- Email: [email protected]
Recalculation of gestational sac losses in multifetal pregnancy
820 Letters
A suction curettage was performed with the patient under general anesthesia at 10 weeks’ gestation for a nonevoluting pregnancy. A hemorrhage rapidly occurred. Repeated suction, uterotonic drugs (oxytocin 40 units and sulprostone 100 µg) and other local methods (vaginal packing and uterine tamponade with Foley catheter) were performed without success. We identified no vaginal or cervical injuries. A placenta accreta area was identified with peroperative transvaginal ultrasonography. Hemoglobin level and hematocrit decreased, respectively, from 12 to 8 g/dL and from 37% to 23%. The patient had disseminated intravascular coagulation and required transfusion (2 units of blood). We performed embolization 2 hours after the suction curettage because the patient continued to bleed. After femoral puncture, initial angiography confirmed a hypervascularized area but did not reveal any arteriovenous malformation. One vaginal and both uterine arteries were embolized with the use of sterile Gelfoam pledgets (Curaspon, CuraCol), which ensured a transient devascularization. Hemorrhage stopped rapidly. The postoperative course was unremarkable, and the patient was discharged home on the fourth day. Diagnostic hysteroscopy 3 months later confirmed the presence of a small placental retention on the remaining synechia. Surgical treatment is contraindicated. The existing literature provides sufficient justification for the use of uterine embolization as first-line treatment (at all gestational ages) for postcurettage bleeding after failure of local and pharmacologic methods. Surgical options still remain available if embolization fails to stop hemorrhage. A rapid transfer to a center where emergency embolization is available should be considered for unresolved hemorrhage after first-trimester curettage. Xavier Deffieux, MD, Nadia Berkane, MD, and Serge Uzan, MD Service de Gynécologie-Obstétrique, CHU Tenon, Paris 75020, France REFERENCES
1. Borgatta L, Chen AY, Reid SK, Stubblefield PG, Christensen DD, Rashbaum WK. Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion. Am J Obstet Gynecol 2001;185:530-6. 2. Deux JF, Bazot M, Le Blanche AF, Tassart M, Khalil A, Berkane N, et al. Is selective embolization of uterine arteries a safe alternative to hysterectomy in patients with postpartum hemorrhage? AJR Am J Roentgenol 2001;177:145-9.
6/8/126627 doi:10.1067/mob.126627
Reply To the Editors: We thank Drs Deffieux and Berkane for their contribution. They have presented another example of the utility of selective pelvic embolization; in this case, embolization was successful when all nonsurgical treatments
September 2002 Am J Obstet Gynecol
had failed. We hope that other physicians will continue to contribute their experiences. Lynn Borgatta, MD, MPH, and Phillip Stubblefield, MD Department of Obstetrics and Gynecology, Boston University School of Medicine, 91 E Concord St, MAT 3, Boston, MA 02118; e-mail: [email protected] 6/8/126626 doi:10.1067/mob.2002.126627
Recalculation of gestational sac losses in multifetal pregnancy To the Editors: We read the interesting report of Dickey et al1 on the probability of spontaneous reduction of multiple pregnancy. The authors provided interesting data collected from a large number of multiple and singleton pregnancies conceived at a private infertility clinic. The results suggesting that pregnancy duration and birth weight were inversely related to the initial gestational sac (GS) number, irrespective of the final birth number, are important and deserve further investigation. However, we have a concern with the authors’ conclusion that placental crowding is a factor in spontaneous reduction of multiple pregnancies before 12 weeks. The authors base this conclusion on the fact that the probability of an individual embryo being lost before 12 weeks was directly related to the number of the initial GSs. However, further analysis of the data suggests that the probability of an individual GS continuing to viability is independent of the number of initial GSs: although the rate of spontaneous losses may vary with subset analysis (eg, maternal age, spontaneous vs induced ovulation, in vitro fertilization or gamete intrafallopian transfer), the authors note that spontaneous reduction occurred in 19.2% of 6149 singleton pregnancies from their infertility practice. Consequently, it may be calculated that the probability of an individual singleton GS continuing to viability is 80.8%. With use of this value, the probability of two GSs of a twin pregnancy both continuing to viability would be 80.8 80.8%, or 65.3%. The probability of all three sacs of a triplet pregnancy continuing to viability is 52.8% and all four sacs of a quadruplet pregnancy continuing is 42.6%. Consequently, the probability of one or more sacs being lost from a twin pregnancy is calculated as 100% minus 65.3% or 34.7%. Similarly, one or more sacs would be lost from triplet pregnancies in 47.2% of cases and from quadruplet pregnancies in 57.4% of cases. These numbers are remarkably similar to the reported spontaneous reduction rate of one or more GSs from this database (twin 36%, triplet 53%, quadruplet 65%). Consequently, use of the spontaneous loss rate for a single GS results in a relatively consistent loss rate when extrapolated to multifetal pregnancies. It appears, therefore, that the individual loss rate is independent of the number of GSs and unlikely to be associated with placental crowding. Placental crowding, nevertheless, may remain a factor in the rates of prematurity and low birth weight, with or without spontaneous losses or therapeutic
Letters 821
Volume 187, Number 3 Am J Obstet Gynecol
reductions. We look forward to continued analysis and results from these authors. Michael G. Ross, MD, MPH, and Omid Khorram, MD Department of Obstetrics and Gynecology, Box 3, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA 90509-2910; e-mail: [email protected]
REFERENCE
1. Dickey RP, Taylor SN, Lu PY, Sartor BM, Storment JM, Rye PH, et al. Spontaneous reduction of multiple pregnancy: incidence and effect on outcome. Am J Obstet Gynecol 2002;186:77-83.
6/8/126624 doi:10.1067/mob.2002.126624
Reply To the Editors: We thank Ross and Khorram for their interest in our paper. Depp et al1 were the first to propose crowding of the developing gestational sacs or lack of appropriate sites for implantation as an explanation for low birth weight and early delivery of twins born after selective reduction of high-order pregnancies. Our study established that infants born after spontaneous reduction of multiple pregnancies also have restricted growth syndrome, have lower birth weight, and may be born prematurely. Placental crowding in cases of multiple implantations is an important cause of low birth weight and premature birth. We believe that it may explain low birth weight of singleton infants born after transfer of multiple embryos during in vitro fertilization.2 We did not find that placental crowding increased the incidence of spontaneous pregnancy loss. Richard P. Dickey, MD, PhD, Peter Y. Lu, MD, Belinda M. Sartor, MD, and John M. Storment, MD Section of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Louisiana State University School of Medicine, Fertility Institute of New Orleans, 6020 Bullard Ave, New Orleans, LA 70128 REFERENCES
1. Depp R, Macones GA, Rosenn MF, Turzo E, Wapner RJ, Weiblatt VJ. Multifetal pregnancy reduction: evaluation of fetal growth in the remaining twins. Am J Obstet Gynecol 1996;174:1233-8. 2. Schieve LA, Meikle SF, Ferre C, Peterson HB, Jeng G, Wilcox LS. Low and very low birth weight infants conceived with use of assisted reproductive technology. N Engl J Med 2002;346:731-7.
6/8/126625 doi:10.1067/mob.2002.126624
Value of bilateral hypogastric artery occlusion for severe obstetric hemorrhage To the Editors: I have read with great interest the article by Oei et al1 about the arterial balloon for hypogastric artery occlusion. This technique, however, has been already described.2 The waiting time in case 1 is puzzling; in the presence of uterine atony and bleeding, a timely ligation of both uterine arteries may have been appropriate. In case 2 it is not clear whether a total or subtotal hysterec-
tomy was performed or how the ultimate hemostasis was attained because no vascular obliteration was mentioned. Blood loss estimations may have been inaccurate; balloon occlusion of one hypogastric artery (case 1) probably did not modify uterine flow, which may have been affected by the profound hypovolemic shock (39 and 111 transfused units, respectively) and not the procedure per se. Functional data derived from hypogastric artery ligations and anatomic knowledge of pelvic anastomosis suggest that an intra-aortic balloon would be more efficient3 because this device occludes all three internal and external lilac and femoral arteries, or more than 90% of pelvic anastomotic flow. The final recommendation may be changed because in a severe obstetric hemorrhage it is necessary to act rapidly, according to a pre-established protocol, and never underestimate blood loses. We should be able then to avoid leaving very ill, hypovolemic patients to the heroic efforts of interventionist radiologists. José Miguel Palacios Jaraquemada, MD University of Buenos Aires, Avenida Corrientes 5087 4° A, Ciudad de Buenos Aires, C141AJD, Argentina REFERENCES
1. Oei SG, Kho SN, Broeke ED, Brolmann HA. Arterial balloon occlusion of the hypogastric arteries: a life-saving procedure for severe obstetric hemorrhage, Am J Obstet Gynecol 2001; 185:1255-6. 2. Dubois J, Garel L, Grignon A, Lemay M, Leduc L. Placenta percreta: balloon occlusion and embolization of the internal lilac arteries to reduce intraoperative blood losses. Am J Obstet Gynecol 1997;176:723-6. 3. Paull JD, Smith I, Williams L, Davison G, Devine T, Holt H. Balloon occlusion of the abdominal aorta during caesarean hysterectomy for placenta percreta. Anaesth Intens Care 1995; 23:731-4.
Response declined 6/8/126639 doi:10.1067/mob.2002.126639
Erythromycin use during pregnancy in relation to pyloric stenosis To the Editors: There have been case studies and epidemiologic reports suggesting that systemic erythromycin use in newborn infants is related to the risk of developing pyloric stenosis. In the recent paper by Louik et al,1 the authors have found, contrary to the previous reports,2,3 that although erythromycin crosses the placenta exposure of infants during pregnancy does not increase the risk of pyloric stenosis. We question whether the fetus or the premature infant who is exposed to erythromycin is not as vulnerable as the term infant. We wonder whether this may be one of the explanations why this study by Louik et al1 has a different conclusion from the previous reports. We also offer data from our institutions in support of this possibility. We have observed that in published case reports and epidemiologic studies of the association between pyloric stenosis and erythromycin, almost all the infants that were treated were close to term and mature.2,3 It is pos-
A suction curettage was performed with the patient under general anesthesia at 10 weeks’ gestation for a nonevoluting pregnancy. A hemorrhage rapidly occurred. Repeated suction, uterotonic drugs (oxytocin 40 units and sulprostone 100 µg) and other local methods (vaginal packing and uterine tamponade with Foley catheter) were performed without success. We identified no vaginal or cervical injuries. A placenta accreta area was identified with peroperative transvaginal ultrasonography. Hemoglobin level and hematocrit decreased, respectively, from 12 to 8 g/dL and from 37% to 23%. The patient had disseminated intravascular coagulation and required transfusion (2 units of blood). We performed embolization 2 hours after the suction curettage because the patient continued to bleed. After femoral puncture, initial angiography confirmed a hypervascularized area but did not reveal any arteriovenous malformation. One vaginal and both uterine arteries were embolized with the use of sterile Gelfoam pledgets (Curaspon, CuraCol), which ensured a transient devascularization. Hemorrhage stopped rapidly. The postoperative course was unremarkable, and the patient was discharged home on the fourth day. Diagnostic hysteroscopy 3 months later confirmed the presence of a small placental retention on the remaining synechia. Surgical treatment is contraindicated. The existing literature provides sufficient justification for the use of uterine embolization as first-line treatment (at all gestational ages) for postcurettage bleeding after failure of local and pharmacologic methods. Surgical options still remain available if embolization fails to stop hemorrhage. A rapid transfer to a center where emergency embolization is available should be considered for unresolved hemorrhage after first-trimester curettage. Xavier Deffieux, MD, Nadia Berkane, MD, and Serge Uzan, MD Service de Gynécologie-Obstétrique, CHU Tenon, Paris 75020, France REFERENCES
1. Borgatta L, Chen AY, Reid SK, Stubblefield PG, Christensen DD, Rashbaum WK. Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion. Am J Obstet Gynecol 2001;185:530-6. 2. Deux JF, Bazot M, Le Blanche AF, Tassart M, Khalil A, Berkane N, et al. Is selective embolization of uterine arteries a safe alternative to hysterectomy in patients with postpartum hemorrhage? AJR Am J Roentgenol 2001;177:145-9.
6/8/126627 doi:10.1067/mob.126627
Reply To the Editors: We thank Drs Deffieux and Berkane for their contribution. They have presented another example of the utility of selective pelvic embolization; in this case, embolization was successful when all nonsurgical treatments
September 2002 Am J Obstet Gynecol
had failed. We hope that other physicians will continue to contribute their experiences. Lynn Borgatta, MD, MPH, and Phillip Stubblefield, MD Department of Obstetrics and Gynecology, Boston University School of Medicine, 91 E Concord St, MAT 3, Boston, MA 02118; e-mail: [email protected] 6/8/126626 doi:10.1067/mob.2002.126627
Recalculation of gestational sac losses in multifetal pregnancy To the Editors: We read the interesting report of Dickey et al1 on the probability of spontaneous reduction of multiple pregnancy. The authors provided interesting data collected from a large number of multiple and singleton pregnancies conceived at a private infertility clinic. The results suggesting that pregnancy duration and birth weight were inversely related to the initial gestational sac (GS) number, irrespective of the final birth number, are important and deserve further investigation. However, we have a concern with the authors’ conclusion that placental crowding is a factor in spontaneous reduction of multiple pregnancies before 12 weeks. The authors base this conclusion on the fact that the probability of an individual embryo being lost before 12 weeks was directly related to the number of the initial GSs. However, further analysis of the data suggests that the probability of an individual GS continuing to viability is independent of the number of initial GSs: although the rate of spontaneous losses may vary with subset analysis (eg, maternal age, spontaneous vs induced ovulation, in vitro fertilization or gamete intrafallopian transfer), the authors note that spontaneous reduction occurred in 19.2% of 6149 singleton pregnancies from their infertility practice. Consequently, it may be calculated that the probability of an individual singleton GS continuing to viability is 80.8%. With use of this value, the probability of two GSs of a twin pregnancy both continuing to viability would be 80.8 80.8%, or 65.3%. The probability of all three sacs of a triplet pregnancy continuing to viability is 52.8% and all four sacs of a quadruplet pregnancy continuing is 42.6%. Consequently, the probability of one or more sacs being lost from a twin pregnancy is calculated as 100% minus 65.3% or 34.7%. Similarly, one or more sacs would be lost from triplet pregnancies in 47.2% of cases and from quadruplet pregnancies in 57.4% of cases. These numbers are remarkably similar to the reported spontaneous reduction rate of one or more GSs from this database (twin 36%, triplet 53%, quadruplet 65%). Consequently, use of the spontaneous loss rate for a single GS results in a relatively consistent loss rate when extrapolated to multifetal pregnancies. It appears, therefore, that the individual loss rate is independent of the number of GSs and unlikely to be associated with placental crowding. Placental crowding, nevertheless, may remain a factor in the rates of prematurity and low birth weight, with or without spontaneous losses or therapeutic
Letters 821
Volume 187, Number 3 Am J Obstet Gynecol
reductions. We look forward to continued analysis and results from these authors. Michael G. Ross, MD, MPH, and Omid Khorram, MD Department of Obstetrics and Gynecology, Box 3, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA 90509-2910; e-mail: [email protected]
REFERENCE
1. Dickey RP, Taylor SN, Lu PY, Sartor BM, Storment JM, Rye PH, et al. Spontaneous reduction of multiple pregnancy: incidence and effect on outcome. Am J Obstet Gynecol 2002;186:77-83.
6/8/126624 doi:10.1067/mob.2002.126624
Reply To the Editors: We thank Ross and Khorram for their interest in our paper. Depp et al1 were the first to propose crowding of the developing gestational sacs or lack of appropriate sites for implantation as an explanation for low birth weight and early delivery of twins born after selective reduction of high-order pregnancies. Our study established that infants born after spontaneous reduction of multiple pregnancies also have restricted growth syndrome, have lower birth weight, and may be born prematurely. Placental crowding in cases of multiple implantations is an important cause of low birth weight and premature birth. We believe that it may explain low birth weight of singleton infants born after transfer of multiple embryos during in vitro fertilization.2 We did not find that placental crowding increased the incidence of spontaneous pregnancy loss. Richard P. Dickey, MD, PhD, Peter Y. Lu, MD, Belinda M. Sartor, MD, and John M. Storment, MD Section of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Louisiana State University School of Medicine, Fertility Institute of New Orleans, 6020 Bullard Ave, New Orleans, LA 70128 REFERENCES
1. Depp R, Macones GA, Rosenn MF, Turzo E, Wapner RJ, Weiblatt VJ. Multifetal pregnancy reduction: evaluation of fetal growth in the remaining twins. Am J Obstet Gynecol 1996;174:1233-8. 2. Schieve LA, Meikle SF, Ferre C, Peterson HB, Jeng G, Wilcox LS. Low and very low birth weight infants conceived with use of assisted reproductive technology. N Engl J Med 2002;346:731-7.
6/8/126625 doi:10.1067/mob.2002.126624
Value of bilateral hypogastric artery occlusion for severe obstetric hemorrhage To the Editors: I have read with great interest the article by Oei et al1 about the arterial balloon for hypogastric artery occlusion. This technique, however, has been already described.2 The waiting time in case 1 is puzzling; in the presence of uterine atony and bleeding, a timely ligation of both uterine arteries may have been appropriate. In case 2 it is not clear whether a total or subtotal hysterec-
tomy was performed or how the ultimate hemostasis was attained because no vascular obliteration was mentioned. Blood loss estimations may have been inaccurate; balloon occlusion of one hypogastric artery (case 1) probably did not modify uterine flow, which may have been affected by the profound hypovolemic shock (39 and 111 transfused units, respectively) and not the procedure per se. Functional data derived from hypogastric artery ligations and anatomic knowledge of pelvic anastomosis suggest that an intra-aortic balloon would be more efficient3 because this device occludes all three internal and external lilac and femoral arteries, or more than 90% of pelvic anastomotic flow. The final recommendation may be changed because in a severe obstetric hemorrhage it is necessary to act rapidly, according to a pre-established protocol, and never underestimate blood loses. We should be able then to avoid leaving very ill, hypovolemic patients to the heroic efforts of interventionist radiologists. José Miguel Palacios Jaraquemada, MD University of Buenos Aires, Avenida Corrientes 5087 4° A, Ciudad de Buenos Aires, C141AJD, Argentina REFERENCES
1. Oei SG, Kho SN, Broeke ED, Brolmann HA. Arterial balloon occlusion of the hypogastric arteries: a life-saving procedure for severe obstetric hemorrhage, Am J Obstet Gynecol 2001; 185:1255-6. 2. Dubois J, Garel L, Grignon A, Lemay M, Leduc L. Placenta percreta: balloon occlusion and embolization of the internal lilac arteries to reduce intraoperative blood losses. Am J Obstet Gynecol 1997;176:723-6. 3. Paull JD, Smith I, Williams L, Davison G, Devine T, Holt H. Balloon occlusion of the abdominal aorta during caesarean hysterectomy for placenta percreta. Anaesth Intens Care 1995; 23:731-4.
Response declined 6/8/126639 doi:10.1067/mob.2002.126639
Erythromycin use during pregnancy in relation to pyloric stenosis To the Editors: There have been case studies and epidemiologic reports suggesting that systemic erythromycin use in newborn infants is related to the risk of developing pyloric stenosis. In the recent paper by Louik et al,1 the authors have found, contrary to the previous reports,2,3 that although erythromycin crosses the placenta exposure of infants during pregnancy does not increase the risk of pyloric stenosis. We question whether the fetus or the premature infant who is exposed to erythromycin is not as vulnerable as the term infant. We wonder whether this may be one of the explanations why this study by Louik et al1 has a different conclusion from the previous reports. We also offer data from our institutions in support of this possibility. We have observed that in published case reports and epidemiologic studies of the association between pyloric stenosis and erythromycin, almost all the infants that were treated were close to term and mature.2,3 It is pos-