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Pregnancy and delivery after heart transplantation
LETTERS TO THE EDITORS The management of prolapse of the umbilical cord To the Editors: In 1970 I published a paper on a method for treatment of prolapse of cord.' The method described was as follows: immediately on diagnosis of prolapse of the cord a No. 16 Foley catheter with a 5 ml balloon was inserted into the urinary bladder and between 500 and 750 ml of normal saline solution was rapidly introduced by means of an infusion set, after which the balloon was inflated and the catheter clamped. This is performed with the patient in a moderate Trendelenburg position. The quantity of saline solution was determined by the appearance of the distended bladder as a visible swelling above the pubis. Usually 500 ml is sufficient. The distended bladder maintained the raised position of the presenting part, thus relieving pressure on the cord, without the necessity for the fingers of an assistant to remain in the vagina for a lengthy period. There is the added advantage that when the bladder is distended uterine contractions often diminish or disappear temporarily. At cesarean section the bladder was emptied before the parietal peritoneum was opened. The above method significantly improved the perinatal results. Twelve years after publication of this article the method was rediscovered by Katz et al. 2 and modified by the addition of intravenous ritodrine to diminish uterine contractions. This method of management was quoted and recommended in textbooks' and other publications.' From my own experience and that of others (Caspi et al.'), the addition of ritodrine seems to be unnecessary. There was no difference in the perinatal morbidity and mortality in cases where the method was used with or without ritodrine. Administration of ritodrine to a woman in labor is known to be potentially dangerous. 6 Because ritodrine itself does not improve the results of this specific procedure, it seems to be reasonable to adhere to the original method for management of prolapse of the umbilical cord. T. Vago, MD 13 Dram Afnca St., Afndar, Ashkelon 78437, Israel
REFERENCES 1. Vago T. Prolapse of the umbilical cord: a method of management. AM] OBSTET GYNECOL 1970;107:967. 2. KarL Z, Lancet M, Borenstein R. Management oflabor with umbilical cord prolapse. AM J OBSTEf GYNECOL 1982; 142: 239. 3. Cunningham FG, MacDonald PC, Gant NF, eds. Williams' obstetrics. 18th ed. Norwalk, Connecticut: Appleton & Lange, 1989:379. 4. Yla-Outinen A. Heinonen PK, Tuimala R. Predisposing and risk factors of umbilical cord prolapse. Obstet Gynecol Surv 1986;41 :503. 5. Caspi E, Lotan Y, Schreyer P. Prolapse of the cord: reduction of perinatal mortality by bladder installation and cesarean section. Isr J Med Sci 1983; 19:541. 6. CanadIan Preterm Labor Intervention Group: Treatment of
1476
preterm labor with the beta adrenergic agonist ritodrine. N Engl J Med 1992;327:308.
Reply
To the Editors: We thank Vago for his comments on the management of prolapse of the umbilical cord. Before 1982 we used the original method of Vago in 15 cases of cord prolapse, namely, filling the urinary bladder with the patient in the Trendelenburg position. Because several ofthese cases occurred during active labor and forceful contractions, concomitant fetal distress continued. Consequently, we added intravenous ritodrine to bladder filling to arrest these contractions in our 1982 study and our 1988' study. Bladder filling alone may sometimes disengage the presenting fetal part and cause some reduction in the contraction amplitude, but it may never arrest the contractions as quickly as needed in an obstetric emergency such as cord prolapse. Ritodrine, on the other hand, has a well-established tocolytic effect and was the logical acljunct to bladder filling. Ritodrine should obviously be withheld when it is contraindicated.' It should be remembered, however, that significant complications of ritodrine therapy were associated with its long-term administration to arrest premature contractions or preterm labor. In the case of umbilical cord prolapse ritodrine is given for a short period, a mean of 36 minutes,' which reduces the potential risk. In fact, with the dosage prescribed by us there was no serious complication in our 51 reported' and in 75 additional (unpublished) cases. Because opponents of ritodrine administration during cord prolapse may not concur with its advantage, a prospective, randomized study (if emergenq' permits true randomization) should be performed to establish its efficacy. On the basis of our experience in over 120 cases and until proved otherwise we advocate ritodrine as an integral part of the management of cord prolapse. Zvi Katz, MD, and Isaac Blickstezn, MD Department of Obstetrics and Gynecology, Kaplan Hospital, 76100 Rehovot, Israel
REFERENCE 1. Katz Z. Shoham Z, Lancet M, Blickstein 1. Mogilner BM, Zald Y. ~anagement oflabor with umbilical cord prolapse: a 5-year study. Obstet Gynecol 1988;72:278-81.
Pregnancy and delivery after heart transplantation
To the Editors: We read with interest the article by Baxi and Rho (Baxi LV, Rho RB. Pregnancy after cardiac transplantation. AM] OnsTET GYNECOL 1993;169:33-4) in which a delivery 4 years after heart transplantation is described. We are glad to report a similar case of a 23-year-old woman who conceived 4 months after heart transplantation and who was delivered vaginally of a
Letters
Volume 170, Number 5, Part 1 Am J Obstet Gynecol
healthy child in the forty-second week of pregnancy.' The patient received a heart transplant in December 1990 because of dilatative cardiomyopathy. Her postoperative course was uneventful, and pregnancy was diagnosed 8 months postoperatively. From week 18 onward she was under the care of our outpatient department. During pregnancy the patient showed no pathologic findings. Ultrasonographic examinations showed slight impairment of fetal growth. Routine laboratory values were within normal ranges. To maintain therapeutic serum levels of cyclosporine, the dose had to be increased to 20 mg/kg of body weight daily during pregnancy. At the beginning of the forty-second week labor was induced by amniotomy. Six hours later the patient gave birth to a healthy male infant (2000 gm, 47 cm, Apgar scores 9, 10, and 10). Several successful pregnancies after heart transplantation have been reported. As can be seen from this case, it is possible to become pregnant shortly after heart transplantation and to give birth to a healthy child, provided the patient remains under medical surveillance. Unfortunately our patient did not comply with repeated requests to appear for follow-up examinations; she had a long history of drug abuse before heart transplantation and may have slid back into the drug scene. Nine months post partum she was hospitalized because of cardiac decompensation. She was recompensated successfully but died 11 months post partum as a result of a chronic graft arteriosclerosis caused by self-initiated discontinuation of immunosuppressive therapy 4 months earlier. Beyond its immediate medical relevance, this case emphasizes the necessity of paying close attention to the psychosocial environment of the patient before pregnancy after heart transplantation is given serious consideration. Regine Ahner, MD I DepaTtment of Obstetrics and C.ynecology, Spltalgasse 23. Vienna 1090, AUltrza REFERENCE
1. Ahner R, Kiss H, Zuckermann A Schwangerschaft und Spontangeburt 13 Monate nach Herztransplantation. Geburtshilfe Frauenheilkd 1993;53:574-6.
Reply To the Ed~tors: I share with interest the issue that is brought out by Ahner in the management of a patient who became pregnant after heart transplantation. Immunosuppression by pharmacologic agents is an integral and important part of management of these patients. A similar case has been published by Key et aI.,' where the patient died after self-discontinuation of immunosuppressants. Such a death is not a function of intervening pregnancy as much as it is the function of lack of immunosuppressants. This issue has to be emphasized, and psychosocial issues must be evaluated not only before considering pregnancy, but also before considering heart transplant. The effort and financial
1477
burden that is encountered in making heart transplant a success warrants regular follow up of these patients by a team of physicians and social workers and, last but not the least, family members. Lax:ml Baxl, MD Department of Obstetncs and Gynecology, Columbla-Pmbytenan Medical Center, 622 W. 168th St., New York, NY 10032 REFERENCE
1. Key Te, Resnik R, Dittrich He, Reisner LS. Successful pregnancy after cardiac transplantation. AM J OSSTET GyNECOL 1989;160:367-71.
Fetal adaptation to shortage of supplies To the Editors: Scherjon et al. (Scherjon SA, SmoldersDehaas H, Kok JH, Zondervan HA. The "brain-sparing" effect: Antenatal cerebral Doppler findings in relation to neurologic outcome in very pre term infants. AM J OBSTET GVNECOL 1993;169:169-75) raise a major question: Is the redistribution of fetal blood advantageous to growth-retarded fetuses? A tolerance limit of the ratio between umbilical/cerebral pulsatility index is determined and the results plotted against fetal death rate, morbidity, and neurologic outcome. We have a number of concerns: (l) patient enrollment, because every pregnancy ending between 25 and 33 weeks' gestation is included in the study, (2) methods, with no sequential Doppler data in 73% of the population, (3) validity of conclusions based on a single investigation (Not taking in consideration fetal heart rate patterns and sequential profiles of growth results in pooling of heterogenous data. As a consequence, the contradiction found between the "unfavorable" effects of hemodynamic adaptation observed in the fetus and the "favorable" effects observed in the neonate is not surprising.), and (4) the median gestational age in days is significantly different in the two groups, 29 weeks in the "normal ratio" group versus 31 in the "raised ratio" group. With an identical median gestational age it is likely that the neurologic outcome would be poorer in the raised ratio group!' 2 and therefore the continuum of casualities demonstrated. From a statistical point of view two comments should be made: (1) before stating that a nonsignificant difference means a lack of association, statistical power of the study should be examined. Because the authors have performed logistic regression, it would have been interesting to know the actual values of the odds ratios of adverse neurologic outcome corresponding to a raised umbilical/cerebral pulsatility index ratio as well as the 95% confidence interval. If the confidence interval is large, it may mean that the lack of relationship is because of a lack of power. (2) "Differences in gestational age explained only 7% of the variance in occurrence of intracranial hemorrhage" cannot be accepted as such because this supposes a gaussian distribution of the criterion under study, which is not the case for occurrence of intracranial hemorrhage. Our experience' and other data I. 5 show how the
REFERENCES 1. Vago T. Prolapse of the umbilical cord: a method of management. AM] OBSTET GYNECOL 1970;107:967. 2. KarL Z, Lancet M, Borenstein R. Management oflabor with umbilical cord prolapse. AM J OBSTEf GYNECOL 1982; 142: 239. 3. Cunningham FG, MacDonald PC, Gant NF, eds. Williams' obstetrics. 18th ed. Norwalk, Connecticut: Appleton & Lange, 1989:379. 4. Yla-Outinen A. Heinonen PK, Tuimala R. Predisposing and risk factors of umbilical cord prolapse. Obstet Gynecol Surv 1986;41 :503. 5. Caspi E, Lotan Y, Schreyer P. Prolapse of the cord: reduction of perinatal mortality by bladder installation and cesarean section. Isr J Med Sci 1983; 19:541. 6. CanadIan Preterm Labor Intervention Group: Treatment of
1476
preterm labor with the beta adrenergic agonist ritodrine. N Engl J Med 1992;327:308.
Reply
To the Editors: We thank Vago for his comments on the management of prolapse of the umbilical cord. Before 1982 we used the original method of Vago in 15 cases of cord prolapse, namely, filling the urinary bladder with the patient in the Trendelenburg position. Because several ofthese cases occurred during active labor and forceful contractions, concomitant fetal distress continued. Consequently, we added intravenous ritodrine to bladder filling to arrest these contractions in our 1982 study and our 1988' study. Bladder filling alone may sometimes disengage the presenting fetal part and cause some reduction in the contraction amplitude, but it may never arrest the contractions as quickly as needed in an obstetric emergency such as cord prolapse. Ritodrine, on the other hand, has a well-established tocolytic effect and was the logical acljunct to bladder filling. Ritodrine should obviously be withheld when it is contraindicated.' It should be remembered, however, that significant complications of ritodrine therapy were associated with its long-term administration to arrest premature contractions or preterm labor. In the case of umbilical cord prolapse ritodrine is given for a short period, a mean of 36 minutes,' which reduces the potential risk. In fact, with the dosage prescribed by us there was no serious complication in our 51 reported' and in 75 additional (unpublished) cases. Because opponents of ritodrine administration during cord prolapse may not concur with its advantage, a prospective, randomized study (if emergenq' permits true randomization) should be performed to establish its efficacy. On the basis of our experience in over 120 cases and until proved otherwise we advocate ritodrine as an integral part of the management of cord prolapse. Zvi Katz, MD, and Isaac Blickstezn, MD Department of Obstetrics and Gynecology, Kaplan Hospital, 76100 Rehovot, Israel
REFERENCE 1. Katz Z. Shoham Z, Lancet M, Blickstein 1. Mogilner BM, Zald Y. ~anagement oflabor with umbilical cord prolapse: a 5-year study. Obstet Gynecol 1988;72:278-81.
Pregnancy and delivery after heart transplantation
To the Editors: We read with interest the article by Baxi and Rho (Baxi LV, Rho RB. Pregnancy after cardiac transplantation. AM] OnsTET GYNECOL 1993;169:33-4) in which a delivery 4 years after heart transplantation is described. We are glad to report a similar case of a 23-year-old woman who conceived 4 months after heart transplantation and who was delivered vaginally of a
Letters
Volume 170, Number 5, Part 1 Am J Obstet Gynecol
healthy child in the forty-second week of pregnancy.' The patient received a heart transplant in December 1990 because of dilatative cardiomyopathy. Her postoperative course was uneventful, and pregnancy was diagnosed 8 months postoperatively. From week 18 onward she was under the care of our outpatient department. During pregnancy the patient showed no pathologic findings. Ultrasonographic examinations showed slight impairment of fetal growth. Routine laboratory values were within normal ranges. To maintain therapeutic serum levels of cyclosporine, the dose had to be increased to 20 mg/kg of body weight daily during pregnancy. At the beginning of the forty-second week labor was induced by amniotomy. Six hours later the patient gave birth to a healthy male infant (2000 gm, 47 cm, Apgar scores 9, 10, and 10). Several successful pregnancies after heart transplantation have been reported. As can be seen from this case, it is possible to become pregnant shortly after heart transplantation and to give birth to a healthy child, provided the patient remains under medical surveillance. Unfortunately our patient did not comply with repeated requests to appear for follow-up examinations; she had a long history of drug abuse before heart transplantation and may have slid back into the drug scene. Nine months post partum she was hospitalized because of cardiac decompensation. She was recompensated successfully but died 11 months post partum as a result of a chronic graft arteriosclerosis caused by self-initiated discontinuation of immunosuppressive therapy 4 months earlier. Beyond its immediate medical relevance, this case emphasizes the necessity of paying close attention to the psychosocial environment of the patient before pregnancy after heart transplantation is given serious consideration. Regine Ahner, MD I DepaTtment of Obstetrics and C.ynecology, Spltalgasse 23. Vienna 1090, AUltrza REFERENCE
1. Ahner R, Kiss H, Zuckermann A Schwangerschaft und Spontangeburt 13 Monate nach Herztransplantation. Geburtshilfe Frauenheilkd 1993;53:574-6.
Reply To the Ed~tors: I share with interest the issue that is brought out by Ahner in the management of a patient who became pregnant after heart transplantation. Immunosuppression by pharmacologic agents is an integral and important part of management of these patients. A similar case has been published by Key et aI.,' where the patient died after self-discontinuation of immunosuppressants. Such a death is not a function of intervening pregnancy as much as it is the function of lack of immunosuppressants. This issue has to be emphasized, and psychosocial issues must be evaluated not only before considering pregnancy, but also before considering heart transplant. The effort and financial
1477
burden that is encountered in making heart transplant a success warrants regular follow up of these patients by a team of physicians and social workers and, last but not the least, family members. Lax:ml Baxl, MD Department of Obstetncs and Gynecology, Columbla-Pmbytenan Medical Center, 622 W. 168th St., New York, NY 10032 REFERENCE
1. Key Te, Resnik R, Dittrich He, Reisner LS. Successful pregnancy after cardiac transplantation. AM J OSSTET GyNECOL 1989;160:367-71.
Fetal adaptation to shortage of supplies To the Editors: Scherjon et al. (Scherjon SA, SmoldersDehaas H, Kok JH, Zondervan HA. The "brain-sparing" effect: Antenatal cerebral Doppler findings in relation to neurologic outcome in very pre term infants. AM J OBSTET GVNECOL 1993;169:169-75) raise a major question: Is the redistribution of fetal blood advantageous to growth-retarded fetuses? A tolerance limit of the ratio between umbilical/cerebral pulsatility index is determined and the results plotted against fetal death rate, morbidity, and neurologic outcome. We have a number of concerns: (l) patient enrollment, because every pregnancy ending between 25 and 33 weeks' gestation is included in the study, (2) methods, with no sequential Doppler data in 73% of the population, (3) validity of conclusions based on a single investigation (Not taking in consideration fetal heart rate patterns and sequential profiles of growth results in pooling of heterogenous data. As a consequence, the contradiction found between the "unfavorable" effects of hemodynamic adaptation observed in the fetus and the "favorable" effects observed in the neonate is not surprising.), and (4) the median gestational age in days is significantly different in the two groups, 29 weeks in the "normal ratio" group versus 31 in the "raised ratio" group. With an identical median gestational age it is likely that the neurologic outcome would be poorer in the raised ratio group!' 2 and therefore the continuum of casualities demonstrated. From a statistical point of view two comments should be made: (1) before stating that a nonsignificant difference means a lack of association, statistical power of the study should be examined. Because the authors have performed logistic regression, it would have been interesting to know the actual values of the odds ratios of adverse neurologic outcome corresponding to a raised umbilical/cerebral pulsatility index ratio as well as the 95% confidence interval. If the confidence interval is large, it may mean that the lack of relationship is because of a lack of power. (2) "Differences in gestational age explained only 7% of the variance in occurrence of intracranial hemorrhage" cannot be accepted as such because this supposes a gaussian distribution of the criterion under study, which is not the case for occurrence of intracranial hemorrhage. Our experience' and other data I. 5 show how the