Management Dilemmas with Major Placental Abruptions in the Midtrimester

EDITORIAL COMMENT": We agree with the authors that these 2 cases of severe placental abruption with coagulopathy at early gestations, with the fetus still alive, will interest readers. Vaginal evacuation after instrumental cervical dilatation at 20 weeks' gestation in a woman with severe coagulopathy and impaired renal function, was a new reading experience for the editor. We wonder if rupture of the membranes with a Drew Smythe catheter is a safer alternative than prostaglandin pessaries when the cervix is tightly closed in such patients. If the liquor drains away perhaps there is less risk of entry ofthromboplastins into the maternal circulaton thus causing coagulation failure. At a Grand Round at the University of Michigan in 1991 the editor was presented a case of severe abruption at term in a nullipara with a tightly closed cervix where Caesarean section was followed by hysterectomy when bleeding from the uterus could not be controlled. The suggestion was made then that a Drew Smythe catheter could probably have allowed amniotomy and vaginal delivery of the dead fetus since it is uncommon to perform Caesarean section when the patient has had severe abruption. We seldom see a Couvelaire uterus. When we do it can be a frightening sight when huge haematomas bulge the uterine wall and suggest that hysterectomy will be necessary. The editor has experience of such a case where fortunately lower segment Caesarean section did not present difficulties with haemorrhage (as in Case I of this paper) and the patient has subsequently had 2 surviving infants born at term by Caesarean section. Although successful outcomes for mother and fetus have been reported following conservative treatment when mid‐trimester placental abruption has caused coagulation failure, such a complication is sufficient reason to justify delivery of the patient even if the fetus is alive and too immature to survive.