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743 Medical Societies ROYAL SOCIETY OF MEDICINE AT a meeting of the obstetrical section on Nov. 16, with Prof. F. J. BROWNE in the chair, a discussion on Placenta Praevia was opened by Mr. C. H. G. MACAFEE, who described the results in 191 cases treated since 1937, with a maternal mortality of 0-5% and a gross foetal mortality of 22%. He spoke of the importance of removing -all cases of placenta praevia to hospital, without vaginal examination unless there is serious haemorrhage. In his own series few cases had been examined before admission, and if this rule were generally observed the maternal mortality would be immediately lowered. One of the main causes of foetal mortality was prematurity. This could be reduced only by carrying on the pregnancy to as near term as possible. In support of this expectant treat- ment he submitted the following arguments : 1. In the absence of vaginal manipulations severe initial haemorrhage is uncommon. A sudden severe hoemor- rhage is theoretically possible in multiparae, but is rare in primigravidae. The proportion of primigravidse and multiparse having no haemorrhage before term is striking. 2. Some have a sharp but small haemorrhage at 30-34 weeks, without further loss. In some of these the placenta can later be palpated inside the os without further hoemor- rhage. This has been found to be due to infarction of the separated area. ’ 3. In his series were many cases where several haemorrhages occurred without embarrassing mother or baby. Foetal death was commoner in the first two years of his series, when pregnancy was terminated earlier. The previous obstetric history might be a guide to treat- ment. Previous easy and rapid deliveries suggested that the case may be treated by the vaginal route, whereas a history of long and difficult labours indicated that such treatment would result in a stillbirth. A history of large babies justified active treatment at an earlier stage. Mr. Macafee appealed for removal of the terms lateral, marginal, and central from obstetric literature, since the two former were not used consistently. He preferred Professor Browne’s classification into four types : (1) where the edge of the placenta dips on to the lower segment ; (2) where the edge of the placenta reaches the internal os ; (3) where the placenta overlaps the internal os but does not cover it at full dilatation ; and (4) where the placenta covers the os when fully dilated. The decision as to when vaginal examination should be carried out must be made by someone with experience. In this series it was performed in all cases, but only after all preparations had been completed for immediately undertaking whatever treatment was deemed appro- priate. Therefore it was postponed until the end of expectant treatment. After the first haemorrhage the cervix and vagina should be inspected per speculum to exclude any local cause of bleeding. He considered vaginal examination essential, because without it nobody could distinguish a placenta praevia from other causes of bleeding or decide on the type and the best method of treatment. Type 1 could be treated by rupture of the membranes. In type 2, if the placenta lay anteriorly, rupture of the membranes was sufficient; but if it was posterior, caesarean section was preferable. Type 3 was associated with the highest fcetal mortality, probably because treatment was required earlier in gestation. In type 4 the results were better : treatment, which was csesarean section, was undertaken nearer term. There was one maternal death due to staphylococcal septicaemia. For anaesthesia, Mr. Macafee used cyclopropane and oxygen. Most of the caesarean sections were done through the lower uterine segment. Mr. L. G. PHILLIPS described the results in 143 con- secutive cases of placenta preevia treated at Queen Charlotte’s Hospital, with a maternal mortality of 1-4%. He attributed the lowered mortality of recent years to four factors. First, general practitioners now recognised that these cases were better treated in hospital, where asepsis, blood-transfusion, and skilled nursing were available. Hence the patients now arrived at hospital in good condition. The second factor, which in his series was the most important, was blood-transfusion. In one published series for 1925-36, 56 cases died of haemorrhage, and of these only 3 had had transfusions. In a modern well-equipped hospital it should be rare for a patient to die of haemorrhage. The third factor was the greater use of caesarean section, which was the best method of treatment in all cases of central placenta prsevia, and all cases in which a sharp haemorrhage occurred with an undilated cervix. More consideration was now given to the claims of the child, and the methods of rearing premature children had so greatly improved that where the child was 36 weeks mature, there was a strong case for caesarean section. The fourth factor was improved team-work. In his own series all cases of placenta praevia were treated as emergencies. They were examined at once under an anaesthetic, the vagina was ironed out, the finger was passed through the cervix, and the position of the placenta was ascertained. If the foetus was a vertex presentation and there was not much bleeding, the membranes were ruptured. If it was a flexed breech and the os two fingers dilated, the membranes were ruptured and a foot drawn down. This was mostly done when the foetus was either small or dead. A vertex was never turned to a breech. If severe haemorrhage followed rupture of the membranes, the vagina was plugged with 3-5 rolls of gauze, soaked in 5% ’ Dettol.’ The plug was never retained for more than 24 hours. If a central placenta praevia was found, caesarean section was done either immediately or after blood-transfusion. In Mr. Phillips’s series of 143 cases treated at Queen Charlotte’s Hospital from 1933, the maternal mortality was 1-4%, the foetal mortality 53%, and the morbidity 16-4%. The foetal mortality was 38% after artificial rupture of the membranes, 93% after bringing down a leg, 6-6% after caesarean section, and 66% after plugging the vagina. Though he was not an ardent supporter of vaginal plugging, there were occasions when it was difficult to avoid. It should be used only in hospital and never in domiciliary practice. Any sepsis that developed in this series was slight and required no treatment. Looking back at his series, he thought he made four mistakes. (1) Many cases could have been left after admission until a severe haemorrhage occurred. (2) The original examination should always have been on the operating-table, so that an immediate caesarean section could be done. (3) There is no advantage in using dilators when trying to establish the edge of the placenta when the os is closed. If a sharp haemorrhage occurs, a csesarean section should be done. (4) In future he would plug less often and do more caesarean sections. Miss JOSEPHINE BARNES first dealt with 538 cases of antepartum haemorrhage, treated at University College Hospital. They were classified into four groups : (1) placenta praevia ; (2) accidental antepartum haemor- rhage ; (3) antepartum haemorrhage of uncertain origin ; and (4) antepartum haemorrhage from extraplacental lesions. Over half the cases fell into the third group and the proportion of cases in this group had increased in recent years, a more expectant attitude being adopted and the number of vaginal examinations reduced. It was the routine practice to pass a speculum on admission so that the cervix and vagina could be inspected to exclude extraplacental lesions. Among the 538 cases there were 140 cases of placenta praevia, and 285 cases of haemorrhage of uncertain origin. The mater- nal mortality of placenta praevia was 2-9% and foetal mortality 52%. Of the 71 dead infants, 38 were lost after bringing down a leg, and this method had now been abandoned. The infant mortality from caesarean section was 18%, from bringing down a leg 97%, from Willett’s forceps 47%, and from rupture of membranes 36%. The two main causes of fcetal death were prema- turity and placental separation. The maternal morbidity- rate was 15%. Vaginal examination should not be done outside hospital and there should be no vaginal plugging. Patients with antepartum haemorrhage, however slight, should be admitted to an institution. On admission a speculum was passed and preparations made for transfusion, but the patient should be treated expect- antly unless there was severe haemorrhage. All patients were advised to stay in hospital till their confinement. 17 o
