Letters When You Need Me To the Editor: I was incensed this week when I read Dr. Theiler’s1 Personal Perspective regarding the annual pelvic examination. In my world of private practice, my patients often come to see me as their only examination of the year, or sometimes in addition to an annual examination with a primary care physician who has no interest in caring for their female parts. During my examination, I emphasize the importance of checking the skin and the vulva as well as the vaginal tissue for disease. I also perform a bimanual examination, which helps me assess not only for masses, but also for tenderness, support, and mobility. Many women believe the pelvic examination is even more important than the physical her primary care physician is providing. The expectations of primary care are such that it is impossible for the primary care provider to keep up with gynecology as well as primary care to provide the best care. This week I will call a patient to give her the news that she has squamous cell carcinoma in situ of the skin. I performed the biopsy at her routine annual examination after noting an abnormalappearing area about 5 cm from her introitus on her inner buttock. I very much doubt her primary care physician would be looking there. If she came in only for Pap tests, she would not be in for 5 years. By the time she would be diagnosed, I can only guess the stage. Guidelines for Letters. Letters posing a question or challenge to an article appearing in Obstetrics & Gynecology should be submitted within 8 weeks of the article’s publication online. Letters received after 8 weeks will rarely be considered. Letters should not exceed 350 words, including signatures and 5 references. A word count should be provided. The maximum number of authors permitted is four, and a corresponding author should be designated (and contact information listed). Letters will be published at the discretion of the Editor. The Editor may send the letter to the authors of the original paper so their comments may be published simultaneously. The Editor reserves the right to edit and shorten letters. A signed author agreement form is required from all authors before publication. Letters should be submitted using the Obstetrics & Gynecology online submission and review system, Editorial Manager (http://ong.edmgr.com).
VOL. 125, NO. 5, MAY 2015
Another patient who came in for her annual examination last week did not disclose on her history forms anything about leakage or incontinence. It is part of our routine annual questionnaire, but she answered no. On examination, she had a grade 3 cystocele, so I asked about her bladder function. She disclosed only then her concerns and problems, and she will be getting fitted for a pessary next week. These stories are weekly occurrences in my busy office located in a suburb of a large metropolitan area. The bimanual examination is part of the complete pelvic examination that reveals more than what the patient tells us or is aware of. The pelvic examination is an opportunity to save lives and make a difference in our patients’ lives. Any gynecologist who has not seen this difference in his or her practice is either not looking carefully enough, not asking the right questions, or simply not seeing enough patients. In other words, it’s not about the money, it’s about the patients. Financial Disclosure: The author did not report any potential conflicts of interest.
Orly Steinberg, MD Mill Creek OB/GYN, Mill Creek, Washington
REFERENCE 1. Theiler R. When you need me. Obstet Gynecol 2014;124:1202–3.
In Reply: I welcome the dialogue incited by my Personal Perspectives article.1 I also appreciate the significance of the annual wellness visit, both for preventive care of the patient and for emotional satisfaction of the physician. We all accumulate anecdotes about unexpected physical examination findings—the proverbial “good catch” that saved a life—and we derive professional satisfaction from these events. However, I fear we also underestimate the number of unnecessary interventions we cause while overestimating the utility of the pelvic examination in the truly asymptomatic patient. As a specialty, we have not shown enough evidence to justify the enormous expense of providing a screening pelvic examination to every woman every
year. Anecdotes no longer suffice—our colleagues, our patients, and our payers demand evidence of benefit, and we simply have yet to demonstrate it. Financial Disclosure: The author did not report any potential conflicts of interest.
Regan N. Theiler, MD, PhD Dartmouth-Hitchcock Medical Center, Department of Obstetrics and Gynecology, Lebanon, New Hampshire
REFERENCE 1. Theiler R. When you need me. Obstet Gynecol 2014;124:1202–3.
Association of Prelabor Cesarean Delivery With Reduced Mortality in Twins Born Near Term To the Editor: We read with great interest the large, population-based study of Roberts et al published in the January issue of Obstetrics and Gynecology,1 reporting an association between prelabor cesarean delivery and reduced mortality in twins born near term. Although these results suggest a protective effect of prelabor cesarean delivery in this population, we believe they should be interpreted cautiously. Results of large retrospective studies are based on registry data rather than complete medical files or information collected prospectively. Therefore, they are difficult to interpret because of the questionable validity and sparseness of the antenatal and postnatal information. Indeed, data such as patient selection for mode of delivery, intertwin delivery interval, second twin presentation, and mainly reasons leading to cesarean for second twin delivery, all strongly related with perinatal morbidity and mortality,2 are lacking in large retrospective studies. Furthermore, using delivery after the onset of labor as a proxy for trial of labor might have been the cause for numerous biases because women with the highest neonatal risks (ie, with pregnancy complications such as placental abruption, abnormal fetal heart rate at the onset of labor,
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1247
chorioamnionitis, or acute twin–twin transfusion syndrome) might have been included in the delivery-after-onset-oflabor group. However, neonatal outcomes are not related to the mode of delivery in these cases. Finally, women in the prelabor cesarean delivery group might have had better pregnancy care than women in the labor group, as suggested by the differences in socioeconomic status. Therefore, suggesting a protective effect of prelabor cesarean delivery from these data would be inappropriate. Because of the large sample size needed, only large prospective studies especially designed to answer the question will help to determine the best management for twin delivery. Such a study is ongoing in France (www. clinicaltrials.gov, NCT01987063). Financial Disclosure: The authors did not report any potential conflicts of interest.
Thomas Schmitz, MD, PhD Service de Gynécologie Obstétrique, Hôpital Robert Debré, Université Paris Diderot, AP-HP, Paris, France François Goffinet, MD, PhD Inserm U953 (ex149), Epidemiological Research Unit on Perinatal Health and Women’s and Children Health and Maternité Port-Royal, Université Paris Descartes, DHU Risk in Pregnancy, Sorbonne Paris Cité Department of Obstetrics and Gynecology, Cochin, Broca, Hôtel Dieu Hospital, AP-HP, Paris, France
REFERENCES
provide guidance. Their finding that labor is associated with increased morbidity and mortality in the second twin when compared with the first twin is certainly concerning. We find the one intrapartum death and four cases of severe hypoxia in the second twin group concerning, because it suggests an absence of or inadequate intrapartum monitoring. This fact, combined with the authors’ finding of improved outcome in the higher socioeconomic cohort, may mean the adverse perinatal outcome for the second twin was not due to order of delivery, but rather access to advanced medical technology and skilled professionals. Comparative analysis of data subsets by provider type—private compared with public and urban compared with suburban–may provide answers to our questions of access. We agree with the authors that lack of information about the obstetric health care providers’ abilities, fetal monitoring, access to operating rooms, and availability of skilled neonatal health care providers are limitations of this article. However, we do not agree that this article quantifies the risks delivery methods pose to twins; rather, we find that these weaknesses in the study simply add further to the confusion about how best to deliver twins. Financial Disclosure: The authors did not report any potential conflicts of interest.
Christopher Folterman, MS St. George’s University, School of Medicine, Grenada, West Indies
1. Roberts CL, Algert CS, Nippita TA, Bowen JR, Shand AW. Association of prelabor cesarean delivery with reduced mortality in twins born near term. Obstet Gynecol 2015;125:103–10.
Shadi Rezai, MD Cassandra E. Henderson, MD Department of Obstetrics and Gynecology, Lincoln Medical and Mental Health Center, Bronx, New York
2. Cruikshank DP. Intrapartum management of twin gestations. Obstet Gynecol 2007;109:1167–76.
REFERENCE
Association of Prelabor Cesarean Delivery With Reduced Mortality in Twins Born Near Term To the Editor:
Roberts et al’s recent article1 explores a contemporary management dilemma for which there is a paucity of data to
1248
Letters
1. Roberts CL, Algert CS, Nippita TA, Bowen JR, Shand AW. Association of prelabor cesarean delivery with reduced mortality in twins born near term. Obstet Gynecol 2015;125:103–10.
In Reply: The authors thank Drs. Schmitz and Goffinet, and Drs. Folterman, Rezai, and Henderson for their interest in our article.1 In the absence of randomized controlled trials, we agree that cohort
studies provide an alternative source of high-quality information for clinicians. Our cohort study uses large, well-validated2–5 population data sets with data that were collected at the time of occurrence, not retrospectively. Neonatal and childhood admissions were collected independently of the birth records. In response to other issues raised, we make the following points: • Population data’s lack of clinical detail is the tradeoff for accurate information on an entire, not just a highly selected (and potentially nonrepresentative), population. • Our study population represents women with uncomplicated twin pregnancies who reached 36 weeks of gestation, for whom clinicians are faced with a decision about prelabor cesarean delivery. • We carefully report outcomes by onset of labor (a situation that can occur regardless of intention), and at no point do we claim this is a proxy for intention. • Although there may have been a (non–statistically significant) tendency toward differential childhood mortality by maternal socioeconomic status, the protective effect of prelabor cesarean delivery against childhood mortality was the same across socioeconomic strata (relative risk50.40). • Because the analyses by birth order accounted for clustering, factors such as access to skilled professionals and operating rooms were matched for each twin pair. • Factors that are unknown before the onset of labor (eg, intertwin delivery interval, acute intrapartum complications) are not relevant to antepartum decision-making. • Information on second twin presentation was available and was not used as an exclusion criterion, because, in Australia, mode of delivery typically is based on first twin presentation. • In 162 (4.2%) of the 3,883 twin pregnancies with labor, the second twin alone was born by intrapartum cesarean delivery. This is one of the risks of a trial of labor. • Acute complications such as abnormal fetal heart rate and twin–twin
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
VOL. 125, NO. 5, MAY 2015
Another patient who came in for her annual examination last week did not disclose on her history forms anything about leakage or incontinence. It is part of our routine annual questionnaire, but she answered no. On examination, she had a grade 3 cystocele, so I asked about her bladder function. She disclosed only then her concerns and problems, and she will be getting fitted for a pessary next week. These stories are weekly occurrences in my busy office located in a suburb of a large metropolitan area. The bimanual examination is part of the complete pelvic examination that reveals more than what the patient tells us or is aware of. The pelvic examination is an opportunity to save lives and make a difference in our patients’ lives. Any gynecologist who has not seen this difference in his or her practice is either not looking carefully enough, not asking the right questions, or simply not seeing enough patients. In other words, it’s not about the money, it’s about the patients. Financial Disclosure: The author did not report any potential conflicts of interest.
Orly Steinberg, MD Mill Creek OB/GYN, Mill Creek, Washington
REFERENCE 1. Theiler R. When you need me. Obstet Gynecol 2014;124:1202–3.
In Reply: I welcome the dialogue incited by my Personal Perspectives article.1 I also appreciate the significance of the annual wellness visit, both for preventive care of the patient and for emotional satisfaction of the physician. We all accumulate anecdotes about unexpected physical examination findings—the proverbial “good catch” that saved a life—and we derive professional satisfaction from these events. However, I fear we also underestimate the number of unnecessary interventions we cause while overestimating the utility of the pelvic examination in the truly asymptomatic patient. As a specialty, we have not shown enough evidence to justify the enormous expense of providing a screening pelvic examination to every woman every
year. Anecdotes no longer suffice—our colleagues, our patients, and our payers demand evidence of benefit, and we simply have yet to demonstrate it. Financial Disclosure: The author did not report any potential conflicts of interest.
Regan N. Theiler, MD, PhD Dartmouth-Hitchcock Medical Center, Department of Obstetrics and Gynecology, Lebanon, New Hampshire
REFERENCE 1. Theiler R. When you need me. Obstet Gynecol 2014;124:1202–3.
Association of Prelabor Cesarean Delivery With Reduced Mortality in Twins Born Near Term To the Editor: We read with great interest the large, population-based study of Roberts et al published in the January issue of Obstetrics and Gynecology,1 reporting an association between prelabor cesarean delivery and reduced mortality in twins born near term. Although these results suggest a protective effect of prelabor cesarean delivery in this population, we believe they should be interpreted cautiously. Results of large retrospective studies are based on registry data rather than complete medical files or information collected prospectively. Therefore, they are difficult to interpret because of the questionable validity and sparseness of the antenatal and postnatal information. Indeed, data such as patient selection for mode of delivery, intertwin delivery interval, second twin presentation, and mainly reasons leading to cesarean for second twin delivery, all strongly related with perinatal morbidity and mortality,2 are lacking in large retrospective studies. Furthermore, using delivery after the onset of labor as a proxy for trial of labor might have been the cause for numerous biases because women with the highest neonatal risks (ie, with pregnancy complications such as placental abruption, abnormal fetal heart rate at the onset of labor,
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1247
chorioamnionitis, or acute twin–twin transfusion syndrome) might have been included in the delivery-after-onset-oflabor group. However, neonatal outcomes are not related to the mode of delivery in these cases. Finally, women in the prelabor cesarean delivery group might have had better pregnancy care than women in the labor group, as suggested by the differences in socioeconomic status. Therefore, suggesting a protective effect of prelabor cesarean delivery from these data would be inappropriate. Because of the large sample size needed, only large prospective studies especially designed to answer the question will help to determine the best management for twin delivery. Such a study is ongoing in France (www. clinicaltrials.gov, NCT01987063). Financial Disclosure: The authors did not report any potential conflicts of interest.
Thomas Schmitz, MD, PhD Service de Gynécologie Obstétrique, Hôpital Robert Debré, Université Paris Diderot, AP-HP, Paris, France François Goffinet, MD, PhD Inserm U953 (ex149), Epidemiological Research Unit on Perinatal Health and Women’s and Children Health and Maternité Port-Royal, Université Paris Descartes, DHU Risk in Pregnancy, Sorbonne Paris Cité Department of Obstetrics and Gynecology, Cochin, Broca, Hôtel Dieu Hospital, AP-HP, Paris, France
REFERENCES
provide guidance. Their finding that labor is associated with increased morbidity and mortality in the second twin when compared with the first twin is certainly concerning. We find the one intrapartum death and four cases of severe hypoxia in the second twin group concerning, because it suggests an absence of or inadequate intrapartum monitoring. This fact, combined with the authors’ finding of improved outcome in the higher socioeconomic cohort, may mean the adverse perinatal outcome for the second twin was not due to order of delivery, but rather access to advanced medical technology and skilled professionals. Comparative analysis of data subsets by provider type—private compared with public and urban compared with suburban–may provide answers to our questions of access. We agree with the authors that lack of information about the obstetric health care providers’ abilities, fetal monitoring, access to operating rooms, and availability of skilled neonatal health care providers are limitations of this article. However, we do not agree that this article quantifies the risks delivery methods pose to twins; rather, we find that these weaknesses in the study simply add further to the confusion about how best to deliver twins. Financial Disclosure: The authors did not report any potential conflicts of interest.
Christopher Folterman, MS St. George’s University, School of Medicine, Grenada, West Indies
1. Roberts CL, Algert CS, Nippita TA, Bowen JR, Shand AW. Association of prelabor cesarean delivery with reduced mortality in twins born near term. Obstet Gynecol 2015;125:103–10.
Shadi Rezai, MD Cassandra E. Henderson, MD Department of Obstetrics and Gynecology, Lincoln Medical and Mental Health Center, Bronx, New York
2. Cruikshank DP. Intrapartum management of twin gestations. Obstet Gynecol 2007;109:1167–76.
REFERENCE
Association of Prelabor Cesarean Delivery With Reduced Mortality in Twins Born Near Term To the Editor:
Roberts et al’s recent article1 explores a contemporary management dilemma for which there is a paucity of data to
1248
Letters
1. Roberts CL, Algert CS, Nippita TA, Bowen JR, Shand AW. Association of prelabor cesarean delivery with reduced mortality in twins born near term. Obstet Gynecol 2015;125:103–10.
In Reply: The authors thank Drs. Schmitz and Goffinet, and Drs. Folterman, Rezai, and Henderson for their interest in our article.1 In the absence of randomized controlled trials, we agree that cohort
studies provide an alternative source of high-quality information for clinicians. Our cohort study uses large, well-validated2–5 population data sets with data that were collected at the time of occurrence, not retrospectively. Neonatal and childhood admissions were collected independently of the birth records. In response to other issues raised, we make the following points: • Population data’s lack of clinical detail is the tradeoff for accurate information on an entire, not just a highly selected (and potentially nonrepresentative), population. • Our study population represents women with uncomplicated twin pregnancies who reached 36 weeks of gestation, for whom clinicians are faced with a decision about prelabor cesarean delivery. • We carefully report outcomes by onset of labor (a situation that can occur regardless of intention), and at no point do we claim this is a proxy for intention. • Although there may have been a (non–statistically significant) tendency toward differential childhood mortality by maternal socioeconomic status, the protective effect of prelabor cesarean delivery against childhood mortality was the same across socioeconomic strata (relative risk50.40). • Because the analyses by birth order accounted for clustering, factors such as access to skilled professionals and operating rooms were matched for each twin pair. • Factors that are unknown before the onset of labor (eg, intertwin delivery interval, acute intrapartum complications) are not relevant to antepartum decision-making. • Information on second twin presentation was available and was not used as an exclusion criterion, because, in Australia, mode of delivery typically is based on first twin presentation. • In 162 (4.2%) of the 3,883 twin pregnancies with labor, the second twin alone was born by intrapartum cesarean delivery. This is one of the risks of a trial of labor. • Acute complications such as abnormal fetal heart rate and twin–twin
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
