Readers React

Vasa previa: preventing an emergency

Nice article on vasa previa [Vasa previa: How to prevent an ob emergency, February 2016]. I note that [the authors] did not mention using fundal pressure to provoke fetal bradycardia (it has an eponym but I can't seem to recall it) as a screening test. 


Richard P Perkins, MD,
MFM

Fort Myers, Florida

In reply:

I am unable to find an eponym in old texts for this test, but did find a description of compressing the presenting vessels via the cervix, which I would not recommend in current practice, given the ready availability of ultrasound and the potential risks if there is inadvertent rupture of the membranes.

Josh Copel, MD

In their otherwise excellent review article on vasa previa, Drs Deng and Copel state in the section titled Intrapartum Diagnosis and Confirmation of HbF that "none of these tests is typically available acutely in labor units."

I practiced obstetrics from 1976 through 2002. When I read Dr Loendersloot's letter in the November 1, 1979 issue of the American Journal of Obstetrics and Gynecology (135[5]:703), describing his test for fetal hemorrhage, I took it upon myself to make it available in the L & D suite of my hospital. All you need is 0.1 N potassium hydroxide. I used the test many times in uncertain situations and it was always negative. Until the day it wasn't. I did a "crash" C-section on that patient with O-negative blood brought up to be immediately available for the baby. The baby was transfused and did well. The test works and is indeed readily available if the KOH is in the L & D suite.

Richard Anscher, MD

Swartswood, New Jersey

In reply:

While the “Apt test” has been used in the past to determine maternal versus fetal origin of blood, it is currently considered a “point of care" (POC) test. To deploy a POC test the labor unit would have to meet the standards of POC testing, including regular quality checks of the solutions and competency exams for the providers performing the test. The rarity of needing the test, and the hurdles to offering it, underlie our comment on lack of ready availability on most labor floors.

Josh Copel, MD

NEXT: Uterus transplant attempt ends in disappointment

Uterus transplant attempt ends in disappointment

Uterine transplantation is a triumph of surgical expertise over good judgment and justice. The procedure has a cost to the patient: multiple operations, immunosuppressive drugs, potential failure to conceive, and the risk of pregnancy complications like preeclampsia and prematurity.

There is a cost to the fetus: the few babies born so far have been prematurely born after complications in pregnancy, and this prematurity can be fatal or result in lifelong morbidity.

There is a cost to society: the associated procedures cost hundreds of thousands of dollars, plus the potential costs of the medical care of a preemie. And what are the benefits? A woman gets to experience the feelings of pregnancy. Really? This is definitely a first-world problem, and social justice would require that doctors say no to this procedure and invest the money in improving third-world health. If a man decides that he wants to experience the feelings of being pregnant, is uterus transplantation into him a justified procedure? He is also born without a uterus.

Society should not abandon women born without a uterus. Instead, the costs of IVF and a surrogate carrier for one child should be born by society, and any children after that should be paid for by the patient.

Joe Walsh, MD

Philadelphia, PA

NEXT: Reaction to 9 views on men in ob/gyn

NEXT: Obamacare from the outside

Obamacare as seen from the outside

A relative of mine, working as an ob/gyn in a private for-profit hospital, recently had her pay knocked down approximately 30%, mainly due to administrative costs, lower insurance reimbursement, forms required, and personnel changes. The point is that the hours, paperwork, and rating system imposed by Obamacare have not been offset by increased wages or pay.

Secondly a close friend (over 15 years as an RN) has relayed to me that at most hospitals the nursing staff’s average age is over 50 and there are going to be serious nursing shortages when they retire. The nurse also told me that hospital ERs are also closing (they are not profitable). She knows of approximately 15 that have closed.

In the beginning, JAMA, ob/gyns, individual medical doctors, hospital administrators, pharma, insurance companies, medical equipment suppliers, etc., all went along with Obamacare. This was based on the false promise of increased revenue because everyone would get healthcare and be required to have health insurance. Sounds great to me; almost like "hope and change." During the past 3 years I have followed ob/gyn news and articles. Most professional ob/gyn magazines have ignored the financial and liability impact of Obamacare. During the last 3-4 months finally I saw a hint of some debate. The professional magazines carry many articles about patient care, test results, drug types, and procedures, but very few articles on serious economic/liability issues that could really harm the medical profession and patient care.

Hospitals, small clinics, and ERs are closing across the country due to HIPAA, USPSTF, National Cancer Inst., State Health Exchanges, FDA, Obamacare, EPA, state regulations, and thousands of new Obamacare mandates. A doctor today doesn't touch his scalpel, prescription, or documentation until he talks with his lawyer. Is this providing for the best patient care when time is always of the essence? Questions that should be addressed:

When are the AMA, ob/gyns, and other medical professionals going to stand up and speak out against a bureaucratic system in far-off DC making patient and interview decisions, rehab regimens, value and drug requirements? Most bureaucrats can't tell an aspirin from a peanut.

When are the medical profession, nursing associations, insurance industry, and related subcontractors going to ban together and tell the elites in Washington, DC that we have had it?

Just a few negatives created by Obamacare from an outsider’s view.

I would hope some doctor out there cares about his profession from the quality service point of view and prefers to make his own decisions. Obamacare is contrary to the very reason we set up our form of government.

It's time to speak up and act. Why should a community organizer with no medical experience and his lap dog (Senator Reid) decide our future?

There is still hope, I don't know about the change.

H L Dunnam

West Linn, Oregon