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.