Splitting Hairs About Splitting Muscles - Ymob

LETTERS TO THE EDITORS
Hypertriglyceridemia in small-for-gestational-age fihers produces a wound that does not depend entirely
fetuses lIpon sutures for restoration of tissue continuity." Sur-
To the Editors: I read with great interest the article by gical transection of the rectus muscles does not fit this
Economides et al. (Economides DL, Crook D, Nico- description.
laides KH. Hypertriglyceridemia and hypoxemia in The risk of subfascial hematoma and the associated
small-for-gestational-age fetuses. AM J OBSTET GYNE- need for a subfascial drain are related to the creation
COL 1990;162:382-6). The authors found elevated of a closed space between the fascia and parietal peri-
plasma triglyceride concentration in samples ob- toneum. Both can be eliminated by meticulous hemo-
tained by cordocentesis for small-for-gestational-age stasis and by allowing the parietal peritoneum to remain
fetuses. open and unsutured. 2
One month earlier we described the increase of cord Gregory P. Sulton, MD
blood triglyceride concentration in small-for-gesta- Department of Obstetrics and Gynecology, University Hospital, In-
tional-age infants born to mothers with placental in- diana University Medical Center, 926 W. Michigan, Indianapolis,
sufficiency.' The mechanism of triglyceride increase in IN 46202
those cases is not well understood. 1 suggest that chronic REFERENCES
fetal hypoxia caused by placental insufficiency is asso~ 1. Condon FE. Appendicitis. In: Sabiston DC, ed. Textbook
ciated with a substantial release of catecholamines. In- of surgery. 13th ed. Philadelphia: WB Saunders, 1986:
creased secretion of catecholamines leads to lipolysis 975-6.
and results in elevated blood fatty acid level. The fetal 2. Pietrantoni M, Pat'sons MT. O'Brien WF, Collins E, Knup-
pel RA, Spellacy WN. Peritoneal closure or non-closure at
liver takes up some of the excess fatty acid and syn- cesarean. Obstet Gynecol 1991;77:293-6.
thesizes endogenous triglycerides that appear in the
fetal serum.
It has been found that the duration of fetal hypoxia Reply
must be considerable, perhaps even an hour or more, To the Editors: Thank you very much for your comments
for it to result in hypertriglyceridemia." regarding our recent article. I agree that "muscle-
I proposed that the level of cord blood triglyceride cutting" more accurately describes the Maylard tech-
may prove to be a useful indicator of chronic fetal nique because the incision through the rectus muscles
hypoxia. is perpendicular to the muscle fibers rather than
Janusz Bartnicki, MD parallel.
Institute of Perinatal Medicine, Mariendorfer Weg 28, D-lGOO Ber- I do not suture the posterior rectus sheath in closing
lin -/4, Germany
vertical and Pfannenstiel incisions. If you do likewise
REFERENCES with the Maylard incision and have had no wound com-
1. Bartnicki J, Szmitkowski M, J6zwik M, Sledziewski A, plications, it may be possible to eliminate the subfascial
Chrostek L, Urban J. Cord blood triglyceridemia in cases drain as you suggest.
of placental insufficiency. Am J Perinatal 1990;7:26-30. B. Frederick Helmkamp, MD
2. Elphick MC, Harrison AT, Lawlor JP, Hull D. Cord blood 3289 Woodburn Road. Suite 320, Annandale, VA 22003-6897
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 Effects ot leukotrienes in the

placental vasculature
To the Editors: Thorp et al. (Thorp JA, Walsh SW, Brath
PC. Comparison of the vasoactive effects of leuko-
Splitting hairs about splitting muscles trienes with thromboxane mimic in the perfused hu-
To the Editors: Helmkamp and Krebs (Helmkamp BF, man placenta. AMJ OBSTET GYNECOL 1988;159:1376-
Krebs H-B. The Maylard incision in gynecologic cancer. 80) have clearly shown that leukotrienes B. (LTB.) and
AM J OBSTET GYNECOL 1990: 163: 1554-7) recently pre- C. (LTC.) do not exert major effects on the placental
sented data substantiating the value of the Maylard vasculature except at high doses (> 1 ILg per bolus in-
abdominal incision. This article was timely, nicely done, jection). It is, however, clear from previous work that
and welcome. The Maylard technique, however, is not prostaglandins may have more potent effects on an-
a "muscle-splitting" incision. It is, rather, a muscle-cut- giotensin II constricted placental vessels than when
ting procedure. Quoting Condon 1 in his chapter on ap- added alone'; therefore we have investigated the effects
pendicitis in Sabiston's Textbook ofSurgery, "... the mus- of coadministration of LTB. or LTC. (5 to 500 ng per
cle-splitting incision (McArther-McBurney) is the time- bolus injection) with angiotensin II (5 ILg per bolus
honored approach and one widely used today.... Its injection) on placental perfusion pressures. The per-
ad vantage is that separation of muscles in the line oftheir fusion system used in this study has been described. 1
1575

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LETTERS TO THE EDITORS

Response declined Effects ot leukotrienes in the

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