It is up to those who provide obstetric care to properly counsel women about the clinical implications of these findings and practice evidencebased medicine. We were delighted that three journals agreed to publish the executive summary simultaneously and would hope that those who perform fetal imaging, radiologists and obstetricians alike, would read this summary. Electronic versions of articles have become the most common way to access articles with less reliance on hard copy journals, so we anticipate there will be wide access to this article. Furthermore, the Journal of Ultrasound in Medicine has a wide readership that includes radiologists and ultrasonographers. The aims of the workshop were to review the current evidence for fetal imaging and the future research agenda. The role of ultrasound laboratory accreditation by the American Institute of Ultrasound in Medicine and the American College of Radiology was not a specific focus of the workshop and therefore was not commented upon. Financial Disclosure: The authors did not report any potential conflicts of interest.
Uma Reddy, MD, MPH Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland Alfred Abuhamad, MD EVMS Medical Group, Norfolk, Virginia Deborah Levine, MD Beth Israel Deaconess Medical Center, Boston, Massachusetts George Saade, MD University of Texas Medical Branch at Galveston, Galveston, Texas
REFERENCE 1. Reddy UM, Abuhamad AZ, Levine D, Saade GR; Fetal Imaging Workshop Invited Participants. Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Obstet Gynecol 2014;123:1070–82.
VOL. 124, NO. 4, OCTOBER 2014
Editor’s Note: This reply to a letter to the editor is being published concurrently in the October 2014 issue (Vol. 33, No. 10) of Journal of Ultrasound in Medicine.
Repeat Midurethral Sling Compared With Urethral Bulking for Recurrent Stress Urinary Incontinence To the Editor:
In reading the article by Gaddi et al,1 I had concern about the accuracy of the demographic data presented in the article and the resulting discussion and conclusions. In Table 1, only 23.9% of the urethral bulking group was listed as menopausal and only 42.9% of the midurethral sling group was listed as menopausal, despite the same table indicating that 80.6% of the urethral bulking group was aged 50 years or older and 63.3% of the midurethral sling group was aged 50 and older. Because 53.7% of the urethral bulking group was aged 60 or older, it makes it difficult to conclude that 29.8% of the 60 and older group was premenopausal. Given the mean older age in the urethral bulking group as well as the above-noted difference in age distribution, I take issue with the conclusion in the Discussion section, “That is, patients who underwent urethral bulking were older, had lower BMI, and were less likely to be menopausal than those undergoing the midurethral sling.” Financial Disclosure: The author did not report any potential conflicts of interest.
Katherine M. Gillogley, MD Department of Obstetrics and Gynecology, Methodist Hospital and UC Davis Medical Center, Sacramento, California
REFERENCE 1. Gaddi A, Guaderrama N, Bassiouni N, Bebchuk J, Whitcomb E. Repeat midurethral sling compared with urethral bulking for recurrent stress urinary incontinence. Obstet Gynecol 2014; 123:1207–12.
In Reply: We appreciate Dr. Gillogley’s comments concerning the menopausal status of our patient cohort.1 On
review of Table 1, there was in fact an error in that the represented data reflect premenopausal rather than postmenopausal status. The revised data are as follows: 76.1% (n551) of the urethral bulking group were menopausal, and 57.1% (n556) of the midurethral sling group were menopausal (P5.01). The data analysis and discussion are based on the correct data. However, this changes our conclusion in that patients who underwent urethral bulking were still older and had lower body mass indexes but were more likely to be menopausal. We apologize for this error. Financial Disclosure: The author did not report any potential conflicts of interest.
Emily L. Whitcomb, MD, MAS Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Southern California Permanente Medical Group, Irvine Medical Center
REFERENCE 1. Gaddi A, Guaderrama N, Bassiouni N, Bebchuk J, Whitcomb EL. Repeat midurethral sling compared with urethral bulking for recurrent stress urinary incontinence. Obstet Gynecol 2014;123:1207–12. Editor’s Note: Readers may refer to a Correction related to this article on page 842.
Postpartum Venous Thromboembolism: Incidence and Risk Factors To the Editor: We read with great interest the article by Tepper et al1 recently published in your prestigious journal. Both the topic and the sample size make the article interesting for obstetricians and general practitioners. The authors calculate the incidence of postpartum venous thromboembolism by week after delivery, focusing the attention on risk factors involved in increasing risk. The authors conclude that, after adjusting for all covariates, advanced age seems to increase the risk of early postpartum venous thromboembolism whereas cesarean delivery seems to increase both early and late postpartum venous thromboembolism. We already have performed an observational study about postpartum prophylaxis, detecting that pneumatic
Letters to the Editor
837
compression stockings represent an effective, low-cost, and safe tool to prevent postpartum venous thromboembolism after elective cesarean delivery in an unscreened population, independently from maternal age.2 On the contrary, in agreement with the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynaecologists, and Chest Guidelines, we suggest that pharmacologic prophylaxis after elective cesarean delivery represents a cost-effective tool only in cases of known adjunctive risk factors different from elective cesarean delivery and maternal age.3–5 Tepper et al calculated the incidence of postpartum venous thromboembolism during the 12 weeks after delivery, concluding that risk for postpartum venous thromboembolism is highest during the first 3 weeks after delivery and remains elevated throughout the first 12 weeks in women with obstetric complications. Despite the fact that the statistical analysis was methodologically correct, the high bias (accurately reported in the Discussion section) affecting the analyzed data render the results not completely useful in deciding whether or not to perform antithrombotic prophylaxis. The absence of validated diagnosis of postpartum venous thromboembolism events (data collection bias of events), the lack of knowledge about patient’s thrombophilia status (patients’ selection bias), the lack of data about peripartum pharmacologic and mechanical thromboprophylaxis (misclassification of exposure bias), the association in the cesarean delivery cohort of both elective and urgent cesarean deliveries, and the low accuracy in defining obstetric risk factors starting from the International Classification of Diseases, 9th Revision, Clinical Modification, made the results and conclusions perhaps only a mathematical and statistical exercise. In our opinion, the article by Tepper et al does not result in a useful way to solve the dilemma of whether or not to use thromboprophylaxis, what type of prophylaxis must be done, and what is the most appropriate timing to perform it. Financial Disclosure: The authors did not report any potential conflicts of interest.
Salvatore Gizzo, Giovanni Battista Nardelli, Marco Noventa,
838
Letters to the Editor
MD MD MD
Department of Woman and Child Health, OB/GYN Unit, University of Padua Padua, Italy
REFERENCES 1. Tepper NK, Boulet SL, Whiteman MK, Monsour M, Marchbanks PA, Hooper WC, et al. Postpartum venous thromboembolism: incidence and risk factors. Obstet Gynecol 2014;123: 987–96. 2. Gizzo S, Noventa M, Anis O, Saccardi C, Zambon A, Di Gangi S, et al. Pharmacological anti-thrombotic prophylaxis after elective caesarean delivery in thrombophilia unscreened women: should maternal age have a role in decision making? J Perinat Med 2014; 42:339–47. 3. Postpartum hemorrhage. ACOG Practice Bulletin No. 76. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1039–47. 4. Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:e691–736S. 5. Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. RCOG green-top guideline No. 37a. November 2009. Available at: http://www.rcog.org. uk/files/rcog-corp/GTG37aReducingRisk Thrombosis.pdf. Retrieved July 31, 2014.
In Reply: We thank Drs. Gizzo, Nardelli, and Noventa for their interest in our article, and their comments give us an opportunity to elaborate on several aspects of our analysis.1 The main objective of our analysis was to calculate the incidence of venous thromboembolism among postpartum women through postpartum week 12 and to examine how certain factors affect that risk according to timing postpartum. Our objectives did not include examining when or how to apply thromboprophylaxis. We agree that the interpretation of epidemiologic studies should consider relevant limitations. In our article, we acknowledge a number of limitations, including concerns about the accuracy and completeness of
claims data and the inability to account for the influence of associated factors such as peripartum pharmacologic thromboprophylaxis and nonpharmacologic thromboprophylaxis. Despite limitations, the results from our work add to the field of knowledge on postpartum venous thromboembolism. Venous thromboembolic disease remains an important cause of peripartum morbidity and mortality,2,3 and our findings highlight the fact that the risk extends into the postpartum period, particularly among women with certain risk factors. We hope our article will help to increase awareness among clinicians and stimulate further study on this issue, including implications for postpartum thromboprophylaxis. Financial Disclosure: The authors did not report any potential conflicts of interest. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Naomi K. Tepper, MD, MPH Sheree L. Boulet, DrPH, MPH Maura K. Whiteman, PhD Michael Monsour, PhD Polly A. Marchbanks, PhD Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia W. Craig Hooper, PhD Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia Kathryn M. Curtis, PhD Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
REFERENCES 1. Tepper NK, Boulet SL, Whiteman MK, Monsour M, Marchbanks PA, Hooper WC, et al. Postpartum venous thromboembolism: incidence and risk factors. Obstet Gynecol 2014;123:987–96. 2. Callaghan WM. Overview of maternal mortality in the United States. Semin Perinatol 2012;36:2–6.
OBSTETRICS & GYNECOLOGY
Uma Reddy, MD, MPH Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland Alfred Abuhamad, MD EVMS Medical Group, Norfolk, Virginia Deborah Levine, MD Beth Israel Deaconess Medical Center, Boston, Massachusetts George Saade, MD University of Texas Medical Branch at Galveston, Galveston, Texas
REFERENCE 1. Reddy UM, Abuhamad AZ, Levine D, Saade GR; Fetal Imaging Workshop Invited Participants. Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Obstet Gynecol 2014;123:1070–82.
VOL. 124, NO. 4, OCTOBER 2014
Editor’s Note: This reply to a letter to the editor is being published concurrently in the October 2014 issue (Vol. 33, No. 10) of Journal of Ultrasound in Medicine.
Repeat Midurethral Sling Compared With Urethral Bulking for Recurrent Stress Urinary Incontinence To the Editor:
In reading the article by Gaddi et al,1 I had concern about the accuracy of the demographic data presented in the article and the resulting discussion and conclusions. In Table 1, only 23.9% of the urethral bulking group was listed as menopausal and only 42.9% of the midurethral sling group was listed as menopausal, despite the same table indicating that 80.6% of the urethral bulking group was aged 50 years or older and 63.3% of the midurethral sling group was aged 50 and older. Because 53.7% of the urethral bulking group was aged 60 or older, it makes it difficult to conclude that 29.8% of the 60 and older group was premenopausal. Given the mean older age in the urethral bulking group as well as the above-noted difference in age distribution, I take issue with the conclusion in the Discussion section, “That is, patients who underwent urethral bulking were older, had lower BMI, and were less likely to be menopausal than those undergoing the midurethral sling.” Financial Disclosure: The author did not report any potential conflicts of interest.
Katherine M. Gillogley, MD Department of Obstetrics and Gynecology, Methodist Hospital and UC Davis Medical Center, Sacramento, California
REFERENCE 1. Gaddi A, Guaderrama N, Bassiouni N, Bebchuk J, Whitcomb E. Repeat midurethral sling compared with urethral bulking for recurrent stress urinary incontinence. Obstet Gynecol 2014; 123:1207–12.
In Reply: We appreciate Dr. Gillogley’s comments concerning the menopausal status of our patient cohort.1 On
review of Table 1, there was in fact an error in that the represented data reflect premenopausal rather than postmenopausal status. The revised data are as follows: 76.1% (n551) of the urethral bulking group were menopausal, and 57.1% (n556) of the midurethral sling group were menopausal (P5.01). The data analysis and discussion are based on the correct data. However, this changes our conclusion in that patients who underwent urethral bulking were still older and had lower body mass indexes but were more likely to be menopausal. We apologize for this error. Financial Disclosure: The author did not report any potential conflicts of interest.
Emily L. Whitcomb, MD, MAS Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Southern California Permanente Medical Group, Irvine Medical Center
REFERENCE 1. Gaddi A, Guaderrama N, Bassiouni N, Bebchuk J, Whitcomb EL. Repeat midurethral sling compared with urethral bulking for recurrent stress urinary incontinence. Obstet Gynecol 2014;123:1207–12. Editor’s Note: Readers may refer to a Correction related to this article on page 842.
Postpartum Venous Thromboembolism: Incidence and Risk Factors To the Editor: We read with great interest the article by Tepper et al1 recently published in your prestigious journal. Both the topic and the sample size make the article interesting for obstetricians and general practitioners. The authors calculate the incidence of postpartum venous thromboembolism by week after delivery, focusing the attention on risk factors involved in increasing risk. The authors conclude that, after adjusting for all covariates, advanced age seems to increase the risk of early postpartum venous thromboembolism whereas cesarean delivery seems to increase both early and late postpartum venous thromboembolism. We already have performed an observational study about postpartum prophylaxis, detecting that pneumatic
Letters to the Editor
837
compression stockings represent an effective, low-cost, and safe tool to prevent postpartum venous thromboembolism after elective cesarean delivery in an unscreened population, independently from maternal age.2 On the contrary, in agreement with the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynaecologists, and Chest Guidelines, we suggest that pharmacologic prophylaxis after elective cesarean delivery represents a cost-effective tool only in cases of known adjunctive risk factors different from elective cesarean delivery and maternal age.3–5 Tepper et al calculated the incidence of postpartum venous thromboembolism during the 12 weeks after delivery, concluding that risk for postpartum venous thromboembolism is highest during the first 3 weeks after delivery and remains elevated throughout the first 12 weeks in women with obstetric complications. Despite the fact that the statistical analysis was methodologically correct, the high bias (accurately reported in the Discussion section) affecting the analyzed data render the results not completely useful in deciding whether or not to perform antithrombotic prophylaxis. The absence of validated diagnosis of postpartum venous thromboembolism events (data collection bias of events), the lack of knowledge about patient’s thrombophilia status (patients’ selection bias), the lack of data about peripartum pharmacologic and mechanical thromboprophylaxis (misclassification of exposure bias), the association in the cesarean delivery cohort of both elective and urgent cesarean deliveries, and the low accuracy in defining obstetric risk factors starting from the International Classification of Diseases, 9th Revision, Clinical Modification, made the results and conclusions perhaps only a mathematical and statistical exercise. In our opinion, the article by Tepper et al does not result in a useful way to solve the dilemma of whether or not to use thromboprophylaxis, what type of prophylaxis must be done, and what is the most appropriate timing to perform it. Financial Disclosure: The authors did not report any potential conflicts of interest.
Salvatore Gizzo, Giovanni Battista Nardelli, Marco Noventa,
838
Letters to the Editor
MD MD MD
Department of Woman and Child Health, OB/GYN Unit, University of Padua Padua, Italy
REFERENCES 1. Tepper NK, Boulet SL, Whiteman MK, Monsour M, Marchbanks PA, Hooper WC, et al. Postpartum venous thromboembolism: incidence and risk factors. Obstet Gynecol 2014;123: 987–96. 2. Gizzo S, Noventa M, Anis O, Saccardi C, Zambon A, Di Gangi S, et al. Pharmacological anti-thrombotic prophylaxis after elective caesarean delivery in thrombophilia unscreened women: should maternal age have a role in decision making? J Perinat Med 2014; 42:339–47. 3. Postpartum hemorrhage. ACOG Practice Bulletin No. 76. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1039–47. 4. Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:e691–736S. 5. Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. RCOG green-top guideline No. 37a. November 2009. Available at: http://www.rcog.org. uk/files/rcog-corp/GTG37aReducingRisk Thrombosis.pdf. Retrieved July 31, 2014.
In Reply: We thank Drs. Gizzo, Nardelli, and Noventa for their interest in our article, and their comments give us an opportunity to elaborate on several aspects of our analysis.1 The main objective of our analysis was to calculate the incidence of venous thromboembolism among postpartum women through postpartum week 12 and to examine how certain factors affect that risk according to timing postpartum. Our objectives did not include examining when or how to apply thromboprophylaxis. We agree that the interpretation of epidemiologic studies should consider relevant limitations. In our article, we acknowledge a number of limitations, including concerns about the accuracy and completeness of
claims data and the inability to account for the influence of associated factors such as peripartum pharmacologic thromboprophylaxis and nonpharmacologic thromboprophylaxis. Despite limitations, the results from our work add to the field of knowledge on postpartum venous thromboembolism. Venous thromboembolic disease remains an important cause of peripartum morbidity and mortality,2,3 and our findings highlight the fact that the risk extends into the postpartum period, particularly among women with certain risk factors. We hope our article will help to increase awareness among clinicians and stimulate further study on this issue, including implications for postpartum thromboprophylaxis. Financial Disclosure: The authors did not report any potential conflicts of interest. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Naomi K. Tepper, MD, MPH Sheree L. Boulet, DrPH, MPH Maura K. Whiteman, PhD Michael Monsour, PhD Polly A. Marchbanks, PhD Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia W. Craig Hooper, PhD Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia Kathryn M. Curtis, PhD Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
REFERENCES 1. Tepper NK, Boulet SL, Whiteman MK, Monsour M, Marchbanks PA, Hooper WC, et al. Postpartum venous thromboembolism: incidence and risk factors. Obstet Gynecol 2014;123:987–96. 2. Callaghan WM. Overview of maternal mortality in the United States. Semin Perinatol 2012;36:2–6.
OBSTETRICS & GYNECOLOGY
