Isadore Dyer

Accidental trauma complicating pregnancy and delivery.

Abstract 1. 1. Fifty-three instances of trauma in pregnancy and 23 of preconceptional trauma have been presented. 2. 2. There were 30 auto vehicle accidents, 5 penetrating wounds of the uterus (3 gunshot and 2 knife), 13 falls, and 3 severe beatings in pregnancy. 3. 3. The effect of pelvic fracture on pregnancy and delivery was reviewed. Thirteen pelvic fractures occurred during pregnancy and 22 prior to pregnancy. 4. 4. Six penetrating wounds of the gravid uterus were studied. One gunshot wound of the uterus which occurred prior to pregnancy was reported. 5. 5. Blunt abdominal trauma produced rupture of abdominal viscera in 5 women and placental separation in 2. No ruptured uteri were observed from blunt trauma. 6. 6. Fetal trauma was observed in 5 patients, and placental injury in 3. 7. 7. There were 2 maternal and 12 fetal deaths. 8. 8. Reference is given to the legal aspects of fetal injury in utero.

An inquiry into the etiology of placental polyps.

Abstract Placenta accreta has been repeatedly linked with the etiology of placental polyps. In the acute category, from personal experiences, this etiologic possibility is presented from a prospective observation. A placental polyp should be anticipated in the patient who has required manual placental removal and where a clinical diagnosis of degrees of placenta accreta was made in one or more previous pregnancies. The amount of space alloted to this entity will vary in most texts from one to two small paragraphs. Mentioned in many old obstetrics texts, it is deleted in most of the present editions. Yet there is no comparable obstetric hazard to the immediate formation of a huge mass of vascular tissue from which hemorrhage may be catastrophic.

Abruptio placentae: A ten-year survey

Abstract 1. 1. Two hundred fourteen cases of severe abruptio placentae are presented. These occurred over a 10 year period. 2. 2. Only severe placental separations are considered (50 per cent or more separation). 3. 3. The incidence is about 1:180 deliveries or 6 per 1,000 and is more common in multigravidas. 4. 4. No constant etiological factor was demonstrated; however, one should have a high index of suspicion when treating the indigent, nonclinic, hypertensive, and toxic patient. 5. 5. Cesarean section is employed freely to empty the uterus whenever vaginal delivery cannot be accomplished promptly. 6. 6. The regimen presented has markedly reduced maternal deaths in our experience.

Spontaneous premature rupture of the fetal membranes

Summary 1. In this study 363 pregnancies with spontaneous premature rupture of the fetal membranes are presented. 2. No etiological factor was found. 3. Factors affecting survival of the pregnancy were gestational age, intrauterine infection, fetal weight, and fetal presentation. 4. Infections were present in 11.8 per cent.

Total hysterectomy at cesarean section and in the immediate puerperal period.

Abstract 1. 1. Eighty-five total hysterectomies at cesarean section or post delivery are herewith presented. Ten are from private practice, and 75 are from the Tulane Obstetrical Services. 2. 2. Although the total number were collected within a three and one-half year period, they represent a small percentage of the total number of cesarean sections performed (150 per year). The present section rate is 3.72 per cent (Tulane). 3. 3. Approximately 44 per cent of the sections are repeat sections and 23 per cent are for disproportion. These added to the relative high incidence of toxemia, fibroids, and abruptio placentae in the Negroes (80 per cent of total deliveries) will eventually produce many women in whom hysterectomy is indicated. 4. 4. The indications for total hysterectomy at cesarean section or in the immediate puerperium are the same as for the subtotal or Porro section. 5. 5. The uterus is amputated above the cervix and the technique for removal of the cervix is described. 6. 6. There were no surgical complications in 73 patients. Seven exhibited shock, 2 hemorrhage, 2 afibrinogenemia, and 1 spinal shock. 7. 7. Postoperative complications were observed in 30 cases consisting of atelectasis (mild), mild ileus, urinary tract infection, and shock. There were two pelvic hematomas of minor degree, 1 cuff hemorrhage, 3 instances of anuria, and 1 of abdominal wound separation. 8. 8. Thirty patients were morbid for 1 or more days (35.3 per cent) and 7 for 3 or more days (8.2 per cent). 9. 9. There were 19 stillbirths, 7 of which occurred in ruptured uteri, 10 from abruptio, 1 from erythroblastosis, and 1 from neglected transverse lie, a rate of 22.3 per cent. 10. 10. Two maternal deaths (2.35 per cent) were incidental to the procedure. One of these mothers had long-standing pertionitis associated with uterine rupture, and the other, with eclampsia, abruptio, Couvelaire uterus, and lower nephron nephrosis, died on the twentieth postoperative day of a cerebral thrombosis. 11. 11. Operative experience has shown that there is no cause to leave the cervix in situ for fear of increased bleeding or operative time. Postpartum vaginal support has been universally sound.

Clinical evaluation of x-ray pelvimetry; a study of 1,000 patients in private practice.

Abstract 1. 1. One thousand patients were studied to evaluate x-ray pelvimetry. 2. 2. These were all private patients delivered by an associated group, with procedure thereby standardized. 3. 3. The method of obtaining x-ray mensuration was not as important as the interest and experience of the roentgenologist. 4. 4. The Johnson and Snow methods were used to obtain pelvic data and the Ball method to obtain fetal data. One roentgenologist in 880 cases used the Johnson method and two, in 120 cases, used the Snow method. 5. 5. There were 850 primigravidas and 150 multiparas. 6. 6. Thirty-two inlet, 197 midplane, and 17 outlet contractions were found. Twenty-eight were in combination. No outlet contraction was found to exist alone. 7. 7. Inlet contractions were no problem. Outlet contractions were not found alone. Midplane contractions, the most common, were studied in detail. 8. 8. Midplane bi-ischial diameters of less than 9.4 cm., a Mengert Index of less than 84, and the transverse-posterior sagittal index of less than 13.3 cm. in this series were found to be critical. There were exceptions to all indices. 9. 9. A more consistent curve was found in considering cephalopelvic relationship. When the cephalopelvic disproportion was distinguished in normal and contracted pelves, an even finer dividing line was drawn in the prognosis for safe vaginal delivery. 10. 10. A large fetal head can be expected to mold to a greater amount than a small fetal head. Disproportion in normal pelves is due to the large fetal head, in contracted pelves to the small pelvic diameters. This explains why greater disproportions are tolerated in normal pelves. 11. 11. In normal pelves vaginal delivery was the rule until the cephalopelvic disproportion exceeded −200 c.c. In contracted pelves vaginal delivery was limited if the disproportion exceeded −51 c.c. 12. 12. A successful approach has been to consider the fetal skull volume, the pelvic volumetric capacity, and the clinical appraisal of a given patient. 13. 13. In no instance, other than frank pelvic deformity, should the roentgenologist dictate obstetrical procedure. 14. 14. There was a stillbirth rate of 0.7 per cent which included three monstrosities. The neonatal death rate was 0.2 per cent. Prematurity and a cerebral hemorrhage accounted for the two. In no fetal death was a contracted pelvis responsible. Three of these fetal deaths are considered preventable. 15. 15. There was no maternal mortality.

Use of cortisone in the prevention of erythroblastosis in infants of Rh-sensitized mothers☆

Abstract 1. 1. Forty-five Rh-negative isoimmunized pregnant women, 40 of whom had previously produced babies affected by erythroblastosis, were studied and given cortisone in the last trimester of pregnancy in an attempt to improve fetal survival. 2. 2. Under meticulous control and selection of patients, the drug was well tolerated by both mother and baby. There was one major reaction in a mother, none in any infant. All reactions were reversible. 3. 3. There were 37 live babies, 8 stillbirths and 5 neonatal deaths. Five liveborn babies were Rh negative. 4. 4. The over-all fetal mortality rate was 28.8 per cent, corrected to 15.5 per cent if 2 preventable deaths and 4 instances of inadequate therapy are deleted. 5. 5. The women studied represent a pregnant population of approximately 15,000 pregnant women. 6. 6. Cortisone did not improve the fetal survival in the group studied.

Management of emergencies during the third stage of labor and in the immediate puerperium.

The major causes of third stage complications are discussed in this article. Emphasis is directed to the causes of hemorrhage which may develop from uterine origin, trauma or abnormal states of the placenta. Experiences with both amniotic fluid and air emboli are developed, and the article completes the survey of the complications with discussion on cardiac decompensation and afibrinogenemia.