770
Letters
sensitive whole cell enzyme-linked immunosorbent assay technique, Rappoport et aI.' did demonstrate the presence of elevated antiendothelial antibody titers in a subpopulation of women with severe preeclampsia. As Blann indicates, similarities between the pathophysiologic features of preeclampsia and rheumatoid vasculitis may provide clues to their causes. The solution of the pathogenesis of preeclampsia and other enigmatic diseases mandates such intellectual contributions from the many disciplines of modern biomedicine. Robert N. Taylor, MD, PhD, Steven A. Friedman, MD, and James M. Roberts, MD University of California, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine M-1489, San Francisco, CA 94143-0550
REFERENCES 1. Redman CWG, Denson KWE, Beilin LJ, Bolton FG, Stirrat GM. Factor-VIII consumption in pre-eclampsia. Lancet 1977;2:1249-52. 2. Rodgers GM, Taylor RN, Roberts JM. Preeclampsia is associated with a serum factor cytotoxic to human endothelial cells. AMJ OBSTETGvNECOL 1988;159:908-14. 3. Rappoport V, Hirata G, Yap HK, Jordan S. Antivascular endothelial cell antibodies in severe preeclampsia. AM J OBSTET GVNECOL 1990; 162: 138-46.
Comment on fetal breathing movements after premature rupture of membranes
To the Editors: We read with great interest the article by Roberts et al. (Roberts AB, Goldstein I, Romero R, Hobbins Je. Fetal breathing movements after premature rupture of membranes. AM J OBSTET GVNECOL 1991;164:821-5). Their study used videotapes of realtime ultrasonography of 30 minutes' duration to study fetal breathing and trunk movements in patients of 24 to 34 weeks' gestational age after membranes were ruptured. In 1988 we published a prospective case-control study on the effect of third-trimester premature rupture of membranes on fetal breathing movements. lOur patients' gestational ages were 28 to 41 weeks. During a 3D-minute biophysical profile test there was a significant decrease in breathing movements after premature rupture of membranes in otherwise uncomplicated pregnancies (90% vs 65%). Fetal body movements were not changed (97% vs 94%). Among the patient group in which amnionitis, neonatal infection, or antepartum fetal distress was later detected the incidence of fetal body movement was decreased to 69%. These results agree with the study of Roberts et al.; however, in that study Table I indicated that the time incidence of fetal breathing movements increased with increased fetal age, from 2.6% at 24 to 28 weeks' gestation to 13.3% at 31 to 34 weeks. In our study there was no difference found in the incidence of fetal breathing activity between preterm (28 to 36 weeks) and term pregnancies. This information is especially important because most biophysical profile tests are done at >28 weeks' gestation. In conclusion, our results complement the study of Roberts et al. in regard to the clinical interpretation of
February 1992 Am J Obstet Gynecol
biophysical profile. Fetal breathing movements during 30 minutes of observation decreased or were absent because of premature rupture of the membranes. It would be interesting to know the incidence of patients with absent breathing movements in the study of Roberts et al. Asko Kivikoski, MD, and Erol Amon, MD Departments of Obstetrics and Gynecology, Washington University School of Medicine, and St. Louis Regional Medical Center, 5535 Delmar Blvd., St. Louis, MO 63112
REFERENCE 1. Kivikoski AI, Amon E, Vaalamo PO, Pirhonen J, Kopta MM. Effect of third-trimester premature rupture of membranes on fetal breathing movements: a prospective case-control study. AM J OBSTET GVNECOL 1988; 159: 1474-7.
Reply To the Editors: I was interested to read the comments by Kivikoski and Amon. I acknowledge the work they have done in this field and that in 1988 they reported that patients with premature rupture of membranes and no complications had less chance of having 60 seconds of continuous breathing on a biophysical profile than normal controls. Kivikoski and Amon are concerned about the impact of these findings on interpretation of the biophysical profile. A recent article compared measurement of total fetal activity (fetal breathing plus fetal movement) with biophysical profiles in 64 patients with premature rupture of membranes. All had amniocentesis performed to diagnose infection. Measurement of total fetal activity proved to be better than biophysical profile in detecting intraamniotic infection. The problem seems to be that the sensitivity in the biophysical profile with regard to movements is set at too low a level, and analysis of the amount of movement performed in 30 minutes together with the amount of breathing gives a better measure of fetal well-being. Kivikoski and Amon asked about the incidence of patients with absent breathing movements in our study. This incidence depends on the gestation, but overall between 24 and 34 weeks, approximately 20% of patients studied with premature rupture of membranes had completely absent fetal breathing movements during a 3D-minute recording. Alistair B. Roberts, MD Department of Obstetrics and Gynaecology, University of Auckland, National Women's Hospital, Claude Road, Auckland 3 , New Zealand
REFERENCE 1. Roberts AB, Goldstein I, Romero R, Hobbins JC. Comparison of total fetal activity measurement with the biophysical profile in predicting intra-amniotic infection in preterm premature rupture of membranes. Ultrasound Obstet Gynaecol 1991; I :36-9.
The natural history of thrombocytopenia associated with preeclampsia To the Editors: Katz et al. are to be congratulated on their fine article. (Katz VL, Thorp JM Jr, Rozas L,
Letters
sensitive whole cell enzyme-linked immunosorbent assay technique, Rappoport et aI.' did demonstrate the presence of elevated antiendothelial antibody titers in a subpopulation of women with severe preeclampsia. As Blann indicates, similarities between the pathophysiologic features of preeclampsia and rheumatoid vasculitis may provide clues to their causes. The solution of the pathogenesis of preeclampsia and other enigmatic diseases mandates such intellectual contributions from the many disciplines of modern biomedicine. Robert N. Taylor, MD, PhD, Steven A. Friedman, MD, and James M. Roberts, MD University of California, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine M-1489, San Francisco, CA 94143-0550
REFERENCES 1. Redman CWG, Denson KWE, Beilin LJ, Bolton FG, Stirrat GM. Factor-VIII consumption in pre-eclampsia. Lancet 1977;2:1249-52. 2. Rodgers GM, Taylor RN, Roberts JM. Preeclampsia is associated with a serum factor cytotoxic to human endothelial cells. AMJ OBSTETGvNECOL 1988;159:908-14. 3. Rappoport V, Hirata G, Yap HK, Jordan S. Antivascular endothelial cell antibodies in severe preeclampsia. AM J OBSTET GVNECOL 1990; 162: 138-46.
Comment on fetal breathing movements after premature rupture of membranes
To the Editors: We read with great interest the article by Roberts et al. (Roberts AB, Goldstein I, Romero R, Hobbins Je. Fetal breathing movements after premature rupture of membranes. AM J OBSTET GVNECOL 1991;164:821-5). Their study used videotapes of realtime ultrasonography of 30 minutes' duration to study fetal breathing and trunk movements in patients of 24 to 34 weeks' gestational age after membranes were ruptured. In 1988 we published a prospective case-control study on the effect of third-trimester premature rupture of membranes on fetal breathing movements. lOur patients' gestational ages were 28 to 41 weeks. During a 3D-minute biophysical profile test there was a significant decrease in breathing movements after premature rupture of membranes in otherwise uncomplicated pregnancies (90% vs 65%). Fetal body movements were not changed (97% vs 94%). Among the patient group in which amnionitis, neonatal infection, or antepartum fetal distress was later detected the incidence of fetal body movement was decreased to 69%. These results agree with the study of Roberts et al.; however, in that study Table I indicated that the time incidence of fetal breathing movements increased with increased fetal age, from 2.6% at 24 to 28 weeks' gestation to 13.3% at 31 to 34 weeks. In our study there was no difference found in the incidence of fetal breathing activity between preterm (28 to 36 weeks) and term pregnancies. This information is especially important because most biophysical profile tests are done at >28 weeks' gestation. In conclusion, our results complement the study of Roberts et al. in regard to the clinical interpretation of
February 1992 Am J Obstet Gynecol
biophysical profile. Fetal breathing movements during 30 minutes of observation decreased or were absent because of premature rupture of the membranes. It would be interesting to know the incidence of patients with absent breathing movements in the study of Roberts et al. Asko Kivikoski, MD, and Erol Amon, MD Departments of Obstetrics and Gynecology, Washington University School of Medicine, and St. Louis Regional Medical Center, 5535 Delmar Blvd., St. Louis, MO 63112
REFERENCE 1. Kivikoski AI, Amon E, Vaalamo PO, Pirhonen J, Kopta MM. Effect of third-trimester premature rupture of membranes on fetal breathing movements: a prospective case-control study. AM J OBSTET GVNECOL 1988; 159: 1474-7.
Reply To the Editors: I was interested to read the comments by Kivikoski and Amon. I acknowledge the work they have done in this field and that in 1988 they reported that patients with premature rupture of membranes and no complications had less chance of having 60 seconds of continuous breathing on a biophysical profile than normal controls. Kivikoski and Amon are concerned about the impact of these findings on interpretation of the biophysical profile. A recent article compared measurement of total fetal activity (fetal breathing plus fetal movement) with biophysical profiles in 64 patients with premature rupture of membranes. All had amniocentesis performed to diagnose infection. Measurement of total fetal activity proved to be better than biophysical profile in detecting intraamniotic infection. The problem seems to be that the sensitivity in the biophysical profile with regard to movements is set at too low a level, and analysis of the amount of movement performed in 30 minutes together with the amount of breathing gives a better measure of fetal well-being. Kivikoski and Amon asked about the incidence of patients with absent breathing movements in our study. This incidence depends on the gestation, but overall between 24 and 34 weeks, approximately 20% of patients studied with premature rupture of membranes had completely absent fetal breathing movements during a 3D-minute recording. Alistair B. Roberts, MD Department of Obstetrics and Gynaecology, University of Auckland, National Women's Hospital, Claude Road, Auckland 3 , New Zealand
REFERENCE 1. Roberts AB, Goldstein I, Romero R, Hobbins JC. Comparison of total fetal activity measurement with the biophysical profile in predicting intra-amniotic infection in preterm premature rupture of membranes. Ultrasound Obstet Gynaecol 1991; I :36-9.
The natural history of thrombocytopenia associated with preeclampsia To the Editors: Katz et al. are to be congratulated on their fine article. (Katz VL, Thorp JM Jr, Rozas L,
