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Splitting hairs about splitting muscles
LETTERS TO THE EDITORS Hypertriglyceridemia in small-for-gestational-age fetuses To the Editors: I read with great interest the article by
Economides et al. (Economides DL, Crook D, Nicolaides KH. Hypertriglyceridemia and hypoxemia in small-for-gestational-age fetuses. AM J OBSTET GYNECOL 1990; 162 :382-6). The authors found elevated plasma triglyceride concentration in samples obtained by cordocentesis for small-for-gestational-age fetuses. One month earlier we described the increase of cord blood triglyceride concentration in small-for-gestational-age infants born to mothers with placental insufficiency.' The mechanism of triglyceride increase in those cases is not well understood. I suggest that chronic fetal hypoxia caused by placental insufficiency is asso c cia ted with a substantial release of catecholamines. Increased secretion of catecholamines leads to lipolysis and results in elevated blood fatty acid level. The fetal liver takes up some of the excess fatty acid · and synthesizes endogenous triglycerides that appear in the fetal serum. It has been found that the duration of fetal hypoxia must be considerable, perhaps even an hour or more, for it to result in hypertriglyceridemia. 2 I proposed that the level of cord blood triglyceride may prove to be a useful indicator of chronic fetal hypoxia. Janusz Bartnicki, MD Institute of Perinatal Medicine, Mariendorfer Weg 28, D-lOOO Ber: lin 44, Germany
REFERENCES 1. Bartnicki J, Szmitkowski M, J6Zwik M, Sledziewski A,
Chrostek L, Urban J. Cord blood triglyceridemia in cases of placental insufficiency. Am J Perinatol 1990;7:26-30. 2. Elphick MC, Harrison AT, Lawlor JP, Hull D. Cord blood hypertriglyceridemia as an index of fetal stress: use of a simple screening test and results of further biochemical analysis. Br J Obstet Gynaecol 1978;85:303-10.
Response declined
Splitting hairs about splitting muscles To the Editors: Helmkamp and Krebs (Helmkamp BF,
Krebs H-B. The Maylard incision in gynecologic cancer. AM J OBSTET GYNECOL 1990; 163: 1554-7) recently presented data substantiating the value of the Maylard abdominal incision. This article was timely, nicely done, and welcome. The Maylard technique, however, is not a "muscle-splitting" incision. It is, rather, a muscle-cutting procedure. Quoting Condon' in his chapter on appendicitis in Sabiston's Textbook of Surgery, " ... the muscle-splitting incision (McArther-McBurney) is the timehonored approach and one widely used today .... Its advantage is that separation of muscles in the line of their
fibers produces a wound that does not depend entirely
upon sutures for restoration of tissue continuity." Surgical transection of the rectus muscles does not fit this description. The risk of subfascial hematoma and the associated need for a subfascial drain are related to the creation of a closed space between the fascia and parietal peritoneum. Both can be eliminated by meticulous hemostasis and by allowing the parietal peritoneum to remain open and unsutured? Gregory P. Sutton, MD Department of Obstetrics and Gynecology, University Hospital, Indiana University Medical Center, 926 W. Michigan, Indianapolis, IN 46202
REFERENCES 1. Condon FE. Appendicitis. In: Sabiston DC, ed. Textbook
of surgery. 13th ed. Philadelphia: WB Saunders, 1986: 975-6. 2. Pietrantoni M, Parsons MT, O'Brien WF, Collins E, Knuppel RA, Spellacy WN. Peritoneal closure or non-closure at cesarean. Obstet GynecoI1991;77:293-6.
Reply To the Editors: Thank you very much for your comments
regarding our recent article. I agree that "musclecutting" more accurately describes the Maylard technique because the incision through the rectus muscles is perpendicular to the muscle fibers rather than parallel. 1 do not suture the posterior rectus sheath in closing vertical and Pfannenstiel incisions. If you do likewise with the Maylard incision and have had no wound complications, it may be possible to eliminate the subfascial drain as you suggest. B. Frederick Helmkamp, MD 3289 Woodburn Road, Suite 320, Annandale, VA 22003-6897
Effects of leukotrienes in the placental vasculature To the Editors: Thorp et al. (Thorp JA, Walsh SW, Brath PC. Comparison of the vasoactive effects of leukotrienes with thromboxane mimic in the perfused human placenta. AMJ OBSTET GYNECOL 1988;159:137680) have clearly shown that leukotrienes B. (LTB 4 ) and C4 (LTC.) do not exert major effects on the placental vasculature except at high doses (> llig per bolus injection). It is, however, clear from previous work that prostaglandins may have more potent effects on angiotensin II constricted placental vessels than when added alone'; therefore we have investigated the effects of coadministration of LTB. or LTC. (5 to 500 ng per bolus injection) with angiotensin II (5 ILg per bolus injection) on placental perfusion pressures. The perfusion system used in this study has been described.'
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Economides et al. (Economides DL, Crook D, Nicolaides KH. Hypertriglyceridemia and hypoxemia in small-for-gestational-age fetuses. AM J OBSTET GYNECOL 1990; 162 :382-6). The authors found elevated plasma triglyceride concentration in samples obtained by cordocentesis for small-for-gestational-age fetuses. One month earlier we described the increase of cord blood triglyceride concentration in small-for-gestational-age infants born to mothers with placental insufficiency.' The mechanism of triglyceride increase in those cases is not well understood. I suggest that chronic fetal hypoxia caused by placental insufficiency is asso c cia ted with a substantial release of catecholamines. Increased secretion of catecholamines leads to lipolysis and results in elevated blood fatty acid level. The fetal liver takes up some of the excess fatty acid · and synthesizes endogenous triglycerides that appear in the fetal serum. It has been found that the duration of fetal hypoxia must be considerable, perhaps even an hour or more, for it to result in hypertriglyceridemia. 2 I proposed that the level of cord blood triglyceride may prove to be a useful indicator of chronic fetal hypoxia. Janusz Bartnicki, MD Institute of Perinatal Medicine, Mariendorfer Weg 28, D-lOOO Ber: lin 44, Germany
REFERENCES 1. Bartnicki J, Szmitkowski M, J6Zwik M, Sledziewski A,
Chrostek L, Urban J. Cord blood triglyceridemia in cases of placental insufficiency. Am J Perinatol 1990;7:26-30. 2. Elphick MC, Harrison AT, Lawlor JP, Hull D. Cord blood hypertriglyceridemia as an index of fetal stress: use of a simple screening test and results of further biochemical analysis. Br J Obstet Gynaecol 1978;85:303-10.
Response declined
Splitting hairs about splitting muscles To the Editors: Helmkamp and Krebs (Helmkamp BF,
Krebs H-B. The Maylard incision in gynecologic cancer. AM J OBSTET GYNECOL 1990; 163: 1554-7) recently presented data substantiating the value of the Maylard abdominal incision. This article was timely, nicely done, and welcome. The Maylard technique, however, is not a "muscle-splitting" incision. It is, rather, a muscle-cutting procedure. Quoting Condon' in his chapter on appendicitis in Sabiston's Textbook of Surgery, " ... the muscle-splitting incision (McArther-McBurney) is the timehonored approach and one widely used today .... Its advantage is that separation of muscles in the line of their
fibers produces a wound that does not depend entirely
upon sutures for restoration of tissue continuity." Surgical transection of the rectus muscles does not fit this description. The risk of subfascial hematoma and the associated need for a subfascial drain are related to the creation of a closed space between the fascia and parietal peritoneum. Both can be eliminated by meticulous hemostasis and by allowing the parietal peritoneum to remain open and unsutured? Gregory P. Sutton, MD Department of Obstetrics and Gynecology, University Hospital, Indiana University Medical Center, 926 W. Michigan, Indianapolis, IN 46202
REFERENCES 1. Condon FE. Appendicitis. In: Sabiston DC, ed. Textbook
of surgery. 13th ed. Philadelphia: WB Saunders, 1986: 975-6. 2. Pietrantoni M, Parsons MT, O'Brien WF, Collins E, Knuppel RA, Spellacy WN. Peritoneal closure or non-closure at cesarean. Obstet GynecoI1991;77:293-6.
Reply To the Editors: Thank you very much for your comments
regarding our recent article. I agree that "musclecutting" more accurately describes the Maylard technique because the incision through the rectus muscles is perpendicular to the muscle fibers rather than parallel. 1 do not suture the posterior rectus sheath in closing vertical and Pfannenstiel incisions. If you do likewise with the Maylard incision and have had no wound complications, it may be possible to eliminate the subfascial drain as you suggest. B. Frederick Helmkamp, MD 3289 Woodburn Road, Suite 320, Annandale, VA 22003-6897
Effects of leukotrienes in the placental vasculature To the Editors: Thorp et al. (Thorp JA, Walsh SW, Brath PC. Comparison of the vasoactive effects of leukotrienes with thromboxane mimic in the perfused human placenta. AMJ OBSTET GYNECOL 1988;159:137680) have clearly shown that leukotrienes B. (LTB 4 ) and C4 (LTC.) do not exert major effects on the placental vasculature except at high doses (> llig per bolus injection). It is, however, clear from previous work that prostaglandins may have more potent effects on angiotensin II constricted placental vessels than when added alone'; therefore we have investigated the effects of coadministration of LTB. or LTC. (5 to 500 ng per bolus injection) with angiotensin II (5 ILg per bolus injection) on placental perfusion pressures. The perfusion system used in this study has been described.'
1575