DISCUSSION. DR. W. C. POWELL, Petersburg, knows of two superstitions that Dr. Barkam had not mentioned-one, tying a string around the waist, the string being saturated with turpentine, a cure for chills and fever; and, second, the stopping of after-pains by placing a saucer of cold water under the bed. SYMPOSIUM PLACENTA PRAEVIA. PLACENTA PRAEVIA-ITS ETIOLOGY, PATHOLOGY AND DIAGNOSIS. By B. H. GRAY, M. D., Richmond, Va. Placenta prævia is one of the four great obstetrical complications, and is responsible for a considerable number of deaths. Its treatment is disputed and its etiology obscure, but recent studies in regard to mortality and complications have advanced our knowledge considerably. Muller's statistics (published 1877), of 876,432 labors, gives the frequency as once in 1,078 cases, while many others have reported widely varying frequency. From reports of statistics for the last three years, in 182,389 labors (Ellice McDonald Surg., Gynec., and Obstet., June, 1911), placenta prævia was found once in 160 labors. This more nearly approximates its frequency. The greater frequency is naturally found in the larger obstetric clinics than elsewhere. Cragin (Am. Jour. Obs., July, 1911), reports in the last 25,000 deliveries at the Sloan Hospital, 223 cases of placenta prævia or 1 in 112+ cases. Varying estimates of its frequency in private practice are given, but it is probably that it is found in about half the number as in the clinics. Etiology. The only known etiological factor in placenta prævia is that it occurs much more frequently in multiparae than in primiparae, the proportion being about nine to one, and the greater the parity the greater the chance of placenta prævia. Doranth's analysis of 30,796 labors shows that placenta prævia was noticed in 0.17, 0.43, 0.65, 1.37, 1.28, 3.39 per cent., according to whether the patients had borne one, two, three, four, five or six children; where they had borne seven to ten, the percentage was 5.51. Warren found that 16 per cent. of his cases were primipara and 49 per cent. multipara. Strassman has also shown that the frequency with which labors had followed has an influence upon the incidence of placenta previa. Classification. Placenta prævia is usually classified into central, or complete; partial, or incomplete; and marginal. In the first, the internal os is completely covered and the placenta is implanted upon the cervical tissue, and so weakens the cervical wall that the danger of hemorrhage is greatly increased in this variety. In partial placenta prævia the greater part of the placenta is implanted on the isthmus, and in the marginal the greater implantation lies over the corpus. The greater mortality is found in the complete variety. It is important in reporting cases to clearly define the variety, as the mortality and morbidity is greater in the central and smaller in the marginal. Causation. The formation of placenta prævia was thought to be due to a low implantation of the ovum in the lower segment of the uterus or to the detachment and reimplantation of a normally situated ovum. The hypertrophic and folded mucosa of the internal os and the angulation of the uterus at this point may combine to practically obliterate the orifice of the internal os, so that the ovum does not escape from the uterine cavity. The researches of Aschoff make it probably that some instances of placenta prævia arise from cleavage of the decidua and low implantation of the ovum. The os is finally obliterated by the growth of the placenta. Hofmeier has also suggested that the condition may occur "from the development of the placenta which takes place in the reflexa of the inferior pole of the ovum." He and Kaltenbach claim that this reflexa of the lower pole gradually bridged over the internal os and eventually became fused with the decidua vera. The placenta was then from its fusion situated at the lower pole. This is, however, the exceptional mode of formation of placenta previa. The effect of changes in the uterine wall from inflammation or atrophy as a result of repeated and frequent pregnancies has been shown by Strassman to predispose toward placenta previa. Such conditions limit the amount of blood going to the placenta and cause it to spread over a greater area in order to get the requisite nourishment. This is borne out by the common occurrence of large surface and thinness of the placenta in this condition. The placenta spreads down and overlaps the internal os and so forms the placenta prævia. When the cervix is included, the overlapping is due to a tongue-like process from the placenta situated at the isthmus. As the mucosa of the isthmus and cervix responds less actively than that of the fundus to the decidual reaction, the placenta is required to be thin and expanded. The salient point to be recognized in the study of the pathological processes of placenta previa is that the site of the placenta is not only altered but also the character of the embedding of the villi is changed, and there is actually abnormal placentation. To properly understand the pathological anatomy of placenta previa, it is of great importance to recognize the three different segments of the uterus--corpus, isthmus and cervix. Normally the corpus alone serves for the attachment of the placenta; the mucous membrane of the isthmus undergoes decidual change and serves for attachment of the membranes; the mucous membrane of the cervix undergoes no change. In placenta prævia, the lower segment, wholly or in part, may give attachment to the placenta. In normal pregnancy the mucosa of the isthmus shares with the corpus in the decidual reaction, although the thickness of the decidual reaction is only one-third that of the corpus. On the other hand, the musculature of the isthmus more closely resembles that of the cervix, since the isthmus in the course of pregnancy is by passive stretching more concerned in the enlargment of the ovi-sac, and is thus transformed into the lower uterine segment (Aschoff, Much. Med. Woch., 1907, No. 50). In placenta prævia the relative thinness of the decidua developed upon the isthmus explains the pentration of the implanted ovular tissues into the substance of the muscalture of the isthmus and cervix. This causes intimate adhesion between the chorionic ville and the walls of the isthmus. Usually there is an absence or diminution of spongiosa of the decidua, splitting of the muscularis, connective tissue hyperplasia, and excessive proliferation of the myometrium. In normal pregnancy, the decidua limits the size of the implantation chamber, prevents an excess of erosive action of the syncytial cells and localizes the expansion of the sinuses. In placenta prævia and ectopic pregnancy, this limiting action of the decidua is diminished or absent, owing to lessened decidual action. In the isthmus, the decidual reaction amounts to only about one-third of that of the corpus, and, in the cervix, it is even less. The deposition of the chorionic elements in the normally close texture of the cervix leads to destruction of its mucosa and penetration of the muscular elements. As a result, the naturally thin uterine wall of the isthmus loses its elasticity and its power to contract. At the time of delivery the placenta may be adherent from penetration into the cervical wall. The cervical wall, as a result of the destructive action of the implantation, becomes thinned and fragile, with a loss of elasticity. The cervical tissue, owing to the increased vascularity, softening and the deep implantation of the villi, becomes friable and prone to laceration. The lower uterine segment is robbed of the contractibility by the proliferation of the villi in the musculature. Since there is a different pathological anatomy between the forms, distinction should be made between complete and partial placenta previa. In complete or central, the placenta is implanted upon cervical tissue where the destruction of the musculature is greater than when the placenta is partially implanted upon the isthmus. The mortality in placenta prævia has decreased enormously since the introduction of antiseptic methods. Ellice McDonald's statistics (Surg., Gynec. and Obstet., June, 1911), of 8,625 cases, give a maternal mortality of 7.22 per cent. of all cases, and a fetal mortality of 55 per cent. In central placenta prævia, the maternal mortality is 15 per cent., and the fetal mortality 71 per cent.; while in partial placenta prævia, the maternal mortality is 4.8 per cent. and the fetal mortality 58 per cent. The maternal mortality of complete placenta prævia is three times that of partial. Complete placenta prævia occurs about once in four times of all forms. The greater mortality of the complete form over the incomplete is not due as much to the situation as to the fact that the cervical wall is more destroyed by the implantation, and is made more liable to hemorrhage from lessened contractibility due to this destruction. The mortality varies very much with different treatment. McDonald's figures show (Studies of Gynecology, Obstetrics, Amer. Med. Pub. Co., 1914), that 1,057 cases were treated by rubber dilating bags, with a maternal mortality of 5.5 per cent., and a fetal mortality of 35 per cent. This method of treatment by means of the rubber Champelier de Ribes bag or hystereurynter of large size (500 c.c.), gives better results for the mother, and a much greater hope of the survival of the child. Schwertze, who compared the methods, found with the rubber bag treatment a maternal mortality of 5.8 per cent., and a fetal of 34.5 per cent. (27.6 per cent. of those weakly) compared with a maternal mortality of 5.45 per cent. and a fetal of 79.35 per cent., in cases treated by combined version. Hannes (Zent. f. Gynok., 1909, 3) has reported 143 cases treated by the bag alone without a death from hemorrhage, although there were eight deaths from other causes, as previous infection, eclampsia, etc. The large rubber bag reduces the mortality of the children from 70 to 35 per cent., according to Ellice McDonald's figures. Thies has compared the chances of survival of the child under various treatments and finds that in Bumm's clinic the fetal mortality is as follows: spontaneous delivery, 12 per cent.; gauze tamponage, 33 per cent.; combined version with slow extraction, 80 per cent.; combined version with rapid extraction, 64 per cent.; vaginal Cesarean section, 50 per cent.; hystereurynter or rubber bag, 14 per cent. Convelaire (Sec. Int. Cong. Obstet. and Gyn. Berlin, 1912) presented the doctrines and results of the French clinics with 584 cases with 8.2 per cent. mortality, and states, if those cases were eliminated which were lost before reaching the clinic, the mortality would be 4 per cent. Infection and violence were responsible for three-fifths of the deaths. Hemorrhage accounted for one-eighth of all deaths. The fetal mortality was between 44 and 60 per cent., and was due to debility caused by prematurity. The percentage of the fetal mortality decreases with the maturity of the children. Tamponing the cervix and vagina, when used in an aseptic manner, will remain a useful and fairly safe method in emergency cases in general practice, although there is a greater danger of sepsis in the treatment by this method. Edgar's series of forty cases (Amer. Jour. Obstet., July, 1911), thirty two of which were tamponed, showed a maternal mortality of 7.5 per cent., and infant mortality of 32.25 per cent. of the thirty-two tamponed cases, two mothers died, one being moribound when entering the hospital, and undelivered; the other died on the fifth day of double lobar pneumonia. Renhardt (Zentr. f. Syn., 1914, XXXVIII, 168) compares 115 tamponed cases with 161 not tamponed. Of the febrile cases, 53 per cent. were tamponed and 34 per cent. not tamponed. Of the deaths from sepsis, five were tamponed and one not tamponed. He concludes that the morbidity and mortality in tamponed cases is noticeably higher, but tamponing cannot always be avoided. When necessary it should be done with careful asepsis. Hemorrhage and its results are the chief dangers in placenta prævia and with its proper control and good treatment the mortality in placenta previa should be small. However, a large percentage of deaths are due to infection and violence. The mortality with immediate and good treatment, should be under 4 per cent. The rubber bag should be the main treatment, with Braxton Hicks' version for those cases where the child is dead or markedly premature. Those children weighing less than five and one-half pounds have small hope of survival. Mason and Williams (in a personal communication to Ellice Mc Donald) stated that 114 of 155 children were born alive, and of these 114 children, 38 per cent. died in a few days. Of the children born alive at full term, 20 per cent. died afterwards; of the children born alive at eight months, 48 per cent. died afterwards; and of the children born alive at seven months, 71 per cent. died afterwards. Thus it may be seen that the danger of the child is increased in direct proportion to the smallness of size and prematurity. In placenta prævia, 70 per cent. of the deaths are directly due to hemorrhage or exhaustion. However, hemorrhage, if treated soon and carefully, may be controlled by obstetric means. Infection, trauma, etc., may be avoided. Under these conditions the mortality should be 4 per cent. or lower. With this obstetric mortality, there is no excuse to add to it the dangers of Cesarean section. Cesarean section presupposes a viable child. Central placenta previa in which alone Cesarean section is advocated, seldom goes to full term, and so the possibility of a premature child with its danger of death must be taken into consideration. Cesarean section, according to Ellice McDonald, has a mortality in 135 collected cases of placenta previa, of 13.6 per cent. Cesarean section, for all conditions in 3,000 cases (Ellice McDonald, N. Y. Med. Jour., March 9 and 16, 1912), has a maternal mortality of 7 per cent. So it will be seen that the treatment of placenta previa by Cesarean section merely adds another danger to that already existing, and one mortality to another. An example of the dangers of placenta prævia may be seen in the reports of the larger obstetrical clinic in this country. At the New York Lying-in Hospital, in 352 Cesarean sections from all causes, there was a maternal mortality of 10.79 per cent., and in 466 cases of placenta previa treated obstetrically, there was a maternal mortality of 15 per cent. It is obvious that, if the danger of Cesarean section should be added to that of placenta previa, the mortality in this hospital would be considerably increased. Most of the advocates of Cesarean section in placenta previa depend upon a few successful cases and an inexact knowledge of the mortality of both conditions. If it should be conceded that Cesarean section is ever applicable to placenta previa, it should be restricted to a primipara at full term with a firm, undilated cervix, central placenta previa, living baby and good recuperative powers. This is a rare type of case because a firm cervix in central placenta previa is rare; placenta previa is not common in primiparae; the majority of cases begin to bleed before term, and the greater number of babies are premature, dead or dying. But this type of case is the only one about which the treatment of placenta previa by Cesarean section has any basis for debate and this type of case is usually better treated obstetrically and not surgically. In the diagnosis of placenta prævia, hemorrhage is the first and most constant sign, occurring usually during the last three months of pregnancy, varying in amount from a slight stain to a profuse and fatal hemorrhage. The first hemorrhage is not usually a severe one. One one-quarter of the cases have pains immediately following hemorrhage, and in the other three-quarters an interval of weeks or months may Occur. In central placenta prævia, hemorrhage is more likely to take place early, and the nearer the full term, the more profuse the hemorrhage, as a rule. Exceptions are, however, noted. The writer has had one case of central placenta previa—a primipara who went to full term with no signs of hemorrhage until labor actually began. Marginal placenta prævia may not cause hemorrhage until labor begins, on account of the placenta being situated higher in the dilating segment of the uterus. The origin of hemorrhage is: from the placental sinuses; from the intravillous spaces of the placenta; from the circular sinus, and rarely from the villi. The natural efforts of straining at labor add considerably to the amount of the hemorrhage. Post partum hemorrhage is one of the most feared complications after delivery of the child. It usually is of the insidious type, coming on an hour or so after delivery. About one-third of the deaths in placenta prævia are due to hemorrhage of this type. Injuries of delivery are not infrequent. Lacerations of the cervix are not uncommon, owing to the destruction of the wall by the embedding of the placenta. In Hauck's 240 cases, considerable laceration occurred in eleven, with two deaths from hemorrhage. Bonnaire's methods of manual dilatation and version gives a large percentage of lacerations of the cervix. In his series of 171 cases, there were twenty severe lacerations. The mortality of this method was 18 per cent., and it is probable that the violence and trauma, causing lacerations, had considerable to do with the large mortality. Infection is the cause of death in from 1 to 2 per cent. of all cases. The morbidity is in the neighborhood of 25 per cent. Mal-positions is frequent and occurs in one-third of all cases. Twins are common, occurring from two to three times more frequently than the average (80 cases). Adherent placenta is a common and annoying complication. This is due to the embedding of the placental villi in the cervical musculature and the lack of decidual reaction limiting the penetration of the villi. Adherent placenta occurs to a greater or less degree in 40 per cent. of cases (McDonald's figures). vein. Plebitis is not an uncommon after-complication. The usual site is the femoral The after-complications of placenta prævia are not confined to the immediate ones, but Radke, in a study of the after-life of eighty placenta prævia patients, found that fifty became pregnant, and of these twenty-three aborted. Sterility followed in 30 per cent., and 57 per cent. suffered from various ailments associated with weakness, malaise and anemia. Hemorrhage is usually the first sign of placenta prævia, and any hemorrhage in a pregnant woman should be an indication for examination. Hemorrhage comes before labor, and often there is considerable interval. The first bleeding usually terminates spontaneously. Examination usually shows the cervix dilated sufficiently to insert one finger and feel the roughened outer surface of the placenta. The lower uterine segment is softer and more succulent than normal. Attempts to produce ballottement drive a soft thick cusion against the head. Manipulations make the cervix bleed easily. The placenta may be sometimes felt above the symphyses and through a thin abdominal wall. The diagnosis is of importance because treatment should follow immediately upon diagnosis. There is nothing more dangerous both to mother and child than expectant treatment, as both become weaker and have their chances of life decreased. At no time is the danger of a sudden fatal hemorrhage absent. The success of the treatment in placenta prævia will depend upon its immediate application and absence of violence and infection. TREATMENT OF PLACENTA PRAEVIA.* By JOHN F. WINN, M. D., Richmond, Va. Professor of Obstetrics, Medical College of Virginia. For this formidable accident there is no one treatment applicable alike to all varieties. With equal emphasis it can be said that the selection or adaptation of methods of treatment in individual cases depends less upon statistics than upon the recognition of certain well-defined and generally-accepted conditions, viz.: whether occurring in private or hospital practice, the condition of the mother when first seen as to the amount of the blood lost, the viability of the fetus, the variety of the prævia, whether occurring during pregnancy or labor, the dilatability of the cervix, *Read before the forty-fifth annual meeting of the Medical Society of Virginia, at Washington, D. C., October 27-30, 1914, as a part of the Symposium on Placenta Previa. The author of this paper, Dr. Winn, as well as Dr. A. F. A. King, who took part in its discussion, have both died since, as was noted in the Semi-Monthly for January 22, 1915. |