The most alarming attacks of hæmorrhage are doubtless at the full term, when the os uteri is beginning to dilate from commencing uterine contractions, and the placenta is centrally attached over it: in these cases the discharge experiences little or no abatement beyond an occasional short remission, but returns with the pains, increasing in profuseness as the gradually dilating os uteri produces a still farther separation of the placenta. Such cases, if left to themselves, would almost necessarily prove fatal. The first fainting fit or two would probably produce a temporary cessation of the discharge, and favour the formation of coagula in the upper part of the vagina; but with returning contractions of the uterus, the hæmorrhage would be renewed with increased violence, and quickly reduce the vital powers. In such cases the patient will probably die undelivered, or soon after the birth of a dead child. In some rare instances, the pains have been sufficiently powerful to force the head through the placenta, and thus enable the mother to be delivered by the natural means, although with little chance of the child being born alive, from the injury which the fœtal vessels in the placenta have received. Portal’s twenty-ninth case terminated in this way. A similar and very interesting case was lately communicated to us by Mr. W. White, of Heathfield, in Sussex, where the placenta appears to have been centrally attached to the os uteri, and where, in consequence of two or three powerful pains, the head was forced through, tearing it quite across. The child was born dead, but the mother did well.
In a few rare cases the placenta has been entirely separated and expelled before the child, but these have usually been attended with a most alarming loss of blood. In almost all the cases related by Mauriceau, and in the majority of those by Giffard, the placenta is stated to have been entirely detached from the uterus, but this was evidently under the mistaken supposition of the placenta having been originally separated from the fundus. “It is extremely rare to meet with a total separation of the placenta. Dr. Clarke informed me that he met with but one case of total separation; the patient dying before he reached the house.” (Collin’s Pract. Treatise, p. 92.) A still more remarkable instance is recorded by Dr. Collins, where the placenta had been expelled many hours (probably about 18) before the birth of the child. “The membranes had ruptured, and the waters been discharged a fortnight previous to admission, from which time, until the evening before she was brought to the hospital, she had more or less hæmorrhage. It was now ascertained that the placenta had been expelled the evening before her admission, and separated by the midwife in attendance. She left the hospital well on the thirteenth day.”[144] (Op. cit. p. 103.) In all these cases the child has been born dead, and must ever be so, where any period of time has elapsed between the expulsion of the placenta and that of the child. The only case we know of where a living child was born after the expulsion of the placenta is recorded by F. Ould. “I found this woman in imminent danger, being seized with faintings and hiccough, having her face pale and Hippocratic. Upon examination, I found the placenta presented to the orifice of the womb, which I immediately extracted; and although the head was far advanced in the passage, I put it back into the womb, and taking hold of the feet brought a living though very weakly child into the world. The mother also recovered, though with much difficulty.” (Treatise on Midwifery, p. 77.) La Motte has described a similar case, but where the child died immediately after birth. (Obs. 238.)
The irregularity with which cases of placental presentation have appeared at different times, have more than once excited notice: thus it frequently happens to ourselves that several years have elapsed without our meeting with a single case, although connected with a large lying-in hospital; whereas, at other times two or three cases have followed each other at comparatively short intervals. In selecting ten successive years from the period during which Dr. Rigby observed the numerous cases recorded in his essay, we see this irregularity remarkably exemplified.
In 1779 three cases.
In 1780 four cases.
In 1781 none.
In 1782 five cases.
In 1783 one case.
In 1784 five cases.
In 1785 two cases.
In 1786 two cases.
In 1787 one case.
In 1788 two cases.
A still more remarkable variation has been described by the celebrated Matthias Saxtorph, of Copenhagen. Having stated that placental presentation had occurred only once in 3600 cases, he adds, “the reader will be astonished when I assure him that this case, which is so rare that I had only seen it twice in so many years, and that I had met with it but once out of so many thousand labours at our lying-in hospital, occurred to me in the last six months, eight times.” (Collect. Soc. Med. Havn. 1774, vol. i. p. 310.) Professor Naegelé has made a similar remark in his lectures, and states, that in some years placental presentation was so frequent that it seemed as if it were almost epidemic.
Experience proves beyond doubt, that, of the serious floodings which occur during the last weeks of pregnancy, the majority arise from the attachment of the placenta to the os uteri. Dr. Rigby also states “that this attachment of the placenta to the os uteri is much oftener a cause of floodings than authors and practitioners are aware of, I am from experience fully satisfied; and so far am I convinced of its frequent occurrence, that I am ready to believe that most, if not all, of those cases which require turning the child, are produced by this unfortunate situation of it.”
The period of pregnancy at which hæmorrhage may come on from placental presentation, varies very considerably. Although, in by far the majority of these cases, it does not come on until the last four or six weeks, it now and then occurs at a much earlier period, viz. the sixth or even the fifth month, and sometimes even earlier. Where this is the case, it must rather be looked upon as one of “accidental” hæmorrhage or abortion, for it can scarcely be supposed that any changes about the os or cervix uteri could have been sufficient to have produced an “unavoidable” separation of the placenta at this time. Thus, for instance, in Dr. Rigby’s seventy-fifth case, the first attack of hæmorrhage had appeared when the patient “was about three months gone with child;” and at that early period could hardly have been attributed to the peculiar situation of the placenta, but to the more common causes of hæmorrhage connected with abortion. In his forty-third case, the hæmorrhage, which came on about the twenty-sixth week, appears at first to have been purely “accidental,” although it was afterwards produced by “unavoidable” attachment of the placenta. “We very seldom meet with unavoidable hæmorrhage before the sixth month of pregnancy; it is not until the cervix uteri begins to distend freely, and the changes that take place previous to the approach of labour commence, any suspicions are observed; consequently, it will be in the last three months of utero-gestation that hæmorrhage of this nature is found to occur.” (Collins, op. cit. p. 93.)
The examination of a case where the placenta presents is not always easy; the natural position of the os uteri during the latter months of pregnancy in the upper part of the hollow of the sacrum makes it very difficult for the finger to reach so completely as to afford us the means of ascertaining satisfactorily whether the placenta be attached to it or not. “For this purpose, however, the usual method with one finger will not always suffice, but the hand must be introduced into the vagina, and one finger insinuated into the uterus; for in several of the following cases it will appear, that though the women were frequently examined in the usual way, the placenta was not discovered till the hand was admitted for the purpose of turning the child.” (Essay, 6th ed. p. 35.)
Treatment. We have already stated that the earlier the period at which the flooding comes on, the less profuse it will be; the treatment, therefore, where the hæmorrhage is inconsiderable, differs but little from that in an ordinary case of abortion or miscarriage. The indications, in fact, are the same, viz. to stop the discharge, and allay any disposition to uterine contraction.
The patient must be placed upon a mattress, and covered as lightly as possible with safety and tolerable comfort to herself. If the circulation be active, the pulse strong, with more or less heat of surface, it may even be desirable to reduce this by means of the lancet. “Under any kind of active hæmorrhage, when the pulse is vigorous, the taking away blood from the arm has uniformly been found useful, by producing contraction by the mere unloading of the vessels, and more especially in diminishing the velocity of blood within them.” (Dewees, Compend. Syst. of Midw. p. 441.) Cold cloths must be applied to the vulva, loins, and over the symphisis pubis; gentle saline laxatives with nitrate of potass should be given if the bowels are confined; and if there be the slightest appearance of the pains, an injection of twenty or thirty drops of Liq. Opii Sedat. into the rectum will be necessary. This may be given immediately where the bowels are not confined, or, if they are, after the rectum has been washed out by a large domestic enema. If necessary, she should also take an opiate by the mouth. Her food must consist of little else than plain drinks, as tea, milk and water, &c., all of which must be taken cold; and she must preserve the most perfect quiet of body as well as mind. We cannot agree with Dr. Dewees in permitting “our patients, under treatment for uterine hæmorrhage, to be five or six days without a discharge from the bowels;” as a loaded state of the lower bowels cannot fail in our opinion to obstruct seriously the free return of the circulation from the pelvic viscera, and thus greatly increase the disposition to congestion and hæmorrhage.