Letters
Volume 163 "'umber 2
Similarly for Toxoplasma, the tests themselves could be made quite accurate for the detection of IgM antibody; however, when we studied the persistence of this antibody we found that a number of patients retained very high antibody levels for many years. Therefore the presence of high titers of IgM antibody could not be used to accurately document the occurrence of an acute infection during pregnancy. Again, for this purpose the test had a very low clinical usefulness. These are just two examples of medical laboratory tests with low clinical usefulness for the clinical applications described. The same tests have higher clinical usefulness when applied to other clinical problems. Many other examples could be described. Numeric estimates of clinical usefulness can be determined by use of the same statistical methods used for sensitivity, specificity, and predictive values. However, the analysis must relate the laboratory data to the clinical information that is of greatest importance. For perinatal herpes, the most significant clinical usefulness would be the relation between the maternal preterm herpes cultures and herpes infection of the newborn child. This clinical usefulness has never been determined. The next most useful clinical usefulness is the relation between pre term cultures and genital herpes at delivery. This was finally determined in 1986 and led to the discontinuation of these procedures. Clearly we must consider the clinical usefulness of each test in relation to the purpose for which it is being used. We must examine the clinical usefulness of the many tests that are already in use and we must require the inclusion of studies and analysis of clinical usefulness for new tests as they become available for clinical medicine. John L. Sever, MD, PhD Children's National Medical Center, III Michigan Ave., N. w., Washington, DC 20010
REFERENCES 1. Galen RS, Gambino SR. Beyond normality: the predictive value and efficiency of medical diagnosis. New York: John Wiley, 1975:2-7. 2. Arvin AM, Hensleigh PA, Prober GG, et al. Failure of antepartum maternal cultures to predict the infant's risk of exposure to herpes simplex virus at delivery. N Engl J Med 1986;315:796-800. 3. Perinatal herpes simplex infections. American College of Obstetricians and Gynecologists. Technical Bulletin 1988: 122. 4. Centers for Disease Control. MMWR 1989;38: 18. 5. Fuccillo DA, Madden DL, Jan N, Sever JL. Difficulties associated with serdogical diagnosis of Toxoplasma gondii infections. Diagn Clin Immunol 1987;5:8-13.
679
more extensive response beyond the scope of the available space. It is one thing for the authors to opine that obstetricians should not own or operate a surrogate parenting agency. It is quite another for them to tell obstetricians not to provide medical services to the parties of surrogate contracts. To begin with, I know of no surrogate parenting agency in which a physician, much less an obstetrician, is a party to a surrogate parenting contract. Surrogate parenting contracts involve an agreement with various provisions between the surrogate and the intended parents, usually husband and (infertile) wife. Physicians are justifiably involved in providing medical care of various types to these three parties: infertility evaluation of all parties, infertility counseling, referral to surrogate parenting agencies, infectious disease screening, genetic counseling, psychiatric evaluation, artificial insemination, management of infertility in the father and surrogate, in vitro fertilization (for gestational surrogates) and ovum donation, I and of course prenatal care of the surrogate. As the authors correctly note elsewhere/ dual relationships with one's patients are ethically troublesome and should be avoided, so physicians should not contaminate their medical role with their patients by adding another one as gatekeeper, administrator, or owner of a surrogate parenting agency in which these same patients have been served. It is presumptuous, if not ridiculous, to categorically reject surrogate parenting contracts as "unethical" per se. Surrogates, no less than living organ donors, obtain a great deal of emotional gratification in their role. 3 . 5 The infertile couple clearly enjoys having a biologically related child to raise, but also immeasurably appreciates the surrogate's altruism. Further, >95% of surrogacy arranagements are concluded without adverse result. Physicians' attempts to "protect" potential surrogates from themselves by rejecting, boycotting, or criminalizing surrogacy are no more justifiable than prohibiting organ donation by living donors in some transplant centers." There is unfortunately a great deal of ignorance and misinformation about surrogate parenting. La Puma et al.'s oversimplistic and biased article does not advance the cause of truth about this matter and certainly does not serve the interests of their infertile patients. Rather, obstetricians should be aware of the potential benefits, as well as risks, of collaborative reproduction for all the parties involved. Robert M. Wettstein, MD Department of Psychiatry, University of Pittsburgh, School of Medicine,3811 O'Hara St., Pittsburgh, PA 15213
Surrogate parenting contracts To the Editors: La Puma et al.'s "Clinician Opinion" article about surrogacy (La Puma J, Schiedermayer DL, Grover J. Surrogacy and Shakespeare: The Merchant's contract revisited. AM J OBSTET GYNECOL 1989;160: 59-62) should not pass without at least a brief rebuttal; the numerous errors of fact therein would require a
REFERENCES I. Sandberg EC. Only an attitude away: the potential of reproductive surrogacy. AM J OBSTET GYNECOL 1989;160: 1441-6. 2. La Puma J, Schiedermayer DL. Outpatient clinical ethics. J Gen Intern Med 1989;4:413-20. 3. Fellner CH, Marshall JR. Kidney donors-the myth of informed consent. Am J Psychiatry 1970;126:124551.
680
Letters
August 1990 Am J Obstet Gynecol
4. Marshall JR, Feller CH. Kidney donors revisited. Am J Psychiatry 1977; 134:575-6. 5. Singer PA, Siegler M, Whitington PF, Lantos JD, et al. Ethics of liver transplantation with living donors. N Engl J Med 1989;321 :620-2. 6. Spital A, Spital M. Donor's choice or Hobson's choice. Arch Intern Med 1985;145:1297-301.
Reply To the Editors: Dr. Wettstein suggests that surrogate pregnancy should be a medical treatment, such as artificial insemination. We suggest that there is such widespread confusion about surrogacy that it is easy to miss our point. Surrogacy is not a medical treatment. Obstetricians should not be forced to consider withdrawing, withholding, or offering surrogacy, as if it were. Surrogacy is a nonmedical process that may lure physicians into . bad business arrangements and can make unwitting middlemen of obstetricians. In regard to transplantation ethics, a fetus is not a kidney. A fetus has no duplicate; surrender of a fetus is different from donation of a kidney. Living related kidney donors can consent or refuse to donate; surrogate mothers currently have no such choice. Sanctioning "collaborative reproduction" restores the paternalism of old, making the obstetrician both deliverer and parent. We appreciate Dr. Wettstein's comments, and we encourage other readers to avoid confusing surrogacy with medical treatment. . John La Puma, MD Center for Clinical Ethics, Lutheran General Hospital, 1775 Dempster St., Park Ridge, IL 60068
David L. Schiedermayer, MD Center for Bioethics, The Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226
John L. Grover, MD Department ofObstetrics and Gynecology, Lutheran General Hospital, 1775 Dempster St., Park Ridge, IL 60068
Can shoulder dystocia be predicted? To the Editors: I feel that James O'Leary, MD, and Helen Leonetti, MD, have done a great disservice to their colleagues who are practicing obstetricians. In their article "Shoulder dystocia: Prevention and treatment" (AM J OBSTET GVNECOL 1990;162:5-9), they give the distinct impression that most if not all shoulder dystocias should be anticipated and/or predicted and thus prevented by performing abdominal delivery. They present several tables identifying prepregnancy historical risk factors, antepartum risk factors, and intrapartum risk factors. Unfortunately they do not present any scientific data to show which risk factor or combination of risk factors would provide reasonable indications for a cesarean delivery. I believe that if Dr. O'Leary and Dr. Leonetti are honest with themselves and with other readers of the JOURNAL they will agree that to prevent one shoulder dystocia dozens of unnecessary cesarean sections with their attendant morbidity and mortality would need to be performed. Unfortunately the legal
profession has access to our professional journals, and I feel that articles like this can and will be used against anyone unfortunate enough as to find himself with a severe shoulder dystocia and an injured infant. It is a rare obstetric patient indeed that does not have at least one or several of the risk factors mentioned by the authors. Gregory L. Gimbel, MD Department of Obstetrics and Gynecology, Parkview Memorial Hospital, Brunswick, ME 04011
Reply To the Editors: McLeod (McLeod A. In discussion: Hopwood HG Jr. Shoulder dystocia: Fifteen years' experience in a community hospital. AM J OBSTET GVNECOL 1982;144:162-6) states: "that 'shoulder dystocia occurs cataclysmically' must be challenged; in many, if not a majority of cases, it can and should be anticipated [italics added]." He goes on to state: "All of these risk factors are identifiable and in most cases should be interpreted as a warning sign [italics added]." Eight years later these same statements are still valid. The intent of our review article was to reemphasize the importance of risk factors for macrosomia and to outline a rational approach to dealing with the issue. James A. O'Leary, MD
Jersey City Medical Center, University of Medicine and Dentistry of New Jersey Affiliate, Baldwin Ave., Jersey City, NJ 07304
Hyperbaric oxygen therapy for air embolism complicating operative hysteroscopy To the Editors: Baggish and Daniell (Baggish MS, Daniell JF. Death caused by air embolism associated with neodymium: yttrium-aluminum-garnet laser surgery and artificial sapphire tips. AM J OBSTET GVNECOL 1989; 161:877-8) reported two deaths caused by air embolism complicating operative hysteroscopy with laser surgery. Hyperbaric oxygen therapy was not mentioned in their article. Immediate therapy with hyperbaric oxygen, however, must be remembered and should be encouraged for those patients with suspected air embolism. Hyperbaric oxygen therapy, a combination of compression-recompression and hyperoxygenation, is effective in the treatment of air embolism in patients who survive the initial insult. Hyperbaric oxygen decreases intravascular bubble size (on the basis of Boyle'S law) and increases the driving pressure of oxygen into tissue, and thus reduces ischemia. The time between embolism and the time of hyperbaric oxygen treatment may determine the outcome in these patients. If necessary, air transportation should be used, either via a pressurized cabin for maintaining sea level pressure or by instructing the pilot to fly as low to the ground as safely possible. 1·3 Gynecologists performing operative hysteroscopy, with or without laser surgery, must maintain a high index of suspicion concerning air embolism when confronted with acute respiratory failure and/or focal or general neurologic deficits in an otherwise healthy
Volume 163 "'umber 2
Similarly for Toxoplasma, the tests themselves could be made quite accurate for the detection of IgM antibody; however, when we studied the persistence of this antibody we found that a number of patients retained very high antibody levels for many years. Therefore the presence of high titers of IgM antibody could not be used to accurately document the occurrence of an acute infection during pregnancy. Again, for this purpose the test had a very low clinical usefulness. These are just two examples of medical laboratory tests with low clinical usefulness for the clinical applications described. The same tests have higher clinical usefulness when applied to other clinical problems. Many other examples could be described. Numeric estimates of clinical usefulness can be determined by use of the same statistical methods used for sensitivity, specificity, and predictive values. However, the analysis must relate the laboratory data to the clinical information that is of greatest importance. For perinatal herpes, the most significant clinical usefulness would be the relation between the maternal preterm herpes cultures and herpes infection of the newborn child. This clinical usefulness has never been determined. The next most useful clinical usefulness is the relation between pre term cultures and genital herpes at delivery. This was finally determined in 1986 and led to the discontinuation of these procedures. Clearly we must consider the clinical usefulness of each test in relation to the purpose for which it is being used. We must examine the clinical usefulness of the many tests that are already in use and we must require the inclusion of studies and analysis of clinical usefulness for new tests as they become available for clinical medicine. John L. Sever, MD, PhD Children's National Medical Center, III Michigan Ave., N. w., Washington, DC 20010
REFERENCES 1. Galen RS, Gambino SR. Beyond normality: the predictive value and efficiency of medical diagnosis. New York: John Wiley, 1975:2-7. 2. Arvin AM, Hensleigh PA, Prober GG, et al. Failure of antepartum maternal cultures to predict the infant's risk of exposure to herpes simplex virus at delivery. N Engl J Med 1986;315:796-800. 3. Perinatal herpes simplex infections. American College of Obstetricians and Gynecologists. Technical Bulletin 1988: 122. 4. Centers for Disease Control. MMWR 1989;38: 18. 5. Fuccillo DA, Madden DL, Jan N, Sever JL. Difficulties associated with serdogical diagnosis of Toxoplasma gondii infections. Diagn Clin Immunol 1987;5:8-13.
679
more extensive response beyond the scope of the available space. It is one thing for the authors to opine that obstetricians should not own or operate a surrogate parenting agency. It is quite another for them to tell obstetricians not to provide medical services to the parties of surrogate contracts. To begin with, I know of no surrogate parenting agency in which a physician, much less an obstetrician, is a party to a surrogate parenting contract. Surrogate parenting contracts involve an agreement with various provisions between the surrogate and the intended parents, usually husband and (infertile) wife. Physicians are justifiably involved in providing medical care of various types to these three parties: infertility evaluation of all parties, infertility counseling, referral to surrogate parenting agencies, infectious disease screening, genetic counseling, psychiatric evaluation, artificial insemination, management of infertility in the father and surrogate, in vitro fertilization (for gestational surrogates) and ovum donation, I and of course prenatal care of the surrogate. As the authors correctly note elsewhere/ dual relationships with one's patients are ethically troublesome and should be avoided, so physicians should not contaminate their medical role with their patients by adding another one as gatekeeper, administrator, or owner of a surrogate parenting agency in which these same patients have been served. It is presumptuous, if not ridiculous, to categorically reject surrogate parenting contracts as "unethical" per se. Surrogates, no less than living organ donors, obtain a great deal of emotional gratification in their role. 3 . 5 The infertile couple clearly enjoys having a biologically related child to raise, but also immeasurably appreciates the surrogate's altruism. Further, >95% of surrogacy arranagements are concluded without adverse result. Physicians' attempts to "protect" potential surrogates from themselves by rejecting, boycotting, or criminalizing surrogacy are no more justifiable than prohibiting organ donation by living donors in some transplant centers." There is unfortunately a great deal of ignorance and misinformation about surrogate parenting. La Puma et al.'s oversimplistic and biased article does not advance the cause of truth about this matter and certainly does not serve the interests of their infertile patients. Rather, obstetricians should be aware of the potential benefits, as well as risks, of collaborative reproduction for all the parties involved. Robert M. Wettstein, MD Department of Psychiatry, University of Pittsburgh, School of Medicine,3811 O'Hara St., Pittsburgh, PA 15213
Surrogate parenting contracts To the Editors: La Puma et al.'s "Clinician Opinion" article about surrogacy (La Puma J, Schiedermayer DL, Grover J. Surrogacy and Shakespeare: The Merchant's contract revisited. AM J OBSTET GYNECOL 1989;160: 59-62) should not pass without at least a brief rebuttal; the numerous errors of fact therein would require a
REFERENCES I. Sandberg EC. Only an attitude away: the potential of reproductive surrogacy. AM J OBSTET GYNECOL 1989;160: 1441-6. 2. La Puma J, Schiedermayer DL. Outpatient clinical ethics. J Gen Intern Med 1989;4:413-20. 3. Fellner CH, Marshall JR. Kidney donors-the myth of informed consent. Am J Psychiatry 1970;126:124551.
680
Letters
August 1990 Am J Obstet Gynecol
4. Marshall JR, Feller CH. Kidney donors revisited. Am J Psychiatry 1977; 134:575-6. 5. Singer PA, Siegler M, Whitington PF, Lantos JD, et al. Ethics of liver transplantation with living donors. N Engl J Med 1989;321 :620-2. 6. Spital A, Spital M. Donor's choice or Hobson's choice. Arch Intern Med 1985;145:1297-301.
Reply To the Editors: Dr. Wettstein suggests that surrogate pregnancy should be a medical treatment, such as artificial insemination. We suggest that there is such widespread confusion about surrogacy that it is easy to miss our point. Surrogacy is not a medical treatment. Obstetricians should not be forced to consider withdrawing, withholding, or offering surrogacy, as if it were. Surrogacy is a nonmedical process that may lure physicians into . bad business arrangements and can make unwitting middlemen of obstetricians. In regard to transplantation ethics, a fetus is not a kidney. A fetus has no duplicate; surrender of a fetus is different from donation of a kidney. Living related kidney donors can consent or refuse to donate; surrogate mothers currently have no such choice. Sanctioning "collaborative reproduction" restores the paternalism of old, making the obstetrician both deliverer and parent. We appreciate Dr. Wettstein's comments, and we encourage other readers to avoid confusing surrogacy with medical treatment. . John La Puma, MD Center for Clinical Ethics, Lutheran General Hospital, 1775 Dempster St., Park Ridge, IL 60068
David L. Schiedermayer, MD Center for Bioethics, The Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226
John L. Grover, MD Department ofObstetrics and Gynecology, Lutheran General Hospital, 1775 Dempster St., Park Ridge, IL 60068
Can shoulder dystocia be predicted? To the Editors: I feel that James O'Leary, MD, and Helen Leonetti, MD, have done a great disservice to their colleagues who are practicing obstetricians. In their article "Shoulder dystocia: Prevention and treatment" (AM J OBSTET GVNECOL 1990;162:5-9), they give the distinct impression that most if not all shoulder dystocias should be anticipated and/or predicted and thus prevented by performing abdominal delivery. They present several tables identifying prepregnancy historical risk factors, antepartum risk factors, and intrapartum risk factors. Unfortunately they do not present any scientific data to show which risk factor or combination of risk factors would provide reasonable indications for a cesarean delivery. I believe that if Dr. O'Leary and Dr. Leonetti are honest with themselves and with other readers of the JOURNAL they will agree that to prevent one shoulder dystocia dozens of unnecessary cesarean sections with their attendant morbidity and mortality would need to be performed. Unfortunately the legal
profession has access to our professional journals, and I feel that articles like this can and will be used against anyone unfortunate enough as to find himself with a severe shoulder dystocia and an injured infant. It is a rare obstetric patient indeed that does not have at least one or several of the risk factors mentioned by the authors. Gregory L. Gimbel, MD Department of Obstetrics and Gynecology, Parkview Memorial Hospital, Brunswick, ME 04011
Reply To the Editors: McLeod (McLeod A. In discussion: Hopwood HG Jr. Shoulder dystocia: Fifteen years' experience in a community hospital. AM J OBSTET GVNECOL 1982;144:162-6) states: "that 'shoulder dystocia occurs cataclysmically' must be challenged; in many, if not a majority of cases, it can and should be anticipated [italics added]." He goes on to state: "All of these risk factors are identifiable and in most cases should be interpreted as a warning sign [italics added]." Eight years later these same statements are still valid. The intent of our review article was to reemphasize the importance of risk factors for macrosomia and to outline a rational approach to dealing with the issue. James A. O'Leary, MD
Jersey City Medical Center, University of Medicine and Dentistry of New Jersey Affiliate, Baldwin Ave., Jersey City, NJ 07304
Hyperbaric oxygen therapy for air embolism complicating operative hysteroscopy To the Editors: Baggish and Daniell (Baggish MS, Daniell JF. Death caused by air embolism associated with neodymium: yttrium-aluminum-garnet laser surgery and artificial sapphire tips. AM J OBSTET GVNECOL 1989; 161:877-8) reported two deaths caused by air embolism complicating operative hysteroscopy with laser surgery. Hyperbaric oxygen therapy was not mentioned in their article. Immediate therapy with hyperbaric oxygen, however, must be remembered and should be encouraged for those patients with suspected air embolism. Hyperbaric oxygen therapy, a combination of compression-recompression and hyperoxygenation, is effective in the treatment of air embolism in patients who survive the initial insult. Hyperbaric oxygen decreases intravascular bubble size (on the basis of Boyle'S law) and increases the driving pressure of oxygen into tissue, and thus reduces ischemia. The time between embolism and the time of hyperbaric oxygen treatment may determine the outcome in these patients. If necessary, air transportation should be used, either via a pressurized cabin for maintaining sea level pressure or by instructing the pilot to fly as low to the ground as safely possible. 1·3 Gynecologists performing operative hysteroscopy, with or without laser surgery, must maintain a high index of suspicion concerning air embolism when confronted with acute respiratory failure and/or focal or general neurologic deficits in an otherwise healthy
