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Vasa previa
EUGENE
S.
GROSECLOSE,
(From
M.U., F.A.C.S.,
the Vi.rgi&z
Baptist
LYNCHBIJRG,
Va.
Aospitat)
the obstetrical complications producing vaginal bleeding in the late prenatal period A MONG or after the onset of labor, vase, previa is seldom mentioned in the obstetrioal literature. This condition is rarely diagnosed before rupture produces hemorrhage, thus creating a severe hazard to the life of the baby, most often with a fatal outcome. Vasa previa has been defined as ‘(a condition in which the blood vessels of the umbilical cord where they enter the placenta present in front of the fetal head in labor. i ‘1 As pointed out by Rucker and Tureman,x in their very comprehensive review of this subject in 1945, this definition is open to several objeetions. The patient need not be in active labor, the fetus need not present by the head, and the umbilical vessel need not be near the placenta. An aberrant vessel may rupture although the umbilical cord may have a normal or central implantation. Likewise, vessels branching between one or more lobes of a multipartite placenta or a placenta suceenturiata may constitute a vasa previa if they cross the internal cervical os and are subject to rupture, either spontaneously or artificially. A velamentous insertion of the cord is usually present and many specimens of this anomally have been encountered, often with the opening of the membranes near or between branches of the umbilical vessels which remain unruptured and therefore these eases are usually unreported in the literature. In the following case spontaneous rupture of a vasa previa occurred prior to the onset of labor in a twin pregnancy, with immediate death in utero of the first twin, and the survival of the second twin following spontaneous delivery. The diagnosis of vasa previa was not made until after delivery was completed, although it was suspected due to the &i&al course of the case associated with a known multiple pregnancy. Rupture of the velamentous vessel also occurred spontaneously in this case without rupture of the amniotic sac. Mrs. F. P. W., a white multipara, aged 31 years, was admitted to the Virginia Baptist Hospital on June 13, 1947, for induction of labor at term. Her pregnancy has been essentially normal until April, 1947, at which time she was hospitalized for threatened premature labor at the seventh month. Following bed rest, sedation, and corpus luteum therapy, all contractions ceased. X-ray of the abdomeu at that time confirmed the diagnosis of a twin pregnancy. Physical examination revealed a tall, slender, poor nourished woman, whose abdomen Two distinct fetal outlines was obviously larger than average for a full-term pregnancy. could be palpated and two normal fetal heart tones were audible. The blood pressure was 118/78. There was no edema. The urine showed a faint trace of albumin and an occasional epithelial cell, the chemical examination being normal. Wassermann test was negative; hemoglobin 82 per cent; Blood type, 2; Rh factor, positive. The past obstetrical history was signifioant only in the fact that her first pregnancy was terminated at full term by breech delivery, after a labor of six hours. During the night of admission, the patient was awakened at 2:00 A.M. by a sudden and rather profuse painless vaginal hemorrhage. Immediate examination revealed the abwce of the fatal heart tone on the left, w-hile the fetal heart tone of the other fetus continued audible and normal. The maternal pulse rate was ti4 and the blood pressure 1213/78. Abdominal examination revealed no tenderness or rigidity. Bleeding ceased shortly after the *Pmented at the Twelfth Obstetricfans and Gynecologists.
Annual Roanoke,
of the South. Atlantic Xeetin Va., Fe%. 9 to 11. 1960. 80
Association
of
Volume 61 Nllmber I initial hemorrhage, and after showed the cervix to be well placental tissue nor pulsating
VA8A
PREVIA
45 minutes mild uterine contractions began. Vaginal effaced, quite soft, and dilated about 3 cm. There vessels palpable, and the amniotic sac was intact.
81 examination were neither
Fig. l.-Maternal surface of the placenta, showing the pale, ischemic color of placenta on the side of the ruptured velamentous vessel, and the dark, normal appearance of the cpnosite half of the placenta.
Fig. 2.-The fetal surface of the placenta, showing the normal central insertion of ,ttz umbilical cord on one side, and the branching velamentous cord on the opposite side. ,thrombosed ends of the large ruptured vessel are clearly seen, with two unruptured velamentoua vessels in the membranes. In view of these findings complicating a twin pregnancy, it was felt that a ruptured ‘vasa previa most likely existed, although such a diagnosis could not be confirmed at this ,time. The membranes were ruptured artificially to stimulate labor and uterine contractions progressed rapidly. The first twin was delivered by forceps after approximately four hours
of labor and IVLS stillborn. The S~CIIJIII 1it irr was ileli\el,eii .-ponlaneoosly lifleoii iuirlilt[b* The tllil,ll .t:ig”
Reference 1. Dorland,
W. A. Newman: American Illustrated Medical Dictionary, 1942, W. B. Saunders Company. 2. Rucker, M. Pierce, and Tureman, Garnet It.: Virginia M. Monthly 511
ALLIED
ARTS
BUILDING.
ed. 39, Philadelphia, 72:
YE,
1945.
S.
GROSECLOSE,
(From
M.U., F.A.C.S.,
the Vi.rgi&z
Baptist
LYNCHBIJRG,
Va.
Aospitat)
the obstetrical complications producing vaginal bleeding in the late prenatal period A MONG or after the onset of labor, vase, previa is seldom mentioned in the obstetrioal literature. This condition is rarely diagnosed before rupture produces hemorrhage, thus creating a severe hazard to the life of the baby, most often with a fatal outcome. Vasa previa has been defined as ‘(a condition in which the blood vessels of the umbilical cord where they enter the placenta present in front of the fetal head in labor. i ‘1 As pointed out by Rucker and Tureman,x in their very comprehensive review of this subject in 1945, this definition is open to several objeetions. The patient need not be in active labor, the fetus need not present by the head, and the umbilical vessel need not be near the placenta. An aberrant vessel may rupture although the umbilical cord may have a normal or central implantation. Likewise, vessels branching between one or more lobes of a multipartite placenta or a placenta suceenturiata may constitute a vasa previa if they cross the internal cervical os and are subject to rupture, either spontaneously or artificially. A velamentous insertion of the cord is usually present and many specimens of this anomally have been encountered, often with the opening of the membranes near or between branches of the umbilical vessels which remain unruptured and therefore these eases are usually unreported in the literature. In the following case spontaneous rupture of a vasa previa occurred prior to the onset of labor in a twin pregnancy, with immediate death in utero of the first twin, and the survival of the second twin following spontaneous delivery. The diagnosis of vasa previa was not made until after delivery was completed, although it was suspected due to the &i&al course of the case associated with a known multiple pregnancy. Rupture of the velamentous vessel also occurred spontaneously in this case without rupture of the amniotic sac. Mrs. F. P. W., a white multipara, aged 31 years, was admitted to the Virginia Baptist Hospital on June 13, 1947, for induction of labor at term. Her pregnancy has been essentially normal until April, 1947, at which time she was hospitalized for threatened premature labor at the seventh month. Following bed rest, sedation, and corpus luteum therapy, all contractions ceased. X-ray of the abdomeu at that time confirmed the diagnosis of a twin pregnancy. Physical examination revealed a tall, slender, poor nourished woman, whose abdomen Two distinct fetal outlines was obviously larger than average for a full-term pregnancy. could be palpated and two normal fetal heart tones were audible. The blood pressure was 118/78. There was no edema. The urine showed a faint trace of albumin and an occasional epithelial cell, the chemical examination being normal. Wassermann test was negative; hemoglobin 82 per cent; Blood type, 2; Rh factor, positive. The past obstetrical history was signifioant only in the fact that her first pregnancy was terminated at full term by breech delivery, after a labor of six hours. During the night of admission, the patient was awakened at 2:00 A.M. by a sudden and rather profuse painless vaginal hemorrhage. Immediate examination revealed the abwce of the fatal heart tone on the left, w-hile the fetal heart tone of the other fetus continued audible and normal. The maternal pulse rate was ti4 and the blood pressure 1213/78. Abdominal examination revealed no tenderness or rigidity. Bleeding ceased shortly after the *Pmented at the Twelfth Obstetricfans and Gynecologists.
Annual Roanoke,
of the South. Atlantic Xeetin Va., Fe%. 9 to 11. 1960. 80
Association
of
Volume 61 Nllmber I initial hemorrhage, and after showed the cervix to be well placental tissue nor pulsating
VA8A
PREVIA
45 minutes mild uterine contractions began. Vaginal effaced, quite soft, and dilated about 3 cm. There vessels palpable, and the amniotic sac was intact.
81 examination were neither
Fig. l.-Maternal surface of the placenta, showing the pale, ischemic color of placenta on the side of the ruptured velamentous vessel, and the dark, normal appearance of the cpnosite half of the placenta.
Fig. 2.-The fetal surface of the placenta, showing the normal central insertion of ,ttz umbilical cord on one side, and the branching velamentous cord on the opposite side. ,thrombosed ends of the large ruptured vessel are clearly seen, with two unruptured velamentoua vessels in the membranes. In view of these findings complicating a twin pregnancy, it was felt that a ruptured ‘vasa previa most likely existed, although such a diagnosis could not be confirmed at this ,time. The membranes were ruptured artificially to stimulate labor and uterine contractions progressed rapidly. The first twin was delivered by forceps after approximately four hours
of labor and IVLS stillborn. The S~CIIJIII 1it irr was ileli\el,eii .-ponlaneoosly lifleoii iuirlilt[b* The tllil,ll .t:ig”
Reference 1. Dorland,
W. A. Newman: American Illustrated Medical Dictionary, 1942, W. B. Saunders Company. 2. Rucker, M. Pierce, and Tureman, Garnet It.: Virginia M. Monthly 511
ALLIED
ARTS
BUILDING.
ed. 39, Philadelphia, 72:
YE,
1945.