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Delivery of tiny neonates
742 Correspondence
July 15,
Am.
Delivery of tiny neonates To the Editors: I should like to write a note in support of Drs. Goldenberg and Davis' suggestion (AM.]. OBSTET. GvNEcoL. 145:645, 1983) that the tiny premature infant be delivered "in caul." Although strong advocates of classical cesarean section 1 for tiny premature infants, we have, over the past 18 months, had four newborn infants who weighed between 600 and 750 gm delivered vaginally. All were delivered in caul and with the "hands off" technique. Three of the four (including two breech presentations) did exceedingly well in the nursery and went home after stays of 3 and 4 months. The fourth infant is still in the nursery with evidence of intraventricular hemorrhage and hydrocephalus. Our brief experience suggests that vaginal delivery can be as atraumatic as delivery by cesarean section, provided that the membranes remain intact and, particularly with breech presentations, there is a hands-off policy of allowing completely spontaneous delivery. As noted by Drs. Goldenberg and Davis, no one institution can collect an adequate series. The need remains for a collaborative study to test which is the best technique for delivery of the tiny infant. Robert C. Goodlin, M.D. Department of Obstetrics and Gynecology University of Nebraska Medical Center 42nd and Dewey Avenue Omaha, Nebraska 68105 REFERENCE 1. Haesslein, H. C., and Goodlin, R. C.: Delivery of the tiny newborn, AM. j. 0BSTET. GYNECOL. 134:192, 1979.
Breast stimulation to ripen cervix To the Editors: I was quite interested in the report by Drs. Elliot and Flaherty (AM.J. 0BSTET. GYNECOL. 145:553, 1983) on the use of breast stimulation to ripen the cervix. We at Downstate Medical Center and Kings County Hospital have extensive experience with the breast stimulation test (BST) and have also considered alternative uses for this technique. Therefore, I was pleased to see a prospective, controlled trial testing breast stimulation as a method for improving the Bishop score. However, we have often noted, in our breast stimulation tests, a subpopulation of women who have hyperstimulation during BST and who have to be counseled about decreasing the amount of stimuli. Therefore, I am somewhat concerned that physicians may apply Drs. Elliot and Flaherty's results (and limitation of monitoring to the first hour) to patients near term who may have underlying problems, such as chronic hypertension or postmaturity, that would both warrant induction and increase the risks from unmonitored uterine contractions, especially if the contractions occurred more frequently then every 2 minutes. Until further testing is done, I suggest that unmonitored breast stimulation not be offered to patients with
19R~l
J. Obstet. Gynecol.
illnesses that predispose toward uteroplacental insufficiency. Although the authors stated that they did not include such patients, they did mention that labor was eventually induced in three patients because of"worsening maternal disease." It is important to bear the risks in mind, since the population for whom induction is beneficial is generally a population with a high incidence of uteroplacental insufficiency. Howard Minkoff, M.D. Department of Obstetrics and Gynecology State University of New York Downstate Medical Center 450 Clarkson Avenue Brooklyn, New York 11203
Hydatoxf lualba: Organism or artifact? To the Editors: In the January 1, 1983, issue of the AMERICAN JouRNAL OF OBSTETRICS AND GYNECOLOGY, we published an article, entitled "Observation of an organism found in patients with gestational trophoblastic disease and in patients with toxemia of pregnancy" (AM. ]. OBSTET. GYNECOL. 145:15, 1983). In the last sentence of the article we stated: "We are fully cognizant of the fact that confirmation by other investigators concerning the nature and significance of our findings is required." Some parasitologists have expressed the opinion that they doubt the described organism to be a parasite. In view of this, the Dean of the Loyola Stritch School of Medicine, Dr. John Tobin, convened a panel of three parasitologists for the purpose of reviewing the material. These reviewers were: Maurice Dale Little, Ph.D., Professor of Parasitology at Tulane University, New Orleans, Louisiana, who acted as Chairman of the Committee, Benedict Jacob Jaskoski, Ph.D., Professor of Biology at Loyola University of Chicago, Chicago, Illinois, and Ralph James Lichtenfels, Ph.D., from the Animal Parasitology Institute, Beltsville, Maryland. All of our material was made available to them. After reviewing the microscopic slides, the committee came to the following "Findings and Conclusions," and we quote: The material examined included slides selected by Miss Lueck and said to contain various forms of the organism in question. The forms on some of these slides were the ones illustrated in the above-mentioned paper. In general, there were two types of forms present on these slides: an elongate form with a central canal and spheroid forms with central dark-staining areas. From our knowledge of the morphologic features of various groups of parasites (protozoa, helminths, etc.), we have concluded that the objects in question are not parasites. Rather, the features of these objects (their structure and birefringence under polarized light) indicate that some are fibers of plant origin and some are crystalline in nature. It seems likely that all are contaminants of the preparation. The source of these objects is not known but it is suspected that the crystalline structures are talc and come from surgical gloves.
Work is being continued in our laboratories to determine the component(s) in the hypotonic concen-
July 15,
Am.
Delivery of tiny neonates To the Editors: I should like to write a note in support of Drs. Goldenberg and Davis' suggestion (AM.]. OBSTET. GvNEcoL. 145:645, 1983) that the tiny premature infant be delivered "in caul." Although strong advocates of classical cesarean section 1 for tiny premature infants, we have, over the past 18 months, had four newborn infants who weighed between 600 and 750 gm delivered vaginally. All were delivered in caul and with the "hands off" technique. Three of the four (including two breech presentations) did exceedingly well in the nursery and went home after stays of 3 and 4 months. The fourth infant is still in the nursery with evidence of intraventricular hemorrhage and hydrocephalus. Our brief experience suggests that vaginal delivery can be as atraumatic as delivery by cesarean section, provided that the membranes remain intact and, particularly with breech presentations, there is a hands-off policy of allowing completely spontaneous delivery. As noted by Drs. Goldenberg and Davis, no one institution can collect an adequate series. The need remains for a collaborative study to test which is the best technique for delivery of the tiny infant. Robert C. Goodlin, M.D. Department of Obstetrics and Gynecology University of Nebraska Medical Center 42nd and Dewey Avenue Omaha, Nebraska 68105 REFERENCE 1. Haesslein, H. C., and Goodlin, R. C.: Delivery of the tiny newborn, AM. j. 0BSTET. GYNECOL. 134:192, 1979.
Breast stimulation to ripen cervix To the Editors: I was quite interested in the report by Drs. Elliot and Flaherty (AM.J. 0BSTET. GYNECOL. 145:553, 1983) on the use of breast stimulation to ripen the cervix. We at Downstate Medical Center and Kings County Hospital have extensive experience with the breast stimulation test (BST) and have also considered alternative uses for this technique. Therefore, I was pleased to see a prospective, controlled trial testing breast stimulation as a method for improving the Bishop score. However, we have often noted, in our breast stimulation tests, a subpopulation of women who have hyperstimulation during BST and who have to be counseled about decreasing the amount of stimuli. Therefore, I am somewhat concerned that physicians may apply Drs. Elliot and Flaherty's results (and limitation of monitoring to the first hour) to patients near term who may have underlying problems, such as chronic hypertension or postmaturity, that would both warrant induction and increase the risks from unmonitored uterine contractions, especially if the contractions occurred more frequently then every 2 minutes. Until further testing is done, I suggest that unmonitored breast stimulation not be offered to patients with
19R~l
J. Obstet. Gynecol.
illnesses that predispose toward uteroplacental insufficiency. Although the authors stated that they did not include such patients, they did mention that labor was eventually induced in three patients because of"worsening maternal disease." It is important to bear the risks in mind, since the population for whom induction is beneficial is generally a population with a high incidence of uteroplacental insufficiency. Howard Minkoff, M.D. Department of Obstetrics and Gynecology State University of New York Downstate Medical Center 450 Clarkson Avenue Brooklyn, New York 11203
Hydatoxf lualba: Organism or artifact? To the Editors: In the January 1, 1983, issue of the AMERICAN JouRNAL OF OBSTETRICS AND GYNECOLOGY, we published an article, entitled "Observation of an organism found in patients with gestational trophoblastic disease and in patients with toxemia of pregnancy" (AM. ]. OBSTET. GYNECOL. 145:15, 1983). In the last sentence of the article we stated: "We are fully cognizant of the fact that confirmation by other investigators concerning the nature and significance of our findings is required." Some parasitologists have expressed the opinion that they doubt the described organism to be a parasite. In view of this, the Dean of the Loyola Stritch School of Medicine, Dr. John Tobin, convened a panel of three parasitologists for the purpose of reviewing the material. These reviewers were: Maurice Dale Little, Ph.D., Professor of Parasitology at Tulane University, New Orleans, Louisiana, who acted as Chairman of the Committee, Benedict Jacob Jaskoski, Ph.D., Professor of Biology at Loyola University of Chicago, Chicago, Illinois, and Ralph James Lichtenfels, Ph.D., from the Animal Parasitology Institute, Beltsville, Maryland. All of our material was made available to them. After reviewing the microscopic slides, the committee came to the following "Findings and Conclusions," and we quote: The material examined included slides selected by Miss Lueck and said to contain various forms of the organism in question. The forms on some of these slides were the ones illustrated in the above-mentioned paper. In general, there were two types of forms present on these slides: an elongate form with a central canal and spheroid forms with central dark-staining areas. From our knowledge of the morphologic features of various groups of parasites (protozoa, helminths, etc.), we have concluded that the objects in question are not parasites. Rather, the features of these objects (their structure and birefringence under polarized light) indicate that some are fibers of plant origin and some are crystalline in nature. It seems likely that all are contaminants of the preparation. The source of these objects is not known but it is suspected that the crystalline structures are talc and come from surgical gloves.
Work is being continued in our laboratories to determine the component(s) in the hypotonic concen-