Postdates is not postmature

Volume 173, Number Am J Obstet Gym01

2

Letters

agree that cutting current is perhaps better suited for this procedure. Last, we disagree with Tennenbaum’s opinion that the capacity to prenatally evaluate and appropriately select fetuses for intervention is far from perfect and that intervention should be used only in extenuating circumstances. With our current protocols for multicomponent sequential fetal urine analysis, we and others have achieved levels of 95% sensitivity for renal function markers’ and salvage rates in treated fetuses that compare favorably with those of nontreated fetuses.” ’ Nonetheless, we continue to strive to develop better methods to more accurately diagnose and treat fetuses with lower obstructive uropathy. We think that fetal cystoscopy3 may add significantly to our understanding of the underlying phenomena, aid in the differential diagnosis, and provide better therapeutic options for these fetuses. This unique case embodies the hope for this new approach to fetal obstructive uropathy. Rub&a A. Quintero, MD, Mark P. Johnson, MD, and Mark I. Evans, MD Center for Fetal Diagnosis and Therapy Fetal Endoscopy Program, Department of Obstetrics State University, Detroit,

and Gynecology, MI 48201

Hutzel

Hospital/Wayne

REFERENCES Cromblehome T, Harrison M, Golbus M, et al. Fetal intervention in obstructive uropathy: prognostic indicators and efficacy of intervention. Obstet Gynecol 1990;162:123944. Johnson M, Bukowski T, Reitleman C, et al. In utero surgical treatment of fetal obstructive uropathy: a new comprehensive approach to identify appropriate candidates for vesicoamniotic shunt therapy. AM J OBSTET GYNECOL 1994; 170: 1770-g. Quintero RA, Romero R, Goqalves LF, et al. Percutaneous fetal cystoscopy in the evaluation and management of the fetus with lower obstructive uropathy [Abstract]. AM J OBSTET GYNECOL 1995;172:427. 6/8/662

03

Do menopause and hormonal replacement therapy influence body cell mass and body fat mass? To the Editors: The conclusion reached by Aloia et al. (Aloia JF, Vaswani A, Russo L, Sheehan M, Flaster E. The influence of menopause and hormonal replacement therapy on body cell mass and body fat mass. AM J OBSTET GYNECOL 1995;1’72:896-900) that “menopause is associated with a gain in fat mass and a loss of lean body mass” cannot be made because of a fatal flaw in the study design. Menopause represents the final menstrual period and occurs during the perimenopause or climacteric. Aloia et al. studied “healthy white women between 6 months and 6 years after a natural menopause.” They demonstrated that this population showed a gain in fat mass and a loss of lean body mass. This may or may not have been associated with menopause aging control

and might simply be explained process. Given that there was no population and that the study

as part of the premenopausal population was

669

not evaluated through the menopause transition, the authors should retract their conclusion. The most that can be stated from a study that was not primarily designed to answer the question referred to was that women after menopause demonstrate a gain in fat mass and a loss of lean body mass. The cause is unexplained by the study. However, this finding is neither unexpected nor original. Wulf H. Utian, MD, Ph? Department of Reproductive Biology, Case Western Reserve University School of Medicine, University MacDonald Womens Hospital, 1 I1 00 Euclid Ave., Cleveland, OH 44106 6/8/66346 Reply

To the Editors: The primary stated purpose of our study was to “determine the efficacy of dietary calcium augmentation in the prevention of early postmenopausal bone density loss in comparison with placebo.” The study design was not flawed. It presented the opportunity to examine the impact of the two interventions and placebo on changes in body composition. The important conclusion is that hormone replacement therapy, given to postmenopausal women (6 months to 6 years) prevents further bone loss and does not prevent the loss of lean tissue. Utian correctly points out our incorrect use of the term “menopause” in the abstract. Our study can strictly only be applied to postmenopausal women within 6 months to 6 years of menopause, although it appears unlikely that the magnitude of changes observed are simply related to aging. Our previous publication’ provides cross-sectional and longitudinal data to support a relationship of loss of lean tissue to menopause. John F. Aloia, MD Department 11501

ofMedicine,

Nassau Hospital,

259 First St., Mineola,

REFERENCE 1. Aloia JF, McGowan DM, Vaswani AN, Relationship of menopause to skeletal Am J Clin Nutr 1991;53:1378-83.

NY

Ross P, Cohen SH. and muscle mass.

6/g/66345

Postdates is not postmature To the Editors: I am writing regarding the article of Larsen et al. (Larsen LG, Clausen Hv, Anderson B, Gram N. A stereologic study of postmature placentas fixed by dual perfusion. AM J OBSTET GYNECOL 1995;172:500-7). The reason for my letter is the use of the word “postmature” in the title of the paper. In the Material and Methods section the authors define postmature as meaning “a pregnancy proceeding after the forty-second week (day 294 after the first day of the last menstrual period).” This is not

the

usually

accepted

definition

of this

term

and

is

therefore quite misleading. Shaw and Paul’ define postmature pregnancy as “postterm pregnancy that has resulted in the birth of a dysmature infant.” The nineteenth edition of Williams’ Obstetrics’ says “postmature literally means ‘after matu-

670

Letters

rity,’ and should be reserved for those infants born with the features of prolonged gestation.” Resnik3 avoids the use of the term altogether. The finding of normal placentas in otherwise normal “postdates” pregnancies should be an expected finding. It would be very interesting to see the results of the same study done on placentas of true “postmature” pregnancies as defined above by Shaw and Paul.’ I would expect different results. R. Daniel Braun, MD Department of Obstetrics and Gynecology, Indiana University, Wishard Memorial Hospital, 1001 W. Tenth St., F-5, Indianapolis, IN 46202 REFERENCES

1. Shaw K, Paul R. Postterm pregnancy. In: Reece EA, Hobbins JC, Mahoney MJ, Petrie RH, eds. Medicine of the fetus and mother. Philadelphia: JB Lippincott, 1992: 1469. 2. Cunningham FG, MacDonald PC, Leveno KJ, Gant NF, Gilstrap LC III, eds. Preterm and postterm pregnancy and fetal growth retardation. In: Williams’ obstetrics. 19th ed. Norwalk, Connecticut: Appleton & Lange, 1993:854. 3. Resnik R. Post-term pregnancy. In: Creasy RK, Resnik R, eds. Maternal-fetal medicine. 3rd ed. Philadelphia: WB Saunders, 1994:521-6.

6/8/66208 Reply

To the Editors: Thank you for the opportunity to answer Braun’s letter concerning our article. Many terms have been used for pregnancy continuing after week 42: prolonged pregnancy, postterm pregnancy, postdate pregnancy, and postmature pregnancy. Consensus on which of “these classic terms” is correct is confusing and needed. “Postterm” might be a better word than postmature, but in the text of the article we defined our material closely.‘~ ’ In our study we included clinical normal pregnancies proceeding after day 294, calculated after the first day of the last menstrual period. In all cases ultrasonographic examination before week 20 was performed and confirmed the day of term. At birth only two babies were asphyctic and both recovered quickly.” In our department all normal pregnancies can proceed after day 294 if the clinical examination, a nonstress test (both performed twice weekly), and fetal movements are normal.’ If we had examined the placentas from dysmature babies (including babies born after day 294), we might have had another result, but further investigations are needed. A study of the placentas from pregnancies with intrauterine growth-retarded pregnancies is \ in progress, but unfortunately we have no preliminary results to present in this letter. Helle V. Clausen, MD, and Lise Grupe Larsen, MD Department of Obstetrics and Gynecology, Hvidovre University Hospital, Kettegaards alle 30, Hvidovre, DK-2650 Denmark

August 1995 Am J Obstet Gynecol

2. Hannah ME, Hannah WJ, Hellmann J, Hewson S, Milner R, Willan A. Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. N Engl J Med 1992;326:1587-92. 3. Larsen LG, Clausen HY, Andersen B, Grzem N. A stereologic study of postmature placentas fixed by dual perfusion. AM J OBSTET GYNECOL 1995;172:500-7.

6/g/66207

Randomized comparison of a new estradiol-releasing vaginal ring versus estriol vaginal pessaries To the Editors: Henriksson et al. (Henriksson L, Stjernquist M, Boquist L, Aander U, Selinus I. A comparative multicenter study of the effects of continuous low-dose estradiol released from a new vaginal ring versus estriol vaginal pessaries in postmenopausal women with symptoms and signs of urogenital atrophy. AM J OBSTET GYNECOL 1994; 17 1:624-32) evaluated among other aspects the acceptability of the treatment. Acceptability was analyzed from data obtained by questioning the patients at 3 and 12 months of treatment. The methods used in questioning were not specified. The acceptability aspects included “treatment according to protocol” and a j-grade scale from “excellent” to “unacceptable” as evaluated by the patient. The first criterion measures compliance rather than acceptability. The authors indicate that the vaginal rings were inserted and removed at 12 weeks by the investigator, whereas the vaginal pessaries were self-administered by the

patients.

Instztute Helsinki,

1. Cunningham FG, MacDonald PC, Leveno KJ, Gant NF, Gilstrap LG III, eds. Williams’ obstetrics. 19th ed. Norwalk, Connecticut: Appleton & Lange, 1993:871-5.

insertion

of

the

relatively

large

and

of Biomedicine,

PL

9,

00014

University

of Helsinki,

Finland

6/8/6598 7

Reply To the Editors: We studied 12 months.

REFERENCES

The

stiff ring requires first squeezing the ring between the forefinger and middle finger into an oval form and then bringing it high up into the vagina, whereas the pessary is simply pushed by one finger. These differences in administration invalidate any comparison of patient acceptibility to a large extent. In more practical terms it remains hard to imagine that a treatment requiring three monthly visits to a health care professional for removal and reinsertion of the ring would be more acceptable in the long term than a self-administered pessary. The follow-up period of the study was too short (one ring) to give information on this. If, on the other hand, the practice of use of this new regimen turns out to be self-administration, as it evidently will be, the current study would give no relevant information as to the acceptability in real life. Arto Saure, MD, PhD

Compliance,

the patients which

was

for 12 weeks, not

good,

was judged

by

the number of patients who were treated according to the protocol. Acceptability was not judged from the method of insertion of pessary or vaginal rings because of the reasons you gave in your letter, but from patient