Letters 781
Volume 165 Number 3
cause of the pain is anatomic, the efficacy of the procedure is more important in selected women.' To say that this procedure "does not appear to be helpful" seems excessive. B. Cristalli, MD Department of Obstetrics and Gynecologic Surgery, Hopital Beaujon, Universitl! de Paris VII, 100 Blvd. General Leclerc, 92118 Clichy Cedex, France
REFERENCE 1. Brochard-Ledouarin LA, Bouquet de Joliniere J, Abeille JP, Seneze J, Levardon M. Ligamentopexie des retroversions uterines sous contr61e coelioscopique. Gynecologie 1989;40: 193-5.
Reply To the Editors: It seems unlikely that any gynecologist would antevert an already anteverted uterus. The association between pelvic varicosities and pelvic pain is well known; had pelvic varicosities been seen, they would have been reported. Pelvic venography is necessary to confirm ovarian vein dilatation and slowed clearance of dye from the pelvis." 2 Analysis of the data collected did not prove the efficacy of the procedure: At least 53.5% of the women in the study felt no better 6 months after laparoscopic ventrosuspension. Gleeson and Gaffney" reached a similar conclusion. Ann F.E. Yoong, MB, ChB St. Bartholomew's Hospital, London EC1A 7BE, England
REFERENCES 1. Beard RW, Pearce S, Highman.JH, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet 1984;2:946-9. 2. Beard RW, Reginald PW, Wadsworth J. Clinical features of women with chronic lower abdominal pain and pelvic congestion. Br J Obstet Gynaecol 1988;95:153-61. 3. Gleeson NC, Gaffney GM. Ventrosuspension-five years of practice at the Rotunda Hospital reviewed. J Obstet GynaecoI1990;10:419-22.
Laparoelytrotomy: Abdominal delivery without uterine incision To the Editors: According to Garrigues,' extraperitoneal approach to the vagina to perform a cesarean section without a uterine incision was first proposed by Joerg in 1806. Several different modifications have been proposed and presented since then. 2 ,3 Under certain circumstances laparoelytrotomy may be inadvertently or, rarely, intentionally performed instead of a low-segment uterine cesarean section.' Goodlin" reported one intentional and four incidental laparoelytrotomies performed at Nebraska University Hospital in 1982. Our letter reports an incidental case of laparoelytrotomy. A 23-year-old primigravid woman was at term and had been in the second stage of labor for approximately 3 hours with no analgesics. The vertex remained at 0 station in the left occipitotransverse position for 1 V2 hours. In the first stage of labor, when the cervix was dilated to 6 cm and 90% effaced, amniotomy had been performed.
The patient underwent a cesarean section because of the indication of cephalopelvic disproportion. With the patient under general anesthesia, the peritoneal cavity was entered. After the bladder flap was deflected downward and retained with a symphysis retractor, a low-transverse uterine incision was made and a 3700 gm male infant in good condition was delivered through the incision without difficulty. At the time of the incision we did not realize that the vagina rather than the lower uterine segment was being entered. When we tried to close the incision, we noted that the cervix was about 0.5 cm above the vaginal incision. The amount of bleeding was normal, and the only complication was a 0.5 cm laceration on the bladder wall with an intact bladder mucosa. This was easily repaired with 2-0 Dexon sutures. The patient was placed on a regimen of antibiotics, penicillin G procaine 800,000 U twice a day intramuscularly and gentamicin 80 mg three times a day intramuscularly. The urethral catheter was in place for 5 days. Patient and infant were discharged in good condition on the seventh postoperative day.
There is a tendency toward longer second stages of labor and avoidance of midforceps delivery. Cesarean sections after long second stages usually have higher morbidity than cesarean sections in uncomplicated cases. Cases like ours should be emphasized and discussed more in the literature so that complications can be decreased. As Goodlin 3 mentioned, for the abdominal-vaginal approach to be effective, the cervix should be completely dilated, elevated, and retracted. The fetal vertex should be in the vagina and the vesicouterine fold should be freed further downward than in conventional cesarean sections. After the bladder is completely retracted, the vagina has a characteristic ballooned, shiny appearance. If there is any doubt about landmarks, the fetus should be approached through the lower uterine segment through an incision on the upper side. Another point is whether the scarred vagina may rupture or become an obstacle to labor. Further knowledge and discussion are necessary in this subject. A technically advanced laparoelytrotomy may become an alternative to conventional cesarean sections under certain circumstances. Ahmet Zeki l~ik, MD, and Melin Gulmezoglu, MD Dr. Zekai Tahir Burak Women's Hospital, Biikliim Sokak 58113, K. Esat 06660, Ankara, Turkey
REFERENCES 1. Garrigues HJ. On gastro-elytrotomy. NY Med J 1878;28:449, 520. 2. Ricci JV, Marr JP. Gastroelytrotomy. In: Principles of extraperitoneal cesarean section. Philadelphia: Blakiston, 1942: 1-24, 3. Goodlin RC. Laparoelytrotomy or abdominal delivery without uterine incision. AM J OBSTET GYNECOL 1982; 144: 990-1. 4. Field CS. Surgical techniques for cesarean section. Obstet Gynecol Clin North Am 1988;15:657.
Prenatal prediction of Down syndrome To the Editors: O'Brien et al. (O'Brien W, Knuppel R, Torres C, Sternlicht D. Potential prenatal predictions of Down syndrome: A statistical analysis. AM J OBSTET GVNECOL 1990; 163: 1796-8) showed that a-fetoprotein,
782
Seplember 199 1 AmJ Obslcl Cynecol
Letters
human chorionic gonadotropin, and biparietal diameterlfemur length ratio all are sufficiently independent to be used in combination for prenatal prediction of Down syndrome. This requires the use of multivariate gaussian statistics, I which have the property that any inaccuracies are multiplied. We statistically examined the screening data of 4605 women routinely screened for fetuses with Down sy ndrome. There were 2834 complete data sets: age at estimated date of confinement, last menstrual period, biparietal diameter (outerto-outer table), femur length, a-fetoprotein, human chorionic gonadotropin , and blood sample collected on the same day as ultrasonographic scan. We demonstrated, using ultrasonographic dating of gestational age expressed as weeks' gestation, that the true calculated risk based o n two parameters (a-fetoprotein and human chorionic gonadotropin) may lie anywhere in the range 78 % to 152% of the actual calculated risk (analytic errors ignored). Similarly, by use of three parameters (a-fetoprotein, human chorionic gonadotropin, and urinary estradiol), the true risk may lie in the range 40% to 250 % of the actual risk (unpublished data). These errors are important because they may result in an incorrect decision about the requirement for amniocentesis and also because they are avoidable. The error is caused by the conversion of a relatively precise measure of fetal development (biparietal diameter) into an imprecise measure (weeks' gestation). Basing gestational age on last menstrual period also is not precise enough because of poor recall by patients and variability of menstrual cycle length. O'Brien et al. showed a trend for biparietal diameter/femur length ratio to decrease between 15 and 18 weeks' gestation. However, they only provided details of the ratio by week of gestation. If biparietal diameter / femur length ratio is to be of use in screening, errors resulting from gestation dating must be avoided as far as possible; therefore we examined the relationship between the ratio and gestational stage assessed by raw biparietal diameter value and by ultrasonographically derived weeks' gestation. We also found a trend in ratio relative to weeks' gestation, but we found that at the edges of the biparietal diameter size band there were significant deviations from the ratio derived by using weeks' gestation to define fetal age. We believe that using actual biparietal diameter and not biparietal diameter-derived weeks' gestation for assessment of gestational age will decrease edge effects, thereby improving the precision of data used to calculate risk. This should significantly improve screening for Down syndrome-associated pregnancy by reducing false-positive and false-negative screening results. Therefore we suggest that, instead of using week-based medians for determining expected biparietal diameterlfemur length ratio, the following linear regression parameters (product moment) such that biparietal diameter/femur length ratio = A + (Biparietal diame-
ter X B) should be used (A = 1.97997; B = -0.0080335; r = -0.202). T.M. Reynolds, MB, ehB, BSc Medical Biochemistry Department, University Hospital of Wales, H eath Park, Cardiff; S. Glamorgan, United Kingdom M.D. Penney, MD Chemical Pathology Department, Royal Gwent Hospital, Cardiff Road, Newport, Gwent, United Kingdom
REFERENCE I . Reynolds T, Penney M. The mathematical basis of multivariate risk screening: with special reference to screening for Down syndrome associated pregnancy. Ann Clin Biochern 1990;27:452-8.
Reply To the Editors: I appreciate the interest the readers have demonstrated in our study and am pleased to see that their findings are similar to ours. I agree with the difficulties encountered in the use of multivariate gaussian statistics and agree that conversion of biparietal diameter (or femur length) measurements to gestational age assessment results in a loss of precision. This conversion, however, allows consideration of several recent parameters in the same framework as the well-established reporting of a-fetoprotein. I suspect that, in spite of the mathematical superiority of computational values, as pointed out by the readers, practical consideration will lead to the use of weekly medians, as has occurred with a-fetoprotein testing. William F. O'Brien, MD Division of Obstetrics and Matemal-Fetal Medicine, Department of Obstetrics and Gynecology, Univenity of South Florida College of Medicine, Suite 529, H arbour Side Medical Tower, Davis Islands, 4 Columbia Dr., Tampa, FL 33606
Is opposition to abortion unethical? To the Editors: The "obstetric ethic" described by Chervenak and McCullough in the November 1990 issue of the JO URNAL (Chervenak FA, McCullough LB. Does obstetric ethics have any role in the obstetrician's response to the abortion controversy? AM J OBSTET GYNECOL 1990; 163: 1425-9) justifies abortion on demand before fetal viability by excluding any opposing arguments that are based on religious traditions. Recently, however, a leading bioethicist noted that the biomedical ethics debate has been impoverished by the a priori exclusion of argume nts that are based on various religious traditions. I In fact, all arguments for and against unrestricted abortion are based on fundamental presuppositions of some type. Whether they are religious is irrelevant. My question to the authors of this Clinical Opinion is, in light of the fundamental presuppositions of their "obstetric ethic," is it unethical for an obstetri-
Volume 165 Number 3
cause of the pain is anatomic, the efficacy of the procedure is more important in selected women.' To say that this procedure "does not appear to be helpful" seems excessive. B. Cristalli, MD Department of Obstetrics and Gynecologic Surgery, Hopital Beaujon, Universitl! de Paris VII, 100 Blvd. General Leclerc, 92118 Clichy Cedex, France
REFERENCE 1. Brochard-Ledouarin LA, Bouquet de Joliniere J, Abeille JP, Seneze J, Levardon M. Ligamentopexie des retroversions uterines sous contr61e coelioscopique. Gynecologie 1989;40: 193-5.
Reply To the Editors: It seems unlikely that any gynecologist would antevert an already anteverted uterus. The association between pelvic varicosities and pelvic pain is well known; had pelvic varicosities been seen, they would have been reported. Pelvic venography is necessary to confirm ovarian vein dilatation and slowed clearance of dye from the pelvis." 2 Analysis of the data collected did not prove the efficacy of the procedure: At least 53.5% of the women in the study felt no better 6 months after laparoscopic ventrosuspension. Gleeson and Gaffney" reached a similar conclusion. Ann F.E. Yoong, MB, ChB St. Bartholomew's Hospital, London EC1A 7BE, England
REFERENCES 1. Beard RW, Pearce S, Highman.JH, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet 1984;2:946-9. 2. Beard RW, Reginald PW, Wadsworth J. Clinical features of women with chronic lower abdominal pain and pelvic congestion. Br J Obstet Gynaecol 1988;95:153-61. 3. Gleeson NC, Gaffney GM. Ventrosuspension-five years of practice at the Rotunda Hospital reviewed. J Obstet GynaecoI1990;10:419-22.
Laparoelytrotomy: Abdominal delivery without uterine incision To the Editors: According to Garrigues,' extraperitoneal approach to the vagina to perform a cesarean section without a uterine incision was first proposed by Joerg in 1806. Several different modifications have been proposed and presented since then. 2 ,3 Under certain circumstances laparoelytrotomy may be inadvertently or, rarely, intentionally performed instead of a low-segment uterine cesarean section.' Goodlin" reported one intentional and four incidental laparoelytrotomies performed at Nebraska University Hospital in 1982. Our letter reports an incidental case of laparoelytrotomy. A 23-year-old primigravid woman was at term and had been in the second stage of labor for approximately 3 hours with no analgesics. The vertex remained at 0 station in the left occipitotransverse position for 1 V2 hours. In the first stage of labor, when the cervix was dilated to 6 cm and 90% effaced, amniotomy had been performed.
The patient underwent a cesarean section because of the indication of cephalopelvic disproportion. With the patient under general anesthesia, the peritoneal cavity was entered. After the bladder flap was deflected downward and retained with a symphysis retractor, a low-transverse uterine incision was made and a 3700 gm male infant in good condition was delivered through the incision without difficulty. At the time of the incision we did not realize that the vagina rather than the lower uterine segment was being entered. When we tried to close the incision, we noted that the cervix was about 0.5 cm above the vaginal incision. The amount of bleeding was normal, and the only complication was a 0.5 cm laceration on the bladder wall with an intact bladder mucosa. This was easily repaired with 2-0 Dexon sutures. The patient was placed on a regimen of antibiotics, penicillin G procaine 800,000 U twice a day intramuscularly and gentamicin 80 mg three times a day intramuscularly. The urethral catheter was in place for 5 days. Patient and infant were discharged in good condition on the seventh postoperative day.
There is a tendency toward longer second stages of labor and avoidance of midforceps delivery. Cesarean sections after long second stages usually have higher morbidity than cesarean sections in uncomplicated cases. Cases like ours should be emphasized and discussed more in the literature so that complications can be decreased. As Goodlin 3 mentioned, for the abdominal-vaginal approach to be effective, the cervix should be completely dilated, elevated, and retracted. The fetal vertex should be in the vagina and the vesicouterine fold should be freed further downward than in conventional cesarean sections. After the bladder is completely retracted, the vagina has a characteristic ballooned, shiny appearance. If there is any doubt about landmarks, the fetus should be approached through the lower uterine segment through an incision on the upper side. Another point is whether the scarred vagina may rupture or become an obstacle to labor. Further knowledge and discussion are necessary in this subject. A technically advanced laparoelytrotomy may become an alternative to conventional cesarean sections under certain circumstances. Ahmet Zeki l~ik, MD, and Melin Gulmezoglu, MD Dr. Zekai Tahir Burak Women's Hospital, Biikliim Sokak 58113, K. Esat 06660, Ankara, Turkey
REFERENCES 1. Garrigues HJ. On gastro-elytrotomy. NY Med J 1878;28:449, 520. 2. Ricci JV, Marr JP. Gastroelytrotomy. In: Principles of extraperitoneal cesarean section. Philadelphia: Blakiston, 1942: 1-24, 3. Goodlin RC. Laparoelytrotomy or abdominal delivery without uterine incision. AM J OBSTET GYNECOL 1982; 144: 990-1. 4. Field CS. Surgical techniques for cesarean section. Obstet Gynecol Clin North Am 1988;15:657.
Prenatal prediction of Down syndrome To the Editors: O'Brien et al. (O'Brien W, Knuppel R, Torres C, Sternlicht D. Potential prenatal predictions of Down syndrome: A statistical analysis. AM J OBSTET GVNECOL 1990; 163: 1796-8) showed that a-fetoprotein,
782
Seplember 199 1 AmJ Obslcl Cynecol
Letters
human chorionic gonadotropin, and biparietal diameterlfemur length ratio all are sufficiently independent to be used in combination for prenatal prediction of Down syndrome. This requires the use of multivariate gaussian statistics, I which have the property that any inaccuracies are multiplied. We statistically examined the screening data of 4605 women routinely screened for fetuses with Down sy ndrome. There were 2834 complete data sets: age at estimated date of confinement, last menstrual period, biparietal diameter (outerto-outer table), femur length, a-fetoprotein, human chorionic gonadotropin , and blood sample collected on the same day as ultrasonographic scan. We demonstrated, using ultrasonographic dating of gestational age expressed as weeks' gestation, that the true calculated risk based o n two parameters (a-fetoprotein and human chorionic gonadotropin) may lie anywhere in the range 78 % to 152% of the actual calculated risk (analytic errors ignored). Similarly, by use of three parameters (a-fetoprotein, human chorionic gonadotropin, and urinary estradiol), the true risk may lie in the range 40% to 250 % of the actual risk (unpublished data). These errors are important because they may result in an incorrect decision about the requirement for amniocentesis and also because they are avoidable. The error is caused by the conversion of a relatively precise measure of fetal development (biparietal diameter) into an imprecise measure (weeks' gestation). Basing gestational age on last menstrual period also is not precise enough because of poor recall by patients and variability of menstrual cycle length. O'Brien et al. showed a trend for biparietal diameter/femur length ratio to decrease between 15 and 18 weeks' gestation. However, they only provided details of the ratio by week of gestation. If biparietal diameter / femur length ratio is to be of use in screening, errors resulting from gestation dating must be avoided as far as possible; therefore we examined the relationship between the ratio and gestational stage assessed by raw biparietal diameter value and by ultrasonographically derived weeks' gestation. We also found a trend in ratio relative to weeks' gestation, but we found that at the edges of the biparietal diameter size band there were significant deviations from the ratio derived by using weeks' gestation to define fetal age. We believe that using actual biparietal diameter and not biparietal diameter-derived weeks' gestation for assessment of gestational age will decrease edge effects, thereby improving the precision of data used to calculate risk. This should significantly improve screening for Down syndrome-associated pregnancy by reducing false-positive and false-negative screening results. Therefore we suggest that, instead of using week-based medians for determining expected biparietal diameterlfemur length ratio, the following linear regression parameters (product moment) such that biparietal diameter/femur length ratio = A + (Biparietal diame-
ter X B) should be used (A = 1.97997; B = -0.0080335; r = -0.202). T.M. Reynolds, MB, ehB, BSc Medical Biochemistry Department, University Hospital of Wales, H eath Park, Cardiff; S. Glamorgan, United Kingdom M.D. Penney, MD Chemical Pathology Department, Royal Gwent Hospital, Cardiff Road, Newport, Gwent, United Kingdom
REFERENCE I . Reynolds T, Penney M. The mathematical basis of multivariate risk screening: with special reference to screening for Down syndrome associated pregnancy. Ann Clin Biochern 1990;27:452-8.
Reply To the Editors: I appreciate the interest the readers have demonstrated in our study and am pleased to see that their findings are similar to ours. I agree with the difficulties encountered in the use of multivariate gaussian statistics and agree that conversion of biparietal diameter (or femur length) measurements to gestational age assessment results in a loss of precision. This conversion, however, allows consideration of several recent parameters in the same framework as the well-established reporting of a-fetoprotein. I suspect that, in spite of the mathematical superiority of computational values, as pointed out by the readers, practical consideration will lead to the use of weekly medians, as has occurred with a-fetoprotein testing. William F. O'Brien, MD Division of Obstetrics and Matemal-Fetal Medicine, Department of Obstetrics and Gynecology, Univenity of South Florida College of Medicine, Suite 529, H arbour Side Medical Tower, Davis Islands, 4 Columbia Dr., Tampa, FL 33606
Is opposition to abortion unethical? To the Editors: The "obstetric ethic" described by Chervenak and McCullough in the November 1990 issue of the JO URNAL (Chervenak FA, McCullough LB. Does obstetric ethics have any role in the obstetrician's response to the abortion controversy? AM J OBSTET GYNECOL 1990; 163: 1425-9) justifies abortion on demand before fetal viability by excluding any opposing arguments that are based on religious traditions. Recently, however, a leading bioethicist noted that the biomedical ethics debate has been impoverished by the a priori exclusion of argume nts that are based on various religious traditions. I In fact, all arguments for and against unrestricted abortion are based on fundamental presuppositions of some type. Whether they are religious is irrelevant. My question to the authors of this Clinical Opinion is, in light of the fundamental presuppositions of their "obstetric ethic," is it unethical for an obstetri-
