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Can shoulder dystocia be prevented?
Volume 163 Number 3
nancy are candidates for conservative treatment modalities. Some authors have recommended limiting attempts to conserve the uterus to the first 8 weeks of pregnancy. 10. II This may be particularly true for those patients treated with methotrexate, because one of five patients treated within the first 8 weeks required additional therapy to control hemorrhage! Beyond 8 weeks, two of three cases required surgical intervention for control of bleeding. 7• 8 Although the numbers are still small, this trend is similar to the experience with methotrexate in treating tubal ectopic pregnancies in which excessive size and high human chorionic gonadotropin titers have been shown to have poorer outcomes. 12 . 13 Currently, experience with contemporary conservative treatment methods beyond the first trimester is extremely limited. Choice of the optimal treatment for a patient who wishes to preserve fertility is difficult. It should be recognized that both of these treatment modalities have inherent morbidities that must be considered by the patient and the physician when selecting a conservative treatment plan. Kevin Bachus, MD Department of Obstetrics and Gynecology, Duke University Medical Center, Box 3143, Durham, NC 27710
REFERENCES 1. Bernstein D, Holzinger M, Ovadia J, et al. Conservative treatment of cervical pregnancy. Obstet Gynecol 1981 ;58: 741-2. 2. Cheng Y, Chang F, Hsieh F, et al. Cervical pregnancy: report of a case with unsuccessful use of methotrexate. J Formosan Med Assoc 1986;85: 1000-8. 3. Nolan TE, Chandler PE, Hess LW. Cervical pregnancy managed without hysterectomy. J Reprod Med 1989;34: 241-3. 4. Reginald PW, Reid JE, Paintin DB. Control of bleeding in cervical pregnancy: two case reports. Br J Obstet Gynaecol 1985;92: 1199-1200. 5. Hurley VA, Beischer NA. Cervical pregnancy: hysterectomy avoided with the use of a large Foley catheter balloon. Aust N Z J Obstet Gynaecol 1988;28:230-2. 6. Kaplan BR, Brandt T, Javaheri G, et al. Successful treatment of a live cervical pregnancy with methotrexate and folinic acid. J Reprod Med 1989;34:853-6. 7. Farabow WS, Fulton JW, Fletcher V, et al. Cervical pregnancy treated with methotrexate. NC Med J 1983;44: 91-3. 8. Wolcott HD, Kaunitz AM, Nuss RC, et al. Successful pregnancy after previous conservative treatment of an advanced cervical pregnancy. Obstet Gynecol 1988;71: 1023-5. 9. Oyer R, Tarakjian D, Lev-Toaff A, et al. Treatment of cervical pregnancy with methotrexate. Obstet Gynecol 1988;71 :469-71. 10. Mattingly RF, Thompson JD. In: TeLinde RW, ed. Operative gynecology. 6th ed. Philadelphia: JB Lippincott, 1985:445-6. 11. Mortimer CW, Aiken DA. Cervical pregnancy. J Obstet Gynaecol Br Commonw 1968;75:741-5. 12. Sauer M, Gorrill M, Rodi I, et al. Nonsurgical management of unruptured ectopic pregnancy: an extended clinical trial. Fertil Steril 1987;48:752-5. 13. Ory SJ, Villanueva AL, Sand PK, et al. Conservative treatment of ectopic pregnancy with methotrexate. AM J OBSTET GYNECOL 1986;154:1299-1306.
Letters
1095
Can shoulder dystocia be prevented? To the Editors: Although the recent article by O'Leary and Leonetti (O'Leary JA, Leonetti HB. Shoulder dystocia: prevention and treatment. AM J OBSTET GVNECOL 1990;162:5-9) was published in the Clinical Opinion section, I am concerned that some of the statements might be misconstrued. The third sentence in the paper implies that many shoulder dystocias can be prevented by quoting a source that states that many shoulder dystocias can be anticipated. Any algorithm to predict shoulder dystocia should include an estimation of the number of falsely alarming predictions of damage to the infant. In other words, how many "unnecessary" cesarean deliveries are necessary to prevent each case of shoulder dystocia? The suggestion that "once a shoulder dystocia, always a cesarean" obviously ignores the fact that there are complicated dynamics that predict whether shoulder dystocia will occur. Just as the necessity for a prior cesarean delivery for management of cephalopelvic disproportion poorly predicts the need for subsequent cesarean delivery for the same indication, in the absence of more compelling data we should not accept the thought that shoulder dystocia will predictably repeat itself. Finally, the order of suggested treatment of shoulder dystocia that the authors propose in Table IV is certainly debatable; however, I would suggest that the maneuvers begin with the least invasive, that is, the McRoberts maneuver. Proceeding with a list as suggested is sensible, although I still am concerned about the suggestion that the head can be forcibly replaced with safety. Although this may be an appropriate procedure in the authors' hands, multisite performance in more patients will make me (and many others) feel more comfortable. Whereas it is certainly true that increasing the cesarean section rate will, as the authors propose, reduce the incidence of shoulder dystocia, it will also increase the incidence of maternal morbidity and mortality. I hope that we can balance these risks in adopting a safe and sane standard for the management of this uncommon, but frightening and potentially disastrous complication of pregnancy. David A. Nagey, MD, PhD Section of Obstetrics, Division of Maternal-Fetal Medicine, School of Medicine, University of Maryland at Baltimore, 22 South Greene St., Baltimore, MD 21201
Reply To the Editors: We appreciate Dr. Nagey's thoughtful and meaningful remarks. It is hoped that by raising the level of anticipation of shoulder dystocia a more thorough clinical assessment would allow the physician to accumulate more data and thus recognize more risk factors for shoulder dystocia (i.e., the flat pelvis). The expression "once a shoulder dystocia, always a cesarean" is based on the assumption that the same set
nancy are candidates for conservative treatment modalities. Some authors have recommended limiting attempts to conserve the uterus to the first 8 weeks of pregnancy. 10. II This may be particularly true for those patients treated with methotrexate, because one of five patients treated within the first 8 weeks required additional therapy to control hemorrhage! Beyond 8 weeks, two of three cases required surgical intervention for control of bleeding. 7• 8 Although the numbers are still small, this trend is similar to the experience with methotrexate in treating tubal ectopic pregnancies in which excessive size and high human chorionic gonadotropin titers have been shown to have poorer outcomes. 12 . 13 Currently, experience with contemporary conservative treatment methods beyond the first trimester is extremely limited. Choice of the optimal treatment for a patient who wishes to preserve fertility is difficult. It should be recognized that both of these treatment modalities have inherent morbidities that must be considered by the patient and the physician when selecting a conservative treatment plan. Kevin Bachus, MD Department of Obstetrics and Gynecology, Duke University Medical Center, Box 3143, Durham, NC 27710
REFERENCES 1. Bernstein D, Holzinger M, Ovadia J, et al. Conservative treatment of cervical pregnancy. Obstet Gynecol 1981 ;58: 741-2. 2. Cheng Y, Chang F, Hsieh F, et al. Cervical pregnancy: report of a case with unsuccessful use of methotrexate. J Formosan Med Assoc 1986;85: 1000-8. 3. Nolan TE, Chandler PE, Hess LW. Cervical pregnancy managed without hysterectomy. J Reprod Med 1989;34: 241-3. 4. Reginald PW, Reid JE, Paintin DB. Control of bleeding in cervical pregnancy: two case reports. Br J Obstet Gynaecol 1985;92: 1199-1200. 5. Hurley VA, Beischer NA. Cervical pregnancy: hysterectomy avoided with the use of a large Foley catheter balloon. Aust N Z J Obstet Gynaecol 1988;28:230-2. 6. Kaplan BR, Brandt T, Javaheri G, et al. Successful treatment of a live cervical pregnancy with methotrexate and folinic acid. J Reprod Med 1989;34:853-6. 7. Farabow WS, Fulton JW, Fletcher V, et al. Cervical pregnancy treated with methotrexate. NC Med J 1983;44: 91-3. 8. Wolcott HD, Kaunitz AM, Nuss RC, et al. Successful pregnancy after previous conservative treatment of an advanced cervical pregnancy. Obstet Gynecol 1988;71: 1023-5. 9. Oyer R, Tarakjian D, Lev-Toaff A, et al. Treatment of cervical pregnancy with methotrexate. Obstet Gynecol 1988;71 :469-71. 10. Mattingly RF, Thompson JD. In: TeLinde RW, ed. Operative gynecology. 6th ed. Philadelphia: JB Lippincott, 1985:445-6. 11. Mortimer CW, Aiken DA. Cervical pregnancy. J Obstet Gynaecol Br Commonw 1968;75:741-5. 12. Sauer M, Gorrill M, Rodi I, et al. Nonsurgical management of unruptured ectopic pregnancy: an extended clinical trial. Fertil Steril 1987;48:752-5. 13. Ory SJ, Villanueva AL, Sand PK, et al. Conservative treatment of ectopic pregnancy with methotrexate. AM J OBSTET GYNECOL 1986;154:1299-1306.
Letters
1095
Can shoulder dystocia be prevented? To the Editors: Although the recent article by O'Leary and Leonetti (O'Leary JA, Leonetti HB. Shoulder dystocia: prevention and treatment. AM J OBSTET GVNECOL 1990;162:5-9) was published in the Clinical Opinion section, I am concerned that some of the statements might be misconstrued. The third sentence in the paper implies that many shoulder dystocias can be prevented by quoting a source that states that many shoulder dystocias can be anticipated. Any algorithm to predict shoulder dystocia should include an estimation of the number of falsely alarming predictions of damage to the infant. In other words, how many "unnecessary" cesarean deliveries are necessary to prevent each case of shoulder dystocia? The suggestion that "once a shoulder dystocia, always a cesarean" obviously ignores the fact that there are complicated dynamics that predict whether shoulder dystocia will occur. Just as the necessity for a prior cesarean delivery for management of cephalopelvic disproportion poorly predicts the need for subsequent cesarean delivery for the same indication, in the absence of more compelling data we should not accept the thought that shoulder dystocia will predictably repeat itself. Finally, the order of suggested treatment of shoulder dystocia that the authors propose in Table IV is certainly debatable; however, I would suggest that the maneuvers begin with the least invasive, that is, the McRoberts maneuver. Proceeding with a list as suggested is sensible, although I still am concerned about the suggestion that the head can be forcibly replaced with safety. Although this may be an appropriate procedure in the authors' hands, multisite performance in more patients will make me (and many others) feel more comfortable. Whereas it is certainly true that increasing the cesarean section rate will, as the authors propose, reduce the incidence of shoulder dystocia, it will also increase the incidence of maternal morbidity and mortality. I hope that we can balance these risks in adopting a safe and sane standard for the management of this uncommon, but frightening and potentially disastrous complication of pregnancy. David A. Nagey, MD, PhD Section of Obstetrics, Division of Maternal-Fetal Medicine, School of Medicine, University of Maryland at Baltimore, 22 South Greene St., Baltimore, MD 21201
Reply To the Editors: We appreciate Dr. Nagey's thoughtful and meaningful remarks. It is hoped that by raising the level of anticipation of shoulder dystocia a more thorough clinical assessment would allow the physician to accumulate more data and thus recognize more risk factors for shoulder dystocia (i.e., the flat pelvis). The expression "once a shoulder dystocia, always a cesarean" is based on the assumption that the same set