lntravascular neuromuscular blockade for fetal transfusion

To the Editors: We thank Dr. Berkowitz and his associates for the

candid review of their experience with the technical aspects of intrauterine, intravascular fetal transfusion (Berkowitz RL, Chitkara U, Witkins I, Lynch L, Me­halek KE. Technical aspects of intra vascular intrauter­ine transfusions: lessons. AM J OBSTET GYNECOL 1987; 157:4-9). Within their series, they describe two unsuccessful procedures caused by displacement of the transfusion needle by fetal motion. They suggest that intravascular neuromuscular blockade of the fetus may decrease the number of failed procedures secondary to such complications.

At our center, we experienced similar difficulties with fetal movement during intravascular transfusion. We have found the intravascular administration of pan­curonium bromide, at a dose of 0.1 mg/kg of estimated fetal weight, to provide efficacious fetal immobiliza­tion and prevent complications resulting from fetal movement.

A separate intrauterine needle insertion is not re­quired. The drug is injected into the umbilical vein immediately after the correct placement of the trans­fusion needle has been determined and initial blood samples obtained. The pharmacologic effect is sus­tained for 1 to 3 hours. Like Ch. de Crespigny et al.' and Seeds et al.,2 we have not witnessed any late fetal complications secondary to curarization.

Our experience leads us to concur with the authors that the intravenous administration of a neuromuscular blockade to the fetus provides convenient and effective fetal immobilization and facilitates intravascular trans­fusion. We would be interested in the experience of other investigators to verify further the ultimate value and safety of this technique.

James W. Byers III, MD Richard H. Aubry, MD Stevrn]. Feinstein, MD

Jorge G. Lodeiro, MD RodnPy A. McLaren, MD Jane P. Srinivasan, MD

Shiraz Sunderji, MD Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology SUNY Health Science Center at Syracu.11' Syracuse, New York 13210

REFERENCES

I. Ch. de Crespigny L, Robinson HP, Quinn :vi, et al. Ultra-sound-guided fetal blood transfusion for severe rhe­sus isoimmunization. Obstet Gynecol I 985;66:529.

2. Seeds JW, Corke BC, Spielman FJ. Prevention of fetal movement during invasive procedures with pancuronium bromide. A~t.J 01\STET GY:\ECOI. 1986;155:818-9.

CORRESPONDENCE

Diabetic control In pregnancy To the Editors:

In the article by Goldman et al. (Goldman JA, Dicker D, Feldberg D, Yeshaya A, Samuel N, Karp M. Pregnancy outcome in patients with insulin-dependent diabetis mellitus with preconceptional diabetic control: a comparative study. AM J 0Bsn:r GYNECOL 1986; 155:293-7), it became evident that there were actually three groups within this patient population: 44 women who attended the preconceptional clinic, 24 women who had diabetic control in early pregnancy, and seven patients who "did not attend and failed to appear." It is unfortunate that the last two groups were combined as we will never know whether most of the problems occurred among the women who did not attend the clinic.

It is not clear what kind of diabetic control was at­tained by the seven women who did not attend the clinic. Also one wonders if the column entitled "Other women" in Table I, p. 294, should represent the 24 women with early diabetic control in that first-trimester hemoglobin, blood glucose level, and insulin dose are listed.

On the basis of data reported in Table II, p. 295, it is reported in the Results section, that " ... the fre­quency of preeclampsia and the cesarean delivery rates in these patients [nonattenders] were higher than in the attending group before conception." The "precon­ceptional diabetic control" group and the "other" group are not compared statistically, however, and a signifi­cant difference is not reported in this article.

This article appears to have considerable merit. How­ever, it may have been analyzed better had the 24 women with early diabetic control and the seven non­attenders been analyzed separately.

]. S. Bastian, MD Department of Obstetrics and Gynecology University of Saskatchewan Saskatoon, Saskatchewan, Canada

Reply

To the Editors: We are grateful to Dr. Bastian for his comments on

our article. We agree with him that the description of the seven patients who did not attend the preconcep­tional diabetic control clinic is inadequate. We wish to

complete it. Our medical center is a referral center for diabetic

women with complicated pregnancies. These seven pa­tients had no preconceptional glucose regulation and were referred to us in the second trimester with poor metabolic control by the end of the first trimester. All metabolic data regarding these patients during the first trimester were available and were included in Table I.

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