LETTERS TO THE EDITORS
Hypertriglyceridemia in small-for-gestational-age
fetuses
To the Editors: I read with great interest the article by
Economides et al. (Economides DL, Crook D, Nico-
laides KH. Hypertriglyceridemia and hypoxemia in
small-for-gestational-age fetuses. AM J OBSTET GYNE-
COL 1990;162:382-6). The authors found elevated
plasma triglyceride concentration in samples ob-
tained by cordocentesis for small-for-gestational-age
fetuses.
One month earlier we described the increase of cord
blood triglyceride concentration in small-for-gesta-
tional-age infants born to mothers with placental in-
sufficiency.' The mechanism of triglyceride increase in
those cases is not well understood. 1 suggest that chronic
fetal hypoxia caused by placental insufficiency is asso~
ciated with a substantial release of catecholamines. In-
creased secretion of catecholamines leads to lipolysis
and results in elevated blood fatty acid level. The fetal
liver takes up some of the excess fatty acid and syn-
thesizes endogenous triglycerides that appear in the
fetal serum.
It has been found that the duration of fetal hypoxia
must be considerable, perhaps even an hour or more,
for it to result in hypertriglyceridemia."
I proposed that the level of cord blood triglyceride
may prove to be a useful indicator of chronic fetal
hypoxia.
Janusz Bartnicki, MD
Institute of Perinatal Medicine, Mariendorfer Weg 28, D-lGOO Ber-
lin -/4, Germany
REFERENCES
1. Bartnicki J, Szmitkowski M, J6zwik M, Sledziewski A,
Chrostek L, Urban J. Cord blood triglyceridemia in cases
of placental insufficiency. Am J Perinatal 1990;7:26-30.
2. Elphick MC, Harrison AT, Lawlor JP, Hull D. Cord blood
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
Splitting hairs about splitting muscles
To the Editors: Helmkamp and Krebs (Helmkamp BF,
Krebs H-B. The Maylard incision in gynecologic cancer.
AM J OBSTET GYNECOL 1990: 163: 1554-7) recently pre-
sented data substantiating the value of the Maylard
abdominal incision. This article was timely, nicely done,
and welcome. The Maylard technique, however, is not
a "muscle-splitting" incision. It is, rather, a muscle-cut-
ting procedure. Quoting Condon 1 in his chapter on ap-
pendicitis in Sabiston's Textbook ofSurgery, "... the mus-
cle-splitting incision (McArther-McBurney) is the time-
honored approach and one widely used today.... Its
ad vantage is that separation of muscles in the line oftheir
fihers produces a wound that does not depend entirely
lIpon sutures for restoration of tissue continuity." Sur-
gical transection of the rectus muscles does not fit this
description.
The risk of subfascial hematoma and the associated
need for a subfascial drain are related to the creation
of a closed space between the fascia and parietal peri-
toneum. Both can be eliminated by meticulous hemo-
stasis and by allowing the parietal peritoneum to remain
open and unsutured. 2
Gregory P. Sulton, MD
Department of Obstetrics and Gynecology, University Hospital, In-
diana University Medical Center, 926 W. Michigan, Indianapolis,
IN 46202
REFERENCES
1. Condon FE. Appendicitis. In: Sabiston DC, ed. Textbook
of surgery. 13th ed. Philadelphia: WB Saunders, 1986:
975-6.
2. Pietrantoni M, Pat'sons MT. O'Brien WF, Collins E, Knup-
pel RA, Spellacy WN. Peritoneal closure or non-closure at
cesarean. Obstet Gynecol 1991;77:293-6.
Reply
To the Editors: Thank you very much for your comments
regarding our recent article. I agree that "muscle-
cutting" more accurately describes the Maylard tech-
nique because the incision through the rectus muscles
is perpendicular to the muscle fibers rather than
parallel.
I do not suture the posterior rectus sheath in closing
vertical and Pfannenstiel incisions. If you do likewise
with the Maylard incision and have had no wound com-
plications, it may be possible to eliminate the subfascial
drain as you suggest.
B. Frederick Helmkamp, MD
3289 Woodburn Road. Suite 320, Annandale, VA 22003-6897
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-
trienes with thromboxane mimic in the perfused hu-
man placenta. AMJ OBSTET GYNECOL 1988;159:1376-
80) have clearly shown that leukotrienes B. (LTB.) and
C. (LTC.) do not exert major effects on the placental
vasculature except at high doses (> 1 ILg per bolus in-
jection). It is, however, clear from previous work that
prostaglandins may have more potent effects on an-
giotensin II constricted placental vessels than when
added alone'; therefore we have investigated the effects
of coadministration of LTB. or LTC. (5 to 500 ng per
bolus injection) with angiotensin II (5 ILg per bolus
injection) on placental perfusion pressures. The per-
fusion system used in this study has been described. 1
1575
1576 Letters
Only the highest bolus injection (500 ng) of LTE, or
LTC. increased the perfusion pressure (LTB.,
17.8 ± 0.3 mm Hg; LTC., 6.2 ± 2.9 mm Hg;
mean ± SEM, 'II = 6); this finding agrees with the ear-
lier study by Thorp et al. Angiotensin II (5 jJ..g per bolus
injection) stimulated a greater increase in perfusion
pressure (34 ± 8 mm Hg, 'II = 13); this was not af-
fected by coadministration of 500 ng LTB. or LTC.
(36.7 ± 13.3 and 26.2 ± 7.6 mm Hg, 11 = 6. respec-
tively). These results support the contention of Thorp
et al. that leukotrienes are not active modulators of the
placental vasculature; it also demonstrates that the leu-
kotrienes have no effect on contracted placental vessels.
It is thus apparent that leukotrienes and prostaglandins
differ markedly in their effects on the placental vas-
culature.
M.H.F. Sullivan, PhD, P.R. Tranter, PhD, and
M.G. Elder, MD
Institute of Obstetrics and Gynaecology, Royal Postgraduate Medical
School, Hammersmith Hospital, Du Cane Road, London, England
WI20HS
REFERENCE
1. Glance DG, Elder MG, Myatt L. The actions of prosta-
glandins and their modulation of angiotensin II in the iso-
lated perfused human placental cotyledon. Trophoblast
Res 1987;2:395-404.
Reply
To the Editors: We are pleased that Sullivan et al. have
confirmed our results that leukotrienes are relatively
weak vasoconstrictors in the human placental vascula-
ture even when the vessels are first constricted with
angiotensin II. It appears that most compounds other
than thromboxane are relatively weak vasoconstrictors
in the human placenta. This probably serves to protect
the placenta from vasoconstriction and assure adequate
perfusion for placental and fetal growth. As more in-
formation accrues, it appears that major vasoconstric-
tive disorders of the placenta such as preeclampsia
involve an imbalance between thromboxane and p.'os-
tacyclin. We believe that understanding the mecha-
nisms regulating placental production of thromboxane
and prostacyclin is extremely important and that re-
search studies directed at uncovering these mechanisms
will provide valuable information concerning the even-
tual treatment of various vasoconstrictive disorders of
pregnancy.
Scott W. Walsh, PhD
Medical College of Virginia, Department of Obstetrics and Gynecol-
ogy, P.O. Box 34, MCV Station, Richmond, VA 23298-003-1
james A. Thorp, MD, and Peter C. Brath, BS
Ulliversity of Texas Medical School at Houston, Depa·rtment of Ob,
stetrics, Gynecology and Reproductive Sciences. 6-13/ Fannin St.,
Suite 3.204, Houston, TX 77030
Infertility and eating disorders
To the Editors: We were very interested to see the results
of the recent study of the eating behavior of women
initially seen for infertility (Stewart DE, Robinson GE,
Goldbloom DS, Wright C. Infertility and eating dis-
November 1991
Am J Obstet Gynecol
orders. AM J OBSTET GYNECOL 1990;163:1196-9).
These results complement our findings.' After admin-
istering the Bulimia Investigatory Test Edinburgh'
(BITE) questionnaire to a large sample of women at-
tending a gynecologic endocrinology clinic (11 = 262),
we found abnormal eating behavior in 24% of the pop-
ulation. Interestingly, the rate of abnormal eating be-
havior was significantly higher (p = 0.02) in women
with ultrasonographic diagnoses of polycystic ovary
syndrome ('II = 153) than in a comparison group of
women (11 = 109) with other causes of menstrual dis-
turbance. Thirty-one percent of women with polycystic
ovary syndrome had abnormal BITE scores compared
with 14% of women with other endocrinopathies. We
would like to know if Stewart et al. analyzed their data
according to diagnosis.
We strongly support the "ecommendation of Stewart
et al. that the eating behavior of women attending fer-
tility clinics or presenting with menstrual disorders be
assessed. Abnormal behaviors such as binge eating or
fasting should be rectified with appropriate therapy
such as the program for bulimia described by Lacey."
Pregnancies that occur in women with anorexia after
ovulation resumes because of weight gain are more
successful than pregnancies that occur when ovulation
resumes because of pharmacologic stimulation! The
26-item Eating Attitudes Test' is a suitable screening
instrument. However, we found the BITE to be more
sensitive and specific for bulimic behavior.
Sara McCluskey, BScHons, Chris Evans, BA, Hubert Lacey,
MD, and Malcolm Pea7'Ce, MD
Departlllellt o/Psychiatry, St. George's Hospital Medical School. Uni-
venity of London, jenner Wing, Cranmer Ten-ace, Tooting, London,
England SWJ7 ORE
REFERENCES
I. McCluskey SE, Evans CDH, Lacey JH, Pearce JM, Jacobs
H. Polycystic ovary syndrome and bulimia. Ferti! Steril
1991;55:287-91.
2. Henderson M, Freeman CPL. A self-rating scale for bu-
limia: the "BITE." Br J Psychiatry 1987; 150: 18-24,
3. Lacey JH. Bulimia nervosa, binge-eating and psychogenic
vomiting: a controlled treatment study and long term out,
come. BMJ 1983;286:1597-678.
4. Van del' Spuy ZM, Steer PJ, McCusker M, S.eele SJ,Jacobs
HS. Outcome of pregnancy in underweight women after
spontaneous and induced ovulation. BMJ 1988;296:962-5.
5. Garner OM, Olmsted MP, Bohr Y, Garfinkel PE. The eating
attitudes test: psychometric features and clinical correlates.
Psychol Med 1982;12:871-8.
Reply
To the Editors: It is indeed interesting that McCluskey
et at. have recently found a prevalence similar to that
reported by us of abnormal eating behavior in women
attending a British gyneCOlogic endocrinology clinic.
However, although our women with abnormal menses
scored significantly higher (p = 0.0001) on the 26-item
Eating Attitudes Test (EAT-26) than women with nor-
mal menses, after full investigation we found only 17%
to have polycystic ovary syndrome.
McCluskey et al. state that the BITE is more sensitive
and specific for bulimic behavior, which may account