- Email: [email protected]
Cervical length may change duringultrasonogprahic examination
Volume 162 Number 5
than the control group. Because of these concerns, it was justified and necessary to report the findings of my meta-analysis with and without the study by Morales et al. 9 If one adds the adverse outcomes (RDS plus infection) in the five accepted studies, there is a statistically significant benefits of antenatal steroids (treatment group 99/285, control group 127/277, P = 0.01). However, if the study by Morales et al." is excluded, the benefit disappears (treatment group 581164, control group 53/153, p = 0.99). None of these four separate studies lO- 13 or my meta-analysis has the power (80%) to demonstrate a significant (P < 0.05) increase in neonatal infection with steroid treatment. Such a study would require a sample size of950 to 1000 patients. It also should be noted that the diangosis of RDS and congenital infection does not carry the same weight regarding outcome, the mortality being seven times higher in congenital infection (Hannah M, Ohlsson A. Unpublished data). The meta-analysis does, however, confirm a significant increase in endometritis (P = 0.002). Contrary to what Dr. Goodlin states, Morales et al. 9 did not report on the incidence of endometritis. Whether appropriate treatment with antibiotics in conjunction with antenatal steroids can eliminate the increased risk for maternal infection and the possible increased risk for fetal-neonatal infection, resulting in a better overall maternal-fetal-neonatal outcome, still is not known. This appears, however, to be a very important question for obstetric and neonatal perinatologists to answer in cooperation, as soon as possible, in a multicenter randomized controlled trial. It is time to replace strong beliefs expressed by perinatologists (obstetric and neonatal) with validated facts. Instead of quoting Lewis Carroll, I prefer to cite his countrymen, Chalmers et al. l7 : "If perinatal medicine is to shed the reputation it has gained in some quarters for reckless development of clinical practice ungrounded in good evidence, then not only must we try harder to ensure that patients are involved in well-controlled rather than poorly controlled experiments, we must also make more determined efforts to ensure that the quality of these controlled experiments improves." Arne Ohlsson, MD Regional Perinatal Unit Women's College Hospital 76 Grenville St. Toronto, Ontario, Canada M5S IB2
REFERENCES I. Monif GRG, Hume R, Goodlin RC. Neonatal considerations in the management of premature rupture of the fetal membranes. Obstet Gynecol Surv 1986;41 :531-7. 2. Ohlsson A, Vearncombe M. Congenital and nosocomial sepsis in infants born in a regional perinatal unit: cause, outcome, and white blood cell response. AM 1 OBSTET GYNECOL 1987;156:407-13. 3. Ohlsson A, Serenius F. Neonatal septicemia in Riyadh, Saudi Arabia. Acta Paediatr Scand 1981;70:825-9.
Correspondence
1355
4. Ohlsson A, Shennan AT, Rose TH. Review of causes of perinatal mortality in a regional perinatal center, 1980 to 1984. AM1 OBSTET GYNECOL 1987;157;443-5. 5. Cox SM, Williams AL, Leveno K1. The natural history of preterm ruptured membranes: what to expect of expectant management. Obstet Gynecol 1988;71 :558-62. 6. Lubchenco LO, Butterfield q, Delaney-Black V, Goldson E, Koops BL, Lazotte DC. Outcome of very-Iow-birthweight infants: does antepartum versus neonatal referral have a better impact on mortality, morbidity, or long-term outcome? AM 1 OBSTET GYNECOL 1989; 160:539-45. 7. Singer .I, Sacks HS, Lucente F, Chalmers TC. Physician attitudes toward applications of computer data base systems . .lAMA 1983;249:1610-4. 8. Williamson .IW, Goldschmidt PG, Colton T. The quality of medical literature: an analysis of validation assessments. In: Bailar .IC III, Mosteller F, eds. Medical uses of statistics. Waltham, Massachusetts: NE1M Books, 1986:370-91. 9. Morales W1, Diebel ND, Lazar A.I, Zadrozny D. The effect of antenatal dexamethasone administration on the prevention of respiratory distress syndrome in preterm gestations with premature rupture of membranes. AM .I OBSTET GYNECOL 1986;154:591-5. 10. Garite TJ, Freeman RK, Linzey EM, Braly PS, Dorchester WL. Prospective randomized study of corticosteroids in the management of premature rupture of the membranes and the premature gestation. AM 1 OBSTET GYNECOL 1981; 141 :508-15. II. Schmidt PL, Sims ME, Strassner HT, Paul RH, Mueller E, McCart D. Effect of antepartum glucocorticoid administration upon neonatal respiratory distress syndrome and perinatal infection. AMJ OBSTET GYNECOL 1984; 148: 17886. 12. lams 1D, Talbert ML, Barrows H, Sachs L. Management of preterm prematurely ruptured membranes: a prospective randomized comparison of observation versus use of steroids and timed delivery. AM.I OBSTET GYNECOL 1985; 151 :32-8. 13. Nelson LH, Meis PJ, Hatjis CG, Ernest .IM, Dillard R, Schey HM. Premature rupture of membranes: a prospective, randomized evaluation of steroids, latent phase, and expectant management. Obstet Gynecol 1985;66: 55-8. 14. Chalmers TC, Smith H, Blackburn B, et al. A method for assessing the quality of a randomized control trial. Controlled Clin Trials 1981;2:31-49. IS. Porreco RP, Burke MS. Selection of study patients with premature rupture of membranes [Letter]. AM J OBSTET GYl\ECOL 1987: I S6:766-7 . . 16. Veille JC. Management of preterm premature rupture of membranes. Clin Perinatol 1898;IS:8S1-62. 17. Chalmers I, Grant A, Elbourne D. Improving the quality of therapeutic trails in perinatal medicine: a professional duty to mothers and children. In: Klaus MH, Fanaroff AA, eds. The year book of perinatal/neonatal medicine. Chicago: Year Book, 1987: IS-9.
Cervical length may change during ultrasonographlc examination To the Editors: Abdominal and vaginal ultrasonography has been shown to hold some promise in the evaluation of the gravid cervix uteri. It has been used not only for measurement of the cervical length, but also for evaluation of the shape of the internal cervical os and canal. The significance of "funneling" of the in-
1356 Correspondence
May 1990 Am J Obstet Gynecol
Fig. l. Appearance of cervix studied by vaginal ultrasonography (Combison 310, 7.5 MHz, Kretz, Austria).
Fig. 2. Same cervix 2 minutes into examination.
ternal os has not been fully elucidated but there is some evidence that its presence may increase the risk of premature birth. Our institution is currently involved in the assessment of the gravid cervix uteri in patients at risk for preterm birth with the use of vaginal ultrasonography. Similar research is being conducted at several centers in the United States. We would like to alert these investigators to an important finding that we have en-
countered in several subjects. We noticed that the cervical length along with the contour of the endocervical canal near the internal cervical os may change during the course of the ultrasonographic examination. This finding had been previously described in patients with classical cervical incompetence. It appears that this phenomenon is not confined to this group only. The "funneling" that may not be apparent or may be minimal at the beginning of the examination, may
Correspondence
Volume 162 Number 5
1357
Fig. 3. Same cervix 4 minutes into examination.
become pronounced over time. This is accompanied by shortening of the cervical length as measured from the apex of the funnel to the level of the external os. In our experience this process is complete within several minutes. It appears that in some subjects this process can be accelerated by gentle manual pressure on the uterus. The funneling can often be accentuated by pressure and, rarely, the funneling does not become apparent at all until pressure is applied. We now include this internal cervical os stress test in all vaginal ultrasonographic cervical evaluations. Figs. 1 to 3 represent an example of this phenomenon. Note that the funneling that appears to be absent at the beginning of the examination became unmistakable by the end of the examination and the cervical length was reduced by about one third during this time period. It must be stressed that an evaluation the gravid cervix with ultrasonography should not be considered complete until this phenomenon is ruled out and, if present, until the length and the shape of the cervix show no further change. Just before the study is terminated, the interval cervical os stress test should be performed. I Sonek, MD The Medical College of Georgia Department of Obstetrics and Gynecology Maternal-Fetal Section Augusta, GA 30912-3350 M. Blumenfeld, MD M. Foley, MD F. Johnson, RN IIams, MD The Ohio State University Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine Columbus, OH 43210
REFERENCE I. Parulekar SG, Kiwi R. Dynamic incompetent cervix uteri: so no graphic observations. J Ultrasound Med 19811;7: 481-5.
Absence of perineal pain does not rule out puerperal hematoma To the Editors: Drs. Chin et al. have written a splendid article (Chin HG, Scott DR, Resnik R, Davis GB, Lurie AL. Angiographic embolization of intractable puerperal hematomas. AM J OBSTET GYNECOL 1989; 160:434-8). It is stated that "excessive perineal pain shortly after delivery ... is the hallmark symptom." This statement is entirely correct. However, if the patient has a vaginal wall hematoma that arises above the levator ani, she may have only steadily increasing weakness and possibly a feeling of pain and pressure in the low back. The absence of perineal pain does not rule out a puerperal hematoma. Any patient who appears to be slipping into a shock-like state after delivery (especially in the absence of excessive vaginal bleeding) should have a vaginal examination to rule out an upper vaginal wall hematoma. Because such hematomas do not distend the sensitive labia and perineum, they may be almost entirely painless, while being very dangerous. Bruce A. Harris, Jr., MD Department of Obstetrics and Gynecology University of Alabama at Birmingham School of Medicine University Station Birmingham, AL 35294 Reply To the Editors: Dr. Harris makes an excellent point that perineal pain experienced by our two patients can be absent in
than the control group. Because of these concerns, it was justified and necessary to report the findings of my meta-analysis with and without the study by Morales et al. 9 If one adds the adverse outcomes (RDS plus infection) in the five accepted studies, there is a statistically significant benefits of antenatal steroids (treatment group 99/285, control group 127/277, P = 0.01). However, if the study by Morales et al." is excluded, the benefit disappears (treatment group 581164, control group 53/153, p = 0.99). None of these four separate studies lO- 13 or my meta-analysis has the power (80%) to demonstrate a significant (P < 0.05) increase in neonatal infection with steroid treatment. Such a study would require a sample size of950 to 1000 patients. It also should be noted that the diangosis of RDS and congenital infection does not carry the same weight regarding outcome, the mortality being seven times higher in congenital infection (Hannah M, Ohlsson A. Unpublished data). The meta-analysis does, however, confirm a significant increase in endometritis (P = 0.002). Contrary to what Dr. Goodlin states, Morales et al. 9 did not report on the incidence of endometritis. Whether appropriate treatment with antibiotics in conjunction with antenatal steroids can eliminate the increased risk for maternal infection and the possible increased risk for fetal-neonatal infection, resulting in a better overall maternal-fetal-neonatal outcome, still is not known. This appears, however, to be a very important question for obstetric and neonatal perinatologists to answer in cooperation, as soon as possible, in a multicenter randomized controlled trial. It is time to replace strong beliefs expressed by perinatologists (obstetric and neonatal) with validated facts. Instead of quoting Lewis Carroll, I prefer to cite his countrymen, Chalmers et al. l7 : "If perinatal medicine is to shed the reputation it has gained in some quarters for reckless development of clinical practice ungrounded in good evidence, then not only must we try harder to ensure that patients are involved in well-controlled rather than poorly controlled experiments, we must also make more determined efforts to ensure that the quality of these controlled experiments improves." Arne Ohlsson, MD Regional Perinatal Unit Women's College Hospital 76 Grenville St. Toronto, Ontario, Canada M5S IB2
REFERENCES I. Monif GRG, Hume R, Goodlin RC. Neonatal considerations in the management of premature rupture of the fetal membranes. Obstet Gynecol Surv 1986;41 :531-7. 2. Ohlsson A, Vearncombe M. Congenital and nosocomial sepsis in infants born in a regional perinatal unit: cause, outcome, and white blood cell response. AM 1 OBSTET GYNECOL 1987;156:407-13. 3. Ohlsson A, Serenius F. Neonatal septicemia in Riyadh, Saudi Arabia. Acta Paediatr Scand 1981;70:825-9.
Correspondence
1355
4. Ohlsson A, Shennan AT, Rose TH. Review of causes of perinatal mortality in a regional perinatal center, 1980 to 1984. AM1 OBSTET GYNECOL 1987;157;443-5. 5. Cox SM, Williams AL, Leveno K1. The natural history of preterm ruptured membranes: what to expect of expectant management. Obstet Gynecol 1988;71 :558-62. 6. Lubchenco LO, Butterfield q, Delaney-Black V, Goldson E, Koops BL, Lazotte DC. Outcome of very-Iow-birthweight infants: does antepartum versus neonatal referral have a better impact on mortality, morbidity, or long-term outcome? AM 1 OBSTET GYNECOL 1989; 160:539-45. 7. Singer .I, Sacks HS, Lucente F, Chalmers TC. Physician attitudes toward applications of computer data base systems . .lAMA 1983;249:1610-4. 8. Williamson .IW, Goldschmidt PG, Colton T. The quality of medical literature: an analysis of validation assessments. In: Bailar .IC III, Mosteller F, eds. Medical uses of statistics. Waltham, Massachusetts: NE1M Books, 1986:370-91. 9. Morales W1, Diebel ND, Lazar A.I, Zadrozny D. The effect of antenatal dexamethasone administration on the prevention of respiratory distress syndrome in preterm gestations with premature rupture of membranes. AM .I OBSTET GYNECOL 1986;154:591-5. 10. Garite TJ, Freeman RK, Linzey EM, Braly PS, Dorchester WL. Prospective randomized study of corticosteroids in the management of premature rupture of the membranes and the premature gestation. AM 1 OBSTET GYNECOL 1981; 141 :508-15. II. Schmidt PL, Sims ME, Strassner HT, Paul RH, Mueller E, McCart D. Effect of antepartum glucocorticoid administration upon neonatal respiratory distress syndrome and perinatal infection. AMJ OBSTET GYNECOL 1984; 148: 17886. 12. lams 1D, Talbert ML, Barrows H, Sachs L. Management of preterm prematurely ruptured membranes: a prospective randomized comparison of observation versus use of steroids and timed delivery. AM.I OBSTET GYNECOL 1985; 151 :32-8. 13. Nelson LH, Meis PJ, Hatjis CG, Ernest .IM, Dillard R, Schey HM. Premature rupture of membranes: a prospective, randomized evaluation of steroids, latent phase, and expectant management. Obstet Gynecol 1985;66: 55-8. 14. Chalmers TC, Smith H, Blackburn B, et al. A method for assessing the quality of a randomized control trial. Controlled Clin Trials 1981;2:31-49. IS. Porreco RP, Burke MS. Selection of study patients with premature rupture of membranes [Letter]. AM J OBSTET GYl\ECOL 1987: I S6:766-7 . . 16. Veille JC. Management of preterm premature rupture of membranes. Clin Perinatol 1898;IS:8S1-62. 17. Chalmers I, Grant A, Elbourne D. Improving the quality of therapeutic trails in perinatal medicine: a professional duty to mothers and children. In: Klaus MH, Fanaroff AA, eds. The year book of perinatal/neonatal medicine. Chicago: Year Book, 1987: IS-9.
Cervical length may change during ultrasonographlc examination To the Editors: Abdominal and vaginal ultrasonography has been shown to hold some promise in the evaluation of the gravid cervix uteri. It has been used not only for measurement of the cervical length, but also for evaluation of the shape of the internal cervical os and canal. The significance of "funneling" of the in-
1356 Correspondence
May 1990 Am J Obstet Gynecol
Fig. l. Appearance of cervix studied by vaginal ultrasonography (Combison 310, 7.5 MHz, Kretz, Austria).
Fig. 2. Same cervix 2 minutes into examination.
ternal os has not been fully elucidated but there is some evidence that its presence may increase the risk of premature birth. Our institution is currently involved in the assessment of the gravid cervix uteri in patients at risk for preterm birth with the use of vaginal ultrasonography. Similar research is being conducted at several centers in the United States. We would like to alert these investigators to an important finding that we have en-
countered in several subjects. We noticed that the cervical length along with the contour of the endocervical canal near the internal cervical os may change during the course of the ultrasonographic examination. This finding had been previously described in patients with classical cervical incompetence. It appears that this phenomenon is not confined to this group only. The "funneling" that may not be apparent or may be minimal at the beginning of the examination, may
Correspondence
Volume 162 Number 5
1357
Fig. 3. Same cervix 4 minutes into examination.
become pronounced over time. This is accompanied by shortening of the cervical length as measured from the apex of the funnel to the level of the external os. In our experience this process is complete within several minutes. It appears that in some subjects this process can be accelerated by gentle manual pressure on the uterus. The funneling can often be accentuated by pressure and, rarely, the funneling does not become apparent at all until pressure is applied. We now include this internal cervical os stress test in all vaginal ultrasonographic cervical evaluations. Figs. 1 to 3 represent an example of this phenomenon. Note that the funneling that appears to be absent at the beginning of the examination became unmistakable by the end of the examination and the cervical length was reduced by about one third during this time period. It must be stressed that an evaluation the gravid cervix with ultrasonography should not be considered complete until this phenomenon is ruled out and, if present, until the length and the shape of the cervix show no further change. Just before the study is terminated, the interval cervical os stress test should be performed. I Sonek, MD The Medical College of Georgia Department of Obstetrics and Gynecology Maternal-Fetal Section Augusta, GA 30912-3350 M. Blumenfeld, MD M. Foley, MD F. Johnson, RN IIams, MD The Ohio State University Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine Columbus, OH 43210
REFERENCE I. Parulekar SG, Kiwi R. Dynamic incompetent cervix uteri: so no graphic observations. J Ultrasound Med 19811;7: 481-5.
Absence of perineal pain does not rule out puerperal hematoma To the Editors: Drs. Chin et al. have written a splendid article (Chin HG, Scott DR, Resnik R, Davis GB, Lurie AL. Angiographic embolization of intractable puerperal hematomas. AM J OBSTET GYNECOL 1989; 160:434-8). It is stated that "excessive perineal pain shortly after delivery ... is the hallmark symptom." This statement is entirely correct. However, if the patient has a vaginal wall hematoma that arises above the levator ani, she may have only steadily increasing weakness and possibly a feeling of pain and pressure in the low back. The absence of perineal pain does not rule out a puerperal hematoma. Any patient who appears to be slipping into a shock-like state after delivery (especially in the absence of excessive vaginal bleeding) should have a vaginal examination to rule out an upper vaginal wall hematoma. Because such hematomas do not distend the sensitive labia and perineum, they may be almost entirely painless, while being very dangerous. Bruce A. Harris, Jr., MD Department of Obstetrics and Gynecology University of Alabama at Birmingham School of Medicine University Station Birmingham, AL 35294 Reply To the Editors: Dr. Harris makes an excellent point that perineal pain experienced by our two patients can be absent in