Volume 162 Number I
study of Rush et aI.' In fact, he cites the results incompletely and selectively. In that study, the increased risk of low birth weight and other adverse outcomes occurred among women who received a high protein supplement. Women who received a balanced supplementation actually had a longer mean gestation and a higher mean birth weight. The importance of nutrition as a potential risk factor during pregnancy was recognized by the Institute of Medicine in its comprehensive study of low birth weight. 1 That report concluded that poor nutritional status before pregnancy and inadequate nutrition during pregnancy increase the risk of low birth weight. Finally, we disagree with Dr. Sepkowitz that "there is no explanation for a black low-birth-weight rate twice that of white newborns." It is not that an explanation does not exist, it is only that we are not wise enough to understand this very complex problem. Ellice Lzeberman, MD, DrPH Kenneth J. Ryan, MD Department of Obstetncs and Gynecology Brigham and Women's Hospital Harvard Medical School 75 Francis St. Boston, MA 02115 Richard R. Monson, MD, ScD Department of Epidemiology Harvard School of Public Health 677 Huntington Ave. Boston, MA 02115 Stephen C. Schoenbaum Harvard Community Health 10 Brookline Place West Brookline. MA 02146 REFERENCES I. Institute of Medicine. Committee to study the prevention of low birth weight: preventing low birth weight. Washington , DC: National Academy Press, 1985. 2. Kessel SS. Villar j, Berendes HW, Nugent RP. The changing pattern of low birth weight in the United States. JAMA 1984;251: 1978-82. 3. Rush D. Stein Z, Susser M. A randomized controlled trial of prenatal nutritional supple mentation in New York City. Pediatrics 1980;65:683-97.
Autotransfusion during cesarean section To the Editors: For a long time autotransfusion has played an important role in the prevention of blood-transmitted disease such as hepatitis and acquired immunodeficiency syndrome. This technique allows the patient to be transfused with his own blood, both in elective and emergency procedures. In the latter, mainly in those cases complicated by major hemorrhage, autotransfusion has proved itself very useful, allowing aspiration, filtration, concentration, washing, and retransfusion of blood by means of special instruments 'and machines. In fact, in the above-mentioned conditions. prestored deposits are not always available or sufficient. We used autotransfusion at I Clinica Ostetrica e Ginecologica of the University of Rome "La Sapienza"
Correspondence
295
in eight women undergoing elective cesarean section to verify the ability of a machine (Cell Saver Ill, Hemonetics Corp., Massachusetts) to clear amniotic fluid from centrifuged blood, which then was transfused back to the patient. Procoagulant activity of amniotic fluid is well known and so are the resulting risks of mixing this biologic fluid with the \'ecovered blood. We evaluated the presence of amniotic fluid both by direct technique, searching for one of its specific components "phosphatidylglycerol," and by indirect technique, analyzing its clotting activity. We used spectrophotometry for the former and prothrombin time for the latter, replacing thromboplastin with amniotic fluid, which is able to promote clotting of plasma control samples. The data obtained allow us to demonstrate an absolute lack of coagulant activity in centrifuged blood and the near disappearance of phosphatidylglycerol in it ; the very small amount we found was mainly because of red cell hemolysis (phosphatidylglycerol is present on erythrocyte membranes) during the procedure. Therefore, we believe that autotransfusion with blood obtained during cesarean section is without risk. We also think it may be a useful, although not a moneysaving procedure, for the mother and perhaps the fetus to avoid a potential source of infection through a heterologous transfusion. In conclusion, we believe that autotransfusion should be performed at the time of cesarean section only when the membranes are not ruptured, to avoid bacterial contamination, and, in case of blood incompatibility, maternal isoimmunization will be easily avoided with Rhogam immune globulin injection. L. Zichella, MD R. Gramolini. MD I Clinzca Ostetnca e Ginecologica Universita "La Sapienza" Policlintco Umberto I V iale del P oliclinico 00161 Rome. Italy Sacrospinous ligament fixation To the Editors: We read with great interest the article by Drs. George W. Morley and John O. L. DeLancey (Sacrospinous ligament fixation for eversion of the vagina. AM J OBSTET GYNECOL 1988;158:872-81). We think the modification described represents an improvement and a simplification ofthe operative technique. On the basis of our limited experience of 31 cases, we make the following observation: in Fig. I, there is a generous circumcision of the vaginal apex. We think this circumcision sacrifices a considerable amount of vaginal skin that might later complicate the approximation of the newly formed vaginal apex to the sacrospinous ligament. We believe that as much as possible of the vaginal skin should be preserved. We perform a longitudinal incision on the vaginal apex, which provides a very good exposure of the peritoneal sac and underlying ~tructures. In most of our
study of Rush et aI.' In fact, he cites the results incompletely and selectively. In that study, the increased risk of low birth weight and other adverse outcomes occurred among women who received a high protein supplement. Women who received a balanced supplementation actually had a longer mean gestation and a higher mean birth weight. The importance of nutrition as a potential risk factor during pregnancy was recognized by the Institute of Medicine in its comprehensive study of low birth weight. 1 That report concluded that poor nutritional status before pregnancy and inadequate nutrition during pregnancy increase the risk of low birth weight. Finally, we disagree with Dr. Sepkowitz that "there is no explanation for a black low-birth-weight rate twice that of white newborns." It is not that an explanation does not exist, it is only that we are not wise enough to understand this very complex problem. Ellice Lzeberman, MD, DrPH Kenneth J. Ryan, MD Department of Obstetncs and Gynecology Brigham and Women's Hospital Harvard Medical School 75 Francis St. Boston, MA 02115 Richard R. Monson, MD, ScD Department of Epidemiology Harvard School of Public Health 677 Huntington Ave. Boston, MA 02115 Stephen C. Schoenbaum Harvard Community Health 10 Brookline Place West Brookline. MA 02146 REFERENCES I. Institute of Medicine. Committee to study the prevention of low birth weight: preventing low birth weight. Washington , DC: National Academy Press, 1985. 2. Kessel SS. Villar j, Berendes HW, Nugent RP. The changing pattern of low birth weight in the United States. JAMA 1984;251: 1978-82. 3. Rush D. Stein Z, Susser M. A randomized controlled trial of prenatal nutritional supple mentation in New York City. Pediatrics 1980;65:683-97.
Autotransfusion during cesarean section To the Editors: For a long time autotransfusion has played an important role in the prevention of blood-transmitted disease such as hepatitis and acquired immunodeficiency syndrome. This technique allows the patient to be transfused with his own blood, both in elective and emergency procedures. In the latter, mainly in those cases complicated by major hemorrhage, autotransfusion has proved itself very useful, allowing aspiration, filtration, concentration, washing, and retransfusion of blood by means of special instruments 'and machines. In fact, in the above-mentioned conditions. prestored deposits are not always available or sufficient. We used autotransfusion at I Clinica Ostetrica e Ginecologica of the University of Rome "La Sapienza"
Correspondence
295
in eight women undergoing elective cesarean section to verify the ability of a machine (Cell Saver Ill, Hemonetics Corp., Massachusetts) to clear amniotic fluid from centrifuged blood, which then was transfused back to the patient. Procoagulant activity of amniotic fluid is well known and so are the resulting risks of mixing this biologic fluid with the \'ecovered blood. We evaluated the presence of amniotic fluid both by direct technique, searching for one of its specific components "phosphatidylglycerol," and by indirect technique, analyzing its clotting activity. We used spectrophotometry for the former and prothrombin time for the latter, replacing thromboplastin with amniotic fluid, which is able to promote clotting of plasma control samples. The data obtained allow us to demonstrate an absolute lack of coagulant activity in centrifuged blood and the near disappearance of phosphatidylglycerol in it ; the very small amount we found was mainly because of red cell hemolysis (phosphatidylglycerol is present on erythrocyte membranes) during the procedure. Therefore, we believe that autotransfusion with blood obtained during cesarean section is without risk. We also think it may be a useful, although not a moneysaving procedure, for the mother and perhaps the fetus to avoid a potential source of infection through a heterologous transfusion. In conclusion, we believe that autotransfusion should be performed at the time of cesarean section only when the membranes are not ruptured, to avoid bacterial contamination, and, in case of blood incompatibility, maternal isoimmunization will be easily avoided with Rhogam immune globulin injection. L. Zichella, MD R. Gramolini. MD I Clinzca Ostetnca e Ginecologica Universita "La Sapienza" Policlintco Umberto I V iale del P oliclinico 00161 Rome. Italy Sacrospinous ligament fixation To the Editors: We read with great interest the article by Drs. George W. Morley and John O. L. DeLancey (Sacrospinous ligament fixation for eversion of the vagina. AM J OBSTET GYNECOL 1988;158:872-81). We think the modification described represents an improvement and a simplification ofthe operative technique. On the basis of our limited experience of 31 cases, we make the following observation: in Fig. I, there is a generous circumcision of the vaginal apex. We think this circumcision sacrifices a considerable amount of vaginal skin that might later complicate the approximation of the newly formed vaginal apex to the sacrospinous ligament. We believe that as much as possible of the vaginal skin should be preserved. We perform a longitudinal incision on the vaginal apex, which provides a very good exposure of the peritoneal sac and underlying ~tructures. In most of our
