LETTERS TO THE EDITORS
Hypertriglyceridemia in small-for-gestational-age
fetuses
To the Editors: I read with great interest the article by
Economides et al. (Economides DL, Crook D, Nico-
laides KH. Hypertriglyceridemia and hypoxemia in
small-for-gestational-age fetuses. AM J OBSTET GYNE-
COL 1990;162:382-6). The authors found elevated
plasma triglyceride concentration in samples ob-
tained by cordocentesis for small-for-gestational-age
fetuses.
One month earlier we described the increase of cord
blood triglyceride concentration in small-for-gesta-
tional-age infants born to mothers with placental in-
sufficiency.' The mechanism of triglyceride increase in
those cases is not well understood. 1 suggest that chronic
fetal hypoxia caused by placental insufficiency is asso~
ciated with a substantial release of catecholamines. In-
creased secretion of catecholamines leads to lipolysis
and results in elevated blood fatty acid level. The fetal
liver takes up some of the excess fatty acid and syn-
thesizes endogenous triglycerides that appear in the
fetal serum.
It has been found that the duration of fetal hypoxia
must be considerable, perhaps even an hour or more,
for it to result in hypertriglyceridemia."
I proposed that the level of cord blood triglyceride
may prove to be a useful indicator of chronic fetal
hypoxia.
Janusz Bartnicki, MD
Institute of Perinatal Medicine, Mariendorfer Weg 28, D-lGOO Ber-
lin -/4, Germany
REFERENCES
1. Bartnicki J, Szmitkowski M, J6zwik M, Sledziewski A,
Chrostek L, Urban J. Cord blood triglyceridemia in cases
of placental insufficiency. Am J Perinatal 1990;7:26-30.
2. Elphick MC, Harrison AT, Lawlor JP, Hull D. Cord blood
hypertriglyceridemia as an index of fetal stress: use of a
simple screening test and results of further biochemical
analysis. Br J Obstet Gynaecol 1978;85:303-10.
Response declined
Splitting hairs about splitting muscles
To the Editors: Helmkamp and Krebs (Helmkamp BF,
Krebs H-B. The Maylard incision in gynecologic cancer.
AM J OBSTET GYNECOL 1990: 163: 1554-7) recently pre-
sented data substantiating the value of the Maylard
abdominal incision. This article was timely, nicely done,
and welcome. The Maylard technique, however, is not
a "muscle-splitting" incision. It is, rather, a muscle-cut-
ting procedure. Quoting Condon 1 in his chapter on ap-
pendicitis in Sabiston's Textbook ofSurgery, "... the mus-
cle-splitting incision (McArther-McBurney) is the time-
honored approach and one widely used today.... Its
ad vantage is that separation of muscles in the line oftheir
fihers produces a wound that does not depend entirely
lIpon sutures for restoration of tissue continuity." Sur-
gical transection of the rectus muscles does not fit this
description.
The risk of subfascial hematoma and the associated
need for a subfascial drain are related to the creation
of a closed space between the fascia and parietal peri-
toneum. Both can be eliminated by meticulous hemo-
stasis and by allowing the parietal peritoneum to remain
open and unsutured. 2
Gregory P. Sulton, MD
Department of Obstetrics and Gynecology, University Hospital, In-
diana University Medical Center, 926 W. Michigan, Indianapolis,
IN 46202
REFERENCES
1. Condon FE. Appendicitis. In: Sabiston DC, ed. Textbook
of surgery. 13th ed. Philadelphia: WB Saunders, 1986:
975-6.
2. Pietrantoni M, Pat'sons MT. O'Brien WF, Collins E, Knup-
pel RA, Spellacy WN. Peritoneal closure or non-closure at
cesarean. Obstet Gynecol 1991;77:293-6.
Reply
To the Editors: Thank you very much for your comments
regarding our recent article. I agree that "muscle-
cutting" more accurately describes the Maylard tech-
nique because the incision through the rectus muscles
is perpendicular to the muscle fibers rather than
parallel.
I do not suture the posterior rectus sheath in closing
vertical and Pfannenstiel incisions. If you do likewise
with the Maylard incision and have had no wound com-
plications, it may be possible to eliminate the subfascial
drain as you suggest.
B. Frederick Helmkamp, MD
3289 Woodburn Road. Suite 320, Annandale, VA 22003-6897
Effects ot leukotrienes in the
placental vasculature
To the Editors: Thorp et al. (Thorp JA, Walsh SW, Brath
PC. Comparison of the vasoactive effects of leuko-
trienes with thromboxane mimic in the perfused hu-
man placenta. AMJ OBSTET GYNECOL 1988;159:1376-
80) have clearly shown that leukotrienes B. (LTB.) and
C. (LTC.) do not exert major effects on the placental
vasculature except at high doses (> 1 ILg per bolus in-
jection). It is, however, clear from previous work that
prostaglandins may have more potent effects on an-
giotensin II constricted placental vessels than when
added alone'; therefore we have investigated the effects
of coadministration of LTB. or LTC. (5 to 500 ng per
bolus injection) with angiotensin II (5 ILg per bolus
injection) on placental perfusion pressures. The per-
fusion system used in this study has been described. 1
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