For more information on the grievance process and its procedures, see www.acog.org/goto/grievance. Financial Disclosure: The authors did not report any potential conflicts of interest.
Ralph W. Hale, MD American College of Obstetricians and Gynecologists, Washington, DC Susannah Frazier, JD American Congress of Obstetricians and Gynecologists, Washington, DC
Special Requirements of Electronic Medical Record Systems in Obstetrics and Gynecology To the Editor: I read with interest the commentary, “Special Requirements of Electronic Medical Record Systems in Obstetrics and Gynecology.”1 Currently, few vendors appear interested in developing electronic medical record platforms that will adequately meet the needs of obstetricians. Hopefully, the development of criteria by the Certification Commission for Healthcare Information Technology will spur development of appropriate electronic medical record platforms. There is little doubt that electronic medical records can improve patient safety and outcomes. The overarching goal is to improve communication between providers and sites of patient care. Yes, it is critical to develop usable platforms for prenatal records in office and hospital systems. Even more critical are alterations in work practices that maximize the use of electronic medical records in the seamless transfer of information from the office, where prenatal care takes place, to the hospital for delivery or emergency visits, and even to consultants. We need to forgo copying of prenatal records to be delivered to labor and delivery units at specified intervals. Imagine seeing a patient in the labor and delivery unit at 24 weeks of gestation with the prenatal records available immediately on the hospital electronic medical record; seeing a pregnant patient in the emergency department with shortness of breath, and the department physician having access to her medical history and prenatal visits; or providing full records to a consultant without copy-
Letters to the Editor
ing and sending records or, worse yet, leaving the consultant to depend on the patient for vital information. In all of these settings, integrated electronic medical records are both more efficient and safer. Gone is the need to elicit history from a patient who may be uncomfortable or may be a poor historian. Imagine having previous office ultrasound images for comparison with current hospital images. Imagine having laboratory results available without having to repeat routine tests. Consider the savings to health care spending. Consider the savings in personnel time to gather the information or draw blood and run laboratory tests. Consider the avoidance of errors in eliciting medical information. One additional issue is the inclusion of significant pregnancy-related complications into ongoing medical records for primary care. Because women with gestational diabetes are at increased risk of developing diabetes later and because women with preterm or recurrent preeclampsia are at increased risk for cardiovascular disease and death, it is critical for this information to be provided to primary care physicians. Whether details are best extracted from medical records or added to problem lists is unclear. These women may require enhanced surveillance, counseling, or prophylactic treatment. This is patient-centered care. Financial Disclosure: The author did not report any potential conflicts of interest.
B. Denise Raynor, MD, MPH Emory University School of Medicine, Atlanta, Georgia
REFERENCE 1. McCoy MJ, Diamond AM, Strunk AL, for the American Congress of Obstetricians and Gynecologists’ Committee on Ambulatory Practice Operations. Special requirements of electronic medical record systems in obstetrics and gynecology. Obstet Gynecol 2010;116: 140 –3. Editor’s Note: McCoy et al agree with Dr. Raynor’s observations.
No Time for Complacency: Labor Inductions, Cesarean Deliveries, and the Definition of “Term” To the Editor: I read with great interest the editorial by Dr. Signore regarding the measur-
able adverse consequences of elective inductions.1 One of her suggestions was the involvement of all relevant stakeholders (eg, faculty, private practitioners, nursing, hospital administrators) in the development and implementation of reforms. I was surprised that on her list of “relevant stakeholders” who should be involved in the discussion of elective inductions that she left off the most important stakeholder of all: the patient. The issue of inductions has personal significance to the specific patient that cannot be measured by outcome studies. For example, a first-time mother asks to be induced early because her husband is being shipped overseas to Afghanistan. She has a noninducible cervix and the induction results in a primary cesarean delivery. I understand that, from a public health aspect, this would be considered a measurable adverse consequence. However, to the patient and her husband, who now have the shared experience of the birth of their child and have the opportunity to spend several days together as a family, this was a successful intervention with which they are both very pleased. No one would argue that this satisfaction would be altered if the newborn had difficulties that resulted in longterm admission to the neonatal intensive care unit. We recently reviewed 109 mother and newborn charts of neonates admitted to the neonatal intensive care unit after being delivered between 36 and 39 weeks. Of these, 9% were either elective inductions or elective repeat cesarean deliveries before 39 weeks. Most of the newborns required no more than 24 hours of care to help with transition. Only one newborn did not leave the hospital with the mother. No newborns had any serious adverse effects. Therefore, at our hospital, which is a Midwestern nonteaching institution with 2,800 deliveries a year, we can give patients a risk ratio specific to our institution. The reason that patients want elective induction are numerous. To the medical profession, many of these reasons seem trivial, but to the patient they are very important. A patient should be counseled about the true risks of any medical procedure, including induction or repeat cesarean delivery before 39 weeks. However, once that counseling has occurred, the question becomes whether a physician believes in patient
OBSTETRICS & GYNECOLOGY
autonomy or takes a more paternalistic view of “knowing what’s best for the patient.” Financial Disclosure: The author did not report any potential conflicts of interest.
Larry Kincheloe, MD Family Care Central, Oklahoma City, Oklahoma
REFERENCE 1. Signore C. No time for complacency: labor inductions, cesarean deliveries, and the definition of “term.” Obstet Gynecol 2010;116:4 – 6.
In Reply: I thank Dr. Kincheloe for his comments and for emphasizing the importance of shared decision making in obstetrics. I do not intend to suggest that choosing an elective delivery is never appropriate, but rather that neither providers nor patients should approach these decisions casually. A night in the neonatal intensive care unit is not a trivial matter for a newborn, and postponing elective delivery until 39 weeks significantly decreases a newborn’s chance of this and numerous other adverse outcomes. Financial Disclosure: The author did not report any potential conflicts of interest.
Caroline Signore, MD, MPH Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
Discordant Blood Chimerism in Dizygotic Monochorionic Laser-Treated Twin-Twin Transfusion Syndrome To the Editor: Monochorionic placentation is the most significant risk factor for twins. Although monochorionic twins are presumed to be monozygotic, and nearly all are, the interesting case reported by Assaf and colleagues1 adds to the small number of reports (most from cases of in vitro embryo manipulation) of monochorionic twins who are dizygotic. Their case illustrates how dizygotic twins might falsely be assumed to be monozygotic if they are determined on first trimester ultrasonography to be monochorionic. Conversely, monozygotic twins might falsely be assumed to be dizy-
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gotic, particularly in cases in which chorionicity has not been determined ultrasonically. This may be caused by differences in their chromosomal complement due to embryologic-genetic mechanisms such as postzygotic nondisjunction. For example, a 46, XY zygote might evolve into twins, one with the original 46, XY chromosomal complement and the other with 45, X, having lost the Y owing to a mitotic error soon after the embryo split. In such cases, the 45, X (Turner syndrome) fetus would appear on ultrasonography to be female and its monozygotic co-twin male. Such confusion usually can be sorted out with the help of appropriate, readily available, DNA studies. Burlingham,2 in his editorial accompanying the case report of Assaf and colleagues, refers to their extremely rare case of chimerism in dizygotic twins as an “experiment of nature” and suggests the importance of follow-up studies on these individuals as adults. Similarly, but unlike dizygotic twining, monozygotic twining is an accident of nature. The authors’ report and Burlingham’s comments bring to mind the age-old question of how much of who we are is due to nature (genes) compared with nurture (environment). Identical twins who were separated shortly after birth, raised by different families, then enrolled in research studies as adults have provided data over the years for many studies of this question. Many of these investigations, however, were performed in the days before the relationship of monochorionic placentation to twin-twin transfusion syndrome was known. The monochorionic placenta provides a potential mechanism in monozygotic twins whereby one twin and not the other may develop a congenital anomaly. An example is the development of heart defects in the recipient (but not the donor) twin in some cases of severe twin-twin transfusion syndrome. Thus, the effect of nurture does not have to await birth, but can begin early in pregnancy. This is illustrated as well in the case reported by Assaf and associates. It is an issue with monochorionic, but not dichorionic, twins. Our colleagues in the social sciences might consider confining future identical-twin studies to that smaller subset of monozygotic twins who are dichorionic. This would be facilitated by the
widespread implementation of first-trimester screening, and determination of twin chorionicity at that time, along with the anticipated long-term availability of stored electronic records of these ultrasound examinations. Financial Disclosure: The author did not report any potential conflicts of interest.
Douglas Hershey, MD Prenatal Diagnosis of Northern California, Sacramento, California
REFERENCES 1. Assaf SA, Randolph LM, Benirschke K, Wu S, Samadi R, Chmait RH. Discordant blood chimerism in dizygotic monochorionic laser-treated twin-twin transfusion syndrome. Obstet Gynecol 2010;116:483–5. 2. Burlingham WJ. Chimerism, tolerance, and twins. Obstet Gynecol 2010;116: 475– 6. Editor’s Note: Assaf et al declined to respond. Dr. Burlingham thinks Dr. Hershey’s comments are entirely appropriate and also declined to respond.
Maternal Outcome After Conservative Treatment of Placenta Accreta To the Editor: Sentilhes et al published a multicenter study on conservative management for placenta accreta (n⫽167) demonstrating that conservative management is a valuable option for patients who are counseled properly and who want to preserve fertility.1 This series reports a success rate of 78% by leaving the placenta in situ, partially or totally, with no attempt to remove it forcibly. No additional uterine devascularization procedure was required in 35% of cases. Nevertheless, Sentilhes et al demonstrate significant risks of serious morbidity (6%) and possibly mortality associated with conservative management. Successful conservative management has the advantage of avoiding a difficult hysterectomy, including urologic complications, especially for placenta percreta. It also avoids psychological affects of hysterectomy and theoretically preserves fertility.2 This approach raises the question of how patients should be counseled concerning “preserved fertility.” We recently contacted by phone all the patients who underwent conserva-
Letters to the Editor