Marginal Placenta Research Articles

Massachusetts Medical Society

COMMITTEE ON MATERNAL WELFAREPost-Partum Hemorrhage Due to Uterine AtonyA 90.7-kg. (200-pound), thirty-year-old gravida 5, para 4, was admitted to the hospital at the twenty-sixth week because of vaginal bleeding. This subsided quickly. Bed rest, sedation, bioflavonoids, vitamin K and iron were prescribed, but anemia persisted on discharge eleven days later, the hemoglobin having risen from 65 per cent to 78 per cent (Sahli). She was not examined, the diagnosis being "probable marginal placenta praevia."Slight bleeding recurred two weeks later, and she was readmitted to the hospital, being seen by a consultant two hours later when there was . . .

Evaluation of placentography in late bleeding of pregnancy.

Placenta praevia is present when the placenta is implanted within the zone of the internal os, so as to cover it in whole or in part. Painless bleeding in the last trimester of pregnancy produces fear in the most expert obstetrician. Although less than one-third of such cases of staining or bleeding are due to placenta praevia, its implications and potentialities for morbidity and mortality in both infant and mother make its diagnosis or exclusion most important. Soft-tissue radiography is a simple, safe, and accurate procedure that requires no special preparation of the patient, no pelvic manipulation, and no injection of an opaque medium. Interpretation of the films requires only understanding, diligence, and observation of all the shadows which are present. Stallworthy (10, 11) states that in no branch of obstetrics has there been such a dramatic reduction in fetal mortality as in the expectant treatment of placenta praevia. The aim is to reduce fetal mortality due to this cause to below 10 per cent (combined stillbirths and neonatal deaths). It is now in general higher, due to intervention and prematurity. Bleeding in the last trimester is frequently considered sufficient cause for vaginal examination. The internal os is invaded, with the attendant risks of infection, precipitation of severe hemorrhage, and induction of premature labor. Furthermore, a marginal placenta may be beyond the examining finger and still cause severe bleeding. Also, the cervix is not always patulous and it would not appear justifiable to dilate for diagnosis, especially if simple roentgen methods can be relied upon with confidence (4). Early diagnosis is important, first because the patient is placed in a position favorable for dealing with an emergency prior to its occurrence; second, because the cause may be dealt with by an elective procedure, with minimal risk to mother and child. Frequently a diagnosis can be made by films alone and without hospitalization (8). Anatomically the uterus at term is a flat, pear-shaped organ with the widest diameter at the cornua. Within it the fetus, which is movable, attempts to assume a position to the best advantage, with the back convex and the ventral surface concave. In addition, the uterus contains the amniotic fluid, which amounts to about a quart, and the placenta, which is fixed in position soon after conception, normally above the equator or in the corpus. The lower uterine segment and cervical areas are not adapted for placentation. These constitute the inactive passage zone between the contractile corpus above and the vagina below. The lower segment is composed largely of elastic tissue and few muscle fibers. It is designed to withstand considerable pressure. The added vascularity with placental attachment in this segment interferes with its normal integrity. The cause of low implantation is not known, but it is definitely associated with multiparity and probably with endometrial disease.

Use of the knott technic of blood irradiation therapy in cases of threatened and inevitable abortion

Thirty consecutive patients with thirty-eight episodes of low abdominal cramps and/or vaginal bleeding and/or premature labors occurring during their pregnancies were treated with the Knott technic of blood irradiation. It was believed that these symptoms indicated the probability of threatened or inevitable abortions. Eight of these patients had incomplete abortions. Three passed dead fetuses after administration of blood irradiation treatment; five passed only placentas after treatment. Curettage was not necessary in any of these eight cases. The uterus returned to normal promptly, infection did not appear and the patients recovered rapidly. Twenty-one patients with thirty episodes of low abdominal cramps and/or vaginal bleeding and/or premature labors were treated with the Knott technic of blood irradiation, usually within twenty-four hours after the appearance of the symptoms (in two cases the treatment was not administered until forty-eight and seventy-two hours after the onset of the symptoms, respectively). In each case the symptoms ceased promptly and all patients in this group continued to term or near-term and were delivered of normal babies. One patient (Case 8) was given blood irradiation treatment as a prophylactic measure during her third pregnancy due to a history of two previous pregnancies, one of which terminated in a stillbirth at seven months and the other in a miscarriage at three and a half months. The patient's pregnancy proceeded uneventfully to normal delivery at term. In only one patient (Case 17) was the treatment unsuccessful. This pregnancy ran a rather stormy course due to marginal placenta previa. Three patients had histories of previous abortions. One patient (Case 8) reported two previous miscarriages at seven and three months respectively, another (Case 22) presented a history of one previous miscarriage and another (Case 25) reported three previous miscarriages. It is interesting to note that rapid subsidence of cramps and bleeding was observed after administration of blood irradiation therapy in each of the thirty episodes previously mentioned, as well as obviation of the necessity for curettage and prompt recovery of the patient in the cases of inevitable or incomplete abortions.

OBSTETRICS IN ARABIA

To the Editor:— You may be interested in some information on obstetrics in Arabia, which is so different from that in America that it is almost unbelievable. I spent two years in Arabia just after the new hospital had opened and when women were fearful of entering unless they were at death's door. The picture is rapidly changing, and more and more normal patients are coming in as they learn our western ways. Of 150 deliveries from July, 1950, to July, 1951, at the Arab hospital in Dhahran, Saudi Arabia, 110 were normal and 40 were complicated. There were no maternal deaths, and there were 15 prenatal deaths. There were 3 ruptured uteri, 1 marginal placenta previa, 1 central placenta previa, 1 ruptured bladder, 1 head appearing at the anus through the rectum rather than through the vagina, one hand presentation, one patient admitted with all delivered but the head

X-Ray visualization of the placenta: Experiences with soft-tissue and cystographic techniques in the diagnosis of placenta previa

It is an established fact that the placenta can be visualized in soft-tissue x-ray films in over 90 per cent of all women who are in the third trimester of pregnancy. This was forecast by Speidel and Turner1 in 1924. In a paper dealing chiefly with x-ray visualization of the uterus and adnexa with the aid of artificial pneumoperitoneum, they stated: “It should be possible, by means of the roentgenogram, by the relation that the head of the fetus bears to the lower segment of the uterus, to determine the degree of encroachment of the placenta upon the internal os, and whether we have a central, lateral, or marginal placenta previa.”During the past several years at the Boston Lying-in Hospital we have made x-ray studies of all cases of uterine bleeding and of transverse or oblique position of the fetus occurring during the third trimester of pregnancy. The purpose of this paper is to report our experience regarding the x-ray diagnosis of placenta previa through the use of the soft-tissue technique introduced by Snow and Powell2 and the cystographic method first described by Ude, Weum, and Urner3.

The trend of modern obstetrics

Among the foregoing are included some advances in treatment whose place of permanence is already guaranteed. One of these is the treatment of central (and some marginal) placenta praevia by Caesarean section, and another is the treatment of acute hydramnios by the withdrawal of amniotic fluid through the abdominal wall. An ideal treatment of other conditions—I mention the toxaemias of pregnancy—has not yet been found. I must mention one condition in which patients are lost: I refer to post-partum haemorrhage. Grave as this condition is, its gravity is often increased manifold by the ill-advised, ill-directed attempts at Crede; ignorance of its many pitfalls is one of the main causes, potential or actual, of death in the third stage of labour or soon afterwards. I do not wish to be disrespectful to the memory of its author, but, instead of being taught as Crede’s manoeuvre, far better to call it Crede’s attack or Crede’s assault, when its potential seriousness and incidentally its many limitations will be better understood. The third stage of labour needs to be thoroughly understood in detail by every doctor practising midwifery. I invariably demand an accurate and detailed knowledge of the third stage from every postgraduate who seeks his L.M. diploma.

Marginal placenta previa treated by artificial rupture of the membranes thirty-nine days before vaginal delivery

Marginal placenta previa treated by artificial rupture of the membranes thirty-nine days before vaginal delivery

THE INTERPRETATION OF EXCESSIVE GONADOTROPIC HORMONES

It has been demonstrated that large quantities of gonadotropic hormones are excreted into the urine when chorionepithelioma or hydatidiform mole is present. It has been shown that up to 50 per cent of the chorionepitheliomas studied have been preceded by hydatidiform moles. It would be advantageous therefore if a diagnosis could be made early by testing the urine for these hormones. It has been contended that if a diagnosis was made before full clinical signs developed, complete eradication of the tumor could be carried out before metastasis occurred. The reports of Leventhal and Saphir, 1 Mathieu and Palmer, 2 Kimbrough 3 and Garber and Young 4 have shown this. REPORT OF CASE C. E. S., a white woman, aged 32, a primipara, secundigravida, last menstruated Dec. 30, 1934. Her first pregnancy was terminated by a low forceps delivery after a slight hemorrhage, which was due to a marginal placenta praevia.

Anatomic description of a case of marginal placenta previa: With a discussion of the etiologic implications

An anatomic description of a case of marginal placenta previa is presented. Interesting findings were: marked scarcity of decidua beneath the placenta, relatively profuse decidual reaction in the cervix and lower uterus, and presence of a circular sinus at the level of the internal os. The implications of these findings regarding etiology, frequency, the cause of bleeding, and the lower uterine segment are discussed.

A review of the methods at present used in the treatment of placenta prævia

1. The facts emerging from the analysis of the figures in the treatment of the various types of placenta praevia by different methods deserve discussion. It is suggested that revision of our present treatment would improve the fœtal and maternal results. 2. At the present time, Caesarean section is not used with sufficient frequency in the treatment of placenta praevia. 3. Simple puncture of the membranes offers the best combined fœtal and maternal results in lateral and marginal placenta praevia. 4. Bipolar version should be reserved for the actively bleeding and exsanguinated cases, particularly when the central placenta praevia is encountered in general practice. 5. The figures relative to the use of the Willet’s forceps are so discouraging that further use of this technique should be questioned.

THE TREATMENT OF PLACENTA PRAEVIA

Foster Kellogg1recently reviewed the changes that have taken place at the Boston Lying-In Hospital with reference to the treatment of placenta praevia. From 1895 to 1915 the method of treatment was version and immediate extraction. The maternal mortality was 19 per cent. From 1915 to 1919, when conservative delivery, bags or Braxton Hicks version and slow delivery had considerably displaced the older method, the mortality dropped to 6 per cent. In 1926, after five years more in which conservative methods had increased from 60 per cent to 76 per cent of the total cases, Kellogg came to the conclusion that all cases of central and partial placenta praevia are best treated by low classic cesarean section, regardless of the condition of the baby; that marginal placenta praevia is best treated by the Voorhees bag; that moribund or very sick patients with placenta praevia should be rested and quieted