- Email: [email protected]
Incidence of morbidity
¥%lume 181, Number 6 AmJ Obstet Gynecol
logical. A better way to achieve the same end is to fully utilize vaginal surgery. T h e r e is n o r e a s o n why m o s t w o m e n with uterine fibroids or previous surgery, as well as a lack of uterine descent or a n e e d for oophorectomy, should n o t u n d e r g o vaginal hysterectomy. T h e reason why such cases are still s u b j e c t e d to a b d o m i n a l (and, m o r e recently, laparoscopic) hysterectomy is not because of a deficiency in vaginal surgery but rather the result of a lack of training and experience. If vaginal hysterectomy was d o n e for uteri that were e q u i v a l e n t in size to 14 weeks' gestation, for instance, almost 70% of w o m e n would be m a n a g e d by vaginal surgery. 3 It is a pity that the same effort currently e x t e n d e d to laparoscopic hysterectomy is not placed on developing this aspect of gynecologic surgery; if it were, far fewer adb o m i n a l (and l a p a r o s c o p i c ) h y s t e r e c t o m i e s w o u l d be done. Vaginal surgery may not be as m o d e r n or exciting as laparoscopic surgery, but who says the new is always better than the old?
Tariq Miskry, MD, Anthony Davies, MD, and Adam L. Magos, MD The RoyaIFreeHospital, London, b}zitedKingdom NW3 2QG REFERENCES 1. Kovac SR. Guidelines to determine the route of hysterectomy. Obstet Gynecol 1995;85:18-23. 2. Magos A, Bournas N, Sinha R, Richardson R, O'Connor H. Vaginal hysterectomy for the large uterus. BrJ Obstet Gynaecol 1996;103:246-51. 3. Davies A, Vizza E, Bournas N, O'Connor H, Magos A. How to increase the portion of hysterectomies performed vaginally. AmJ Obstet Gynecol 1998;179:1008-12.
6/8/102956
Letters 1581
ogist m o r e c o n f i d e n c e in p e r f o r m i n g a vaginal hysterectomy, even in the presence of those factors that in the past the average surgeon would consider a contraindication to vaginal hysterectomy. At the p r e s e n t time n o o n e can a r g u e that a very skilled vaginal s u r g e o n can p e r f o r m p r o c e d u r e s that would be d e e m e d beyond the skills of the practicing gynecologist. T h e comparison is to help the gynecologist, who does most of this surgery abdominally, to use the vaginal route with the help o£ laparoscopy. This is an additional o p t i o n in the a r m a m e n t a r i u m for the time being. T h e r e is no substitute for the vaginal surgeon who can p e r f o r m the feats m e n t i o n e d here, but in the m e a n t i m e the laparoscopically assisted vaginal hysterectomy should provide the m e a n s to p e r f o r m m o r e vaginal hysterectomies. Given these premises, no c o m m e n t is c o n s i d e r e d necessary to the n u m b e r s of feasibility given in this letter. We noticed that the authors repeatedly used the term laparoscopic hysterectomy. At the present time, so as not to increase thc confusion already f o u n d in the literature, it would be better for the authors to review the classification of laparoscopic hysterectomy published by Garry et al I in 1994 and to refer correctly to our p r o c e d u r e as laparoscopically assisted vaginal hysterectomy. It is a pity that the authors have not yet m a n a g e d to teach their skills in vaginal surgery to the o t h e r consultants of their hospital, where, as they are reporting, the c u r r e n t rate o£ a b d o m i n a l h y s t e r e c t o m y is as h i g h as 68.4% .2
Riccardo Marana, MD, and Enrico Zupi, MD Via Cassia 591, 00189, Rome, Italy REFERENCES
Reply To the Editors: We are pleased to h e a r that the authors have recently discovered, maybe t h r o u g h Italian connections, the i m p o r t a n c e of vaginal surgery and successfully p e r f o r m e d vaginal hysterectomies on uteri ranging up to 20 weeks' size. We are surprised that the authors of the letter did not recognize the University Hospitals where the study was carried out. There, for years, the few very skilled vaginal surgeons have p e r f o r m e d similar operations a c c o r d i n g to the Austrian and Italian tradition of vaginal surgery. However, these are not the skills of the majority of gynecologists. We are in a g r e e m e n t that vaginal h y s t e r e c t o m y is p r e f e r a b l e to a b d o m i n a l hysterectomy; however, evidence-based m e d i c i n e shows that a very large p e r c e n t a g e of hysterectomies are still d o n e via the a b d o m i n a l route, indicating that most gynecologists do not feel c o n f i d e n t e n o u g h with the vaginal route. T h e purpose of our study was to show that the current training in laparoscopic techniques may give the gynecol-
1. GanT R, Reich H, Liu CY. Laparoscopic hysterectomy--definitions and indications. Gynaecol Endosc 1994;3:1-3. 2. Davies A, Vizza E, Bournas N, O'Connor H, Magos A. How to increase the proportion of hysterectomies performed vaginally. ArnJ Obstet Gynecol 1998;179:1008-12.
6/8/102957
Incidence of morbidity To the Editors: I a m writing r e g a r d i n g the article by B o t t o m s et al ( B o t t o m s SF, Paul RH, M e r c e r BM, MacPherson CA, Caritis SN, Moawad AH, et al. Obstetric determinants of neonatal survival: Antenatal predictors of neonatal survival and morbidity in extremely low birth weight infants Am J Obstet Gynecol 1999;180:665-9). I was struck by the m a r k e d differences in the i n c i d e n c e of morbidity in the study of Bottoms et al as c o m p a r e d with o u r data t published at almost the same time. The difference, of course, is that Bottoms et al looked at markers o f l o n g - t e r m m o r b i d i t y in the hospital, whereas we looked at long-term disabilities at follow-up.
1582 Letters
In assessing our data we looked at the correlation of longterm disability with things that can be m e a s u r e d in the nursery. Only about half of the babies with grade III intraventricular h e m o r r h a g e will have significant handicaps, whereas 85% of babies with grade IV will have significant handicaps. T h e vast majority of babies who receive oxygen for 120 days after birth will be off oxygen by the age of 1 year and will be essentially normal f r o m a p u l m o n a r y standpoint, except for subtle differences in p u l m o n a r y f u n c t i o n studies and a h i g h e r i n c i d e n c e of asthma. Most babies with grade III retinopathy of prematurity will have n o r m a l vision with glasses, and even infants with unilateral grade IV retinopathy may be minimally h a n d i c a p p e d . We f o u n d that l u m p i n g grades III a n d IV i n t r a v e n t r i c u l a r h e m o r r h a g e with g r a d e IV retinopathy gave a p p r o x i m a t e l y the right n u m b e r s for disabled infants. A l t h o u g h about a third of these infants were not disabled, this m o r e or less m a t c h e d the n u m b e r of infants without these criteria who were disabled. Looking at the actual outcomes of the infants rather than markers of possible morbidity, we f o u n d that 60% of infants of 25 weeks' gestation who were alive at birth were intact at follow-up, and there was a greater percentage of m o r e mature infants. H a l f of the surviving infants of 23 or 24 weeks' gestation were intact at follow-up. This is not to discount the i m p o r t a n c e of having early markers of long-term morbidity so that a quick assessm e n t of the effects of i n t e r v e n t i o n s can be made. However, the data p r e s e n t e d by Bottoms et al are old e n o u g h that real follow-up information should be available at this time. Michael H. LeBlanc, MD Professorof Pediatrics, Schoolof Medicine, The University of Mississippi Medical Centeg, 2500 N State St, Jackson, MS 39216-4505 REFERENCE 1. LeBlanc MH, Graves GR, Rawson TW, MoffittJ. Long-term outcome of infants at the margin of viability.J Miss State Med Assoc 1999;40:111-4. 6/8/102954
Reply To the Editors: We appreciate LeBlanc's interest in our article. We evaluated antenatal characteristics, intrapartum events, and u h r a s o n o g r a p h i c findings to d e t e r m i n e whether different factors would be useful to obstetricians
December 1999 AmJ Obstet Gynecol
in p r e d i c t i n g mortality and "serious morbidity" at 120 days after birth. In summary, we f o u n d female gender, black race, m a g n e s i u m sulfate exposure, and intrapartum uhrasonographic findings (increasing f e m u r length and biparietal diameter) to be associated with i m p r o v e d survival. T h e r e were no survivors with both a f e m u r length <3.7 cm and a biparietal d i a m e t e r <5.0 cm. We could not identify u l t r a s o n o g r a p h i c findings that w o u l d select a p o p u l a t i o n assured of d e v e l o p i n g serious m o r b i d i t y at 120 days. Because of this, it is unlikely that the studied antepartum markers will be useful in predicting m o r e remote morbidity. Long-term evaluation is not planned. T h e National Institute of Child H e a l t h and H u m a n D e v e l o p m e n t Neonatal Research Network continues to provide detailed data r e g a r d i n g a large n u m b e r of infants weighing <1500 g (n = 9,186) at delivery 1 and has recently p r e s e n t e d long-term o u t c o m e s for 1527 infants weighing <1000 g.2, 3 We believe that these data can provide m o r e accurate estimates of long-term morbidity in this extremely high-risk population. We believe that the i m p o r t a n t clinical message of our study is that it is possible to utilize fetal b i o m e t r y in predicting neonatal mortality but n o t morbidity r e m o t e f r o m delivery. We anticipate, however, that the b i o m e t r i c limit o f viability will change with c o n t i n u e d i m p r o v e m e n t s in perinatal outcomes of the extremely low-birth-weight neonate. Brian M. Merceg, MD, Cora A. MacPherson, MS, and Donald McNellis, MD, for the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network Address for correspondence: Brian M. Merceg, MD, 853Jefferson Ave, Rm E-102, Memphis, TN38103 REFERENCES 1. Stevenson DK, Wright LL, Lemons JA, Oh W, Korones SB, Papile L-A, et al. Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1993 through December 1994. AmJ Obstet Gynecol 1998;179:1632-9. 2. Vohr BR, Dusick A, Steichen J, Wright L, Verter J, Mele L. NICHD Neonatal Research Follow-up Study Bethesda. Neurodevelopmental and functional outcome of extremely low birth weight (ELBW) infants [abstract]. Pediatr Res 1998;43:233a. 3. Steichen J, Vohr BR, Dusick A, Wright L, Verter J, Mele L. NICHD Neonatal Research Follow-up Study Bethesda. Developmental resource (DR) utilization and health outcome in extremely low birthweight (ELBW) (401-1000 gm) infants [abstract]. Pediatr Res 1998;43:230a.
6/8/102955
logical. A better way to achieve the same end is to fully utilize vaginal surgery. T h e r e is n o r e a s o n why m o s t w o m e n with uterine fibroids or previous surgery, as well as a lack of uterine descent or a n e e d for oophorectomy, should n o t u n d e r g o vaginal hysterectomy. T h e reason why such cases are still s u b j e c t e d to a b d o m i n a l (and, m o r e recently, laparoscopic) hysterectomy is not because of a deficiency in vaginal surgery but rather the result of a lack of training and experience. If vaginal hysterectomy was d o n e for uteri that were e q u i v a l e n t in size to 14 weeks' gestation, for instance, almost 70% of w o m e n would be m a n a g e d by vaginal surgery. 3 It is a pity that the same effort currently e x t e n d e d to laparoscopic hysterectomy is not placed on developing this aspect of gynecologic surgery; if it were, far fewer adb o m i n a l (and l a p a r o s c o p i c ) h y s t e r e c t o m i e s w o u l d be done. Vaginal surgery may not be as m o d e r n or exciting as laparoscopic surgery, but who says the new is always better than the old?
Tariq Miskry, MD, Anthony Davies, MD, and Adam L. Magos, MD The RoyaIFreeHospital, London, b}zitedKingdom NW3 2QG REFERENCES 1. Kovac SR. Guidelines to determine the route of hysterectomy. Obstet Gynecol 1995;85:18-23. 2. Magos A, Bournas N, Sinha R, Richardson R, O'Connor H. Vaginal hysterectomy for the large uterus. BrJ Obstet Gynaecol 1996;103:246-51. 3. Davies A, Vizza E, Bournas N, O'Connor H, Magos A. How to increase the portion of hysterectomies performed vaginally. AmJ Obstet Gynecol 1998;179:1008-12.
6/8/102956
Letters 1581
ogist m o r e c o n f i d e n c e in p e r f o r m i n g a vaginal hysterectomy, even in the presence of those factors that in the past the average surgeon would consider a contraindication to vaginal hysterectomy. At the p r e s e n t time n o o n e can a r g u e that a very skilled vaginal s u r g e o n can p e r f o r m p r o c e d u r e s that would be d e e m e d beyond the skills of the practicing gynecologist. T h e comparison is to help the gynecologist, who does most of this surgery abdominally, to use the vaginal route with the help o£ laparoscopy. This is an additional o p t i o n in the a r m a m e n t a r i u m for the time being. T h e r e is no substitute for the vaginal surgeon who can p e r f o r m the feats m e n t i o n e d here, but in the m e a n t i m e the laparoscopically assisted vaginal hysterectomy should provide the m e a n s to p e r f o r m m o r e vaginal hysterectomies. Given these premises, no c o m m e n t is c o n s i d e r e d necessary to the n u m b e r s of feasibility given in this letter. We noticed that the authors repeatedly used the term laparoscopic hysterectomy. At the present time, so as not to increase thc confusion already f o u n d in the literature, it would be better for the authors to review the classification of laparoscopic hysterectomy published by Garry et al I in 1994 and to refer correctly to our p r o c e d u r e as laparoscopically assisted vaginal hysterectomy. It is a pity that the authors have not yet m a n a g e d to teach their skills in vaginal surgery to the o t h e r consultants of their hospital, where, as they are reporting, the c u r r e n t rate o£ a b d o m i n a l h y s t e r e c t o m y is as h i g h as 68.4% .2
Riccardo Marana, MD, and Enrico Zupi, MD Via Cassia 591, 00189, Rome, Italy REFERENCES
Reply To the Editors: We are pleased to h e a r that the authors have recently discovered, maybe t h r o u g h Italian connections, the i m p o r t a n c e of vaginal surgery and successfully p e r f o r m e d vaginal hysterectomies on uteri ranging up to 20 weeks' size. We are surprised that the authors of the letter did not recognize the University Hospitals where the study was carried out. There, for years, the few very skilled vaginal surgeons have p e r f o r m e d similar operations a c c o r d i n g to the Austrian and Italian tradition of vaginal surgery. However, these are not the skills of the majority of gynecologists. We are in a g r e e m e n t that vaginal h y s t e r e c t o m y is p r e f e r a b l e to a b d o m i n a l hysterectomy; however, evidence-based m e d i c i n e shows that a very large p e r c e n t a g e of hysterectomies are still d o n e via the a b d o m i n a l route, indicating that most gynecologists do not feel c o n f i d e n t e n o u g h with the vaginal route. T h e purpose of our study was to show that the current training in laparoscopic techniques may give the gynecol-
1. GanT R, Reich H, Liu CY. Laparoscopic hysterectomy--definitions and indications. Gynaecol Endosc 1994;3:1-3. 2. Davies A, Vizza E, Bournas N, O'Connor H, Magos A. How to increase the proportion of hysterectomies performed vaginally. ArnJ Obstet Gynecol 1998;179:1008-12.
6/8/102957
Incidence of morbidity To the Editors: I a m writing r e g a r d i n g the article by B o t t o m s et al ( B o t t o m s SF, Paul RH, M e r c e r BM, MacPherson CA, Caritis SN, Moawad AH, et al. Obstetric determinants of neonatal survival: Antenatal predictors of neonatal survival and morbidity in extremely low birth weight infants Am J Obstet Gynecol 1999;180:665-9). I was struck by the m a r k e d differences in the i n c i d e n c e of morbidity in the study of Bottoms et al as c o m p a r e d with o u r data t published at almost the same time. The difference, of course, is that Bottoms et al looked at markers o f l o n g - t e r m m o r b i d i t y in the hospital, whereas we looked at long-term disabilities at follow-up.
1582 Letters
In assessing our data we looked at the correlation of longterm disability with things that can be m e a s u r e d in the nursery. Only about half of the babies with grade III intraventricular h e m o r r h a g e will have significant handicaps, whereas 85% of babies with grade IV will have significant handicaps. T h e vast majority of babies who receive oxygen for 120 days after birth will be off oxygen by the age of 1 year and will be essentially normal f r o m a p u l m o n a r y standpoint, except for subtle differences in p u l m o n a r y f u n c t i o n studies and a h i g h e r i n c i d e n c e of asthma. Most babies with grade III retinopathy of prematurity will have n o r m a l vision with glasses, and even infants with unilateral grade IV retinopathy may be minimally h a n d i c a p p e d . We f o u n d that l u m p i n g grades III a n d IV i n t r a v e n t r i c u l a r h e m o r r h a g e with g r a d e IV retinopathy gave a p p r o x i m a t e l y the right n u m b e r s for disabled infants. A l t h o u g h about a third of these infants were not disabled, this m o r e or less m a t c h e d the n u m b e r of infants without these criteria who were disabled. Looking at the actual outcomes of the infants rather than markers of possible morbidity, we f o u n d that 60% of infants of 25 weeks' gestation who were alive at birth were intact at follow-up, and there was a greater percentage of m o r e mature infants. H a l f of the surviving infants of 23 or 24 weeks' gestation were intact at follow-up. This is not to discount the i m p o r t a n c e of having early markers of long-term morbidity so that a quick assessm e n t of the effects of i n t e r v e n t i o n s can be made. However, the data p r e s e n t e d by Bottoms et al are old e n o u g h that real follow-up information should be available at this time. Michael H. LeBlanc, MD Professorof Pediatrics, Schoolof Medicine, The University of Mississippi Medical Centeg, 2500 N State St, Jackson, MS 39216-4505 REFERENCE 1. LeBlanc MH, Graves GR, Rawson TW, MoffittJ. Long-term outcome of infants at the margin of viability.J Miss State Med Assoc 1999;40:111-4. 6/8/102954
Reply To the Editors: We appreciate LeBlanc's interest in our article. We evaluated antenatal characteristics, intrapartum events, and u h r a s o n o g r a p h i c findings to d e t e r m i n e whether different factors would be useful to obstetricians
December 1999 AmJ Obstet Gynecol
in p r e d i c t i n g mortality and "serious morbidity" at 120 days after birth. In summary, we f o u n d female gender, black race, m a g n e s i u m sulfate exposure, and intrapartum uhrasonographic findings (increasing f e m u r length and biparietal diameter) to be associated with i m p r o v e d survival. T h e r e were no survivors with both a f e m u r length <3.7 cm and a biparietal d i a m e t e r <5.0 cm. We could not identify u l t r a s o n o g r a p h i c findings that w o u l d select a p o p u l a t i o n assured of d e v e l o p i n g serious m o r b i d i t y at 120 days. Because of this, it is unlikely that the studied antepartum markers will be useful in predicting m o r e remote morbidity. Long-term evaluation is not planned. T h e National Institute of Child H e a l t h and H u m a n D e v e l o p m e n t Neonatal Research Network continues to provide detailed data r e g a r d i n g a large n u m b e r of infants weighing <1500 g (n = 9,186) at delivery 1 and has recently p r e s e n t e d long-term o u t c o m e s for 1527 infants weighing <1000 g.2, 3 We believe that these data can provide m o r e accurate estimates of long-term morbidity in this extremely high-risk population. We believe that the i m p o r t a n t clinical message of our study is that it is possible to utilize fetal b i o m e t r y in predicting neonatal mortality but n o t morbidity r e m o t e f r o m delivery. We anticipate, however, that the b i o m e t r i c limit o f viability will change with c o n t i n u e d i m p r o v e m e n t s in perinatal outcomes of the extremely low-birth-weight neonate. Brian M. Merceg, MD, Cora A. MacPherson, MS, and Donald McNellis, MD, for the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network Address for correspondence: Brian M. Merceg, MD, 853Jefferson Ave, Rm E-102, Memphis, TN38103 REFERENCES 1. Stevenson DK, Wright LL, Lemons JA, Oh W, Korones SB, Papile L-A, et al. Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1993 through December 1994. AmJ Obstet Gynecol 1998;179:1632-9. 2. Vohr BR, Dusick A, Steichen J, Wright L, Verter J, Mele L. NICHD Neonatal Research Follow-up Study Bethesda. Neurodevelopmental and functional outcome of extremely low birth weight (ELBW) infants [abstract]. Pediatr Res 1998;43:233a. 3. Steichen J, Vohr BR, Dusick A, Wright L, Verter J, Mele L. NICHD Neonatal Research Follow-up Study Bethesda. Developmental resource (DR) utilization and health outcome in extremely low birthweight (ELBW) (401-1000 gm) infants [abstract]. Pediatr Res 1998;43:230a.
6/8/102955