- Email: [email protected]
Care of the premature infant
354
June 1, 1981 Am. J. Obstet. Gynecol.
Correspondence
cortisol, Pediatr. 4. Murphy, fluid and 47:212,
and cortisone during infancy and childhood, Res. 14:39, 1980. B. E. P.: Conjugated glucocorticoids in amniotic fetal lung maturation, J, Clin. Endocrinol. Metab. 1978.
Reply to Dr. Sippell To the Editors: I would like to thank Dr. Sippell for his interest in my correspondence and for his comment. The observation of higher fluorescence of corticosterone compared to cortisol was made by using known standards of corticosterone and cortisol; the higher fluorescence of corticosterone over cortisol consequently is beyond any doubt, although that does not necessarily reflect higher levels of corticosterone over cortisol in the amniotic fluid. We made no attempt to characterize the different corticosteroids in the amniotic fluid and fully agree with Dr. Sippell’s observation on the amniotic fluid corticosteroid level with the use of a specific radioassay procedure. It is comforting to note that Dr. Sippell also thinks along similar lines regarding the reliability of corticosterone and cortisol sulfates over unconjugated cortisol to predict respiratory distress syndrome. There are evidences. however, that fetal pulmonary maturity depends on other hormones besides fetal adrenal corticosteroids, e.g., prolactin, thyroxine, and insulin levels. Trishit Kumar Mukherjee, M.D., Ph.D. Department of Obstetrics and Gynecology Long Island College Hospital Brooklyn, New York 11201
Care of the premature infant To the Editors: Dr. Kirkley’s recent article (AM. J. OBSTET. GYNECOL. 137:873, 1980) in which he characterizes and describes a newborn intensive care unit has the same grace, good taste, and manners as someone claiming that all hysterectomies are unnecessary and gynecologists who perform them do so only for financial gain. Rather than comment directly on this emotionally based (the rationale for referring to Dr. Edelin is beyond me), selectively biased (has Dr. Kirkley never encountered a normal NICU survivor?), apples-andoranges (strategy for otherwise normal premature infants based on an analysis derived from infants with severe congenital malformations is as valid as planning therapy for cervical carcinoma based on data derived from patients with ovarian neoplasms) analysis, attention should instead be drawn to a recent well-conceived and balanced presentation concerned with many of the same issues.’ However, comments on three specific aspects of Dr. Kirkley’s essay are very much in order. First, the statement, “Sick neonates .who are admitted to a neonatal
Table
I. Mortality Weight (gm)
<750 751-1,000 l,OOl-1,250 1,251-1,500 1,501-2,000 2,001-2,500 >2,500
Total
by birth
weight*
No. alive
No. dead
2 16 20 36 86 69 203 432
8 6 7 4 2 1 lo 38
Survival C%) 20 73 74 90 98 99 95 92
*Does not include congenital anomalies incompatible with life. Data collected from April 1, 1979, through May 31, 1980.
intensive care unit in a university setting have a better prognosis than those who are not,” fails to recognize that excellent perinatal care is occurring in nonuniversity hospitals in many parts of the country. ‘4s an example, neonatal survival data from this unit are shown in Table I. Without belaboring the point, the survival data from this private non-university hospital are comparable to those of any university NICU in the country. Second, if, as suggested by Dr. Kirkley, small premature babies delivered by himself are subsequently transported to a NICU, then failure to recognize the inherent advantage of maternal transport as opposed to newborn transport2 may in part be contributing to the subsequent neonatal morbidity that apparently afHicts his practice. Finally, an apparent failure to communicate with his neonatal colleagues regarding perinatal patient care planning and intrauterine versus extrauterine risk/ benefit ratios is evident in many of the examples used in his essay. It appears that Dr. Kirkley does not enjoy the advantage of practicing in a perinatal system in which patient problems and solutions to those problems are mutually and prospectively defined. There is no doubt that difficult medical, administrative, and ethical questions have arisen in modern perinatal care. There is no doubt that these questions must be resolved by honest and reasoned thinking by everyone involved in this type of care. It is extremely unfortunate that from the prestige afforded a presidential address a better effort at defining and answering modern perinatal dilemmas was not forthcoming. G. Eric Knox, M.D. John Fangman, M.D. Ronald Hoekstra, M.D. Elizabeth Perkett, M.D. David Brasel, M.D. Departments of Perinatology and Neonatology The Perinatal Center Abbott-Northwestern Hospital 2525 Chicago Avenue Minneapolis, Minnesota 55404
Volume Number
140 3
REFERENCES
1. Budetti, P., McManus, P., Barrand, N., and Heinen, L.: The Cost Effectiveness of Neonatal Intensive Care, Washington, D. C., February 22, 1980, U. S. Congress, Office of Technology Assessment. 2. Harris, T.: Toward a rational appraisal of maternal transport, Perinat. Neonat. Med., November-December, 1979, p. 13.
Reply to Knox et al. To the Editors: The letter from Dr. Knox and his colleagues is rather difficult to answer. I made the decision to present the subject, “Fetal survival-What price,” as my presidential address because I felt that we had advanced so far so rapidly, and would no doubt make much greater progress in solving the problems of fetal survival, that we must take stock of where we were and, more importantly, of where we wished to go. The address was well received at the time of its presentation to 500 physicians and their spouses. Since that time I have had more than 25 letters and many phone calls from complete strangers who congratulated me on having chosen such a timely subject. (At this time more such letters are still coming.) All stated that this is a problem to which obstetricians must address themselves. To date, I have not received a single derogatory letter, such as the one from Dr. Knox and his colleagues. Also I have received more than 75 requests for reprints of my address from all over the United States and many foreign countries. In an effort to answer the letter from Dr. Knox and his colleagues point by point, I would like to state that I do not believe paragraph one is worthy of any comment. The purpose of referring to Dr. Edelin was clearly stated in the text of my address, I think. Therefore, 1 suggest that the address be re-read by them. I am sorry that they misinterpreted my statements regarding NICU survivors as “selective bias.” In response to paragraph three, I do wish to apologize. I should have stated <‘a university setting or one of equal or better standards.” The chart presented by Dr. Knox and his colleagues with the results in their NICU is of little value as there were only 18 cases of fetal survival in those infants weighing 1,000 gm or less (a very small series). More important is the fact that the chart tells us nothing of the quality of life of these neonates. I would like to know what these 18 babies will be like at age 7 or older. Again I ask this question: “Is survival enough or is the quality of life of the survivor to be taken into consideration?’ In reply to paragraph four, there is a NICU unit in our hospital, but until very recently there was not a full-time neonatologist on the hospital staff. On several occasions I have tried to have a pregnant patient transferred to a nearby university hospital, but because of a shortage of bassinets our patients were not accepted for
Correspondence
355
transfer. Most obstetricians in our state have had similar experiences. In paragraph five, Dr. Knox and his colleagues are correct in assuming that I did not often consult a neonatologist. I did not as none was available. Unfortunately this is probably the situation in perhaps 90% of all hospitals in the United States. The last paragraph of the letter is also not worthy of comment. Unfortunately, the rambling letter from Dr. Knox. and his colleagues does not really deal with the theme of my address. This is most regrettable because I am sure we all might have benefited from their expertise. William H. Kirkley, M.D. 2000 South Andrews Azrenue Fort Lauderdale, Florida 333 I6
Risk of cardiovascular disease following hysterectomy To the Editors: Before gynecologists “consider advising premenopausal women considering hysterectomy on the risks of coronary heart disease following the procedure,” based on the report by Brandon S. Centerwall, M.D., M.P.H. (Premenopausal hysterectomy and cardiovascular disease, AM. J. OBSTET. GYNECOL. 139:58, 1981), I am of the opinion that more information is needed than that presented in the aforementioned report. Furthermore, it would be hoped that women considering hysterectomy are so considering based on sound medical advice that hysterectomy is indicated. Therefore, into the equation, one needs to add the risks to which such women are exposed by refusing the advice for hysterectomy. This leads to a consideration of one of the three items not included in the report. These missing items make the report, in my opinion, merely preliminary and speculative, to wit: the indication for hysterectomy, be it for bleeding disorder, prolapse, leiomyomas, tuboovarian abscess, endometriosis, atypical hyperplasia, or other, whether the surgery was accomplished transvaginally or transabdominally, whether or not other procedures were done concurrently, such as bladder or vaginal repair, and whether or not there were complications, perhaps requiring rehospitalization and repeat surgery. One would expect there to be quite a difference in ovarian function between a multiparous woman with prolapse and a nulliparous woman with endometriosis or atypical hyperplasia. The complexity of the surgery, likely to be more so if done transabdominally as opposed to transvaginally, may have different influences on that
part
uterine
artery
ian
function,
of the
ovarian
branches, even
though
blood
thereby the
supply
coming
compromising
integrity
of the
from
ovarovarian
arteries is maintained. Although such may be rare, as reported by Beavis and associates,’ it has been docu-
June 1, 1981 Am. J. Obstet. Gynecol.
Correspondence
cortisol, Pediatr. 4. Murphy, fluid and 47:212,
and cortisone during infancy and childhood, Res. 14:39, 1980. B. E. P.: Conjugated glucocorticoids in amniotic fetal lung maturation, J, Clin. Endocrinol. Metab. 1978.
Reply to Dr. Sippell To the Editors: I would like to thank Dr. Sippell for his interest in my correspondence and for his comment. The observation of higher fluorescence of corticosterone compared to cortisol was made by using known standards of corticosterone and cortisol; the higher fluorescence of corticosterone over cortisol consequently is beyond any doubt, although that does not necessarily reflect higher levels of corticosterone over cortisol in the amniotic fluid. We made no attempt to characterize the different corticosteroids in the amniotic fluid and fully agree with Dr. Sippell’s observation on the amniotic fluid corticosteroid level with the use of a specific radioassay procedure. It is comforting to note that Dr. Sippell also thinks along similar lines regarding the reliability of corticosterone and cortisol sulfates over unconjugated cortisol to predict respiratory distress syndrome. There are evidences. however, that fetal pulmonary maturity depends on other hormones besides fetal adrenal corticosteroids, e.g., prolactin, thyroxine, and insulin levels. Trishit Kumar Mukherjee, M.D., Ph.D. Department of Obstetrics and Gynecology Long Island College Hospital Brooklyn, New York 11201
Care of the premature infant To the Editors: Dr. Kirkley’s recent article (AM. J. OBSTET. GYNECOL. 137:873, 1980) in which he characterizes and describes a newborn intensive care unit has the same grace, good taste, and manners as someone claiming that all hysterectomies are unnecessary and gynecologists who perform them do so only for financial gain. Rather than comment directly on this emotionally based (the rationale for referring to Dr. Edelin is beyond me), selectively biased (has Dr. Kirkley never encountered a normal NICU survivor?), apples-andoranges (strategy for otherwise normal premature infants based on an analysis derived from infants with severe congenital malformations is as valid as planning therapy for cervical carcinoma based on data derived from patients with ovarian neoplasms) analysis, attention should instead be drawn to a recent well-conceived and balanced presentation concerned with many of the same issues.’ However, comments on three specific aspects of Dr. Kirkley’s essay are very much in order. First, the statement, “Sick neonates .who are admitted to a neonatal
Table
I. Mortality Weight (gm)
<750 751-1,000 l,OOl-1,250 1,251-1,500 1,501-2,000 2,001-2,500 >2,500
Total
by birth
weight*
No. alive
No. dead
2 16 20 36 86 69 203 432
8 6 7 4 2 1 lo 38
Survival C%) 20 73 74 90 98 99 95 92
*Does not include congenital anomalies incompatible with life. Data collected from April 1, 1979, through May 31, 1980.
intensive care unit in a university setting have a better prognosis than those who are not,” fails to recognize that excellent perinatal care is occurring in nonuniversity hospitals in many parts of the country. ‘4s an example, neonatal survival data from this unit are shown in Table I. Without belaboring the point, the survival data from this private non-university hospital are comparable to those of any university NICU in the country. Second, if, as suggested by Dr. Kirkley, small premature babies delivered by himself are subsequently transported to a NICU, then failure to recognize the inherent advantage of maternal transport as opposed to newborn transport2 may in part be contributing to the subsequent neonatal morbidity that apparently afHicts his practice. Finally, an apparent failure to communicate with his neonatal colleagues regarding perinatal patient care planning and intrauterine versus extrauterine risk/ benefit ratios is evident in many of the examples used in his essay. It appears that Dr. Kirkley does not enjoy the advantage of practicing in a perinatal system in which patient problems and solutions to those problems are mutually and prospectively defined. There is no doubt that difficult medical, administrative, and ethical questions have arisen in modern perinatal care. There is no doubt that these questions must be resolved by honest and reasoned thinking by everyone involved in this type of care. It is extremely unfortunate that from the prestige afforded a presidential address a better effort at defining and answering modern perinatal dilemmas was not forthcoming. G. Eric Knox, M.D. John Fangman, M.D. Ronald Hoekstra, M.D. Elizabeth Perkett, M.D. David Brasel, M.D. Departments of Perinatology and Neonatology The Perinatal Center Abbott-Northwestern Hospital 2525 Chicago Avenue Minneapolis, Minnesota 55404
Volume Number
140 3
REFERENCES
1. Budetti, P., McManus, P., Barrand, N., and Heinen, L.: The Cost Effectiveness of Neonatal Intensive Care, Washington, D. C., February 22, 1980, U. S. Congress, Office of Technology Assessment. 2. Harris, T.: Toward a rational appraisal of maternal transport, Perinat. Neonat. Med., November-December, 1979, p. 13.
Reply to Knox et al. To the Editors: The letter from Dr. Knox and his colleagues is rather difficult to answer. I made the decision to present the subject, “Fetal survival-What price,” as my presidential address because I felt that we had advanced so far so rapidly, and would no doubt make much greater progress in solving the problems of fetal survival, that we must take stock of where we were and, more importantly, of where we wished to go. The address was well received at the time of its presentation to 500 physicians and their spouses. Since that time I have had more than 25 letters and many phone calls from complete strangers who congratulated me on having chosen such a timely subject. (At this time more such letters are still coming.) All stated that this is a problem to which obstetricians must address themselves. To date, I have not received a single derogatory letter, such as the one from Dr. Knox and his colleagues. Also I have received more than 75 requests for reprints of my address from all over the United States and many foreign countries. In an effort to answer the letter from Dr. Knox and his colleagues point by point, I would like to state that I do not believe paragraph one is worthy of any comment. The purpose of referring to Dr. Edelin was clearly stated in the text of my address, I think. Therefore, 1 suggest that the address be re-read by them. I am sorry that they misinterpreted my statements regarding NICU survivors as “selective bias.” In response to paragraph three, I do wish to apologize. I should have stated <‘a university setting or one of equal or better standards.” The chart presented by Dr. Knox and his colleagues with the results in their NICU is of little value as there were only 18 cases of fetal survival in those infants weighing 1,000 gm or less (a very small series). More important is the fact that the chart tells us nothing of the quality of life of these neonates. I would like to know what these 18 babies will be like at age 7 or older. Again I ask this question: “Is survival enough or is the quality of life of the survivor to be taken into consideration?’ In reply to paragraph four, there is a NICU unit in our hospital, but until very recently there was not a full-time neonatologist on the hospital staff. On several occasions I have tried to have a pregnant patient transferred to a nearby university hospital, but because of a shortage of bassinets our patients were not accepted for
Correspondence
355
transfer. Most obstetricians in our state have had similar experiences. In paragraph five, Dr. Knox and his colleagues are correct in assuming that I did not often consult a neonatologist. I did not as none was available. Unfortunately this is probably the situation in perhaps 90% of all hospitals in the United States. The last paragraph of the letter is also not worthy of comment. Unfortunately, the rambling letter from Dr. Knox. and his colleagues does not really deal with the theme of my address. This is most regrettable because I am sure we all might have benefited from their expertise. William H. Kirkley, M.D. 2000 South Andrews Azrenue Fort Lauderdale, Florida 333 I6
Risk of cardiovascular disease following hysterectomy To the Editors: Before gynecologists “consider advising premenopausal women considering hysterectomy on the risks of coronary heart disease following the procedure,” based on the report by Brandon S. Centerwall, M.D., M.P.H. (Premenopausal hysterectomy and cardiovascular disease, AM. J. OBSTET. GYNECOL. 139:58, 1981), I am of the opinion that more information is needed than that presented in the aforementioned report. Furthermore, it would be hoped that women considering hysterectomy are so considering based on sound medical advice that hysterectomy is indicated. Therefore, into the equation, one needs to add the risks to which such women are exposed by refusing the advice for hysterectomy. This leads to a consideration of one of the three items not included in the report. These missing items make the report, in my opinion, merely preliminary and speculative, to wit: the indication for hysterectomy, be it for bleeding disorder, prolapse, leiomyomas, tuboovarian abscess, endometriosis, atypical hyperplasia, or other, whether the surgery was accomplished transvaginally or transabdominally, whether or not other procedures were done concurrently, such as bladder or vaginal repair, and whether or not there were complications, perhaps requiring rehospitalization and repeat surgery. One would expect there to be quite a difference in ovarian function between a multiparous woman with prolapse and a nulliparous woman with endometriosis or atypical hyperplasia. The complexity of the surgery, likely to be more so if done transabdominally as opposed to transvaginally, may have different influences on that
part
uterine
artery
ian
function,
of the
ovarian
branches, even
though
blood
thereby the
supply
coming
compromising
integrity
of the
from
ovarovarian
arteries is maintained. Although such may be rare, as reported by Beavis and associates,’ it has been docu-