Obstetric emergencies
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7194.1342 (Published 15 May 1999) Cite this as: BMJ 1999;318:1342All rapid responses
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They illustrate intra-uterine death by an X-ray of the pregnant maternal abdomen. They comment on the presence of Spalding's sign i.e. overlap of the cranial bones of the foetus and comment that ultrasound changes after death are a more functional nature and not so helpful at showing structural change.
In my opinion this is a travesty of modern practice. Ultrasound illustrates structural changes extremely well including the presence of Spalding's sign, gas in the foetal vessels, oedema of the foetal skin and the obvious lack of foetal heartbeat indicating the presence of foetal demise. It is, in fact, far more reliable than an X-ray in that it indicates foetal death immediately after the event. It is in no way acceptable in the 1990s to perform radiographs on pregnant women to ascertain foetal death which the inclusion of a radiograph in this article implies. The last radiograph to detect foetal death in our Hospital was performed in the early 1980s and 1 would be ashamed if it was any later. If this article is meant to be historical it should say so.
To suggest that radiography in any way is acceptable in pregnancy totally contravenes current guidelines and 1 am more than a little surprised at its inclusion and note that the radiograph is not referred to in the article at any point.
Yours sincerely,
Dr Carole A Luck FRCR Consultant Radiologist
Competing interests: No competing interests
Dear Sirs
In your article on Obstetric emergencies/ abruptio placentae, you comment that "Until this blood arrives, other plasma expanding fluids, such as Haemaccel, should be used" in resuscitation of the shocked patient.
In a recent systematic review on resuscitation in trauma patients-
Choi PT, Yip G, Quinonez LG, Cook DJ Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med 1999 Jan;27(1):200-10
- the authors concluded that there was no advantage in the use of colloid plasma substitutes over crystalloids in fluid resuscitation of trauma victims. Is there an advantage to using Haemacel during interval resuscitation in abruptio placentae?
Sincerely George McGillivray
Competing interests: No competing interests
AMniotic Fluid Embolism Register
AMNIOTIC FLUID EMBOLISM REGISTER
The article on Obstetric emergencies(1) highlights the bad prognosis for women with Amniotic Fluid Embolism. Whilst they mention treatment with steroids, plasma expansion and delivery there is little evidence to suggest whether this can improve outcome. There is now a national register of cases, which has been running for nearly two years with the intention of trying to look at the different treatments used and trying to compare survivors with deaths. The register is detailed in the Confidential Enquiries into Maternal Deaths "Why Mothers Die"(2). The criteria for diagnosis and inclusion into the register are
- Acute hypotension or cardiac arrest - Acute hypoxia (dyspnoea, cyanosis or respiratory arrest) - Coagulopathy (laboratory evidence of intravascular coagulation or severe haemorrhage) - Onset of all of the above during labour, Caesarean section or within 30 minutes of delivery. - No other clinical condition or potential explanation for the symptoms and signs.
If there are any suspected or confirmed cases they should be reported to me via my secretary on 01274-364520.
To date, 16 cases have been reported from 1997 and 1998 and four maternal deaths - a mortality of 25%. Obviously the dataset is too small at the moment to get any clear information so the reporting of further cases is very important.
Competing interests: No competing interests