August 1990 Am J Obstet Gynecol

4. Marshall JR, Feller CH. Kidney donors revisited. Am J Psychiatry 1977; 134:575-6. 5. Singer PA, Siegler M, Whitington PF, Lantos JD, et al. Ethics of liver transplantation with living donors. N Engl J Med 1989;321 :620-2. 6. Spital A, Spital M. Donor's choice or Hobson's choice. Arch Intern Med 1985;145:1297-301.

Reply To the Editors: Dr. Wettstein suggests that surrogate pregnancy should be a medical treatment, such as artificial insemination. We suggest that there is such widespread confusion about surrogacy that it is easy to miss our point. Surrogacy is not a medical treatment. Obstetricians should not be forced to consider withdrawing, withholding, or offering surrogacy, as if it were. Surrogacy is a nonmedical process that may lure physicians into . bad business arrangements and can make unwitting middlemen of obstetricians. In regard to transplantation ethics, a fetus is not a kidney. A fetus has no duplicate; surrender of a fetus is different from donation of a kidney. Living related kidney donors can consent or refuse to donate; surrogate mothers currently have no such choice. Sanctioning "collaborative reproduction" restores the paternalism of old, making the obstetrician both deliverer and parent. We appreciate Dr. Wettstein's comments, and we encourage other readers to avoid confusing surrogacy with medical treatment. . John La Puma, MD Center for Clinical Ethics, Lutheran General Hospital, 1775 Dempster St., Park Ridge, IL 60068

David L. Schiedermayer, MD Center for Bioethics, The Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226

John L. Grover, MD Department ofObstetrics and Gynecology, Lutheran General Hospital, 1775 Dempster St., Park Ridge, IL 60068

Can shoulder dystocia be predicted? To the Editors: I feel that James O'Leary, MD, and Helen Leonetti, MD, have done a great disservice to their colleagues who are practicing obstetricians. In their article "Shoulder dystocia: Prevention and treatment" (AM J OBSTET GVNECOL 1990;162:5-9), they give the distinct impression that most if not all shoulder dystocias should be anticipated and/or predicted and thus prevented by performing abdominal delivery. They present several tables identifying prepregnancy historical risk factors, antepartum risk factors, and intrapartum risk factors. Unfortunately they do not present any scientific data to show which risk factor or combination of risk factors would provide reasonable indications for a cesarean delivery. I believe that if Dr. O'Leary and Dr. Leonetti are honest with themselves and with other readers of the JOURNAL they will agree that to prevent one shoulder dystocia dozens of unnecessary cesarean sections with their attendant morbidity and mortality would need to be performed. Unfortunately the legal

profession has access to our professional journals, and I feel that articles like this can and will be used against anyone unfortunate enough as to find himself with a severe shoulder dystocia and an injured infant. It is a rare obstetric patient indeed that does not have at least one or several of the risk factors mentioned by the authors. Gregory L. Gimbel, MD Department of Obstetrics and Gynecology, Parkview Memorial Hospital, Brunswick, ME 04011

Reply To the Editors: McLeod (McLeod A. In discussion: Hopwood HG Jr. Shoulder dystocia: Fifteen years' experience in a community hospital. AM J OBSTET GVNECOL 1982;144:162-6) states: "that 'shoulder dystocia occurs cataclysmically' must be challenged; in many, if not a majority of cases, it can and should be anticipated [italics added]." He goes on to state: "All of these risk factors are identifiable and in most cases should be interpreted as a warning sign [italics added]." Eight years later these same statements are still valid. The intent of our review article was to reemphasize the importance of risk factors for macrosomia and to outline a rational approach to dealing with the issue. James A. O'Leary, MD

Jersey City Medical Center, University of Medicine and Dentistry of New Jersey Affiliate, Baldwin Ave., Jersey City, NJ 07304

Hyperbaric oxygen therapy for air embolism complicating operative hysteroscopy To the Editors: Baggish and Daniell (Baggish MS, Daniell JF. Death caused by air embolism associated with neodymium: yttrium-aluminum-garnet laser surgery and artificial sapphire tips. AM J OBSTET GVNECOL 1989; 161:877-8) reported two deaths caused by air embolism complicating operative hysteroscopy with laser surgery. Hyperbaric oxygen therapy was not mentioned in their article. Immediate therapy with hyperbaric oxygen, however, must be remembered and should be encouraged for those patients with suspected air embolism. Hyperbaric oxygen therapy, a combination of compression-recompression and hyperoxygenation, is effective in the treatment of air embolism in patients who survive the initial insult. Hyperbaric oxygen decreases intravascular bubble size (on the basis of Boyle'S law) and increases the driving pressure of oxygen into tissue, and thus reduces ischemia. The time between embolism and the time of hyperbaric oxygen treatment may determine the outcome in these patients. If necessary, air transportation should be used, either via a pressurized cabin for maintaining sea level pressure or by instructing the pilot to fly as low to the ground as safely possible. 1·3 Gynecologists performing operative hysteroscopy, with or without laser surgery, must maintain a high index of suspicion concerning air embolism when confronted with acute respiratory failure and/or focal or general neurologic deficits in an otherwise healthy

Can shoulder dystocia be predicted?

680 Letters August 1990 Am J Obstet Gynecol 4. Marshall JR, Feller CH. Kidney donors revisited. Am J Psychiatry 1977; 134:575-6. 5. Singer PA, Sieg...
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