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    PIIS0002937807011209

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    www.AJOG.

    org Letters to the Editors

    REPLY
    Thank you for your thoughtful comments on our study. As you tal outcomes, the increase in gestational age at delivery saves
    know, 1 of the key points in performing a cost analysis is de- money, mostly in neonatal intensive care unit costs. The results
    ciding what studies to include in the estimates. Because medi- of this cost analysis do not eliminate the need for individual
    cal costs and intensity of treatment vary greatly between coun- physicians to evaluate the available evidence and decide
    tries, we chose to focus our cost estimates on the United States whether they feel comfortable with the risks and benefits of
    alone. To infer the absolute (not proportional) decline in pre- prescribing a drug for a particular patient. f
    term rates that could be expected, an estimate of the preterm
    Jennifer Bailit, MD, MPH
    birth rate was also needed from the US population. We ob- Division of Maternal-Fetal Medicine
    tained the baseline risk of preterm birth for patients with a Department of Obstetrics and Gynecology
    prior preterm birth from the paper by Mercer et al.1 MetroHealth Medical Center
    The trial by Meis et al2 has been criticized for having a pre- 2500 MetroHealth Dr.
    term birth rate that was quite high. Although some have spec- Cleveland, OH 44109
    ulated that castor oil in the placebo given to the placebo group jbailit@metrohealth.org
    increased the risk of preterm birth, there are no clinical data to Mark E. Votruba, PhD, MPP
    support this assertion. The 17 ␣ hydroxyprogesterone caproate The Center for Health Care Research and Policy
    in twins and triplets: a randomized study (STTARS) trial pre- MetroHealth Medical Center
    sentation at the Society for Maternal-Fetal Medicine meeting Department of Economics
    in 2007 showed a preterm birth rate in the placebo group that Weatherhead School of Management
    was similar to national rates, suggesting that castor oil in the Case Western Reserve University
    placebo does not cause preterm birth.3 More likely the trial by Cleveland, OH 44109
    Meis et al attracted a motivated cohort of women who were at
    very high risk for preterm birth. REFERENCES
    Of course, if a treatment does not work, it will not be cost 1. Mercer BM, Goldenberg RL, Moawad AH, et al. The preterm prediction
    effective. As noted, we chose the Meis estimates because they study: effect of gestational age and cause of preterm birth on subsequent
    obstetric outcome. National Institute of Child Health and Human Devel-
    were consistent with metaanalyses on the effectiveness of 17 opment Maternal-Fetal Medicine Units Network. Am J Obstet Gynecol
    alpha-hydroxyprogesterone caproate (17P). Reconstruction of 1999;181:1216-21.
    our analysis based on 1 of these “metaestimates” with the ex- 2. Meis PJ, Klebanoff M, Thom E, et al. Prevention of recurrent preterm
    clusion of the Meis results would result in a larger cost savings. delivery by 17 alpha-hydroxyprogesterone caproate. N Engl J Med
    We chose to use the most conservative numbers. 2003;348:2379-85.
    3. Caritis SN, Rouse DJ. A randomized controlled trial of 17-hydroxypro-
    At the meeting of the Society for Maternal-Fetal Medicine in gesterone caproate (17-OHPC) for the prevention of preterm birth in
    2007, 4-year child follow-up results from the Meis trial were twins. Am J Obstet Gynecol 2006;195:S2.
    presented.4 The follow-up study was reassuring as to the safety 4. Northen A. 4-Year follow-up of children exposed to 17alpha hy-
    of 17P. However, whether 17P ultimately is shown to improve droxyprogesterone caproate (17P) in utero. Am J Obstet Gynecol
    long-term outcomes and not just perinatal outcomes is not 2006;195:S6.
    critical to our study. Regardless of whether it improves neona- © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.09.023

    Lower uterine segment varices: Significance and management


    TO THE EDITORS: We read with interest the case report by 1. Prior to making a uterine incision, Kelly clamps or sutures
    Matsuo and Kimura with an impressive image at cesarean are applied on either side laterally as well as above and below
    section.1 proposed incision3 on the vessels if there are several vessels
    The authors speculate that previous classical section may to decrease blood flow. Additionally, we maintain tampon-
    have contributed to the development of these prominent ade on these vessels against the presenting fetal part as the
    vessels. incision is being made to minimize blood loss.
    It is, however, not uncommon to encounter these prominent 2. The incision is then swiftly made between the clamps whereby
    vessels in cases of placenta previa, irrespective of previous uter- there is diminished blood flow at the site of incision.
    ine surgery.2 3. The infant is then delivered in an expeditious manner.
    The authors have rightly shown their concern about such 4. As the authors mentioned, the delivery of the baby results
    distended veins and considerable blood loss if lower segment in the collapse of these vessels.
    cesarean section incision is directly over the vessels.
    In the presence of such findings, we have managed such a The key is to restrict the blood flow in the area of the
    situation in a different manner with favorable results. proposed incision, move quickly, and have ring forceps

    DECEMBER 2007 American Journal of Obstetrics & Gynecology 687


    Letters to the Editors www.AJOG.org

    available to apply on cut edges promptly to reduce blood REFERENCES


    loss. f 1. Matsuo K, Kimura T. Uterine varices during pregnancy. Am J Obstet
    Gynecol 2007;197:112.e1.
    Laxmi V. Baxi, MD 2. Frede TE. Ultrasonic visualization of varicosities in the female genital
    Sloane Hospital For Women at Columbia University Medical tract. J Ultrasound Med 1984;3:365-9.
    Center 3. Briscoe CC. Prophylactic ligation of enlarged lower uterine segment
    New York Presbyterian Hospital veins at cesarean section. Obstet Gynecol 1964;24:783.
    622 West 168 St.
    New York, NY 10032
    lvb1@columbia.edu © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.09.021

    REPLY
    Thank you very much for your interest in our case.1 Baxi in- associated with placenta previa. For that reason, transverse
    troduced a different approach to the management of the prom- hysterotomy in uterine corpus was performed. f
    inent uterine varices during cesarean section. This approach
    Koji Matsuo, M.D
    was exactly opposite to what we had performed in our case.
    Department of Obstetric, Gynecology, and Reproductive Sciences
    Transverse hysterotomy in uterine corpus and hemostatic University of Maryland School of Medicine
    clamp of uterine varices are both options for this rare compli- University of Maryland Medical Center
    cation during pregnancy. Obstetricians need to be familiar 22 South Greene St.
    with the pros and cons in both approaches. Hysterotomy in PO Box 290
    uterine corpus gives a faster approach to delivery, although Baltimore, MD 21201
    there may be an increased risk of uterine rupture in future kmats001@umaryland.edu
    pregnancies. A hemostatic clamp of uterine varix requires me-
    Tadashi Kimura, MD, PhD
    ticulous surgical skills and may take longer but is doable with
    Department of Obstetrics and Gynecology
    low transverse hysterotomy. Circumstances surrounding ce-
    Osaka University Graduate School of Medicine
    sarean section are key in choosing the appropriate approach
    Osaka, Japan
    (eg, an emergent situation, a surgeon’s level of comfort, and
    number and locations of uterine varices).
    In our case, there were at least 5 large varices, and each vessel REFERENCE
    was distended more than an index finger size. Furthermore, 1. Matsuo K, Kimura T. Uterine varices during pregnancy. Am J Obstet
    Gynecol 2007;197:112.e1.
    our concern at the time of cesarean section was the possible
    hypervascularity within the wall of the uterine lower segment © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.09.020

    Risk factors for primary and subsequent anal sphincter lacerations:


    A comparison of cohorts by parity and prior mode of delivery
    TO THE EDITORS: I read with interest the article by J. L comes, however, a risk factor for this complication when ex-
    Lowder et al,1 and I would like to make the following com- cessive and inordinate traction is applied, a likely occurrence in
    ments. First, their recommendation of the vacuum extractor the presence of unrecognized cephalopelvic disproportion
    (VE) over forceps delivery in nulliparous women to lower the (CPD), in concomitance with a median episiotomy. Therefore,
    risk of anal sphincter laceration (ASL) overlooks the fact that I would not discourage the use of forceps, which can be reso-
    these 2 instruments are not equivalent and thus cannot be used lutive when a cesarean section is either contraindicated by ma-
    interchangeably. In fact, whereas the latter is used to actively ternal conditions or preparation for it cannot be made in a
    deliver the baby (ie, to replace the vis a tergo), the former is timely fashion, and the VE cannot be used because it is either
    used to augment, not replace, the natural forces of labor. My not suitable (artificial rotation) or downright contraindicated
    second observation relates to the obvious assumption by the (preterm delivery, face or brow presentation, aftercoming
    authors that the association of ASL with forceps delivery, found head, suspected fetal coagulation defect, scalp sampling of fetal
    in their retrospective review, proves causality. In fact, the sim- blood).
    ple observation that not all nulliparous women who undergo a Rather, I would recommend that before applying this instru-
    forceps delivery suffer ASL, demonstrated the opposite. ment, every effort be made to rule out CPD and opt strictly for
    As most obstetricians properly trained in the use of this in- a mediolateral episiotomy, whose objective is precisely to re-
    strument will agree, forceps is not inherently dangerous. It be- duce the likelihood of third-degree laceration.2 f

    688 American Journal of Obstetrics & Gynecology DECEMBER 2007

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