A randomised trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional...
1
876 C 0 R R E S PO ND E NC E 2 Smith GCS, Smith MFS, McNay MB, Fleming JEF. First trimester growth and risk of low birth weight. NEngl JMed 1998; 339 1817- 1822. 3 Mittendorf R, Williams MA, Berkey CS, Lieberman E, Monson RR. Predictors of human gestational length. Am J Obsret Gynecol 1993; 168: 480-484. 4 Hutchon D, Kearney C. Clinical interpretation of ultrasound biometry for dating and for assessment of fetal growth using a wheel and chart; is it sufficientlyaccurate? Ultrasound Obsrer Gynecol. In press. The seven surgeons of King’s: a fable by ESOP (Received 8 February 1999) Sic We read with great interest the commentary by Rennie and Cardozo (Vol 105, December 1998)’. Massive haemorrhage is a serious and challenging condition that is often difficult to manage. The article does well in highlighting the variety of treatments of this problem and its lessons should be. learnt by the seasoned pelvic surgeon as well as those who are in training. We fully endorse the comments made by the authors regarding the difficulty in keeping pace with coagulation deficit in the face of intractable haemorrhage. The implications of this catastrophe are even more pronounced in the more frequently encountered obstetrical haemorrhage. We had similar h o m t j h g experiences twice in the last six months during elective caesarean sections. The two cases were performed due to previous caesarean section and associated placenta praevia and both culminated in caesarean hysterectomy due to mas- sive intrapartum blood loss. In our second case a consultant haema- tologist was involved at an early stage, and cryoprecipitate, fresh frozen plasma and platelets were given appropriately. Despite trans- fusing 41 units of blood there was no haematological evidence of a coagulation deficit, yet massive haemorrhage continued necessitating packing the abdomen as a temporary measure to stop the bleeding. It was removed forty-eight hours later uneventfully. Bleeding caused by coagulation disorders is at microvascular level and all the blood components used in replacement therapy can- not plug up holes in larger arteries and veins. The difficulty with haemorrhage in the pelvis stems from lacerations of deep pelvic veins, and can vary in magnitude from trivial to life threatening. Pelvic veins may be fragile, tortuous, hidden from view, and dis- tended. Moreover gynaecological surgeons do not have the luxury of using tourniquets to control bleeding. Another moral to the story is that whenever extensive pelvic dis- section is anticipated or encountered intraoperatively, the help given by a haematologist at an early stage may have a considerable impact on the outcome. Additionally, a member of the operating or anaes- thetic teams should be dedicated to monitor blood loss and replace- ment. In the excitement of the moment it is very possible to lose count of the number of units of blood, blood components, crystal- loids and other fluids that have been given as well as the amount of blood loss. One strength of the article is the surgeons’ realistic appraisal of their limitations; it is a wise individual who knows when to seek assistance. The attitude of the surgeon may be the deciding factor in the outcome of the situation, a point worth stressing in the training of junior surgeons. Ambreen Anwer & Nazar Amso Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff Reference 1 Rennie J, Cardozo L. The seven surgeons of King’s: a fable by ESOP. BrJObster GynaecoZ1998; 105: 1241. A randomised trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: outcome at four years (Received 7 June 1999) Sic I should like to point out that in this paper by the Aberdeen Endome- trial Ablation Trials Group (Vol106, April 1999)’ Dr D. E. Parkin and Dr D. R. Abramovich should have been included in the acknowledge- ments as part of the Writing Committee. Adrian Grant Health Services Research Unit, University of Aberdeen Reference 1 Aberdeen Endometria1 Ablation Trials Group. A randomised trial of endometrial ablation versus hysterectomy for the treatment of dys- functional uterine bleeding: outcome at four years. Br J Obstet Gynaecoll999; 106 360-366. 0 RCOG 1999 Br J Obstet Gynaecol 106,874-876
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Transcript of A randomised trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional...
876 C 0 R R E S PO ND E NC E
2 Smith GCS, Smith MFS, McNay MB, Fleming JEF. First trimester growth and risk of low birth weight. NEngl JMed 1998; 339 1817- 1822.
3 Mittendorf R , Williams MA, Berkey CS, Lieberman E, Monson RR. Predictors of human gestational length. Am J Obsret Gynecol 1993; 168: 480-484.
4 Hutchon D, Kearney C. Clinical interpretation of ultrasound biometry for dating and for assessment of fetal growth using a wheel and chart; is it sufficiently accurate? Ultrasound Obsrer Gynecol. In press.
The seven surgeons of King’s: a fable by ESOP (Received 8 February 1999)
Sic We read with great interest the commentary by Rennie and Cardozo (Vol 105, December 1998)’. Massive haemorrhage is a serious and challenging condition that is often difficult to manage. The article does well in highlighting the variety of treatments of this problem and its lessons should be. learnt by the seasoned pelvic surgeon as well as those who are in training.
We fully endorse the comments made by the authors regarding the difficulty in keeping pace with coagulation deficit in the face of intractable haemorrhage. The implications of this catastrophe are even more pronounced in the more frequently encountered obstetrical haemorrhage. We had similar h o m t j h g experiences twice in the last six months during elective caesarean sections. The two cases were performed due to previous caesarean section and associated placenta praevia and both culminated in caesarean hysterectomy due to mas- sive intrapartum blood loss. In our second case a consultant haema- tologist was involved at an early stage, and cryoprecipitate, fresh frozen plasma and platelets were given appropriately. Despite trans- fusing 41 units of blood there was no haematological evidence of a coagulation deficit, yet massive haemorrhage continued necessitating packing the abdomen as a temporary measure to stop the bleeding. It was removed forty-eight hours later uneventfully.
Bleeding caused by coagulation disorders is at microvascular level and all the blood components used in replacement therapy can- not plug up holes in larger arteries and veins. The difficulty with haemorrhage in the pelvis stems from lacerations of deep pelvic veins, and can vary in magnitude from trivial to life threatening. Pelvic veins may be fragile, tortuous, hidden from view, and dis- tended. Moreover gynaecological surgeons do not have the luxury of using tourniquets to control bleeding.
Another moral to the story is that whenever extensive pelvic dis- section is anticipated or encountered intraoperatively, the help given by a haematologist at an early stage may have a considerable impact on the outcome. Additionally, a member of the operating or anaes- thetic teams should be dedicated to monitor blood loss and replace- ment. In the excitement of the moment it is very possible to lose count of the number of units of blood, blood components, crystal- loids and other fluids that have been given as well as the amount of blood loss.
One strength of the article is the surgeons’ realistic appraisal of their limitations; it is a wise individual who knows when to seek assistance. The attitude of the surgeon may be the deciding factor in the outcome of the situation, a point worth stressing in the training of junior surgeons.
Ambreen Anwer & Nazar Amso Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff
Reference 1 Rennie J, Cardozo L. The seven surgeons of King’s: a fable by ESOP.
BrJObster GynaecoZ1998; 105: 1241.
A randomised trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: outcome at four years (Received 7 June 1999)
Sic I should like to point out that in this paper by the Aberdeen Endome- trial Ablation Trials Group (Vol106, April 1999)’ Dr D. E. Parkin and Dr D. R. Abramovich should have been included in the acknowledge- ments as part of the Writing Committee.
Adrian Grant Health Services Research Unit, University of Aberdeen
Reference 1 Aberdeen Endometria1 Ablation Trials Group. A randomised trial of
endometrial ablation versus hysterectomy for the treatment of dys- functional uterine bleeding: outcome at four years. Br J Obstet Gynaecoll999; 106 360-366.
0 RCOG 1999 Br J Obstet Gynaecol 106,874-876
