1100

Letters

September 1990 Am J Obstet Gynecol

published only 2 months before the submission of our article.' Robert J. Stiller, MD Division of Maternal-Fetal Medicine, Bridgeport Hospital, 267 Grant St., Bridgeport, CT 06610

REFERENCE I. Goldstein S, Snyder JR, Watson C, Danon M. Very early pregnancy detection with endovaginal ultrasound. Obstet Gynecol 1988;72:200.

A convenient method to identify prior surgical procedures To the Editors: Current standards of practice mandate adequate documentation of medical care. Such standards derive in part from legal concerns but increasingly, obstetric and gynecologic care is often predicated on an adequate disclosure of a patient's prior medical and surgical history. As examples, repeat cesarean sections may be avoided and a trial of vaginal delivery attempted if documentation of a lower uterine segment incision can be made. 1 Similarly, tubal reanastomoses may be scheduled based solely on a review of the operative report describing the type of tubal ligation, thereby avoiding the cost and risk of laparoscopy! However, the mobility of our population, particularly evident in the military services, frequently results in a

fragmented medical record, and the question remains with regard to exactly what sort of care had previously been rendered. The concept of personally carried medical records is one potential solution and in fact is not new to obstetrics and gynecology. A cumulative, hand-carried obstetric record (mutterpass) is common practice in the Federal Republic of Germany, and a pocket identification card has been used in the gynecologic population to document the placement of an intrauterine contraceptive device. We extended this concept to surgical procedures and designed an identification card to document the type of either cesarean section or tubal surgery (Fig. I). The card provides space for identification of the type and date of the procedure and is similar in size to a standard credit card. On the reverse side, we chose to display a sketch of our medical center and our address, although any logo(s) or private practice name(s) could be depicted. We currently distribute the card to any patient who has either delivery by cesarean section, tubal ligation, or tubal surgery when the risk of ectopic pregnancy is increased. Use of this card should provide a convenient and immediate means to document prior surgical care, especially in emergent circumstances, and may be used while awaiting formal medical records and operative reports. Gerard S. Letterie, MAj, MG, USA, joseph P. Bruner, MAj, MG, USA, and Albert P. Sarno, jr., MAj, MG, USA Department of Obstetrics and Gynecology, Tripier Army Medical Center, Honolulu, HA 96859-5000

REFERENCES

SURGICAL PROCEDURE IDENTIFICATION CARD

I. Paul RH, Phelan JP, Yeh S-Y. Trial of labor in the patient with a prior cesarean birth. AM J OSSTET GYNECOL 1985; 151 :297-304. 2. Opsahl MS, Klein TA. Role oflaparoscopy in the evaluation of candidates for sterilization reversal. Fertil Steril 1987; 48:546-9.

TRIPLERAMC HONOLULU. HAWAII 96859·5000 TAMC Form 251, 1 Mar 90 (08)

Fetal Doppler velocimetry in twins To the Editors: Divon et al. (Divon MY, Girz BA, Sklar A, Guidetti DA, Langer O. Discordant twins-A prospective study of the diagnostic value of real-time ultrasonography combined with umbilical artery velocimetry. AM] OBSTET GYNECOL 1989;161:757-60) performed umbilical artery velocimetry with a continuouswave Doppler system and stated that the presence of either a 15% difference in ultrasonographic estimates of fetal weight or a 15% difference in systolic! diastolic ratios correctly identified 78% of discordant pairs. With a pulse-wave Doppler-duplex system enabling accurate sampling of vessel because of its depth resolution, we have shown 1 that from ultrasound criteria and Doppler study of the umbilical and fetal internal carotid arteries, decreased fetal internal carotid artery pulsatility index (cutoff value :s 1.2) was found to be the best predictor of twin discordancy (sensitivity 83%, specificity 95%, positive predictive value 91 %, negative predictive value 91 %). Pulsatility index determination provides direct

NAM~

________________

'ROCEDURE: _ _ _ _ __ INDICATION: _ _ _ _ __ DATE: ________________ SIGNATURE: ____________

Fig. 1. Identification card for surgical procedures.

Volume 163 Number 3

evidence of the brain-sparing effect in the growthretarded fetus!- 3 The umbilical artery Doppler assessment may present problems in twin gestations because it is not always easy to verify which fetus is associated with the umbilical vessel under study. Our findings suggest that it may be more practical to use ultrasonographic weight estimation below the 10th percentile (sensitivity 67%) or below the 25th percentile (sensitivity 92%) as a screening tool and then perform Doppler studies to determine the twin fetus at risk. With these sequential tests the specificity is improved (91 %,98%) at the expense of reduced sensitivity (56%, 76%, respectively). S. Degani, MD Department of Obstetrics and Gynecology, Ultrasound Unit, Bnai Zion Medical Center, P.O.B. 4940, Haifa 31048, Israel

REFERENCES 1. Degani S, Paltieli Y, Lewinsky R, Shapiro I, Sharf M. Fetal internal carotid artery flow velocity time waveforms in twin pregnancies. j Perinat Med 1988;16:405-9. 2. Wladimiroff jW, Tonge HM, Stewart PA. Doppler assessment of cerebral blood flow in human fetus. Br j Obstet GynaecoI1986;93:471-5. 3. Wladimiroff jW, Van Den Wijngaard jAGW, Degani S, Noordam Nj, Van Eyck j, Tonge HM. Cerebral and umbilical arterial blood flow velocity waveforms in normal and growth retarded pregnancies: a comparative study. Obstet Gynecol 1987;69:705-9.

Letters

11 01

renal steroidogenesis and has been useful in the control of hypercortisolism, although it is teratogenic and embryotoxic in animals. Amado et al. l recently reported the use of ketoconazole in a woman with deteriorating Cushing's syndrome caused by an adrenal adenoma from 32 weeks' gestation until 36 hours before cesarean section at 37 weeks. The clinical and biochemical response was excellent. Cortisol and aldosterone levels decreased, the level of 11deoxycortisol increased, and there was no diminution in the levels of either estradiol or progesterone; a normal healthy female infant was delivered and remained well after 18 months. Obviously, "one swallow doesn't make a summer," but their work deserves further investigation. M. J. Divers, BSc Hons, MB, ehB Department of Obstetrics and Gynaecology, Bassetlaw District General Hospital, Kilton, Worksop, Nottinghamshire, England S81 OBD

REFERENCE 1. Amado jA, Pesquera C, Gonzalez EM, Otero M, Freijanes j, Alvarez A. Successful treatment with ketoconazole of Cushing's syndrome in pregnancy. Postgrad Med j 1990; 66:221-3.

Response declined

Vaginal birth after abdominal delivery Reply To the Editors: We appreciate the interest of Dr. Degani in our recent article. As suggested, umbilical artery velocimetry studies are occasionally difficult in twin gestation. Pulsed-wave, duplexed devices may provide some help; however, we do not think that these devices can establish with certainty the association between the umbilical cord and the fetus. Our experience with discordant twins indicates that a combined analysis of both Doppler velocimetry and estimated fetal weight yields superior results to these obtained by initial analysis of the differences between fetal weights. Therefore we see no need for a "twostep" diagnostic approach. Michael Y. Divon, MD Department of Obstetrics and Gynecology, The Albert Einstein College of Medicine, 1825 Eastchester Road, Bronx, NY 10461

Ketoconazole treatment of Cushing's syndrome in pregnancy To the Editors: I was most interested to read the useful and comprehensive review of Cushing's syndrome and pregnancy by Aron et al. (Aron DC, Schnall AM, Scheeler LR. Cushing's syndrome and pregnancy. AM J OBSTET GYNECOL 1990; 162:244-52). Experience with medical therapy has been extremely limited. Ketoconazole blocks IIJ3-hydroxylase, 170.hydroxylase, and cholesterol side-chain cleavage in ad-

To the Editors: We would like to comment on the article by Yetman and Nolan (Yetman TJ, Nolan TE. Vaginal birth after cesarean section: A reappraisal of risk. AM J OBSTET GYNECOL 1989;161:1I19-23). The authors conclude that successful vaginal birth after cesarean section carries a higher risk for significant perineal lacerations. This conclusion cannot be drawn from the data presented because the authors do not report the number of episiotomies used for delivery within the study and control groups. Because midline episiotomy predisposes the anal sphincter and rectum to injury, I·. a higher incidence of episiotomy in either group could have confounded the results. The combination of vaginal vault lacerations, cervical lacerations, and third- and fourth-degree lacerations under the single heading of perineal lacerations is also misleading. These four separate categories of birth canal trauma should have been analyzed separately. Whether the incidence of any of these individual lacerations would have been different between the control and study groups by a statistically significant margin cannot be ascertained from the data as published. This is important because the authors draw attention to rectovaginal fistula as a potentially serious consequence of "perineal lacerations." However, rectovaginal fistulas are the occasional consequence of fourth-degree perineal lacerations but not of cervical, vaginal vault, or third-degree lacerations. Similarly, it would be important to know if cervical lacerations were significantly more common in the study group, because cervical lac-

Fetal Doppler velocimetry in twins.

1100 Letters September 1990 Am J Obstet Gynecol published only 2 months before the submission of our article.' Robert J. Stiller, MD Division of Ma...
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