery should be by the abdominal route. With partial placenta praevia and sometimes with a marginal when the cervix is uneffaced, firm, and not favorable for labor, cesarean section is also to be preferred. The type of cesarean operation used varies with the clinic. Reports of placenta praevia in recent years indicate a trend toward the use of the laparotrachelotomy, in preference to the classical cesarean section. Local anesthesia may be employed in selected cases. Low classical cesarean section may help to avoid the placental site, but laparotrachelotomy affords less risk from infection, the site of bleeding can be packed with greater ease, and there is less likelihood of rupture of the uterus in subsequent labors. In neglected cases in which the initial warning of bleeding has been ignored and because of lowered resistance the patient has become infected, and especially in those cases in which vaginal packing has been used, a Porro cesarean section may be the procedure of choice.
MANAGEMENT OF PLACENTA PRAEVIA
655
PROGNOSIS
Kerr,9 in a review of maternal deaths from placenta praevia before 1930, reported 70 per cent were due to shock and hemorrhage, and 30 per cent were due to sepsis. It is well to remember that the maternal mortality in vaginal deliveries is caused primarily by shock and hemorrhage, while in cesarean sections it is due to infection. The prognosis is much more favorable now than even ten years ago. I believe that two factors are responsible, namely: (a) the earlier and more frequent use of large blood transfusions; and (b) the greater frequency of cesarean sections. Arnell and Guerriero,4 in reporting 260 cases of placenta praevia at the Charity Hospital, New Orleans, stated that in only 34 per cent of this total were blood transfusions given, but of the patients seen in the last two years, 88 per cent were transfused. At Bellevue Hospital, New York,!' 2 in the period 1922-32, only 21 per cent of the patients with placenta praevia received blood transfusions, and for the period 1933-38, 50 per cent received transfusions with a resulting decrease in mortality from 11.5 per cent to 2.0 per cent. One death occurred in fifty cases, the patient having been an emergency admission in extremis. . Arnell and Guerrier0 4 reported the maternal mortality rate was five times greater when the vaginal route was used than when cesarean section was employed. Likewise the danger to the fetus is about five times greater from the vaginal than the abdominal route. This is easily understood because the majority of the infants are premature and have less chance of surviving the trauma of vaginal deliveries. They reported further that in the first five years only 27 per cent of the cases of placenta praevia were treated by cesarean section. During this period the maternal mortality was 11.3 per cent. In the second five years, 45 per cent of the cases of placenta praevia were treated by cesarean section, and here the maternal mortality was 5.1 per cent. Siegel,5 in a study of 332 consecutive cases of placenta praevia at the University of Maryland Hospital and Baltimore City Hospital, reported a maternal mortality of 6.6 per cent in vaginal deliveries, and 1.9 per cent from cesarean section. The fetal mortality was 27.8 per cent from cesarean section and 48.8 per cent in vaginal deliveries.
GEORGE LOVERIDGE BOWEN
SUMMARY AND CONCLUSIONS
1. All patients who experience painless bleeding in the last trimester of pregnancy should be placed in a hospital immediately for study and diagnosis. 2. Internal examinations should not be made in the home, nor should vaginal packing be attempted there. 3. Following admission to a hospital the blood should be typed. A complete blood count and cell volume determination are desirable. 4. Blood loss must be replaced early by whole blood transfusions; other fluids are inadequate substitutes. S. When time permits, roentgenography may be of value for diagnosis. 6. If the patient continues to bleed after admission to the hospital, arrangements should be made immediately for a vaginal examination. However, if the bleeding stops, the patient may be kept in bed for several days before the vaginal examination is made. 7. Vaginal examination should be made in the delivery or operating room, under strict asepsis, with adequate equipment and personnel ready to institute whatever treatment is considered best. 8. The treatment should suit the needs of the individual, and either the vaginal or abdominal route may be used for delivery~
9. The methods recommended for controlling hemorrhage and facilitating vaginal delivery are: (a) rupture of membranes alone, or combined with Willett's clamp, or in breech presentations a foot brought down for a tampon; (b) metreurysis when indicated; or (c) Braxton Hicks version when indicated. 10. Tamponade and expectant treatment are to be em-· ployed only rarely. 11. Accouchement force should never be used. 12. Two factors have been responsible for the reduction of maternal and fetal mortality in placenta praevia: (a) the more frequent and early employment of multiple blood transfusions; and (b) the use of cesarean section in selected cases. BmLIOGRAPHY 1. AIlison, H. M.: Review of Placenta Praevia, Bellevue Hospital, New York.
1922-32. Unpublished report.
MANAGEMENT OF PLACENTA PRAEVIA 2. Salter, Hiram P.: Review of Placenta Praevia, Bellevue Hospital, New York, 1933-38. Unpublished report. 3. Davis, M. E.: Surg., Gynec. & Obst., 68: 504-512, 1940. 4. ArneIl, R. E. and Guerriero, W. F.: Am. J. Obst. & Gynec., 39: 32, 1940. 5. Siegel, L A.: Am. J. Obst. & Gynec., 39: 301, 1940. 6. Ude, Weum and Urner: Am. J. Roentgenoi., 31: 230, 1934. 7. Carvalho, M. A.: Am. J. Obst. & Gynec., 39: 306, 1940. 8. Brown, W. H. and Dippel, A. L.: Bull. Johns Hopkins Hospital, 66: 90, 1940. 9. Kerr, J. M.: Maternal Mortality and Morbidity. Baltimore, Williams & WiIkins, 1933, p. 124. 10. WiIIett, J. A.: Proc. Roy. Soc. Med., 18: 90, 1925. 11. Caldera, R.: J. Obst. & Gynec. Brit. Emp., 46: 531, 1939. VOL. 25-42
CLINIC OF DR. GEORGE LOVERIDGE BOWEN FRENCH HOSPITAL MANAGEMENT OF PLACENTA PRAEVIA
PLACENTA praevia is generally classified as: (1) complete placenta praevia, in which the internal os of the uterine cervix is entirely covered by the placenta; (2) partial placenta praevia, in which the internal os is partly covered by the placenta, and (3) marginal placenta praevia, in which the placenta approximates the internal os but does not encroach upon it. Frequency.-In two large sefies of deliveries recently reviewed, placenta praevia occurred in a ratio of 1 to 105 in 26,116 Iabors,ll and 1 to 134 in 34,879 labors.4 The relative frequency of the three types of placenta praevia is reported in several large hospital series as follows: Complete, Partial, Marginal, Per Cent Per Cent Per Cent Bellevue Hospital, New York1.2. . 23 25 42 (10% unclassified) Charity Hospital, New Orleans'.... 3i 33 30 Chicago Lying-In3 . • . . . • • • • . • • • . 34 13 52 Maryland University and Baltimore City Hospitals". . . . . . . . . . . .. 2() 26 47
The variations in the frequency of the three grades may be clue to the difference in the amount of dilatation at the time vaginal examinations are made, making accurate diagnosis difficult. Etiology.-The etiology is unknown, although various theories have been advanced to explain the low implantation of the placenta. We do know that the condition occurs more frequently in multigravid than in primigravid women, and more frequently in white than in Negro women. Symptoms.-The cardinal symptom is painless bleeding. This is usually seen in the last trimester of pregnancy, although it may occur in the earlier months. Reports show that 40 to SO 649
GEORGE LOVERlDGE BOWEN
per cent of all women who experience this symptom in the last trimester have placenta praevia. Diagnosis.-Ev'en though the bleeding is slight the patient should be placed in a hospital for study and diagnosis. Transportation entails no great risk provided an internal examination is not done in the home. As the clotted blood provides good hemostasis it should not be dislodged, nor should any attempt be made to pack the vagina. Effective vaginal packing is difficult with ideal surroundings and equipment, and even when properly done it increases the risk of infection. It may be desirable to give the patient ~ grain of morphine before she. is moved. Immediately following admission to the hospital the blood is typed and, if time permits, a complete blood count and hemoglobin and cell volume de terminations are made. After the initial hemorrhage, the patient with sedation and bed rest may not bleed again for intervals varying from a few hours to several days. Therefore, if the bleeding stops, the patient may be kept in bed for four or five days before any vaginal examination is done. During this waiting period roentgenography may be helpful in making a diagnosis. Ude et al. 6 in 1934 reported filling the bladder with a radiopaque substance before taking x-ray pictures. This shows the relationship between the bladder and the lower uterine segment. When the placenta is implanted low on the anterior wall, its structure is interposed between the presenting part and the lower uterine segment and thereby decreases the proximity of the presenting part to the bladder. However, Carvalh0 7 obtained some false positives where factors other than a low implanted placenta were present which caused an upward displacement of the fetal head. In addition, the procedure was found of little value when the placenta was implanted low on the posterior wall. Brown and Dippel 8 have reported accurate determination of placental location by soft tissue roentgenography after distending the bladder with air. Further work along these lines may develop more practical and helpful aids. At present a sterile vaginal examination is our most satisfactory method of diagnosis. For this examination the patient must be taken to the delivery room, complete aseptic technic
MANAGEMENT OF PLACENTA PRAEVIA
651
is essential, and all equipment and personnel must be in readiness to institute any necessary procedure. In some clinics a team is scrubbed and the operating room is set up for a cesarean section before the vaginal examination is begun. The resulting decrease in maternal mortality, as shown by the reports from one clinic where this precaution is observed, well justifies it. If no placenta praevia is found a bivalve speculum should be inserted to inspect the cervix. If placenta praevia is found there may be further and profuse bleeding following the vaginal examination. A blood donor must be present as there is no substitute for blood to replace the loss from hemorrhage, and whole blood is indicated. TREATMENT
The only contribution which the physician can make to the prophylaxis of placenta praevia is to tell patients to notify their physicians when any bleeding is seen. The general principles which govern the active treatment are: hospitalization, control of hemorrhage, replacement of blood loss, and termination of pregnancy when the diagnosis is established. Choice of Method of Delivery.-Two methods of delivery are available, vaginal and abdominal. To decide which is preferable one must weigh several factors. The optimum method is the one which minimizes the following hazards: blood loss, trauma with ensuing shock, and infection. Most writers agree that in complete placenta praevia cesarean section is the procedure of choice. In marginal or partial placenta praevia, to decide the method of delivery one must consider the period of gestation, the viability and the size of the fetus, the parity of the patient, and the condition of the cervix. With a marginal placenta praevia, and occasionally with a partial placenta praevia, when the cervix is soft, partly dilated and favorable for labor, the baby may be delivered through the vagina. However, when the cervix is firm, unfavorable for labor and relatively closed, the abdominal route is preferred . . Vaginal Delivery of the Infant.-There are several methods to consider when one decides upon vaginal delivery: 1. Rupture of the Membranes.-This, the simplest method, allows the presenting part to fit against the placenta
GEORGE LOVERIDGE BOWEN
and control the bleeding. It may be combined with the use of the Willett 10 clamp on the baby's scalp to keep pressure against the low implanted placenta; or, in case of a breech, one foot may be brought down and used as a tampon. In some of these patients small amounts of pituitary extract, beginning with 1-minim doses, may be administered to start uterine contractions. The Willett forceps (Fig. 58) is a modification of the T-shaped de Martel scalp clamp, and was introduced in England in 1925. After rupturing the membranes this clamp is fastened to the baby's scalp and gentle traction is applied to keep it against the placenta and cervix. While this clamp has not been used in the clinics with which the writer is associated, Davis 3 reports favorably on its use at the Chicago Lying-In
Fig. 58.-WilIett scalp obstetrical forceps.
Hospital, and the reports in the contemporary English literature are most favorable. Davis states that the scalp injury may be disregarded. Sometimes by external version it is possible to convert a vertex to a breech before rupturing the membranes in order to provide a leg for a tampon. If either of these combinations is employed, it must be remembered that dilation of the cervix requires time, and neither undue pressure nor manual effort to hasten it may be used. Furthermore, delivery must not be attempted until the dilatation is complete. 2. Metreurysis.-Metreurysis is not as popular today as it was ten years ago.' However, the Voorhees bag is still used in some clinics when artificial rupture of the membranes fails to control the bleeding.
MANAGEMENT OF PLACENTA PRAEVIA
653
There are two methods of inserting a bag: Ca) For intraovular insertion the membranes are ruptured and the bag is placed against the fetal side of the placenta. The disadvantages of this method are infection of the amniotic sac, and increased fetal anoxemia from interference with the placental circulation. Cb) For extra-ovular insertion the bag is inserted into the lower uterine segment without rupturing the membranes. This method may cause premature separation of the low implanted placenta. The writer prefers the intra-ovular method. The bag must be perfectly filled and a light, steady weight of 250 to 500 gm. must be applied for traction; intermittent pulling should not be countenanced because of the risk of tearing the cervix. A No. 4 or No. 5 bag must be used. 3. Braxton Hicks Version.-This has been used less in recent years. It is a valuable method when the baby is small and its viability is in doubt. The disadvantages are the necessity for anesthesia, trauma to the baby, and fetal anoxemia from interference with placental circulation. After the leg has been brought down it may be held, but traction must never be made as severe laceration of the lower uterine segment may result. A review of the mortality statistics shows the dangers of this error. Methods which meet with disfavor are: tamponade, accouchement force, and expectant treatment. Tamponade to be effective must be done thoroughly; blood clots must be removed and in doing this more bleeding may follow. Furthermore, the danger of introducing infection is a serious one. Accouchement force, by manual or mechanical methods, is mentioned only to be condemned. Expectant treatment has no place in the care of patients with active bleeding. However, it may be used in the case of patients who have bled but once and stopped, and who have a baby of questionable viability. With such findings the patient must be in bed in the hospital, under the observation of a well trained staff, and with a blood bank or donor available. In managing the third stage of labor, again one should individualize. If the patient does not bleed it is well to wait for separation of the placenta and deliver it in the accustomed
GEORGE LOVERIDGE BOWEN
manner. However, if there is bleeding a manual removal of the placenta is imperative, followed by inspection of the cervix with adequate exposure and a good light. Right-angled retractors facilitate exposure of the cervix, and several sponge forceps are essential to grasp the cervical rim and thoroughly inspect it. Repair of any bleeding cervical laceration should be done at once. One must be aware constantly of the danger of shock and try to avoid it by a minimum of trauma, and by treating hemorrhage by adequate transfusions of whole blood. If the patient is bleeding from the placental site, the uterus and vagina should be packed completely with plain 2inch gauze. Part of this packing may be removed in twelve hours, and the remainder in twenty-four hours. The writer saw one patient with placenta praevia packed with iodoform gauze who died five days later from iodoform poisoning. As iodoform has little proved value except as a deodorant, plain gauze packing is recommended. Abdominal Delivery of the Infant.-As previously stated, when a central placenta praevia is found in the last trimester of pregnancy, delivery should be by the abdominal route. With partial placenta praevia and sometimes with a marginal when the cervix is uneffaced, firm, and not favorable for labor, cesarean section is also to be preferred. The type of cesarean operation used varies with the clinic. Reports of placenta praevia in recent years indicate a trend toward the use of the laparotrachelotomy, in preference to the classical cesarean section. Local anesthesia may be employed in selected cases. Low classical cesarean section may help to avoid the placental site, but laparotrachelotomy affords less risk from infection, the site of bleeding can be packed with greater ease, and there is less likelihood of rupture of the uterus in subsequent labors. In neglected cases in which the initial warning of bleeding has been ignored and because of lowered resistance the patient has become infected, and especially in those cases in which vaginal packing has been used, a Porro cesarean section may be the procedure of choice.
MANAGEMENT OF PLACENTA PRAEVIA
655
PROGNOSIS
Kerr,9 in a review of maternal deaths from placenta praevia before 1930, reported 70 per cent were due to shock and hemorrhage, and 30 per cent were due to sepsis. It is well to remember that the maternal mortality in vaginal deliveries is caused primarily by shock and hemorrhage, while in cesarean sections it is due to infection. The prognosis is much more favorable now than even ten years ago. I believe that two factors are responsible, namely: (a) the earlier and more frequent use of large blood transfusions; and (b) the greater frequency of cesarean sections. Arnell and Guerriero,4 in reporting 260 cases of placenta praevia at the Charity Hospital, New Orleans, stated that in only 34 per cent of this total were blood transfusions given, but of the patients seen in the last two years, 88 per cent were transfused. At Bellevue Hospital, New York,!' 2 in the period 1922-32, only 21 per cent of the patients with placenta praevia received blood transfusions, and for the period 1933-38, 50 per cent received transfusions with a resulting decrease in mortality from 11.5 per cent to 2.0 per cent. One death occurred in fifty cases, the patient having been an emergency admission in extremis. . Arnell and Guerrier0 4 reported the maternal mortality rate was five times greater when the vaginal route was used than when cesarean section was employed. Likewise the danger to the fetus is about five times greater from the vaginal than the abdominal route. This is easily understood because the majority of the infants are premature and have less chance of surviving the trauma of vaginal deliveries. They reported further that in the first five years only 27 per cent of the cases of placenta praevia were treated by cesarean section. During this period the maternal mortality was 11.3 per cent. In the second five years, 45 per cent of the cases of placenta praevia were treated by cesarean section, and here the maternal mortality was 5.1 per cent. Siegel,5 in a study of 332 consecutive cases of placenta praevia at the University of Maryland Hospital and Baltimore City Hospital, reported a maternal mortality of 6.6 per cent in vaginal deliveries, and 1.9 per cent from cesarean section. The fetal mortality was 27.8 per cent from cesarean section and 48.8 per cent in vaginal deliveries.
GEORGE LOVERIDGE BOWEN
SUMMARY AND CONCLUSIONS
1. All patients who experience painless bleeding in the last trimester of pregnancy should be placed in a hospital immediately for study and diagnosis. 2. Internal examinations should not be made in the home, nor should vaginal packing be attempted there. 3. Following admission to a hospital the blood should be typed. A complete blood count and cell volume determination are desirable. 4. Blood loss must be replaced early by whole blood transfusions; other fluids are inadequate substitutes. S. When time permits, roentgenography may be of value for diagnosis. 6. If the patient continues to bleed after admission to the hospital, arrangements should be made immediately for a vaginal examination. However, if the bleeding stops, the patient may be kept in bed for several days before the vaginal examination is made. 7. Vaginal examination should be made in the delivery or operating room, under strict asepsis, with adequate equipment and personnel ready to institute whatever treatment is considered best. 8. The treatment should suit the needs of the individual, and either the vaginal or abdominal route may be used for delivery~
9. The methods recommended for controlling hemorrhage and facilitating vaginal delivery are: (a) rupture of membranes alone, or combined with Willett's clamp, or in breech presentations a foot brought down for a tampon; (b) metreurysis when indicated; or (c) Braxton Hicks version when indicated. 10. Tamponade and expectant treatment are to be em-· ployed only rarely. 11. Accouchement force should never be used. 12. Two factors have been responsible for the reduction of maternal and fetal mortality in placenta praevia: (a) the more frequent and early employment of multiple blood transfusions; and (b) the use of cesarean section in selected cases. BmLIOGRAPHY 1. AIlison, H. M.: Review of Placenta Praevia, Bellevue Hospital, New York.
1922-32. Unpublished report.
MANAGEMENT OF PLACENTA PRAEVIA 2. Salter, Hiram P.: Review of Placenta Praevia, Bellevue Hospital, New York, 1933-38. Unpublished report. 3. Davis, M. E.: Surg., Gynec. & Obst., 68: 504-512, 1940. 4. ArneIl, R. E. and Guerriero, W. F.: Am. J. Obst. & Gynec., 39: 32, 1940. 5. Siegel, L A.: Am. J. Obst. & Gynec., 39: 301, 1940. 6. Ude, Weum and Urner: Am. J. Roentgenoi., 31: 230, 1934. 7. Carvalho, M. A.: Am. J. Obst. & Gynec., 39: 306, 1940. 8. Brown, W. H. and Dippel, A. L.: Bull. Johns Hopkins Hospital, 66: 90, 1940. 9. Kerr, J. M.: Maternal Mortality and Morbidity. Baltimore, Williams & WiIkins, 1933, p. 124. 10. WiIIett, J. A.: Proc. Roy. Soc. Med., 18: 90, 1925. 11. Caldera, R.: J. Obst. & Gynec. Brit. Emp., 46: 531, 1939. VOL. 25-42