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1. 1. Two hundred and twenty-six cases of placenta previa with a total perinatal mortality rate of 12.4 per cent are reviewed. 2. 2. The fetal mortality rate in the 123 cases of partial placenta previa was 5.7 per cent and 20.4 per cent in the 103 cases of total placenta previa. 3. 3. The factors responsible for the perinatal wastage are discussed. 4. 4. A uterine incision through the placental site does not appear to increase the perinatal loss. 5. 5. Expectancy offered no advantages to 45 per cent of the cases because the infant was of term size. In another 21 per cent, despite prematurity, maternal and fetal indications dictated immediate delivery. 6. 6. Expectant management was feasible in only 34 per cent of the cases. In this group, expectancy increased the perinatal salvage so that it approximated that of the immediately treated group. 7. 7. Thus, two decades after the introduction of expectant management, the problem of prevention of prematurity and intrauterine anoxia still remains.

Premature rupture of the membranes about or shortly before term has previously been studied in detail, but premature rupture at an earlier stage of pregnancy has received little attention. Since, however, no small proportion of premature deliveries start with rupture of the membranes, we felt it would be of interest to analyse a group of such patients, especially in respect to the value and risks of expectant management. It is generally agreed that after premature rupture of the membranes around term, labour sets in spontaneously within 24-48 hours in 70-90 per cent of the cases (Biskin and Biskin, 1957; C r o n and Brown, 1953; E k v a l l et al., 1961; Embrey, 1953; L e b h e r z et al., 1961; M o r t o n et al., 1942; Schulze, 1929). Several authors have demonstrated an increasing infant mortality with increasing latent period (i. e. the period from rupture to start of labour) (Embrey, L e b h e r z et aI. M o r t o n et d.), while the increase in infant morbidity is slight and the maternal mortality very low. Furthermore, it has been shown by several authors B a i n b r i d g e et al., 1958; Calkins , 1952; EssenMoller, 1936; F r e d r i k s o n , 1937; Sunde, 1937) that the first stage of labour is shorter if the membranes rupture early, so that such an onset of labour would not appear to be unfavourable in all respects.

Keywords: PROM; preterm labour; chorioamnionitisDOI: http://dx.doi.org/10.3329/jcmcta.v22i1.9106 JCMCTA 2011; 22(1): 15-19

Localization of the source of massive hemorrhage from pelvic fractures is not often made clinically, and the results of expectant management or of hypogastric artery ligation are frequently unsatisfactory. Three patients with pelvic fractures and rapid blood loss were examined by transfemoral aortography. In all of them, bleeding originated from obturator artery branches In the vicinity of fractures involving the pubic rami. In two of these patients, hemorrhage was controlled by selective catheterization of the anterior division of the hypogastric artery, followed by injection of autologous clotted blood. Arterial bleeding from pelvic fractures may be more common than has previously been supposed. Arteriographic localization of the bleeding site should improve selection of patients for surgical exploration, when the described method of hemostasis fails.

Fertility potential can be protected by the expectant management of patients with undescended testes in whom spontaneous descent by puberty is likely and by performance of orchiopexy before puberty in cases in which some abnormality makes spontaneous descent impossible. Awareness of anatomic pitfalls and careful attention to clinical evidence help to make the distinction between the two groups. To determine the quality of the testes put into the scrotum and to predict the fertility potential in the boy with bilateral retention, biopsy should be done routinely at the time of orchiopexy.

One hundred five cases of placenta previa with one maternal death (0.95 per cent) and twenty-nine fetal deaths (28 per cent) are reviewed. The adequate replacement of blood loss, and caution in the use of vaginal manipulations, with delivery either by cesarean section, or induction of labor by rupture of the membranes, dependent upon the station of the presenting part, the degree of previa, and the condition of the cervix, have improved the maternal results in placenta previa. An improvement in the fetal results is dependent upon an attempt to carry these patients closer to term. Of seventy-four babies weighing 2,500 Gm. or more, eight (10 per cent) were lost, while on the other hand, of thirty-one babies weighing less than 2,500 Gm., twenty-one (68 per cent) were lost. An attempt to carry patients with placenta previa to term seems to be reasonably safe and is worthy of trial, although some of them will go into spontaneous labor prematurely, while others will have such persistent or profuse bleeding that one is reluctant to continue an expectant attitude. In forty-one patients so managed, there were five fetal deaths (12 per cent), four prematures, and one term baby which died of congenital defects.

A 1959 study at a naval hospital snowed that expectant management of 166 cases of placenta previa helped save many infants and lessened the danger for mothers. This follow-up study corroborates the original results. Half the patients benefited, one mother died, and the corrected perinatal mortality was under 6 percent.

THE MANAGEMENT of stab wounds of the abdomen in civilian practice is presently a subject of controversy. 1 Those who propose immediate laparotomy in all cases of suspected peritoneal violation have statistical evidence to support the thesis that exploration is the preferred method of management. 2 Indeed, immediate exploration has been, until recently, a surgical tenet. There are now scattered reports of expectant management of such injuries with equally impressive statistical evidence of success. 3 In any large metropolitan hospital, stab wounds of the abdomen are a common clinical entity. In our hospital we see approximately 100 stab wounds of the abdomen each year. Until recently we have been firm practitioners of immediate exploration with acceptable morbidity and mortality (unpublished data). However, upon reviewing our previous experience, it has become apparent that a great economic saving could be effected if a safe method of diagnosis were established for the nonpenetrating

Prolonged, tedious nursing care and the everpresent danger of meningeal rupture attend the expectant management of infants with myelomeningocele. Conversely, early operation minimizes the special care of these infants, decreases hospital stay, and may ease subsequent bracing and gait training. In the past, we have preferred early surgical treatment of myelomeningocele, but have been discouraged by difficulties encountered in obtaining skin and soft tissue closure in very large lesions. These are the infants whose defects are so large that neither primary midline closure nor the utilization of local rotational pedicle flaps is feasible. To facilitate repair of large myelomeningoceles we have, for the past two years, used large bilateral bipedicled advancement flaps and have achieved success in all seven patients treated by this method. Technique The method of repair is illustrated in the Figure ( B and D ). Bipedicled verticle flaps of skin and soft tissue are outlined bilaterally adjacent to