British Journal of Obstetrics and Gynaecology

October 1918. Vol85. pp 196-197

THE VALUE OF CARDIOTOCOGRAPHY IN ABRUPT10 PLACENTAE

CASE REPORT

BY

P. R. SAUNDERSON,
Senior House OfJicer
AND

P. J. STEER,Medical Research Council Fellow

Department of Obstetrics, St Mary's Hospital, London W2 I N Y

Summary
The main indication for Caesarean section in cases of placental abruption is
fetal distress. We report a patient in whom clinical examination, including
auscultation of the fetal heart, suggested a mild haemorrhage, which would
normally have been managed conservatively, but continuous fetal heart rate
monitoring showed severe asphyxia, necessitating emergency Caesarean section
at which a large concealed haemorrhage was found.

CASEREPORT heart detector, showed late decelerations of

A 22-YEAR-OLD Negro woman attended our
antenatal clinic from the ninth week of
pregnancy. An ultrasound examination
confirmed her menstrual dates and showed
an anterior upper segment placenta. The blood
pressure a t booking was 120/70 mm Hg.
At 37 weeks the blood pressure was
150/100 mm Hg and there was a trace of
protein in the urine. Abdominal examination
was normal and the patient was advised to
come into hospital later the same day. On
admission three hours later, she complained
of moderate vaginal bleeding for one hour
and mild backache.
On examination the blood pressure was
160/100 mm Hg, the pulse 90/minute and the
temperature 36.5 "C. The patient was not
distressed. The uterus was slightly tender on
the right and was felt to tighten about every
minute.
Speculum examination showed the cervix
to be closed with fresh bleeding through the
external 0s. The fetal heart rate was 150 beats/
minute and regular. The cardiotocograph,
using an external Doppler ultrasonic fetal
796
the fetal heart rate after every contraction,
a mild baseline tachycardia and loss of
variability (Fig. 1).
A Caesarean section was performed within
one hour of the patient's admission. About
one-third of the placenta was separated from
the uterus by 300 ml of clot. A live female
infant weighing 2 -82 kg was delivered with
Apgar scores of 4 ,7 and 10 a t 1,5 and 10 minutes
respectively. The venous cord pH was 7.09.
Postoperatively the mother received two units
of blood and the baby was observed in the
special care baby unit for 24 hours. Both were
discharged healthy on the ninth day.
DISCUSSION
Modern British textbooks (Scott, 1976;
Garrey et al, 1974) emphasize the conservative
approach to severe placenta abruption, which
Scott (1976) describes as (a) liberal blood
transfusion, (b) sedation, (c) vaginal amniotomy
and (d) oxytocin infusion. In minor cases,
particularly if the bleeding is revealed, Garrey
et a1 (1974) state that treatment is by bed rest,
sedation and observation. In keeping with these
 CARDIOTOCOGRAPHY IN ABRUPT10 PLACENTAE 797

200
180
FETAL
HEART
RATE
(beats/
minute)

UTERINE
CONTRACTIONS
- by external
transducer
5 10 15 20 25

MINUTES
FIG.1
Cardiotocograph showing severe fetal asphyxia after placental abruption.

conservative policies, most series describe a
low Caesarean section rate but a high perinatal
mortality rate, for example, Caesarean section
rates of 3 . 1 , 8 . 6 , 12.9 and 16.4 per cent with
perinatal losses of 51, 50, 38 and 55 per cent
respectively (Paintin, 1962; Hibbard and
Jeffcoate, 1966; Lunan, 1973; Blair, 1973).
We suggest that many of the poor results
in the published series of abruptio placentae
are due to failure to diagnose antepartum
fetal distress early enough. The present case
report illustrates that acute fetal distress can
occur even in an apparently mild case of revealed
abruption. Continuous fetal heart rate
monitoring revealed the characteristic late
decelerations of fetal hypoxia which was
undetectable by normal auscultatory methods
since the rate was at most times within ‘normal’
limits (120 to 160 beats/minute).
That the hypoxia was leading to progressive
fetal acidosis was confirmed by the low cord
vein pH. It is clear that continuous fetal heart
rate monitoring should be a major priority in
the assessment of all cases of antepartum
haemorrhage.
ACKNOWLEDGEMENT
We thank Mr D. B. Paintin for permission
to report a patient under his care.
REFERENCES
Blair, R. G . (1973): Journalof Obstetrics and Gynaecology
of the British Commonwealth, 80,242.
Garrey, M. M., Goran, A. D. T., Hodge, C. H., and
Collander, R. (1974): Obstetrics Illustrated, 2nd
edition. Churchill Livingstone, Edinburgh, p 438.
Hibbard, B. M., and Jeffcoate, T. N. A. (1966):
Obstetrics and Gynecology, 27, 155.
Lunan, C. B. (1973): Journal of Obstetrics and
Gynaecology of the British Commonwealth, 80, 120.
Paintin, D. B. (1962): Journal of Obstetrics and
Gynaecology of the British Commonwealth, 69, 614.
Scott, J. S. (1976): Integrated Obstetrics and Gynaecology
for Postgraduates. Edited by C. J. Dewhurst.
2nd edition. Blackwell Scientific Publication,
Oxford, p 271.