treatment of bleeding in the first and third trimesters of pregnancy

Abstract 1. 1. Bleeding during the first third of pregnancy occurred in bout 10 per cent of all obstetric patients admitted to the New York Lying-in Hospital in the past ten-year period. 2. 2. This bleeding was due mainly to abortion, complete or incomplete, or to threatened abortion. 3. 3. Other causes of bleeding were: (a) ectopic pregnancy, (b) hydatidiform mole, (c) erosion of cervix or polyps, (d) chorionepithelioma, (e) carcinoma of the cervix. 4. 4. The proper treatment for patients with bleeding of the first trimester includes hospitalization, bed rest, blood grouping and matching, and physical examination. Observation for a varying period of time is essential in threatened as well as incomplete abortion. Conservative treatment is recommended in the presence of potential or actual infection of the uterine eavity. 5. 5. Vitamin E and perhaps progesterone are of value in certain cases of threatened abortion. A low basal metabolic rate must be corrected with proper thyroid therapy. 6. 6. Dilatation and curettage are performed on the basis of continued or excessive bleeding in incomplete or threatened abortion. The Aschheim-Zondek test is of value in these eases. 7. 7. Curettage is not performed in infected patients. Hemorrhage in these patients may necessitate evacuation of the uterus with the finger or ovum forceps, used with utmost care. 8. 8. The treatment for ectopic pregnancy is laparotomy with adequate transfusion. 9. 9. Cervical erosion, polyps, and carcinoma of the cervix, although infrequent causes of bleeding, must be ruled out by examination. If these are present, the appropriate therapy is applied. In carcinoma of the cervix, early treatment is essential and must be carried out irrespective of the gestation. 10. 10. Bleeding of the last third of pregnancy is due usually to placenta previa or premature separation of the placenta. 11. 11. The incidence of placenta previa was 0.52 per cent and of premature separation of the normally implanted placenta 0.36 per cent. 12. 12. All patients with bleeding in the latter third of pregnancy must be hospitalized and a suitable donor or blood from a blood bank procured immediately. 13. 13. In all these cases, except those in shock or with excessive bleeding, an observation period of several days is indicated. 14. 14. Our treatment in placenta previa is conservative, including the introduction of a bag in certain cases, except in central placenta previa, or in partial placenta previa with a fairly closed, long, or rigid cervix. In this latter group cesarean section becomes the procedure of choice. 15. 15. In premature separation of the normally implanted placenta, cesarean section is performed unless the cervix is partially dilated and early vaginal delivery may be expected. 16. 16. Where cesarean section is performed for premature separation of the placenta, hysterectomy should be done only in those cases where great disintegration of the muscular wall of the uterus is present and the organ does not contract satisfactorily. 17. 17. With the treatment as outlined above our maternal mortality from placenta previa was 0.75 per cent and from premature separation of the placenta 3.2 per cent. The maternal mortality in all patients with antepartum bleeding during the last trimester of pregnancy, including low implantation and undiagnosed placenta previa, was 0.71 per cent. 18. 18. We do not advocate wider use of cesarean section in placenta previa on the basis that it will increase the number of living infants, for cesarean section still carries an appreciable maternal mortality due to infection and hemorrhage.