Placenta praevia and growth retardation Intra uterIne

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					                                                                                          SAMT   DEEL 67   23 FEBRUARIE 1985      291

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Placenta praevia and Intra-uterIne
growth retardation·

                                                                     neonate weighed 850 g, but according' to dates the pregnancy
   Summary                                                           had been of 37 weeks' duration. This grossly growth-retarded
                                                                     infant thrived during the neonatal period. The placental weight
   In 297 cases of placenta praevia, intra-uterine growth            was 250 g.
   retardation was noted in 17,5% of the neonates. This
   indicates the need for careful monitoring of fetal
   growth and function during the conservative                       Discussion
   management of placenta praevia.
                                                                     This case suggested an association between IUGR and placenta
   S Atr Med J 1985; 67: 291-292.                                    ~ra~vla. The association seems to be confirmed by a 17,5%
                                                                     inCidence of growth-retarded infants in association with
                                                                     placenta praevia, as compared with an overall incidence of
                                                                     IUGR of 9,5%.
                                                                        It is important to bear' this possible association in mind
Anention was drawn to the possible aSSOCiatIon of intra-
                                                                     since the contemporary management of proven placenta praevia
uterine growth retardation (IUGR) with placenta praevia by
                                                                     is conservative until there is certain fetal lung maturity, unless
the occurrence of such a case. The association of infants who
                                                                     intervention is indicated earlier for maternal reasons. Fetal
are small for gestational age with placenta praevia was then
                                                                     growth and function should be monitored carefully during this
assessed by retrospective analysis of the records at the Groote
                                                                     period of conservative management,
Schuur Hospital Maternity Centre, Cape Town.
                                                                        The adequacy of fetal growth in placenta praevia is contro-
                                                                     versial. Woods el al. 2 designed a study to assess whether the
                                                                     site of placental insertion in Ulero was a determinant of fetal
Results                                                              growth. Th~ site was assessed after vaginal delivery by inspec-
Among the 111613 consecutive patient records scanned there           tIon of the site of membrane rupture in relation to the placenta
were 328 cases of placenta praevia (0,3%). Twin pregnancies          in 187 cases. They concluded from this study (which did not
and stillbirths were.excluded, leaving 297 liveborn infants of       include cases of placenta praevia) that the site of placental
kno~n weight and gestational age.
                                                                     insertion is not a determinant of birth weight or length.
   IUGR was defined as a birth weight below the lOth percen-            Brenner el al.,3 in an analysis of 185 cases of placenta
tile fOI: gestational age, according to the chart designed by        praevia, concluded that there was no difference in the mean
Lubchenco el al. I According to the above criteria 52 infants        birth weights. However, they made no anempt to compare
were small for gestational age, an incidence of 17,5%. The           weight with gestational age. In their series there was an
overall incidence of infants small for gestational age in the        incidence of congenital anomalies of 6,7% compared with an
                                                                     overall incidence of 3,2%. Varma4 analysed fetal growth by
same unit by the same definition (excluding twin deliveries
and stillbirths) was 9,5%.                                           serial ultrasound examinations in 150 cases of placenta praevia.
                                                                     There were 24 infants small for gestational age (16%), a figure
                                                                     rising to 30% in cases of placenta praevia grades 3 and 4.
Case report                                                             There are many reasons for the possible association between
                                                                     placenta praevia and growth retardation. The lower uterine
The patient, aged 29 years, was in her third pregnancy after 10      segment may be a less vascular implantation site and placenta
years of secondary infertility. She had undergone a bilateral        praevias are often adherent with areas of fibrosis. There is also
reconstructive salpingostomy 12 months previously. At 32             an increased incidence of first-trimester bleeding which may,
weeks' gestation she presented at the Centre with a painless         by partial separation, decrease the placental exchange surface
antepartum haemorrhage. Ultrasound examination showed a              area. Although the blood loss from placenta praevia is almost
fetus with a biparietal diameter of 68 mm (i.e. equivalent to 26     entirely maternal, circumstances such as trauma to the placenta
weeks' gestation) and a low-lying posterior placenta which was       due to examination or coitus may result in some fetal blood
not considered to be a placenta praevia. At 35 weeks' gestation      loss which could retard' fetal growth. The increased incidence
the head circumference of the fetus was 260 mm (equivalent to        of fetal abnormalities may be a contributory factor.
26 weeks) and the abdominal circumference 215 mm (25                    In addition, and perhaps fundamentally, the parity and
weeks); the liquor was markedly reduced.                             socio-econotnic background of patients with placenta praevia
   At caesarean section a partly detached placenta praevia           must be considered. If the majority of patients presenting with
which extended across the internal os was en,countered. The          placenta praevia are of high parity or low socio-economic class,
                                                                     the increased incidence of IUGR could be simply coinci-

Department of Obstetrics and Gynaecology, University of
Cape Town and Groote Schuur Hospital Maternity Centre,               Conclusion
Cape Town
J. DOMMISSE, F.R.c.o.G.,Senior Lecturer and Principal Obslelrician
and Gynaecologisl                                                    In our unit the incidence of growth retardation in association
                                                                     with placenta praevia was 17,5%. This indicates that fetal
 292        SAMJ     VOLUME 67      23 FEBRUARY 1985

'. growth and function should be.carefully monitored during the        Thanks are due to Mrs C. Lawley, Department of Medical
   conservative management of patients with placenta praevia.        Informatics, University of Cape Town, for data analysis.
   This could be particularly important in patients who have
   repeated bleeding or major degrees of placenta praevia.
      Serial ultrasound examinations, including calculation of the   REFERENCES
   head circutnference and abdominal circumference ratios and
                                                                      1. Lubchenco LO, Hansman C, Boyd E. Intrauterine growth in length and
   liquor volume assessment, should be performed regularly.              head circumference as estimated from live binhs at gestational ages from 26
   Non-stress cardiotocography should be repeated as indicated.          to 42 weeks. Pediarrics 1966; 37: 403-408.
   Amniocentesis under ultrasonic guidance may be indicated to        2. Woods DL, Malan AF, Heese HDeV, Leader LR. The site of placental
                                                                         insertion and fetal growth. S Afr MedJ 1980; 57; 1087-1088.
   confirm fetal lung maturity, and corticosteroids administered      3. Brenner WE, Edelman DA, Hendricks CH. Characteristics of patients with
   if delivery before 32 weeks' gestation is unavoidable. The            placenta previa and results of expectant management. Am J Obsrer Gynecol
                                                                         1978; 132: 180-189.
   neonate should be assessed carefully for evidence of IUGR,         4. Varma TR. Fetal growth and placental function in patients with placenta
   anaemia due to blood loss and congenital abnormalities.               praevia.J Obscer Gynaecol Br Cwlth 1973; 80: 311-315.

 The birth of a child with a congenital
Part I. Some difficulties experienced by parents in the maternity home

B. DE '{VET,              S. CYWES

                                                                     taken to establish the first awareness of preliminary symptoms
                                                                     on the part of parents of babies with cystic fibrosis, oesophageal
   Summary                                                           atresia, Hirschsprung's disease or an anorectal malformation
   An investig?tive study of 90 cases in which a baby                and to elicit the difficulties, if any, experienced by parents in
   had been born with cystic fibrosis, oesophageal                   the maternity home before the diagnosjs was established.
   atresia, Hirschsprung's disease or an anorectal mal-
   formation was undertaken to establish the duration
   of the prediagnostic phase and the difficulties                   Subjects and methods
   experienced by parents before discharge from the
   maternity home. The congenital anomalies requiring                A random sample of 83 families with 90 affected children was
   immediate surgical intervention were diagnosed very               drawn from the 247 families into which babies with the
   soon after birth. A wider diversity of problems were              abovementioned conditions who were later treated at the Red
   encountered in the case of those conditions with a                Cross War Memorial Children's Hospital, Cape Town, had
   longer prediagnostic phase. The problems en-                      been born. There were 17 cases of cystic fibrosis, 30 of
   countered by parents, viz. lack of communication                  Hirschsprung's disease, 23 of oesophageal atresia, and 20 of
   with staff, fantasies of gross anomalies with fear for            anorectal malformation; 55 of the patients were male and 35
   the baby's life, and the lack of viewing and mothering            female. Information was obtained from hospital records and
   of the baby are discussed, and some long-term                     tape-recorded interviews during home visits which were done
   effects are highlighted.                                          as part of a broader study. For the purposes of the present
                                                                     study the prediagnostic phase was defmed as the period between
   S Air Med J 1985; 67: 292-296.                                    the date of the first medical consultation for preliminary
                                                                     symptoms and the date on which a diagnosis was made and
                                                                     recorded in the hospital file.

The, difficul~ies related to the prediagnostif phase in cases of
cYStIC fibrOSIS have been well documented. - However, much           Results
less is known about this aspect when a baby with a surgically
correctable congenital anomaly is born. This study was under-        Cystic fibrosis
                                                                        In the case of cystic fibrosis the prediagnostic phase had
                                                                     ranged from a few days to 4 years (Table I). The 5 babies
Department of Paediatric Surgery, Institute of Child                 (29%) diagnosed within the 1st week of life had been suffering
Health, University of Cape Town and Red Cross War                    from meconium ileus 4 or were the second affected child in the
Memorial Children's Hospital, Cape Town .                            family.l For these parents a prediagnostic phase in the true
B. DE WET, D.PHIL., Principal Research Social Worker
                                                                     sense was really non-existent. In contrast, the remaining 12
S. CYWES, M.MED. (SURG.), F.A.C.S., F.R.C.S., Professor and Head
                                                                     sets' of parents had experienced a growing awareness of

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