- Email: [email protected]
Sound stimulation test and fetal well-being
Correspondence 829
Volume 151 Number 6
article: "At delivery, viruses could not be isolated from the baby's nasal washings or from the placenta or amniotic fluid." These data are presented in Table IA. The child and mother were followed up for 3 months after delivery. No sequelae were noted in the mother or newborn infant. We did not find evidence of any chronic infection. Thank you for allowing us to clarify and emphasize these points. James A. McGregor, M.D.C.M. University of Colorado Health Sciences Center Department of Obstetrics and Gynecology B198 4200 East Ninth Avenue Denver, Colorado 80262 Tubal ligation: A misnomer
To the Editors: "Once upon a time," in the year I881, in Toledo, Ohio, a physician named S.S. Langren' described the procedure of tubal ligation. He performed the operation post partum on a patient after her second cesarean section. In his paper he stated that he "first intended to remove the ovaries with Smith's pile clamps and cautery, but in consideration of the danger of hemorrhage jeopardizing the operation, the fallopian tubes were tied instead with a strong silk ligature about one inch from the uterine attachment." Hence the term "tubal ligation" has prevailed and flourished through the decades for more than 100 years. It would be difficult if not impossible, to know when this procedure was abandoned for more specific and effective techniques. In the South Bronx, even today, we still have patients requesting that their "tubes be tied" and "not cut." The request is made with the concept that they may be "untied" at a later date, when they are better prepared for further pregnancy. The permanent status of infertility suggested by "cutting" the tubes as opposed to "tying" them is apparently emotionally unacceptable. According to several of my colleagues from
Table I. Currently used methods of tubal sterilization Abdominal Laparotomy Minilaparotomy Pomeroy Irving Madlener (noncutting) Salpingectomy Total or partial Vaginal approach for above Laparoscopic Electrocautery Falope ring Clips Hulka Filshie Hysteroscopic Silicone plugs Tubal sclerosing agents
the Caribbean, India, and Africa, the procedure is still being performed in certain regions. There are also reports of subsequent pregnancies occurring after tubal ligation. This apparently represents either recanalization of the fallopian tubes or failure to ligate them properly. It is interesting that medical and all third-party insurance carriers still accept and honor the term "tubal ligation," although medicaid codes it more specifically and appropriately as "tubal transection." The current most used and acceptable methods for tubal interruption are listed in Table I. With the current emphasis on quality assurance, meaningful informed consent, and proper documentation, the term "tubal ligation" should be abandoned. In its place the term "tubal transection" is more appropriate, or the term "tubal interruption" with the specific procedure used. John T. Parente, M.D., F.A.C.O.G. Carol Costello, M.D. The Bronx-Lebanon Hospital Center 1650 Grand Concourse Bronx, New York 10457 REFERENCE 1. Langren SS. A case of cesarean section twice successfully
performed on the same patient. Am J Obstet Dis Women 1881;14:78-94.
Sound stimulation test and fetal well-being To the Editors: An article by Serafini et al. (Serafini P, Lindsay MBJ, Nagey DA, Pupkin MJ, Tseng P, Crenshaw C Jr. Antepartum fetal heart rate response to sound stimulation: the acoustic stimulation test. AM J OBSTET GvNECOL, I 984; I 48:4 I-5 I) suggested that an acoustic stimulation test is able to replace the traditional nonstress test (NST) in the screening of hypoxic fetuses. Another question is the value of this test as a complementary procedure in case of a nonreactive NST. A recent work by our group' indicates that a sound stimulation test could be useful in this case. We used a 5second, I I 0 dB white noise generated by a loudspeaker. Unlike Serafini et al., we submitted the mother to a masking noise delivered by a headphone, in order to avoid indirect fetal stimulation through maternal reactions. A total of 93 tests were performed in 78 highrisk pregnancies with suspicious or abnormal NST recordings (Fischer's score ,,;;;7). The results showed a good correlation between the NST and the sound stimulation test. The sound stimulation test was negative (no fetal response) in IO%, 48%, and 100%, respectively, of NSTs with Fischer's score of 7, 6, or ,,;;;5. Thus we have confirmed that a poor fetal reaction to acoustic stimuli is correlated with the severity of hypoxia. When the sound stimulation test is not used as a primary screening test, baseline NST patterns should be taken into account. In case of severe abnormalities of the NST, no complementary test is needed (100% of I I
830
Correspondence
March 15, 1985 Am J Obstet Gynecol
fetuses with Fischer's score ~5 showed a negative sound stimulation test and low Apgar score and/or acidosis at birth). On the other hand, when the NST is only suspicious (Fischer's score of 6 or 7), the sound stimulation test has a good discriminatory value in detecting the risk of neonatal distress. Among 62 such cases evaluated within 7 days of delivery, a 27% ( 17 of 62) overall rate of neonatal depression (low Apgar score at 5 minutes and/or acidosis in the umbilical artery at birth) was noticed. The sound stimulation test was interpreted as reactive in 44 cases of this group, with only eight depressed neonates (18%). In the other 18 cases, a negative, nonreactive sound stimulation test was followed by birth of nine depressed infants (50%). The difference is statistically significant (p < 0.02). Thus we have confirmed that a sound stimulation test is a low-cost, easy, and reliable procedure, useful in the prognostic evaluation of a suspicious NST. D. Querleu, M.D. C. Boutteville, M.D. X. Renard G. Crepin, M.D. Department of Obstetrics and Gynecology University of Lille II and Maternite Paul Gelle A venue Julien Lagache 59100 Roubaix, France REFERENCES 1. Querleu D, Boutteville C, Renard X, Crepin G. Evaluation diagnostique de la souffrance foetale pendant le grossesse au moyen d'un test de stimulation sonore. J Gynecol Obstet Biol Reprod I 984; I3:789-96. 2. Fischer WM, Stude I, Brandt H. Ein Vorschlag zur Beurteilung des antepartualen Kardiotokogramms. Z Geburtshilfe Perinatol I976;I80:1I7-23.
Gestational age according to fetal sex in twins To the Editors: Inspired by the twin study on duration of gestation according to fetal sex published by Newton et al. (New-
ton W, Keith L, Keith D. The Northwestern University multihospital twin study. IV. Duration ·of gestation according to fetal sex. AM J OBSTET GYNECOL 1984;149:655) we reconsidered our twin data published in 1979.' We studied 1655 twin pairs with a menstrual age> 16 weeks born at the Department of Obstetrics and Gynecology of the University Hospital between 1931 and 1975 and at the training school for midwives from 1948 to 1957, both in Amsterdam. In 1485 twin pairs, gestational age, placentation, parity, and fetal sex were known. Statistical procedures used were multiple regression analyses and analyses of variance. In Table I we present the mean gestational age of 1485 twins according to placentation, parity, and sex; monochorial twins were found to have a significantly shorter duration of pregnancy than dichorial twins by 10.6 days. The mean gestational age of twin pregnancies in multiparous women was found to be significantly longer than in primiparous women by 3.9 days. As is obvious from Table I and in common with Newton et al., male twin pregnancies were found to be shorter than both female and male/female twins; however, this difference was not statistically significant at the 0.05 level. However, we cannot confirm the findings concerning birth weights in twins given by Newton et al. Therefore, Table I also contains the mean birth weight according to placentation, parity, and sex. Dichorial twin infants were found to be heavier than monochorial twin infants. In complete accordance with observations in singleton infants 2 we found that twin infants of multiparous women were heavier than those of primiparous women (mean effect of parity: 132 gm) and that, in twins, boys were heavier than girls (mean effect of sex: 121 gm). 1 All of these differences were statistically significant. Obviously male twin pregnancies show a somewhat shorter mean duration of gestational age, although not statistically significant, as compared to that of other twins. One explanation could be that male twins, being
Table I. Mean gestational age and mean birth weight in 1485 twin pairs in relation to placentation, parity, and fetal sex
Twin pairs
Monochorial (n = 349) Primiparous women Multiparous women Dichorial (n = I I36) Primiparous women Multiparous women
Mean gestational age (days)
Mean birth weight
Sex
No. of twin pairs
Male-male Female-female Male-male Female-female
8I 73 94 IOI
246.5 243.9 247.4 251.4
2030 I957 2284 2I79
Male-male Female-female Male-female Male-male Female-female Male-female
I51 133 154 201 189 308
255.8 256.2 256.4 258.4 261.3 260.5
2289 2234 2346 2518 2463 2534
(gm)
Volume 151 Number 6
article: "At delivery, viruses could not be isolated from the baby's nasal washings or from the placenta or amniotic fluid." These data are presented in Table IA. The child and mother were followed up for 3 months after delivery. No sequelae were noted in the mother or newborn infant. We did not find evidence of any chronic infection. Thank you for allowing us to clarify and emphasize these points. James A. McGregor, M.D.C.M. University of Colorado Health Sciences Center Department of Obstetrics and Gynecology B198 4200 East Ninth Avenue Denver, Colorado 80262 Tubal ligation: A misnomer
To the Editors: "Once upon a time," in the year I881, in Toledo, Ohio, a physician named S.S. Langren' described the procedure of tubal ligation. He performed the operation post partum on a patient after her second cesarean section. In his paper he stated that he "first intended to remove the ovaries with Smith's pile clamps and cautery, but in consideration of the danger of hemorrhage jeopardizing the operation, the fallopian tubes were tied instead with a strong silk ligature about one inch from the uterine attachment." Hence the term "tubal ligation" has prevailed and flourished through the decades for more than 100 years. It would be difficult if not impossible, to know when this procedure was abandoned for more specific and effective techniques. In the South Bronx, even today, we still have patients requesting that their "tubes be tied" and "not cut." The request is made with the concept that they may be "untied" at a later date, when they are better prepared for further pregnancy. The permanent status of infertility suggested by "cutting" the tubes as opposed to "tying" them is apparently emotionally unacceptable. According to several of my colleagues from
Table I. Currently used methods of tubal sterilization Abdominal Laparotomy Minilaparotomy Pomeroy Irving Madlener (noncutting) Salpingectomy Total or partial Vaginal approach for above Laparoscopic Electrocautery Falope ring Clips Hulka Filshie Hysteroscopic Silicone plugs Tubal sclerosing agents
the Caribbean, India, and Africa, the procedure is still being performed in certain regions. There are also reports of subsequent pregnancies occurring after tubal ligation. This apparently represents either recanalization of the fallopian tubes or failure to ligate them properly. It is interesting that medical and all third-party insurance carriers still accept and honor the term "tubal ligation," although medicaid codes it more specifically and appropriately as "tubal transection." The current most used and acceptable methods for tubal interruption are listed in Table I. With the current emphasis on quality assurance, meaningful informed consent, and proper documentation, the term "tubal ligation" should be abandoned. In its place the term "tubal transection" is more appropriate, or the term "tubal interruption" with the specific procedure used. John T. Parente, M.D., F.A.C.O.G. Carol Costello, M.D. The Bronx-Lebanon Hospital Center 1650 Grand Concourse Bronx, New York 10457 REFERENCE 1. Langren SS. A case of cesarean section twice successfully
performed on the same patient. Am J Obstet Dis Women 1881;14:78-94.
Sound stimulation test and fetal well-being To the Editors: An article by Serafini et al. (Serafini P, Lindsay MBJ, Nagey DA, Pupkin MJ, Tseng P, Crenshaw C Jr. Antepartum fetal heart rate response to sound stimulation: the acoustic stimulation test. AM J OBSTET GvNECOL, I 984; I 48:4 I-5 I) suggested that an acoustic stimulation test is able to replace the traditional nonstress test (NST) in the screening of hypoxic fetuses. Another question is the value of this test as a complementary procedure in case of a nonreactive NST. A recent work by our group' indicates that a sound stimulation test could be useful in this case. We used a 5second, I I 0 dB white noise generated by a loudspeaker. Unlike Serafini et al., we submitted the mother to a masking noise delivered by a headphone, in order to avoid indirect fetal stimulation through maternal reactions. A total of 93 tests were performed in 78 highrisk pregnancies with suspicious or abnormal NST recordings (Fischer's score ,,;;;7). The results showed a good correlation between the NST and the sound stimulation test. The sound stimulation test was negative (no fetal response) in IO%, 48%, and 100%, respectively, of NSTs with Fischer's score of 7, 6, or ,,;;;5. Thus we have confirmed that a poor fetal reaction to acoustic stimuli is correlated with the severity of hypoxia. When the sound stimulation test is not used as a primary screening test, baseline NST patterns should be taken into account. In case of severe abnormalities of the NST, no complementary test is needed (100% of I I
830
Correspondence
March 15, 1985 Am J Obstet Gynecol
fetuses with Fischer's score ~5 showed a negative sound stimulation test and low Apgar score and/or acidosis at birth). On the other hand, when the NST is only suspicious (Fischer's score of 6 or 7), the sound stimulation test has a good discriminatory value in detecting the risk of neonatal distress. Among 62 such cases evaluated within 7 days of delivery, a 27% ( 17 of 62) overall rate of neonatal depression (low Apgar score at 5 minutes and/or acidosis in the umbilical artery at birth) was noticed. The sound stimulation test was interpreted as reactive in 44 cases of this group, with only eight depressed neonates (18%). In the other 18 cases, a negative, nonreactive sound stimulation test was followed by birth of nine depressed infants (50%). The difference is statistically significant (p < 0.02). Thus we have confirmed that a sound stimulation test is a low-cost, easy, and reliable procedure, useful in the prognostic evaluation of a suspicious NST. D. Querleu, M.D. C. Boutteville, M.D. X. Renard G. Crepin, M.D. Department of Obstetrics and Gynecology University of Lille II and Maternite Paul Gelle A venue Julien Lagache 59100 Roubaix, France REFERENCES 1. Querleu D, Boutteville C, Renard X, Crepin G. Evaluation diagnostique de la souffrance foetale pendant le grossesse au moyen d'un test de stimulation sonore. J Gynecol Obstet Biol Reprod I 984; I3:789-96. 2. Fischer WM, Stude I, Brandt H. Ein Vorschlag zur Beurteilung des antepartualen Kardiotokogramms. Z Geburtshilfe Perinatol I976;I80:1I7-23.
Gestational age according to fetal sex in twins To the Editors: Inspired by the twin study on duration of gestation according to fetal sex published by Newton et al. (New-
ton W, Keith L, Keith D. The Northwestern University multihospital twin study. IV. Duration ·of gestation according to fetal sex. AM J OBSTET GYNECOL 1984;149:655) we reconsidered our twin data published in 1979.' We studied 1655 twin pairs with a menstrual age> 16 weeks born at the Department of Obstetrics and Gynecology of the University Hospital between 1931 and 1975 and at the training school for midwives from 1948 to 1957, both in Amsterdam. In 1485 twin pairs, gestational age, placentation, parity, and fetal sex were known. Statistical procedures used were multiple regression analyses and analyses of variance. In Table I we present the mean gestational age of 1485 twins according to placentation, parity, and sex; monochorial twins were found to have a significantly shorter duration of pregnancy than dichorial twins by 10.6 days. The mean gestational age of twin pregnancies in multiparous women was found to be significantly longer than in primiparous women by 3.9 days. As is obvious from Table I and in common with Newton et al., male twin pregnancies were found to be shorter than both female and male/female twins; however, this difference was not statistically significant at the 0.05 level. However, we cannot confirm the findings concerning birth weights in twins given by Newton et al. Therefore, Table I also contains the mean birth weight according to placentation, parity, and sex. Dichorial twin infants were found to be heavier than monochorial twin infants. In complete accordance with observations in singleton infants 2 we found that twin infants of multiparous women were heavier than those of primiparous women (mean effect of parity: 132 gm) and that, in twins, boys were heavier than girls (mean effect of sex: 121 gm). 1 All of these differences were statistically significant. Obviously male twin pregnancies show a somewhat shorter mean duration of gestational age, although not statistically significant, as compared to that of other twins. One explanation could be that male twins, being
Table I. Mean gestational age and mean birth weight in 1485 twin pairs in relation to placentation, parity, and fetal sex
Twin pairs
Monochorial (n = 349) Primiparous women Multiparous women Dichorial (n = I I36) Primiparous women Multiparous women
Mean gestational age (days)
Mean birth weight
Sex
No. of twin pairs
Male-male Female-female Male-male Female-female
8I 73 94 IOI
246.5 243.9 247.4 251.4
2030 I957 2284 2I79
Male-male Female-female Male-female Male-male Female-female Male-female
I51 133 154 201 189 308
255.8 256.2 256.4 258.4 261.3 260.5
2289 2234 2346 2518 2463 2534
(gm)