R.S. Siddall

Cesarean section in detroit during 1945—A comparison with 1925 and 1930☆

Abstract In Detroit, during 1945, there were 1,000 cesarean sections, or one in 37 births, as contrasted to 154 or one in 217 deliveries in 1925 (Welz), and 203 or one in 167 in 1930 (Seeley). On the other hand, maternal mortality with cesarean section for these series were 13 per cent in 1925, 4.4 per cent in 1930, and only 0.8 per cent in 1945. The fetal death rates for the same years were 11, 12.8, and 7.8 per cent. The incidence of the operation during 1945 in the fourteen larger hospitals with 1,000 or more deliveries varied from one in 78 to one in 13 births, and, in most instances, the 1945 rates represented increases over those for 1925 and 1930, thus reflecting the general trend for the city as a whole. The low cervical operation had become the one most frequently employed by 1945 and, as before, showed distinct maternal advantage over the classical type. Cesarean-hysterectomy and extraperitoneal section were only forty in number but without mortality. The hospitals were divided into three groups according to numbers of deliveries as follows: 2,000 or more—5 hospitals; 1,000 to 1,999—9 hospitals; and less than 1,000—25 hospitals. In the first two groups there were 13,997 and 13,130 deliveries with a maternal mortality rate of 1.1 per 1,000 for both. In these same two groups, cesarean sections had incidences of 3.6 and 2.5 per cent, with death rates of 0.39 and 0.62 per cent, respectively. In the third group, there were 6,946 deliveries in the 25 hospitals, with a general maternal mortality of 3.46 per 1,000, and a cesarean section incidence of 2.4 per cent with 2.38 per cent deaths. Moreover, three of the four cesarean fatalities ascribable in whole or in part to questionable treatment occurred in these hospitals. The number of cesarean sections done for the various indications increased markedly in all important categories. However, the proportional variations remained remarkably constant except for the toxemias of pregnancy. Cesarean sections for these conditions had increased from 26 in 1925 to 73 in 1945, but these figures represented a decrease from 17 per cent of all sections in 1925 down to 7 per cent in 1945. The proportional and absolute increase under the heading “Miscellaneous” is explained in part by some new indications such as “Rh negative.” An outstanding feature, on comparing the three periods, is the marked reduction in cesarean section mortality—from the appalling rate of 13 per cent in 1925, to 4.4 in 1930, and down to only 8 cases or 0.8 per cent in 1945. In spite of this good record for 1945, there was, however, good reason to believe, on the basis of the available data, that poor judgment and disregard of indications and contraindications were largely responsible for two of the eight deaths. In at least two others, the indications for abdominal delivery were highly questionable. Regarding the conditions for which cesarean section was done, the toxemias remain the most serious—three deaths in 73 during 1945. There were also two fatalities among the 164 operations for placenta previa and premature separation of the placenta. No deaths occurred in 166 elective sections performed because of previous cesarean, and none in the 384 done for cephalopelvic disproportion. Only a few details were secured regarding the fetal deaths. Of the 78 infants lost, 28 (35.8 per cent) are known to have been stillborn, and 25 (32 per cent) were neonatal deaths. At least 13, or 16.6 per cent, were premature infants. Three were maldeveloped, and five deaths were attributed to erythroblastosis. This analysis of cesarean sections from Detroit led to some interesting conclusions, comparisons with other communities, and other data as follows: A rise in hospital confinements during the twenty years to more than 94 per cent of the deliveries in 1945 was accompanied by a reduction in the general maternal mortality to 1.6 per 1,000 live births. At the same time, there was an increase in cesarean sections from 154 in 1925 to 1,000 in 1945, a percentage of 2.7, or one in 37 births. This high incidence is in accord with the average (2.84 per cent) obtained from the recent studies in various states and cities. The Detroit cesarean section mortality rate of 0.8 per cent compared very favorably with that of these other communities. In Detroits largest and, generally speaking, better organized obstetric services, there were 75 per cent of the citys deliveries with a substantially lower over-all mortality. In these hospitals there was also a definitely higher incidence of cesarean section, but again a very low death rate (0.48 per cent). In view of the markedly increased incidence of cesarean sections on the one hand and the greatly decreased mortality on the other, it is well to ask if too many are now being done or if too few were done before. There is evidence that, in 1945, many sections were done for scant reason, to say the least. Apparently there is widespread disregard of the fact that, though the death rate is low, surgically speaking, it represents a high immediate obstetric risk, as well as a definite hazard for future pregnancies. On the other side of the question, it is noteworthy that in 1945 at least 20 of the 58 maternal deaths were considered to have been preventable, a number of them by timely cesarean section. Both sides of the question, then, seem to involve a proper regard for established indications and contraindications. Specifically pointing the way to further improvement, as mentioned before, is the fact that, in at least four of the eight cesarean deaths in 1945, the fatal outcome was in considerable part due to faulty judgment or management. The fetal mortality rate of 7.8 per cent in the 1945 cesarean sections, though definitely better than in previous years, is still twice the over-all death rate for infants during the first year of life. The fact that 36 per cent were stillborn again emphasizes the fact that cesarean section does not necessarily offer the best chances for a living child. Hence, there is no justification for undue extension of the use of cesarean section for purely fetal indications.

Weight changes and toxemia of late pregnancy

Abstract A series of 100 private patients with definite toxemia of late pregnancy had an average gain in weight of 17 pounds during the last four lunar months of pregnancy, as compared to 15.7 pounds for normals. Sixty-one of these 100 toxemia patients gained at least twice the normal averages at one or more observation periods during this time, while 39 at no time showed such excessive gains. The presence or absence of excessive weight increases bore little or no relationship to the severity or to the type of the toxemia. In 37 patients, excessive weight gain preceded definite signs of toxemia, but in the remaining 63 it appeared along with or after these signs, or not at all. Moreover, it was also present in about 45 per cent of the normals. Sudden or abrupt weight increase was somewhat more frequent with toxemia than among normal patients but was far from the rule. The occurrence of excessive weight gains in pregnancy would appear to be of doubtful significance in predicting impending toxemia and of secondary value, at most, in the diagnosis of the actual disease.

Prophylactic penicillin during labor in infection-prone patients

Abstract Although penicillin given during labor should theoretically give protection against infection, there are as yet only a few reports which present reliable data indicating actual results. In the present experiment 100 obstetrical patients with premature rupture of the membranes for at least 20 hours, labor for 20 hours or more, or both were given prophylactic penicillin at regular intervals before delivery; whereas a like number of controls were untreated. Taking into account the differences in the two groups (as shown by comparisons of the length of labor, lapse of time after premature rupture of the membranes, incidence of antepartum fever, inflammation of the placenta, etc.) there was demonstrated a considerable protection against puerperal infection in such patients from the use of penicillin during labor. However, welcome as is this protection, the prevention was so far from complete in these infection-prone patients as to suggest only a very cautious extension of the indications for delivery by cesarean section in such difficult cases. In agreement with Keettel, Scott, and Plass, there was some reason to believe that the use of larger prophylactic doses of penicillin should be expected further to reduce the occurrence of puerperal infection. On theoretical grounds it has been suggested that the fetus should receive some protection against antenatal infection from the penicillin given to the mother before delivery, though factual evidence regarding this seems to be largely lacking. In the present series the gross results, as well as an analysis of the figures, failed to indicate any advantage to the child from prophylactic antepartum treatment of the mother.

Sclerosis and related senile changes of the fallopian tubes

Abstract With advancing sexual age, the Fallopian tubes undergo certain changes consisting, first of all and most typically, of a marked hypertrophy and sclerosis involving the connective tissue of the folds. Later, there is also a replacement of ciliated epithelium by nonciliated and flatter cells. This sclerosis was noted in a high proportion (45 per cent) of cases with uterine leiomyofibromas. But the occurrence had little or no relationship to the size of the tumors. Moreover, an investigation of a like number of cases, which corresponded in all particulars except for the absence of even tiny fibroids, showed the condition in approximately the same proportion, the incidence increasing in both series with advancing age. Sclerosis of the Fallopian tubes showed no relationship to the history regarding previous pregnancies. The incidence of the condition was increased with the development of irregularities and anomalies of menstruation, and this was most marked with the onset of the climacteric and afterwards. The same tendency was noted also with the histologic evidences of sex hormone diminution. However, both here and with the menstrual changes there were definite exceptions to the general rules. Examination of a small series of tubes associated with pregnancy showed that sclerosis is occasionally present, and therefore it (or its cause) is not an absolute barrier to pregnancy. Left unanswered, however, were such questions as its possible role as a relative factor in sterility and also as a cause of tubal pregnancy. An interesting point incidental to the main purpose of this study was the discovery of such a high frequency of leiomyofibromas of the uterus in the material from Harper Hospital as to cast doubt on statistical studies which apparently indicate a relationship between fibroids and certain other conditions, particularly carcinoma of the uterine fundus.

Ovarian tumor prophylaxis by left oophorectomy.

Abstract The available evidence indicates that at the time of operation resulting in loss of reproductive ability, the removal of one ovary in women too young for complete castration has definite prophylactic value in avoiding future ovarian neoplasms. Objections to this procedure are few and appear to be a small risk compared to the protection gained. In our material the most common, important neoplasms were found more often on the left side. Consequently, there seems to be more prophylactic advantage in removing the left ovary. Our investigation has offered no good reason why the left ovary should be more often involved than the right.

Pituitary extract for dystocia due to uterine inertia in the first stage of labor

Abstract Although large injections of posterior pituitary extract are admittedly dangerous when given in labor, this does not mean that small doses cannot be given with reasonable safety and advantage in prolonged first stage of labor due to poor labor pains. In 62 such cases (definitely in labor at term and with normal children) there was efficient and lasting stimulation of pains in 42. Five patients given pituitary extract plus artificial rupture of the membranes had good stimulation. Some patients were given two or more courses of repeated doses, good results for the individual courses being about 50 per cent. This percentage was approximately the same for primiparas and multiparas and also for different degrees of cervical dilatation, except for 6 cm. or more dilatation in multiparas where there was good effect in all 5 instances. In this series of 62 very difficult cases, intervention before full dilatation of the cervix was required in only 3, these being among those with only slight or temporary stimulation. That the method is not entirely free of danger is shown by the fact that there was one case of tetanic contraction of the uterus after a 2 minim injection without detectable injury to mother or child. Because of this experience and for other reasons, we recommend that the initial dose be no larger than 1 minim. One maternal death followed difficult operative delivery after full dilatation of the cervix and was not ascribable to use of pituitary extract in the first stage. The child in this case was subjected to craniotomy. Three other babies died in utero, but with evidence pointing to difficult labor rather than use of pituitary extract as the cause. There were no neonatal deaths or diagnosable birth injuries in the 58 babies born alive.

Leiomyofibroma of the uterus and endometrial carcinoma

Summary The frequent coexistence of fibromyomas of the uterus and endometrial carcinoma has been the subject of considerable conjecture and investigation regarding its significance from both clinical and etiologic standpoints. It has never been satisfactorily established, however, that the high incidence of fibroids can be considered as peculiar to or characteristic of corpus carcinoma, and not just simply a reflection of the frequent occurrence of fibromyomas. In order to remedy the surprising dearth of information on this essential and basic point, a study was made of hysterectomies at Harper Hospital. Among 2,246 consecutive abdominal hysterectomy cases there were 44 with endometrial carcinoma, an incidence of 2 per cent. In this series there were 1,672 with a diagnosis (1,389 primary and 283 secondary) of fibromyomas, of which only 15, or 0.9 per cent, showed carcinoma. In marked contrast, the group of 574 without fibroids had an incidence of 29, or 5.1 per cent, with uterine fundus cancer. As a. check on this unexpected finding, a series of 50 endometrial carcinoma cases were compared with a like number of noncancerous instances, falling into the same age groups, and in whom the operations had been done for various reasons other than fibromyomas. Of the carcinomatous uteri there were 18 with fbroids, while in the other group the number was 23. There is no evidence in these data to indicate that fibromyomas of the uterus and endometrial carcinoma have an affinity for each other, but rather the reverse.