PLACENTA PRAEVIA AND ABRUPTIO PLACENTAE
Cesarean delivery is used frequently of late in placenta praevia.
It may be necessary also in abruptio placentae, gunshot wounds of
the abdomen during pregnancy, sometimes in appendicitis complicating
gestation, rarely in prolapse of the cord to save the child, and
when twins become interlocked in delivery. Placenta praevia is
a development of the placenta in that part of the uterus which
dilates at the end of gestation or during delivery. This dilatation,
with the mechanical pressure of the child, detaches the placenta
enough to cause a hemorrhage which may be fatal to the woman if not
checked. The hemorrhages begin sometimes as early as the sixth month
of gestation, but most frequently in the eighth month. Premature
labor is a common effect. The position of the placenta may cause
malposition of the fetus, prolapse of the cord, weak pains, air
embolism into the blood, rupture of the uterus, sepsis, profound
anemia, and other evils. The child may be premature, puny, have
collapsed lungs, hemorrhages, and it is very likely to be killed in
delivery. The mortality of the women varies, but it averages about 7
per cent; that of the children averages 61 per cent.
The tendency with obstetricians is to deliver the child as soon as
the diagnosis has been made. When the bleeding is slight, and the
child is viable, one may delay delivery provided the woman will
remain in bed in a good maternity hospital without moving. At home
the woman may "flood" and bleed to death before a physician can
reach her. If the woman refuses to go to a hospital, and to permit
the induction of labor, any physician who has regard for his own
reputation will drop the case and leave the woman to her own devices.
There are various methods of treatment, and much depends on the
position of the abnormally placed placenta. The treatments all
consist in stopping the hemorrhage for the instant, emptying the
uterus, insuring permanent hemostasis, and meeting the anemia. The
Braxton-Hicks version is one method. The child is quickly turned so
that the head is upward in the uterus, and a leg is pulled down to
plug the cervix uteri until there is enough dilatation to extract the
child. Very many children are lost by this method. When the placenta
praevia is marginal to the cervix or lateral in the uterus the child
has a better chance when a colpeurynter, or inflatable rubber bag, is
inserted in the cervix as a plug. Much skill and discrimination is
required in the management of this bag until the child is delivered.
The obstetrician may be obliged to sit by the bed and hold on to
the bag for from three to twelve hours. Hasty extraction through a
poorly dilated cervix is a very dangerous process, as a tear cannot
be repaired quickly enough, as a rule, to check the hemorrhage, which
will be fatal. When version has been done haste may compress the head
in the tight cervix and asphyxiate the child.
When the child is viable a cesarean section is by far the best method
for the child, as it lowers the fetal mortality from 61 to about
5 per cent. The mother, too, has a better chance by the cesarean
section, provided it is done by a competent man, early in labor
before infection has set in, and in a hospital.
If the child is not viable the hemorrhage must be stopped to save the
woman's life. As a rule, the hemorrhages are not dangerous before the
seventh month. In the 128 deaths of Müller's statistics there was not
one before the seventh month of gestation. Hirst, however, says he
has been obliged to empty the uterus at the fifth month for placenta
praevia. The woman must be kept in bed, the foot of the bed elevated,
sedatives used, and so on, as in threatened abortion, and the vagina
tamponed securely with cotton. If it is evident that the fetus is
dead, it must be extracted as in the case of a viable fetus. If it is
probable that the fetus is alive, it is to be treated as in a case
of inevitable abortion as described in the chapter on Abortion.
The tamponing of the vagina to stop the hemorrhage will cause the
abortion of the fetus indirectly. This is another double-effect case,
and the tamponing is morally permissible provided the intention is
correct.
Abruptio placentae is a tearing loose of a placenta which is situated
in the normal position, not abnormally as in placenta praevia. The
cause may be a disease of the placenta or decidua; for example,
syphilis, chronic metritis, traumatism from a blow or fall, jumping
from a carriage-step, and so on. Nephritis is often found where there
is abruptio placentae. In labor the placenta may be torn loose by a
version, by the delivery of the first of a pair of twins, or because
the cord is too short.
There is always profuse hemorrhage, which is usually concealed at
first, but finally external. It is possible at times for a woman
to bleed to death into her own uterus, when it is distensible. The
mortality is about 50 per cent. for the women, and where there is
concealed hemorrhage about 95 per cent. of the children are lost. A
differential diagnosis is to be made to exclude placenta praevia,
rupture of the uterus, extrauterine pregnancy, rupture of an
appendical abscess, gall-stone colic, or intraäbdominal injury.
If the child is viable it must be delivered as quickly as possible.
If it is dead and the head is developed, craniotomy should be done to
hasten extraction. When the abruptio takes place before the seventh
month of gestation the fetus will die in about ten minutes, whether
in the uterus or outside it; no matter what method might be adopted
to empty the uterus, the child would be dead before delivery. The
diagnosis would have to be made and instruments prepared, and this
would take up more than the ten minutes of life left to the fetus. It
is necessary to get the fetus out to stop the bleeding of the open
sinuses by contraction of the uterus.
The removal of the fetus here is not like an artificial abortion.
In abortion the abortionist separates the placenta from the uterine
sinuses and so kills the fetus; the removal from the uterus is
secondary to that separation which kills. The common notion of
moralists that death is caused in abortion by taking the child out
of the uterus is inexact--tearing loose the placenta is the real
cause. In a removal of the fetus after an abruptio placentae the
death of the fetus is not caused by the physician at all, but by the
force that effected the abruptio. As the child will be dead before
sufficient dilatation of the cervix to deliver it can be attained,
there is no objection to beginning the delivery as soon as the
diagnosis is clear.