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Placenta previa: The role of conservative management in a controlled study
PLACENTA PREVIA: THE ROLE OF CONSERVATIVE MANAGEMENT IN A CONTROLLED STUDY” JAMES P. SEMMENS,~OMMANDER (From
the Department
of Obstetrics,
U. S. Naval
Hospital,
Portsmouth,
(MC) USN””
Virginia)
ROM Jan. 1, 1954, to June 1, 1957, 166 cases of placenta previa which occurred in 18,408 deliveries were studied as part of an over-all fetal mortality evaluation at the U. S. Naval Hospital, Portsmouth, Virginia. This significant number of cases in a relatively short time permitted an evaluation of strict conservative management with (1) adequate amounts of readily available blood, (2) newer broad-spectrum antibiotics, and (3) recently improved radiological diagnostic techniques. Certain acceptable methods of diagnosis and treatment were found to have margins of error and dangers limiting their usefulness. To some physicians, conservative management means only a period of observation with specific plans to effect delivery by cesarean section at the onset of the next bleeding episode, when blood and operating facilities arc more readily available; whereas it should mean the prolongation of intrauterine gestation for the infant, support of the maternal circulation, and delivery at the time and by the method that best serve the interests of the mother and infant. Time permits a more accurate diagnosis and allows for selection of the optimum method of delivery, protecting the mother and the fetus in the current pregnancy and offering a better maternal prognosis for future pregnancies. These inherent benefits of conservative management have prompted this report.
F
Material
and Sources
During the 41 months’ study, there were 18,408 deliveries on our Obstetrical Service. All cases of bleeding after the twentieth week of gestation were considered. The diagnosis of placenta previa in all caseswas made by one or more of the following methods: (1) x-ray, either by soft-tissue technique or air cystograms; (2) sterile vaginal examination, usually with double setup; (3) visualization of the placental site at the time of cesarean section; and (4) visualization or palpation of the placenta through the dilated cervix at delivery. Classification The classification”, x of placenta previa employed is that recommended by Greenhill, Titus, McCormick, and Eastman in 1949, namely, total, partial, and low lying or marginal. not Naval
to
*The opinions or assertions be construed as ofilcial or **Present address Department Base. Charleston, S. C.
contlined herein are the private reflecting the view of the Naval of Ohstptrirs an,1 C,ynecolo~y.
ones of the author Service at large. I’. S. Navnl Hospital.
and
are 1:. S.
64
HEMMENS
.2m. .I. Obst. & Gynec.
[‘ml:irv.
195’)
Incidence
The types of placenta l)revia occurGng in this study were: 43 CRS~S 01 total (25.9 per cent) j 56 cases of partial (34.9 per cent) ; and 65 cases of low lying (39.2 per cent), of which 13 were low lying posterior (so-called “dangerous placentas”). The specia1 significance of this type will be discussed later under treatment and methods of delivery. Reviewing Table II, the four authors4, 5, 13 and 14, 30 reporting the bulk of cases in the literature (5,175 cases) report total placenta previa in 23 to 81 per cent of cases or an a,verage of 26 per cent. Another group of author+ “‘. I1 (409 cases) report total placenta previa in 37 to 41 per cent of ca.ses. The variables arc in the number of partial and low lying placenta previas reported. Tlabor is a factor, as a laterally implanted placenta. in t,hc IOWCI* utcrinc sc~grncnt may be diagnosed a.s partial without labor or low lying with labor, illld a total without labor ma,y prose to be a ljartial with labor and retraction of the lowc~r utc~rinc segment.
AUTHOR
--
Reilly2 Berkeley (Eastman j 5 Davidson Eadie and RandalP Johnson14 Hibbardll Schmitz20 Hatten, Kirkpatrick and Thornton10 Semmens (this study)
_-.._____-PERIOD UNIIEIF S’TUUY -1940-1950
TABLE
so. Ok 1)ELIVERIES .-_~-~~--
90.
34,548
01’
1954 1939-1950 1947-1954 1941-1951.
32,505 26,136 50,000 48,143 17,745
162 5,000 137 .l31 201 “13 112
1947-1954 1954-1957
13,“3ti 18,408
59 166
1950-1955
11.
IKCILIENCE ____--__.
_-_-_.
OF
L’IAcENTA -_______
!?KRVIA
HY
TYPE AUTHOR
Beilly:! Berkeley (Eastman) 5 Davidson3 Eadie and Randall+ Eastman5 Hatten, Kirkpatrirk and Thornton10 HiLtbard .Tohnsonls. 14 SehmiWo Semmens (this study) -.-.-~.~-.~-~-
CASES
I i NO.
OY CASES
-TOTAI; 1 a~R
162 4,508 137 131 304
-~.~_.
59 213 11’0 113 166 -.__ -__~_~-
___
OF 1 i
I /
RATIO ~--
c/o
1:212 1:98 1:235 1:200 1:250 1:226 1:158
0.47 0.98 0.42 0.50 0.32 0.42 0.60
1:?%4 1:109
0.4-k 0.92
TYPE
PLACENTA
__---~ PREVIA
PARTIAI,
LOW
LYING
%
%
r 23.6 39.6 24.5 i’3.0
1” 0 G7
6.0 55.7
14.0
51.0
20.6 29.0
54.9 48.0
ST.0 30.8 28.0 31.3 25.9
Ii.0 21.8 18.0 26.7 34.9 lving
46.0 37.5 42.0 42.0 39.2 8.0
--:
Idlw
posteri
-
Placenta previa is a complication that favors the multipara 4:1 or more. This is borne out in all studies, as reported in Table III; JohnsonI* reports 76 per cent, Schmitz 2o80 per cent, and Hibbard” more than 90 per cent,. Our incidence of multiparity was 78.3 per cent, with one in 1.0 a grand multipara. Primigravidas (normally 40 per cent of the ohstetrica.1 population on our service) accounted for only 21.7 per cent of the placenta previas. The average age of our patients was 24.5 ycal-s, while Eastman” states that Strassmann found the average age of his patients to be 32.9 years, with an average of 6.38 labors.
\‘olume Ytlmber
CONSERVATIVE
77 I
TABLE
III.
MANAGEMENT PARITY
OF PATIENTS
TOTAL NO. CASES
AUTIIOR Hi'r)hardll
OF PLACENTA WITH
PLACENTA
PRIMIGRAVIDAS %
PREVIA
65
PREVIA
GRANDMULTIPARAS %
MULTIPARAS %
213 120
10.0 24.0
90.0 76.0
-
80.0
-
Semmens (this study)
166
21.7
78.3
7.2
Schmitzzo
112
20.0
Onset of First Significant
Bleeding
The early onset of significant bleeding is the basis of the rationale for conservative management. Twenty-five patients were admitted to the service bleeding before the thirtieth week of gestation and another 25 were admitted before the thirty-third week. Thus one-third of all our patients depended upon continued intrauterine gestation for increased fetal salvage. Twentyone of these patients could have been delivered of previable fetuses, yet there were only 13 infants delivered weighing less than 1,000 grams, and 2 of these survived. The 10 infants who lived must be considered salvaged primarily because their delivery occurred at a more advanced period of gestation. The intermediate group (34 to 37 weeks) also has a better prognosis if delivery can be delayed at least until the maternal circulation has been stabilized; however, many of these patients are delivered shortly after admission because labor is well established and continuing blood loss threatens the fetus with anosia. The time of onset of bleeding in other studies of placenta previa is compared in Table IV. It is significant that Eadie and Randall’ reported a 77.1 per cent incidence of bleeding before the thirty-seventh week, attended by a 43.2 per cent uncorrected fetal mortality. Our series showed 53 per cent before the thirty-seventh week and a 15.9 per cent uncorrected fetal mort,ality. TABLE
IV.
ONSET
OF BLEEDING 1
TIME OF ONSET Prior to Third Trimester.22-28 weeks 22-31
weeks
ASSOCIATED
EADIE AND RANDALL4 %
17-12.9
WITH (
PLACENTA
SEMMENS (THIS STUDY) %
PREVIA I
SCHMITZ?O %
15- 9.0 s-
Trimester.28-30 weeks 31-33 weeks
7.0
Third
31-38 34-37 38-40 Term-Active
19-14.5 21-16.0
6- 3.6 2515.1
weeks weeks
39-29.7
42-25.3
weeks
25-19.1
32-19.3
38-33.0 66-60.0
Labor.-
40 weeks plus
5-
3.8
46-27.7
Presentations There were 21 transverse lies (12.6 per cent) which is 35 times the incidence (0.34 per cent) expected with a normally implanted placenta. There were 21 breech presentations (12.6 per cent) which is 3 tz’mesthe normal expected rat,e. Only 2 of the t,ransverse lies occurred in a second twin. Of 124 vertex presentations (74.8 per cent), there were 3 brows and 3 occiput posteriors.
66
SEMMENS
Management The management of third-trimester bleeding consists of four distinct no recta.1 examinations, 11~1 phases. l‘hc first is that rendered in the home: vaginal csaminations, no pm-king, immediate hospitalization, preferably by amhnfancr. Tho second phase is untlcrt,akcn at the time of admission to the hospital ntld includrs : ( I ) abdominal examination noting rigidity, Or loca.lized tendcrnrss, station, and present.ation; (2) bed rest a.nd observation unlrss the blcrding is brisk and fails to abatr and shock t.hrcat,ens ; (:3) typing and CI’OSSmatching for ant.icipated blood loss ; (4) base line hemoglobin, hematocrit, and red blood count; (5) No. 18 ncctlle in a vein with fluids running; (6) nothing by mouth (liquids and soft diet arc not offered until bleeding has ceased fox 24 hours) ; (‘i) fibrinogen lcvrls (%*hneidrr m&hod) when ahruptio placentac~ is snspectcd, ant1 smears for nnclratrd ~1 crlls if rasa prrvia is a possibility. Tn thr thirtl phase, 01’ trcaltmc~nt, thy pat.icnts mny br (livided into t.wo gtwups : (1 ) Thosr who cont,innc to blcrcl ant1 thrcatrn to go int,o shock a’t*ca rsaminrtl under strrilr ~lonhlc setup an(l tlrliverrd by thr safest and most cspctlicnt. mrthotl. (2) ‘t%(JSc who stop hlwcling uiitlcta the rcgitnc onthird in I)hasc! two arc r\~all~atrtl by s-ray I)l;lrc,rttogt,aI’hy aftor a short titnr intrrval (prcfcrably aftrr th(t thirsty-srcontl wcrk’). Va,ginal rsaminaticms arc‘ drfcrrrcl of, placrnta, prcvia and when the s-ra.y is positivr for, or highly suggestire unless thr pregnancy is beyond 37 weeks. Patients ax rsamincd vaginally onlwhrn t,hc periotl nf grstation farors dclivrrv in prrfc~cncr to observation (38 wreks) or when bleeding rcc’uys. nccrssita.&ng t.hc sr7cctiori of a. tncthoc7 of clrlivcry. All p&ruts with nrgatirr placentopralns are rsaminrtl raginnlly. by sprculum and digita&, treat.ed, and discharged. The elrction of thr nld.hncI of tlrli\c.ry might 1.x ronsitlct4 as the fourth phase of managcmcnt. It is 1~~~7 on the condition of the ccrvis and thr tlrgree of placenta prcvia prrsent. 111 the long, closrd crrvis (characteristic of the nullipa.rn), patients with total and partial placenta previa. arc usually delirercd by cesarean section if near term. Low Iring placenta previa is trrntctl by artificial rupture of the mCtljbranrs, allowlng the presenting par1 to tatnponadc thr placenta in the lowcr uterine srpmrnt. Failurr of thr presenting part to cngagr, as is common in low lying posterior placenta previa. is usually attradc4 by rscrssivc hlrrding am1 crsa.rcan se&m is rssential. Thr short soft crrvix (rharactrl*ist.ic of the multipara) lrnds itself to vaginal delirerv in partial pIac?nta prrvia. and low I;ving pIac.rnta previa once tlir men)brxnes have brcn ruptuycd. All pntirnts with total placenta prcvia ant1 clcrasional patients with partial placenta pyryia. who continue to blcr~l a1.r ~lclivrrrd by rrsarca,n section. Ttleally. (1) thr matrrnnl systolic blood prcssut~r shouIc1 1~ 90 mm. Hp ot high(Jr at thr liter of oprration. (2) the placrnta should bc srparatr(l rathrr than pcrforatcd. (3) the cord should br rlampcd imlncdiat,elp following (lplivrrp. (4) blo~tl counts should hr takrn on 2.11 babirs and anrmia treate(l rarly by t,ransfusinn, (5) a.lZ unnecessary intrautrrinr manipulation should br nvoidrd, ineluding manua.I rrmov;ll of the placenta, (6) t.hcrc shonlti l,r p~-~~It~pt tlrlircry once dilatation is complete. occiput posteriors rotated, and low t’o~*ceps rmploq’cd whrn spontanrnns clclivrry is unt imtnincut.
Diagnostic S-m?/.-Good
A poor trchniqne
Aids
x-ray t,rchniqnc is impsrativct in conservative nlanagrmrnt. or false negative film may cause the patient to he snbjcctrcl in
Volume Number
77 I
CONSERVATIVE
MANAGEMENT
OF
PLACENTA
67
PREVIA
vaginal examination at a time when incited bleeding could force delivery of an immature or premature infant. A total of 200 placentograms were taken during the interval of the study, 63 of these on patients with placenta previa proved clinically during labor or at delivery. The placenta was identified in the lower uterine segment in 59 of these cases (93.7 per cent). The exact type of placenta In 7 cases loralizaprevia was diagnosed by x-ray in 52 cases (82.5 per cent). tion of the placenta was inconclusive as to type (6 were total and 1 was a partial). Of 141 cases reported as negative, only 4 reports were proved to bc in error (2 were partial and 2 were low lying placenta previa) . This is an over-all Rccuracy of 98 per cent (Table V) . Hibbardl’ reported 90 per cent positive placental identification by x-ray in his series. Seven&n air cystograms were taken when soft-tissue technique failed to give definite placental localization and placenta previa was strongly suspected. All were positive and the localization was 100 per cent accurate, as confirmed at delivery. TABLE V. EMPLOYMENT OF PLACENTOGRAPHY MANAGEMENT OF PLACENTA PREVIA AT THE
U.
AS A DIAGNOSTIC S. NAVAL HOSPITAL,
AID IN THE PORTSXOI~TH,
‘is,
NO.
placentograms taken during study placentograms reported as negative for placenta previa Total number of patients with clinically proved placenta previa who had placentograms Erroneous diagnosis Positive clinically, negative x-ray Partial placenta previa Low lying placenta previa Negative clinically, positive x-ray Placenta identified in lower uterine segment Actual type of placenta previa by x-ray inconclusive as to type of placenta previa Total placenta previa Partial placenta previa Special x-ray techniques employed Air cystograms taken 17 Standing laterals 70 Erroneous diagnosis Over-all accuracy of placentography all types
CONSERVATIVE VIRGINIIY
200
Total Total
141
ti3 4
2.0
59 52 7
100.0 93.7 82.5 17.5
4 2 2 0
6 1 27 0 196 : 200 -_I
100.0 98.0
-
Unengaged Presenting P&.-In 50 cases (30 per cent) either abnormal presentation or an unengaged presenting part were found at the time of admission. Minor episodes of bleeding that are associated with an abnormal presentation or unengaged presenting part warrant study to rule out placenta previa. The primigravida at term with an unexplained floating presenting part should have a standing lateral film taken for soft-tissue study along with pelvimetry. Double Xetup Xterile Vaginal Examination.-Sterile vaginal examination in the operating suite with the patient prepared for possible abdominal delivery was employed 44 times with one error, an sccuracy of 97.8 per cent. In the face of heavy blood loss and labor, vaginal examination is only a timeconsuming and aggravating procedure to a patient in shock. X-ray, the amount and nature of the bleeding, and determination of presentation and engagement are all equally reliable indications for surgical intervention. Vaginal examination is reserved for : (1) equivocal cases near term without bleeding, (2) cases of total placenta previa near term diagnosed only by x-ray and not bleeding, and (3) suspected cases of low lying posterior placenta There were no repeat vaginal examinations done in this series. previa.
SEMMENS
68
Supportive Managem&.-A total of 263 units of blood were given, averaging 1.6 units per patient; 41 of 43 patients with total placenta previa were transfused (97.5 per cent) with 139 units ( 3.28 per patient) ; 34 of 56 patients with partial pIacenta previa ware transfused (60.7 per cent) with 81 units (1.15 per patient) : 7 of 13 with low lying posterior placenta previa were transfused (61.5 per cent) with 17 units (1.3 per patient) ; and 17 of 54 with low lying placenta previa were transfused (31.5 per c’ent) with 26 units (0.48 per patlrmt). Therms is a close parallel between partial placenta previa and low lying posterior placenta prcvia in blootl requil~c~lncnts to cc~ver lossc~s. This is illustratrtl ill Fig. 1. Nethods of Dt&wy.-- The methods of delivering the 169 infants are shown in Table VI. The 3 low lying placenta previas encountered at repeat cesarean section were unsuspected prior to operation. One Port-0 C'~LWR.II section was tfone for severe amnionitis in a case of total placenta J)revia. One hyst,et*ccto~*ly was performed aft,er ccsarean section for focal placenta accrcrtw complicating tot,al placenta previa. The patient bled from t,he lower uterine segment postoperatively necessitating 9,000 ml. blood replacement before anil during cm(‘rgcncy operation. A second postcesarean section hvsterect0rn.v was done on a -&O-year-old grand multipara found to have rchcurrent total placcrrta prcvia ill successive pregnancies as well as two previous (‘~~‘sarcan s&ions.
___.-_I____
-_?_-----
METHOD
OF DELIVERY
1. Spontaneous 2. Low forceps 3. Midforceps 4. Breech extra.cticm or assist 5. Version and extraetim 6. Transverse low cervical cesarean section
7. Porro hysterectomy 8. Hysterectomy post cesarean section
-.-
ms
-__
1
53
33 7 1:i
~
34.1 19.5
1.1 7.7
1
) 'TOTAr, __-_--..-
0 1
0
/ ( I'ARTIAL
6 3
I) 0
0
0
1
;
g
61
xi. 1
41
10
L,
1
1.1
2
( !gR
76
1.L 0.6
I,OW LYING
24 10
2
1
! j
19
3
33
0
0
ii
0
0
0
CONSERVATIVE
MANAGEMENT
OF
PLACENTA
69
PREVIA
conz&ntions.-The complications associated with placenta previa in this series are listed in Table VII. Premature rupture of the membranes and snbsequent amnionitis proved quite disastrous from a fetal standpoint. Rupture of the membranes accompanied by bleeding from placenta prcvia offers an excellent cult,urc medium for bacterial growth and the amnionitis is usually SCT’CPC. TABLE
VI r.
MEDICAL, SURGICAL, ASSOCIATED WITH
AND OBSTETRICAL PLACENTA PREVIA
COMPLICATIONS -
Amnionitis Diabetes mellitus, Class D Epilepsy (grand mal) Fibromyomas of the uterus (8 cm.) Hepatomegaly, splenomegaly (etiology?) Hypertension Pneumonia, lobar, bilateral Polyhvdramnios Pre-eElampsia Pvelitis Rheumatic heart disease, Grade II Ureteral calculus
1 1 1 1 1 1 3 8 6 1
Intrapartum.-
Contraction ring, lower Focal placenta accreta Prolapse of the cord Retained or adherent
uterine
segment
1 1 7 4
placenta
Postpartum.-
Cerebral venous thrombosis Endometritis Peritonitis, postoperative (cesarean section Wound dehiscence (cesarean section)
and hysterectomy)
1 3 1 1
Intra partum, there was a 4.2 per cent incidence of prolapse of the cord, which resulted in 2 stillbirths and 2 neonatal deaths. Abnormal presentations and unengaged presenting parts were responsible for the increased incidence. There were also 4 cases of retained placenta and one of focal placenta accreta that was discussed earlier. The postpartum complications were limited to infection in the form of endometritis or peritonitis depending upon the route of the delivery. OllC wound dehiscence occurred in a case of total placenta previa that had been complicated ante partum by resistant pyelitis. Anesthesia.-Anesthesia for the vaginal deliveries was chiefly conduction in type. S’pinal (saddle block) was employed to deliver the primigravida who was stabilized and not actively bleeding in the second stage of labor. Pudendal block was the anesthesia of choice for the delivery of the multipara or the primigravida with minimal bleeding in whom a hypotensive reaction could not be risked. Cesarean sections were performed under spinal anesthesia when bleeding was minimal or absent, and under local (Xylocaine 0.5-1.0 per cent) when fetal distress, bleeding, or shock was the indication. There were 7 operative procedures carried out under cyclopropane anesthesia with only 3 infant survivals; this high fetal mortality rate (57 per cent) is similar to that reported by Hibbardl’ (30.3 per cent).
Results In 66.2 per cent of the patients labor was so well established that they failed to stop bleeding, anoxia and shock threatened the fetus and mother,. and delivery was accomplished within 12 hours after admission. An additional 5.4 per cent of the patients either continued to bleed or had a short latent period followed by labor and more bleeding and were delivered within 24 hours after
70
Am. J.0bst.k J.u,wy.
SEMMFNS 1 L
Gym.
I'Ii'I
admission. Thus, as a result of labor atld/or blocding, 71.6 per cent UC 111~ patients were delivered on the day of admission, lcaving only 28.4 per CC~LI who could bc managed conscrvativcly. Only 22.3 l)ct* cent gained one additima week or IHOT(: of gcstationa.1 tlevc~loprnc:nt for their infants, siticc 6 J>Cl' cent wert dclivcrctl bcforc t.hc scvcnth hospital clay. In this conscrvatire group, 19 of the pnticnts WVIY atlttlitted b~forc~ thr thirty-second week and 18 bcforc the t,hirty-sixth week of gcstat,ion. Only 5 of their infants weighed less than 1,500 grams and 22 (60 per cent) weighed over 2,500 grams st birth. There wire 1,192 additional hospital days before delivery, an average of 32.2 days per patient. The quantity of bIood given. 39,500 ml., or 2.13 units per patient, was 20 per cent) less than that requirrd t.o support the patients who were bleeding a.ctiveIy at the time of admission and delivery. Of interest is the fact. that in t,hc group treated expectantly there were 20 per cent more total placenta previas than in the general stucl)
(25.9 versus 45.9 per cent), ,Seventy-two of the 110 delivrrirs which occurred in the first 23 hours produced mature infants, with only 2 perinat,al deaths, neither of which was caused by early delivery. Labor and/or bleeding necessitated t.hc delivery of 27 prematurr ant1 11 immuturc infants within the first 12 hours following admission, and 6 more premature a,nd 2 immature infants were drlivcrcd within 24 hours following admission. Fetal survival with conscrrativc management was 89.1 per cent, which is 5 per cent better than WI* espcricnce in the en&c study. When one recalls that 52 per cent of the infants in the cntirc study WC~C mature by gestational age at the time of admission as compared to only 8 per cent of the conservative group, the merit of this attack on pren1aturit.y and associatctl fetal losses in th(J management of placenta prcvia. is srlf-cvidcnt. The maternal mortality rate was zero and t,he uncorrcctcd fetal mortality rate was 15.9 per cent. There were 3 infants with congenital anomalies incompatible with life. a corrcctcd fetal mortality of 14.1 per cent (Table V’JIJ). --_
TABLE
VTII.
MATERNAL
AND --.------~-..-zzz:~~ /
FETAL
MORTALITY -:I-
ASSOCIATED WIT~I PI,AcEE;TA PREVIA - ~~~ --__-_~~ .i MATFRNAT > , / FETAL
AUTHOR
-.__
Ueilly2 Davidson3 Eadie and Randall% Grant, F. G.9 Hatten, Kirkpatrick, and Thornton10 Johnson14 Macafe& (2 series) Conservative treatment Immediate treatment Macafee (personal series) Schmitz2o Scnrmens, V. S. Naval Irospital, Portsmouth, \-
T’iyinia
1940-1910 1946-1950 (1957) (1954;l
28.2 9.8 13.0 x1.2 unKmwtet1 11.9
(1947.1944) (1939-195n)
26.3 21.0
uncorrwted
I
1,000 plus 1,000 plus 177 112
(1937.1944) (1941-1951) ( 1954-194;) . t
IGG
5.9 7.0 0.57 0.89
51.0 69.0 23.5 22.3
0.0
15.9 14.1
"llrolvc:tl~~1 CorrectN~
Comment We were prompted to undertake this study of the conservative management of placenta previa because: (1) a rcducecl incidence of premature dcliveries offered the best mCans of improving fetal salvage, and (2) temporization permitted more accurate diagnosis and a much better prognosis for the mother in her current as well as her future pregnancies.
We feel that any bleeding before and during labor deserves a conccrtcd effort to make a positive diagnosis; and if placenta previa is found to 1~ present, no matter what the circumstances, all the benefits of hospital management must be afforded to the mother and her unborn infant. Delivery of a viable infant and replacement of maternal blood loss do not excuse th(h obstetrician from making a positive diagnosis, and the indiscriminate use of terms such as “marginal sinus rupture” to classify cases that border bctwecn abruptio placentae and placenta previa should be discouraged. The younger average age of patients (24.5 years) suggests that placenta previa need not be a complication of the older multipara. Repeated prcgnancies in a short time interval are probably equally responsible for the uterine changes that predispose a patient to an abnormal placental implantation. There were 3 patients who had had placenta previa in a previous prcgnancy. One had total placenta previa in 2 successive pregnancies. Johnson reports 2 recurrences of placenta previa among 120 patients. The clinical significance of abnormal presentation is evident with 35 times as many transverse lies and 3 times as many breech presentations with placenta previa. The 4.2 per cent incidence of prolapse of the cord is an anticipated consequence of the large percentage of unengaged presenting parts (60 pet cent) at the time of labor and delivery. There werr 56 transverse lies in 16,532 deliveries (0.34 per cent) during the years 1954 to 1956, inclusive, and 19 (34 per cent) were associated with placenta prcvia. Anteroposterior and soft-tissue lateral x-ray for fetal position a.nd placental localization at the same time makes good sense in the evaluation of the patient suspected of having a transverse lie. Bleeding is evidence of labor in placenta preria, since it is brought about by retraction of the lower uterine segment from the placenta during dilatation of the cervix. Increasing bleeding and evidence of uterine contractions call fol prompt delivery. Bleeding in excess of 500 ml. in a single episode seldom abates, and if it is allowed to continue and exceed 1,000 ml. before delivery, the fetal mortality rate doubles. Excessive x-ray exposure of the fetus should be avoided and the single standing soft-tissue lateral film has been the most effective method of screening suspected cases. Fifteen per cent of the cases x-rayed were positively diagnosed in this manner. A selective filtration technique such as that described by Reeves and Cahoon17 offers the best visualization of the placenta and uterus on lateral view. In a review of approximately 5,000 cases of placenta previa report,ed in the literature,4* 5, I43 2o the incidence of total placenta previa is 26 per cent. WC feel that a ccsarean section rate more than 15 per cent above the percentage of t,otal placenta previas reflects an easy but not always sound solution to this problem. Surgical procedures on the gravid uterus leave weaker scars, espcrially if the incision is in the placental site. The only valid indications for abdominal delivery in placenta previa other than total are: abnormal presentations, low lying posterior placentas that prevent engagement, and the occasional partial placenta previa in the primigravida and certain multiparas who continue to bleed. The problem of anesthesia, especially in the presence of shock or ncnr* shock, is extremely difficult. One is barely able to transfuse these patients rapidly enough to offer the circulatory support necessary t,o cffcct an cmcrgency abdominal delivery. Regional or local anesthesia offers a greatc>t* margin of safety for the mother and her baby. It has been pointed out that. there was no fetal loss in 7 cesarean sections clone under local anesthesia fol tot,al placenta previa with excessive bleeding; whereas we cxpcricnced a 50
SEMMENS
per cent fetal loss in a comparable thesia. Two of the infants subjected in the lungs and pneumonia.
delivered under cyclopropane ancsto autopsy showed hemorrhagic changes
gronp
Summary One hundred sixty-six cases of placenta previa in 18,408 deliveries at the TJ. 8. Naval Hospital, Portsmouth, Virginia, a.re presented and reviewed. The management is discussed in detail. Diagnostic aids, including s-ray and SCOWtive filtration techniques, and sterile vaginal examination are appraised f01 Methods of delivery are discussed, a.ccuracy as well as hazard to t,he patient. Section rates rnorp including specific indications for abdominal delivery. than 15 per cent above the nurnbctwf total placenta, previas arc felt to represent an easy but unwise soWion for bleeding problems. Major complications associated with placenta prcvia and abnormal prtscntat,ions are mentioned, and the choice of anesthesia for abtiominal as well as vaginal delivery, especially in the face of rircula.tory instability, is discussed. An additional month or I~OW of continutd in!-rantcrine gestation for the infants was a.veragcd in 22.3 per cent of casts ; 88 per cent of t,ht fct.uses in t,his group wercl immat,urc or prcma.turt~ hy pest;\tionnl age :ri the time of ndrrlissiolr : 60 per cent of the infants wt+qht~(l ov(bt* 2.500 grams at the tiltlc of tlclivct*y. and an orcr-all fetal surviva,l rate of 89.1 pi* cent was ctscditccl to this gron~~ of pat.itMs. Despite there being alrJIOSt twice the number of total plaet’ntil prcvias in this group, the actual blood nct~tfs were 20 per cent. Jnssthan among patients who were in active labor ancl bleeding at the time of admission. For an additional 31.5 per cent of the patients tc~nlporization permitted more accuracy in t,hc diagnosis of the type of placenta preria present and t,hc selection of a method of delivery which offered the infant a.nd mot.her the best prognosis in the current. pregnancy R.SwckJ1as in fut.urc prngnantics. 1 wi,dr to rsprcss my appreciation to C!aptain Jhvighf. A. t’dlitgu~ I MC: ) ITRN, Dependents Service, U. S. Naval Hospital, Portsmouth, Virginia, for his aid and in the preparation of this report, and to F. J. 8. and G. CT. B. for t-heir editorial aid.
Chief of comment
References 1. Bartldomew, R. A., and others: Obst. & Gynec. 1: 41, 1053. 2. Beilly, J. S.. Greenberg. M. M.. Aaron. J. B., and Peck, S. .J.: Ahr. J. OI
11. 12.
13. 14. 15.
68. . 6.50
1954
F. G.: .T. O&t.‘& &vnaec. lirit. I*:mp. 62: -LX. 1935. J. Q,, Kirkpatrick; S. A., and ‘t’hornt,on, W. N., .Jr.: Ax\r. J. OBST. & GYNEC. 11’81, 11)55. Hitrbard, I,. T.: Ohxt. $ (?ynec. 8: iii::, 7!#i. James, 11. W., awl Misch, K. A.: .J. Obst. & Gynaec. Hril. J*hp. 62: 551, 1955. Johnson, H. W.: AM. J. OBST. & GYNCC. 50: 2-23, 19-G. Johnson, H. W.: .4r~1. J. Oas~. & GYNEC. 59: 1236, 195r). Maeafee, C. H. G.: Postgrad. M. J. 25: 297, 1949.
9. Grant, 10. Hatten,
70:
CONSERVATIVE 16. 17. 1s. 19. 20. 21. 22. 23. 24.
Macafee, Reeves, Russell, Russell, Schmitz, Stallworthy, Watson, Weinberg, Weinberg,
MANAGEMENT
OF
PLACENTA
PREVIA
C. H. G.: J. Obst. & Gynaec. Brit. Emp. 52: 313, 1945. R. J., and Cahoon, J. B.: M. Radiog. & Photog. 28: 2, 1952. J. K.: Lancet 269: 322, 1955. Lancet 268: 785,1955. J. K., and Warrick, C. K.: H. E., O’Dea, N. J., and Isaacs, J. H.: Obst. & Gynec. 3: 3, 1954. J.: Aa6.J. OBST.& GYNEC.~~: 720,195l. H. G.: West. J. Surg. 63: 151, 1955. A., Rizzi, J., McManus, R., and Rivera, J.: Obst. & Gynec. 8: 396, 1956. A., and Deckoff, S.: Obst. & Gynec. 10: 146, 1957.
73
the Department
of Obstetrics,
U. S. Naval
Hospital,
Portsmouth,
(MC) USN””
Virginia)
ROM Jan. 1, 1954, to June 1, 1957, 166 cases of placenta previa which occurred in 18,408 deliveries were studied as part of an over-all fetal mortality evaluation at the U. S. Naval Hospital, Portsmouth, Virginia. This significant number of cases in a relatively short time permitted an evaluation of strict conservative management with (1) adequate amounts of readily available blood, (2) newer broad-spectrum antibiotics, and (3) recently improved radiological diagnostic techniques. Certain acceptable methods of diagnosis and treatment were found to have margins of error and dangers limiting their usefulness. To some physicians, conservative management means only a period of observation with specific plans to effect delivery by cesarean section at the onset of the next bleeding episode, when blood and operating facilities arc more readily available; whereas it should mean the prolongation of intrauterine gestation for the infant, support of the maternal circulation, and delivery at the time and by the method that best serve the interests of the mother and infant. Time permits a more accurate diagnosis and allows for selection of the optimum method of delivery, protecting the mother and the fetus in the current pregnancy and offering a better maternal prognosis for future pregnancies. These inherent benefits of conservative management have prompted this report.
F
Material
and Sources
During the 41 months’ study, there were 18,408 deliveries on our Obstetrical Service. All cases of bleeding after the twentieth week of gestation were considered. The diagnosis of placenta previa in all caseswas made by one or more of the following methods: (1) x-ray, either by soft-tissue technique or air cystograms; (2) sterile vaginal examination, usually with double setup; (3) visualization of the placental site at the time of cesarean section; and (4) visualization or palpation of the placenta through the dilated cervix at delivery. Classification The classification”, x of placenta previa employed is that recommended by Greenhill, Titus, McCormick, and Eastman in 1949, namely, total, partial, and low lying or marginal. not Naval
to
*The opinions or assertions be construed as ofilcial or **Present address Department Base. Charleston, S. C.
contlined herein are the private reflecting the view of the Naval of Ohstptrirs an,1 C,ynecolo~y.
ones of the author Service at large. I’. S. Navnl Hospital.
and
are 1:. S.
64
HEMMENS
.2m. .I. Obst. & Gynec.
[‘ml:irv.
195’)
Incidence
The types of placenta l)revia occurGng in this study were: 43 CRS~S 01 total (25.9 per cent) j 56 cases of partial (34.9 per cent) ; and 65 cases of low lying (39.2 per cent), of which 13 were low lying posterior (so-called “dangerous placentas”). The specia1 significance of this type will be discussed later under treatment and methods of delivery. Reviewing Table II, the four authors4, 5, 13 and 14, 30 reporting the bulk of cases in the literature (5,175 cases) report total placenta previa in 23 to 81 per cent of cases or an a,verage of 26 per cent. Another group of author+ “‘. I1 (409 cases) report total placenta previa in 37 to 41 per cent of ca.ses. The variables arc in the number of partial and low lying placenta previas reported. Tlabor is a factor, as a laterally implanted placenta. in t,hc IOWCI* utcrinc sc~grncnt may be diagnosed a.s partial without labor or low lying with labor, illld a total without labor ma,y prose to be a ljartial with labor and retraction of the lowc~r utc~rinc segment.
AUTHOR
--
Reilly2 Berkeley (Eastman j 5 Davidson Eadie and RandalP Johnson14 Hibbardll Schmitz20 Hatten, Kirkpatrick and Thornton10 Semmens (this study)
_-.._____-PERIOD UNIIEIF S’TUUY -1940-1950
TABLE
so. Ok 1)ELIVERIES .-_~-~~--
90.
34,548
01’
1954 1939-1950 1947-1954 1941-1951.
32,505 26,136 50,000 48,143 17,745
162 5,000 137 .l31 201 “13 112
1947-1954 1954-1957
13,“3ti 18,408
59 166
1950-1955
11.
IKCILIENCE ____--__.
_-_-_.
OF
L’IAcENTA -_______
!?KRVIA
HY
TYPE AUTHOR
Beilly:! Berkeley (Eastman) 5 Davidson3 Eadie and Randall+ Eastman5 Hatten, Kirkpatrirk and Thornton10 HiLtbard .Tohnsonls. 14 SehmiWo Semmens (this study) -.-.-~.~-.~-~-
CASES
I i NO.
OY CASES
-TOTAI; 1 a~R
162 4,508 137 131 304
-~.~_.
59 213 11’0 113 166 -.__ -__~_~-
___
OF 1 i
I /
RATIO ~--
c/o
1:212 1:98 1:235 1:200 1:250 1:226 1:158
0.47 0.98 0.42 0.50 0.32 0.42 0.60
1:?%4 1:109
0.4-k 0.92
TYPE
PLACENTA
__---~ PREVIA
PARTIAI,
LOW
LYING
%
%
r 23.6 39.6 24.5 i’3.0
1” 0 G7
6.0 55.7
14.0
51.0
20.6 29.0
54.9 48.0
ST.0 30.8 28.0 31.3 25.9
Ii.0 21.8 18.0 26.7 34.9 lving
46.0 37.5 42.0 42.0 39.2 8.0
--:
Idlw
posteri
-
Placenta previa is a complication that favors the multipara 4:1 or more. This is borne out in all studies, as reported in Table III; JohnsonI* reports 76 per cent, Schmitz 2o80 per cent, and Hibbard” more than 90 per cent,. Our incidence of multiparity was 78.3 per cent, with one in 1.0 a grand multipara. Primigravidas (normally 40 per cent of the ohstetrica.1 population on our service) accounted for only 21.7 per cent of the placenta previas. The average age of our patients was 24.5 ycal-s, while Eastman” states that Strassmann found the average age of his patients to be 32.9 years, with an average of 6.38 labors.
\‘olume Ytlmber
CONSERVATIVE
77 I
TABLE
III.
MANAGEMENT PARITY
OF PATIENTS
TOTAL NO. CASES
AUTIIOR Hi'r)hardll
OF PLACENTA WITH
PLACENTA
PRIMIGRAVIDAS %
PREVIA
65
PREVIA
GRANDMULTIPARAS %
MULTIPARAS %
213 120
10.0 24.0
90.0 76.0
-
80.0
-
Semmens (this study)
166
21.7
78.3
7.2
Schmitzzo
112
20.0
Onset of First Significant
Bleeding
The early onset of significant bleeding is the basis of the rationale for conservative management. Twenty-five patients were admitted to the service bleeding before the thirtieth week of gestation and another 25 were admitted before the thirty-third week. Thus one-third of all our patients depended upon continued intrauterine gestation for increased fetal salvage. Twentyone of these patients could have been delivered of previable fetuses, yet there were only 13 infants delivered weighing less than 1,000 grams, and 2 of these survived. The 10 infants who lived must be considered salvaged primarily because their delivery occurred at a more advanced period of gestation. The intermediate group (34 to 37 weeks) also has a better prognosis if delivery can be delayed at least until the maternal circulation has been stabilized; however, many of these patients are delivered shortly after admission because labor is well established and continuing blood loss threatens the fetus with anosia. The time of onset of bleeding in other studies of placenta previa is compared in Table IV. It is significant that Eadie and Randall’ reported a 77.1 per cent incidence of bleeding before the thirty-seventh week, attended by a 43.2 per cent uncorrected fetal mortality. Our series showed 53 per cent before the thirty-seventh week and a 15.9 per cent uncorrected fetal mort,ality. TABLE
IV.
ONSET
OF BLEEDING 1
TIME OF ONSET Prior to Third Trimester.22-28 weeks 22-31
weeks
ASSOCIATED
EADIE AND RANDALL4 %
17-12.9
WITH (
PLACENTA
SEMMENS (THIS STUDY) %
PREVIA I
SCHMITZ?O %
15- 9.0 s-
Trimester.28-30 weeks 31-33 weeks
7.0
Third
31-38 34-37 38-40 Term-Active
19-14.5 21-16.0
6- 3.6 2515.1
weeks weeks
39-29.7
42-25.3
weeks
25-19.1
32-19.3
38-33.0 66-60.0
Labor.-
40 weeks plus
5-
3.8
46-27.7
Presentations There were 21 transverse lies (12.6 per cent) which is 35 times the incidence (0.34 per cent) expected with a normally implanted placenta. There were 21 breech presentations (12.6 per cent) which is 3 tz’mesthe normal expected rat,e. Only 2 of the t,ransverse lies occurred in a second twin. Of 124 vertex presentations (74.8 per cent), there were 3 brows and 3 occiput posteriors.
66
SEMMENS
Management The management of third-trimester bleeding consists of four distinct no recta.1 examinations, 11~1 phases. l‘hc first is that rendered in the home: vaginal csaminations, no pm-king, immediate hospitalization, preferably by amhnfancr. Tho second phase is untlcrt,akcn at the time of admission to the hospital ntld includrs : ( I ) abdominal examination noting rigidity, Or loca.lized tendcrnrss, station, and present.ation; (2) bed rest a.nd observation unlrss the blcrding is brisk and fails to abatr and shock t.hrcat,ens ; (:3) typing and CI’OSSmatching for ant.icipated blood loss ; (4) base line hemoglobin, hematocrit, and red blood count; (5) No. 18 ncctlle in a vein with fluids running; (6) nothing by mouth (liquids and soft diet arc not offered until bleeding has ceased fox 24 hours) ; (‘i) fibrinogen lcvrls (%*hneidrr m&hod) when ahruptio placentac~ is snspectcd, ant1 smears for nnclratrd ~1 crlls if rasa prrvia is a possibility. Tn thr thirtl phase, 01’ trcaltmc~nt, thy pat.icnts mny br (livided into t.wo gtwups : (1 ) Thosr who cont,innc to blcrcl ant1 thrcatrn to go int,o shock a’t*ca rsaminrtl under strrilr ~lonhlc setup an(l tlrliverrd by thr safest and most cspctlicnt. mrthotl. (2) ‘t%(JSc who stop hlwcling uiitlcta the rcgitnc onthird in I)hasc! two arc r\~all~atrtl by s-ray I)l;lrc,rttogt,aI’hy aftor a short titnr intrrval (prcfcrably aftrr th(t thirsty-srcontl wcrk’). Va,ginal rsaminaticms arc‘ drfcrrrcl of, placrnta, prcvia and when the s-ra.y is positivr for, or highly suggestire unless thr pregnancy is beyond 37 weeks. Patients ax rsamincd vaginally onlwhrn t,hc periotl nf grstation farors dclivrrv in prrfc~cncr to observation (38 wreks) or when bleeding rcc’uys. nccrssita.&ng t.hc sr7cctiori of a. tncthoc7 of clrlivcry. All p&ruts with nrgatirr placentopralns are rsaminrtl raginnlly. by sprculum and digita&, treat.ed, and discharged. The elrction of thr nld.hncI of tlrli\c.ry might 1.x ronsitlct4 as the fourth phase of managcmcnt. It is 1~~~7 on the condition of the ccrvis and thr tlrgree of placenta prcvia prrsent. 111 the long, closrd crrvis (characteristic of the nullipa.rn), patients with total and partial placenta previa. arc usually delirercd by cesarean section if near term. Low Iring placenta previa is trrntctl by artificial rupture of the mCtljbranrs, allowlng the presenting par1 to tatnponadc thr placenta in the lowcr uterine srpmrnt. Failurr of thr presenting part to cngagr, as is common in low lying posterior placenta previa. is usually attradc4 by rscrssivc hlrrding am1 crsa.rcan se&m is rssential. Thr short soft crrvix (rharactrl*ist.ic of the multipara) lrnds itself to vaginal delirerv in partial pIac?nta prrvia. and low I;ving pIac.rnta previa once tlir men)brxnes have brcn ruptuycd. All pntirnts with total placenta prcvia ant1 clcrasional patients with partial placenta pyryia. who continue to blcr~l a1.r ~lclivrrrd by rrsarca,n section. Ttleally. (1) thr matrrnnl systolic blood prcssut~r shouIc1 1~ 90 mm. Hp ot high(Jr at thr liter of oprration. (2) the placrnta should bc srparatr(l rathrr than pcrforatcd. (3) the cord should br rlampcd imlncdiat,elp following (lplivrrp. (4) blo~tl counts should hr takrn on 2.11 babirs and anrmia treate(l rarly by t,ransfusinn, (5) a.lZ unnecessary intrautrrinr manipulation should br nvoidrd, ineluding manua.I rrmov;ll of the placenta, (6) t.hcrc shonlti l,r p~-~~It~pt tlrlircry once dilatation is complete. occiput posteriors rotated, and low t’o~*ceps rmploq’cd whrn spontanrnns clclivrry is unt imtnincut.
Diagnostic S-m?/.-Good
A poor trchniqne
Aids
x-ray t,rchniqnc is impsrativct in conservative nlanagrmrnt. or false negative film may cause the patient to he snbjcctrcl in
Volume Number
77 I
CONSERVATIVE
MANAGEMENT
OF
PLACENTA
67
PREVIA
vaginal examination at a time when incited bleeding could force delivery of an immature or premature infant. A total of 200 placentograms were taken during the interval of the study, 63 of these on patients with placenta previa proved clinically during labor or at delivery. The placenta was identified in the lower uterine segment in 59 of these cases (93.7 per cent). The exact type of placenta In 7 cases loralizaprevia was diagnosed by x-ray in 52 cases (82.5 per cent). tion of the placenta was inconclusive as to type (6 were total and 1 was a partial). Of 141 cases reported as negative, only 4 reports were proved to bc in error (2 were partial and 2 were low lying placenta previa) . This is an over-all Rccuracy of 98 per cent (Table V) . Hibbardl’ reported 90 per cent positive placental identification by x-ray in his series. Seven&n air cystograms were taken when soft-tissue technique failed to give definite placental localization and placenta previa was strongly suspected. All were positive and the localization was 100 per cent accurate, as confirmed at delivery. TABLE V. EMPLOYMENT OF PLACENTOGRAPHY MANAGEMENT OF PLACENTA PREVIA AT THE
U.
AS A DIAGNOSTIC S. NAVAL HOSPITAL,
AID IN THE PORTSXOI~TH,
‘is,
NO.
placentograms taken during study placentograms reported as negative for placenta previa Total number of patients with clinically proved placenta previa who had placentograms Erroneous diagnosis Positive clinically, negative x-ray Partial placenta previa Low lying placenta previa Negative clinically, positive x-ray Placenta identified in lower uterine segment Actual type of placenta previa by x-ray inconclusive as to type of placenta previa Total placenta previa Partial placenta previa Special x-ray techniques employed Air cystograms taken 17 Standing laterals 70 Erroneous diagnosis Over-all accuracy of placentography all types
CONSERVATIVE VIRGINIIY
200
Total Total
141
ti3 4
2.0
59 52 7
100.0 93.7 82.5 17.5
4 2 2 0
6 1 27 0 196 : 200 -_I
100.0 98.0
-
Unengaged Presenting P&.-In 50 cases (30 per cent) either abnormal presentation or an unengaged presenting part were found at the time of admission. Minor episodes of bleeding that are associated with an abnormal presentation or unengaged presenting part warrant study to rule out placenta previa. The primigravida at term with an unexplained floating presenting part should have a standing lateral film taken for soft-tissue study along with pelvimetry. Double Xetup Xterile Vaginal Examination.-Sterile vaginal examination in the operating suite with the patient prepared for possible abdominal delivery was employed 44 times with one error, an sccuracy of 97.8 per cent. In the face of heavy blood loss and labor, vaginal examination is only a timeconsuming and aggravating procedure to a patient in shock. X-ray, the amount and nature of the bleeding, and determination of presentation and engagement are all equally reliable indications for surgical intervention. Vaginal examination is reserved for : (1) equivocal cases near term without bleeding, (2) cases of total placenta previa near term diagnosed only by x-ray and not bleeding, and (3) suspected cases of low lying posterior placenta There were no repeat vaginal examinations done in this series. previa.
SEMMENS
68
Supportive Managem&.-A total of 263 units of blood were given, averaging 1.6 units per patient; 41 of 43 patients with total placenta previa were transfused (97.5 per cent) with 139 units ( 3.28 per patient) ; 34 of 56 patients with partial pIacenta previa ware transfused (60.7 per cent) with 81 units (1.15 per patient) : 7 of 13 with low lying posterior placenta previa were transfused (61.5 per cent) with 17 units (1.3 per patient) ; and 17 of 54 with low lying placenta previa were transfused (31.5 per c’ent) with 26 units (0.48 per patlrmt). Therms is a close parallel between partial placenta previa and low lying posterior placenta prcvia in blootl requil~c~lncnts to cc~ver lossc~s. This is illustratrtl ill Fig. 1. Nethods of Dt&wy.-- The methods of delivering the 169 infants are shown in Table VI. The 3 low lying placenta previas encountered at repeat cesarean section were unsuspected prior to operation. One Port-0 C'~LWR.II section was tfone for severe amnionitis in a case of total placenta J)revia. One hyst,et*ccto~*ly was performed aft,er ccsarean section for focal placenta accrcrtw complicating tot,al placenta previa. The patient bled from t,he lower uterine segment postoperatively necessitating 9,000 ml. blood replacement before anil during cm(‘rgcncy operation. A second postcesarean section hvsterect0rn.v was done on a -&O-year-old grand multipara found to have rchcurrent total placcrrta prcvia ill successive pregnancies as well as two previous (‘~~‘sarcan s&ions.
___.-_I____
-_?_-----
METHOD
OF DELIVERY
1. Spontaneous 2. Low forceps 3. Midforceps 4. Breech extra.cticm or assist 5. Version and extraetim 6. Transverse low cervical cesarean section
7. Porro hysterectomy 8. Hysterectomy post cesarean section
-.-
ms
-__
1
53
33 7 1:i
~
34.1 19.5
1.1 7.7
1
) 'TOTAr, __-_--..-
0 1
0
/ ( I'ARTIAL
6 3
I) 0
0
0
1
;
g
61
xi. 1
41
10
L,
1
1.1
2
( !gR
76
1.L 0.6
I,OW LYING
24 10
2
1
! j
19
3
33
0
0
ii
0
0
0
CONSERVATIVE
MANAGEMENT
OF
PLACENTA
69
PREVIA
conz&ntions.-The complications associated with placenta previa in this series are listed in Table VII. Premature rupture of the membranes and snbsequent amnionitis proved quite disastrous from a fetal standpoint. Rupture of the membranes accompanied by bleeding from placenta prcvia offers an excellent cult,urc medium for bacterial growth and the amnionitis is usually SCT’CPC. TABLE
VI r.
MEDICAL, SURGICAL, ASSOCIATED WITH
AND OBSTETRICAL PLACENTA PREVIA
COMPLICATIONS -
Amnionitis Diabetes mellitus, Class D Epilepsy (grand mal) Fibromyomas of the uterus (8 cm.) Hepatomegaly, splenomegaly (etiology?) Hypertension Pneumonia, lobar, bilateral Polyhvdramnios Pre-eElampsia Pvelitis Rheumatic heart disease, Grade II Ureteral calculus
1 1 1 1 1 1 3 8 6 1
Intrapartum.-
Contraction ring, lower Focal placenta accreta Prolapse of the cord Retained or adherent
uterine
segment
1 1 7 4
placenta
Postpartum.-
Cerebral venous thrombosis Endometritis Peritonitis, postoperative (cesarean section Wound dehiscence (cesarean section)
and hysterectomy)
1 3 1 1
Intra partum, there was a 4.2 per cent incidence of prolapse of the cord, which resulted in 2 stillbirths and 2 neonatal deaths. Abnormal presentations and unengaged presenting parts were responsible for the increased incidence. There were also 4 cases of retained placenta and one of focal placenta accreta that was discussed earlier. The postpartum complications were limited to infection in the form of endometritis or peritonitis depending upon the route of the delivery. OllC wound dehiscence occurred in a case of total placenta previa that had been complicated ante partum by resistant pyelitis. Anesthesia.-Anesthesia for the vaginal deliveries was chiefly conduction in type. S’pinal (saddle block) was employed to deliver the primigravida who was stabilized and not actively bleeding in the second stage of labor. Pudendal block was the anesthesia of choice for the delivery of the multipara or the primigravida with minimal bleeding in whom a hypotensive reaction could not be risked. Cesarean sections were performed under spinal anesthesia when bleeding was minimal or absent, and under local (Xylocaine 0.5-1.0 per cent) when fetal distress, bleeding, or shock was the indication. There were 7 operative procedures carried out under cyclopropane anesthesia with only 3 infant survivals; this high fetal mortality rate (57 per cent) is similar to that reported by Hibbardl’ (30.3 per cent).
Results In 66.2 per cent of the patients labor was so well established that they failed to stop bleeding, anoxia and shock threatened the fetus and mother,. and delivery was accomplished within 12 hours after admission. An additional 5.4 per cent of the patients either continued to bleed or had a short latent period followed by labor and more bleeding and were delivered within 24 hours after
70
Am. J.0bst.k J.u,wy.
SEMMFNS 1 L
Gym.
I'Ii'I
admission. Thus, as a result of labor atld/or blocding, 71.6 per cent UC 111~ patients were delivered on the day of admission, lcaving only 28.4 per CC~LI who could bc managed conscrvativcly. Only 22.3 l)ct* cent gained one additima week or IHOT(: of gcstationa.1 tlevc~loprnc:nt for their infants, siticc 6 J>Cl' cent wert dclivcrctl bcforc t.hc scvcnth hospital clay. In this conscrvatire group, 19 of the pnticnts WVIY atlttlitted b~forc~ thr thirty-second week and 18 bcforc the t,hirty-sixth week of gcstat,ion. Only 5 of their infants weighed less than 1,500 grams and 22 (60 per cent) weighed over 2,500 grams st birth. There wire 1,192 additional hospital days before delivery, an average of 32.2 days per patient. The quantity of bIood given. 39,500 ml., or 2.13 units per patient, was 20 per cent) less than that requirrd t.o support the patients who were bleeding a.ctiveIy at the time of admission and delivery. Of interest is the fact. that in t,hc group treated expectantly there were 20 per cent more total placenta previas than in the general stucl)
(25.9 versus 45.9 per cent), ,Seventy-two of the 110 delivrrirs which occurred in the first 23 hours produced mature infants, with only 2 perinat,al deaths, neither of which was caused by early delivery. Labor and/or bleeding necessitated t.hc delivery of 27 prematurr ant1 11 immuturc infants within the first 12 hours following admission, and 6 more premature a,nd 2 immature infants were drlivcrcd within 24 hours following admission. Fetal survival with conscrrativc management was 89.1 per cent, which is 5 per cent better than WI* espcricnce in the en&c study. When one recalls that 52 per cent of the infants in the cntirc study WC~C mature by gestational age at the time of admission as compared to only 8 per cent of the conservative group, the merit of this attack on pren1aturit.y and associatctl fetal losses in th(J management of placenta prcvia. is srlf-cvidcnt. The maternal mortality rate was zero and t,he uncorrcctcd fetal mortality rate was 15.9 per cent. There were 3 infants with congenital anomalies incompatible with life. a corrcctcd fetal mortality of 14.1 per cent (Table V’JIJ). --_
TABLE
VTII.
MATERNAL
AND --.------~-..-zzz:~~ /
FETAL
MORTALITY -:I-
ASSOCIATED WIT~I PI,AcEE;TA PREVIA - ~~~ --__-_~~ .i MATFRNAT > , / FETAL
AUTHOR
-.__
Ueilly2 Davidson3 Eadie and Randall% Grant, F. G.9 Hatten, Kirkpatrick, and Thornton10 Johnson14 Macafe& (2 series) Conservative treatment Immediate treatment Macafee (personal series) Schmitz2o Scnrmens, V. S. Naval Irospital, Portsmouth, \-
T’iyinia
1940-1910 1946-1950 (1957) (1954;l
28.2 9.8 13.0 x1.2 unKmwtet1 11.9
(1947.1944) (1939-195n)
26.3 21.0
uncorrwted
I
1,000 plus 1,000 plus 177 112
(1937.1944) (1941-1951) ( 1954-194;) . t
IGG
5.9 7.0 0.57 0.89
51.0 69.0 23.5 22.3
0.0
15.9 14.1
"llrolvc:tl~~1 CorrectN~
Comment We were prompted to undertake this study of the conservative management of placenta previa because: (1) a rcducecl incidence of premature dcliveries offered the best mCans of improving fetal salvage, and (2) temporization permitted more accurate diagnosis and a much better prognosis for the mother in her current as well as her future pregnancies.
We feel that any bleeding before and during labor deserves a conccrtcd effort to make a positive diagnosis; and if placenta previa is found to 1~ present, no matter what the circumstances, all the benefits of hospital management must be afforded to the mother and her unborn infant. Delivery of a viable infant and replacement of maternal blood loss do not excuse th(h obstetrician from making a positive diagnosis, and the indiscriminate use of terms such as “marginal sinus rupture” to classify cases that border bctwecn abruptio placentae and placenta previa should be discouraged. The younger average age of patients (24.5 years) suggests that placenta previa need not be a complication of the older multipara. Repeated prcgnancies in a short time interval are probably equally responsible for the uterine changes that predispose a patient to an abnormal placental implantation. There were 3 patients who had had placenta previa in a previous prcgnancy. One had total placenta previa in 2 successive pregnancies. Johnson reports 2 recurrences of placenta previa among 120 patients. The clinical significance of abnormal presentation is evident with 35 times as many transverse lies and 3 times as many breech presentations with placenta previa. The 4.2 per cent incidence of prolapse of the cord is an anticipated consequence of the large percentage of unengaged presenting parts (60 pet cent) at the time of labor and delivery. There werr 56 transverse lies in 16,532 deliveries (0.34 per cent) during the years 1954 to 1956, inclusive, and 19 (34 per cent) were associated with placenta prcvia. Anteroposterior and soft-tissue lateral x-ray for fetal position a.nd placental localization at the same time makes good sense in the evaluation of the patient suspected of having a transverse lie. Bleeding is evidence of labor in placenta preria, since it is brought about by retraction of the lower uterine segment from the placenta during dilatation of the cervix. Increasing bleeding and evidence of uterine contractions call fol prompt delivery. Bleeding in excess of 500 ml. in a single episode seldom abates, and if it is allowed to continue and exceed 1,000 ml. before delivery, the fetal mortality rate doubles. Excessive x-ray exposure of the fetus should be avoided and the single standing soft-tissue lateral film has been the most effective method of screening suspected cases. Fifteen per cent of the cases x-rayed were positively diagnosed in this manner. A selective filtration technique such as that described by Reeves and Cahoon17 offers the best visualization of the placenta and uterus on lateral view. In a review of approximately 5,000 cases of placenta previa report,ed in the literature,4* 5, I43 2o the incidence of total placenta previa is 26 per cent. WC feel that a ccsarean section rate more than 15 per cent above the percentage of t,otal placenta previas reflects an easy but not always sound solution to this problem. Surgical procedures on the gravid uterus leave weaker scars, espcrially if the incision is in the placental site. The only valid indications for abdominal delivery in placenta previa other than total are: abnormal presentations, low lying posterior placentas that prevent engagement, and the occasional partial placenta previa in the primigravida and certain multiparas who continue to bleed. The problem of anesthesia, especially in the presence of shock or ncnr* shock, is extremely difficult. One is barely able to transfuse these patients rapidly enough to offer the circulatory support necessary t,o cffcct an cmcrgency abdominal delivery. Regional or local anesthesia offers a greatc>t* margin of safety for the mother and her baby. It has been pointed out that. there was no fetal loss in 7 cesarean sections clone under local anesthesia fol tot,al placenta previa with excessive bleeding; whereas we cxpcricnced a 50
SEMMENS
per cent fetal loss in a comparable thesia. Two of the infants subjected in the lungs and pneumonia.
delivered under cyclopropane ancsto autopsy showed hemorrhagic changes
gronp
Summary One hundred sixty-six cases of placenta previa in 18,408 deliveries at the TJ. 8. Naval Hospital, Portsmouth, Virginia, a.re presented and reviewed. The management is discussed in detail. Diagnostic aids, including s-ray and SCOWtive filtration techniques, and sterile vaginal examination are appraised f01 Methods of delivery are discussed, a.ccuracy as well as hazard to t,he patient. Section rates rnorp including specific indications for abdominal delivery. than 15 per cent above the nurnbctwf total placenta, previas arc felt to represent an easy but unwise soWion for bleeding problems. Major complications associated with placenta prcvia and abnormal prtscntat,ions are mentioned, and the choice of anesthesia for abtiominal as well as vaginal delivery, especially in the face of rircula.tory instability, is discussed. An additional month or I~OW of continutd in!-rantcrine gestation for the infants was a.veragcd in 22.3 per cent of casts ; 88 per cent of t,ht fct.uses in t,his group wercl immat,urc or prcma.turt~ hy pest;\tionnl age :ri the time of ndrrlissiolr : 60 per cent of the infants wt+qht~(l ov(bt* 2.500 grams at the tiltlc of tlclivct*y. and an orcr-all fetal surviva,l rate of 89.1 pi* cent was ctscditccl to this gron~~ of pat.itMs. Despite there being alrJIOSt twice the number of total plaet’ntil prcvias in this group, the actual blood nct~tfs were 20 per cent. Jnssthan among patients who were in active labor ancl bleeding at the time of admission. For an additional 31.5 per cent of the patients tc~nlporization permitted more accuracy in t,hc diagnosis of the type of placenta preria present and t,hc selection of a method of delivery which offered the infant a.nd mot.her the best prognosis in the current. pregnancy R.SwckJ1as in fut.urc prngnantics. 1 wi,dr to rsprcss my appreciation to C!aptain Jhvighf. A. t’dlitgu~ I MC: ) ITRN, Dependents Service, U. S. Naval Hospital, Portsmouth, Virginia, for his aid and in the preparation of this report, and to F. J. 8. and G. CT. B. for t-heir editorial aid.
Chief of comment
References 1. Bartldomew, R. A., and others: Obst. & Gynec. 1: 41, 1053. 2. Beilly, J. S.. Greenberg. M. M.. Aaron. J. B., and Peck, S. .J.: Ahr. J. OI
11. 12.
13. 14. 15.
68. . 6.50
1954
F. G.: .T. O&t.‘& &vnaec. lirit. I*:mp. 62: -LX. 1935. J. Q,, Kirkpatrick; S. A., and ‘t’hornt,on, W. N., .Jr.: Ax\r. J. OBST. & GYNEC. 11’81, 11)55. Hitrbard, I,. T.: Ohxt. $ (?ynec. 8: iii::, 7!#i. James, 11. W., awl Misch, K. A.: .J. Obst. & Gynaec. Hril. J*hp. 62: 551, 1955. Johnson, H. W.: AM. J. OBST. & GYNCC. 50: 2-23, 19-G. Johnson, H. W.: .4r~1. J. Oas~. & GYNEC. 59: 1236, 195r). Maeafee, C. H. G.: Postgrad. M. J. 25: 297, 1949.
9. Grant, 10. Hatten,
70:
CONSERVATIVE 16. 17. 1s. 19. 20. 21. 22. 23. 24.
Macafee, Reeves, Russell, Russell, Schmitz, Stallworthy, Watson, Weinberg, Weinberg,
MANAGEMENT
OF
PLACENTA
PREVIA
C. H. G.: J. Obst. & Gynaec. Brit. Emp. 52: 313, 1945. R. J., and Cahoon, J. B.: M. Radiog. & Photog. 28: 2, 1952. J. K.: Lancet 269: 322, 1955. Lancet 268: 785,1955. J. K., and Warrick, C. K.: H. E., O’Dea, N. J., and Isaacs, J. H.: Obst. & Gynec. 3: 3, 1954. J.: Aa6.J. OBST.& GYNEC.~~: 720,195l. H. G.: West. J. Surg. 63: 151, 1955. A., Rizzi, J., McManus, R., and Rivera, J.: Obst. & Gynec. 8: 396, 1956. A., and Deckoff, S.: Obst. & Gynec. 10: 146, 1957.
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