13 April 1968
Considerable variation was found from case to case in the pro-
portion of cells containing glycogen.
Weak P.A.S. positivity was significantly related to short first
tained remission and survival, high initial peripheral blood
blast count, and short duration of symptoms at the time of
diagnosis. The results suggest that P.A.S. positivity is inversely
related to the rate of progression of lymphoblastic leukaea.
Furthr work is being carried out to elucidate this finding.
I would like to thank Dr. M. L. N. Willoughby, consultant
haeatologist, Royal Hospital for Sick Children, Glasgow, for his
advice in the preparation of this paper and Dr. F. G. J. Hayhoe,
Department of Medicine, University of Cambridge, for critiism
and useful suggestions.
of Professor J. H. Hutchison and Drs. R. A. Shanks, D. H. Wallace,
G. C. Ameil, J. 0. Craig, E. N. Coleman, W. Hamilton, and
J. A. Inall, under whose care these patients were admitted.
cytochemical tests were performed by Mr. F. G. Jewell. This work
I also wish to acknowledge the co-operation
has been supported by a grant from the Leukaemia Research Fund
H. C. LAURIE, M.B., GCHD.
Department of Haematology,
Royal Hospital for Sick Children,
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Spontaneous Uterine Rupture Caused
by Placenta Percreta
Brit, med.J., 1968,2, 97-98
Placenta accreta is the abnormal adherenge of the chorionic
vili to the myometrium, and is associated with partial or com-
plete absence of the decidua basalis, and in particular the
stratum spongiosum (Phaneuf, 1933; Kistner et a., 1952).
Three degrees are recognized, according to the extent of tropho-
Placenta accreta vera is the term applied
when villi are in juxtaposition with the myomeium.
placenta increta the villi partially penetrate the myomium.
Placenta percreta indicates that the villi have invaded the full
hickess of myometnum to or through the serosa of the
uterus, causing incomplete or complete uterine rupture respec-
Spontaneous rupture of the uterus due to placenta percreta
is one of the most urgent obstetrical catastrophes, resulting
in rapid exsanguination and high mortality in spite of prompt
anti-shock therapy and massive blood transfusion.
Sumawong et al. (1966) found 30 cases of rupture caused by
placenta percreta and added three cases of their own. A search
of the literature has revealed only three previous reports of
spontaneous rupture due to placenta accreta concomitant with
placenta praevia (Bakanow, 1928; Callender and King, 1949;
Malkasian and Welch, 1964). The last of these was a case of
placenta praevia percreta.
This paper describes two cases of spontaneous uterine
rupture due to placenta percreta, one of which was associated
with placenta praevia. As pointed out by Rotton and Friedman
(1957), the necessity for expeditious therapy when this condi-
tion is encountered makes imperative its clinical recoiion
In a review
A 36-year-old multipara was admitted to hospital as an emer-
gency case on 14 July 1966 in a state of collapse.
stated that she had her last menstrual period six months previously.
She had been well until five hours before admission, when she experi-
enced a continuous pain in her right shoulder while in bed.
soon developed a lancinating pain under the left costal margin and
fainting attacks. No vaginal bleeding or discharge occurred.
Her three previous pregnancies, labours, and puerperia were
Her youngest child was 2* years old.
had no previous illnesses or operations.
General examination revealed a state of shock.
was 97.6° F. (36.4° C.), pulse barely perceptible at 136 a minute,
and respiration was sighing and shallow; the blood pressure was
Gross pallor of the mucous membrane was present.
On abdominal examination there was marked distension with free
fluid.Generalized tenderness and guarding were elicited, and, apart
from uterine enlargement consistent with a 26-week gestation, no
other abnormality was detected.
Vaginal examination was not contributory.
Intraperitoneal haemorrhage due to rupture of the uterus, rupture
of the spleen or its blood vessels, and extrauterine pregnancy, in
that order, were considered in the differential diagnosis.
Investigations.-Full blood count showed a haemoglobin of 28%
Haldane, and an acute pot-haemorrhagic anaemia.
fibrinogen level was 285 mg./100 ml.
On admission resuscitation was begun with intravenous fluids,
morphine hydrochloride, metaraminol
cortisone, oxygen, and compatible group B rhesus-positive blood
as soon as the latter became available.
After an infusion of 2.500 ml. of blood the systolic pressure was
audible at 80 mm. Hg and the pulse improved to about 110 a
While she was being transferred to the operating-theatre
the blood pressure dropped to nil.
were simultaneously given under pressure and the necessary calcium
gluconate was administered.
Some improvement in the patient's
condition occurred and it was decided to proceed with immediate
The peritoneal cavity contained about 2,000 ml. of blood and
The uterus was consistent with a 26-week gestation.
uterine fundus was perforated by placental tissue (see Fig.) and
bleeding was occurring from that site.
Both Fallopian tubes and ovaries were normal
Haemostasis was secured and the abdomen sutured
The eighth litre of blood was being given at the con-
clusion of the operation when cardiac arrest suddenly occurred.
With the endotracheal tube still in situ the lungs were ventilated
and immediate external cardiac massage was performed.
failed to maintain an adequate circulation, left anterior thoracotomy
through the fourth intercostal space was performed and direct cardiac
massage resulted in the return of a regular heart beat.
and respiration were maintained for two and a quarter hours, when
arrest of the heart again occurred.
were of no avail.
This was followed by progressive weakness and
The foetal heart was not audible.
tartrate (Aramine), hydro-
The next two bottles of blood
Total hysterectomy was
All measures at resuscitation