Commentary
Crisco is an effective vaginal lubricant
Letters to the Editor from our readers
Dr. Garcia responds:
While I can appreciate the comments from my co-editor, Dr. Goldstein, I believe he is defocusing the real issue regarding pregnancies occurring in scar defects caused by previous cesarean section. Rather than creating an issue with the semantics of “ectopic,” I would have preferred to read that Dr. Goldstein was emphasizing the potentially significant, if not fatal, complications and management of cesarean scar pregnancies as he did with co-authors Dr. Timor-Trisch and Dr. Monteagudo in a recent OBG Management article.1
To clarify the terminology, I used “cesarean scar ectopic pregnancy” as it was quoted from the work of Tower and colleagues.2 This terminology adequately describes the location of the pregnancy, as many cesarean scar defects are not just located in the isthmus of the uterus but in the cervix itself.3 And by all accounts a pregnancy at this location would be considered to be a cervical pregnancy, which ACOG defines as ectopic. The following definition of ectopic pregnancy is taken from Dr. Goldstein’s reference to ACOG Practice Bulletin #94: “Nearly all ectopic pregnancies (97%) are implanted within the fallopian tube, although implantation can occur within the abdomen, cervix, ovary, or uterine cornua.”4 Indeed if ACOG uses “ectopic” to describe a pregnancy within the cervix, then “cesarean scar ectopic pregnancy” should be adequate to describe the location of a potentially dangerous pregnancy.
Dr. Goldstein is concerned that our colleagues may become confused by the terminology “cesarean scar ectopic pregnancy” because the word “ectopic” might denote a less clinically significant scenario. Yet I say that anyone confused by the location of the pregnancy has not understood the part of the descriptive term that is “cesarean scar” regardless of the use of “ectopic.” Any clinician treating a patient with a cesarean scar pregnancy would benefit from Dr. Goldstein and his colleagues’ article for diagnosis and management of this critical and potentially life-threatening scenario.
References
1. Timor-Trisch IE, Monteagudo A, Goldstein SR. How to identify and manage cesarean scar pregnancy. OBG Manag. 2014;26(6):19–27.
2. Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013;20(5):562–572.
3. Garcia A. Update on minimally invasive gynecology. OBG Manag. 2014;26(4):18–32.
4. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 94: Medical management of ectopic pregnancy. Obstet Gynecol. 2008;111(6):1479–1485.
Totally painless birth: A new concept in obstetrical anesthesia and labor management
A recent review on epidural anesthesia for pain management during labor, which was published in the New England Journal of Medicine,1 starts with the following case presentation: “A 30-year-old nulliparous woman at 39 weeks gestation is undergoing induction of labor for premature rupture of membranes. She is currently receiving an oxytocin infusion, and her cervical dilatation is 1 cm. Her obstetrician has ordered intermittent intravenous administration of Fentanyl for pain relief, but she feels nauseated, has been unable to rest, and describes her pain as 9 on scale of 10.”
The case we present in this letter sounds totally different: A 26-year-old multiparous woman at 39 weeks’ gestation is scheduled for induction of labor because of a decreased amount of amniotic fluid detected on prenatal ultrasonography. On admission, her cervix is 1-cm dilated and 60% effaced. She has no uterine contractions, and she describes her pain as 0 on the scale of 10. Anticipating a long induction and unwilling to experience any pain, the patient requests and is offered epidural anesthesia prior to oxytocin administration. Labor takes longer than expected but ultimately results in the birth of a healthy child. At no time during the course of labor and delivery does the mother experience any pain or discomfort, and she reports an extremely satisfying experience.
Traditionally, epidural anesthesia is administered upon maternal request when labor pain becomes difficult or intolerable. Many obstetricians discourage the use of epidural anesthesia prior to the onset of the active stage of labor, where the cervix is 4- to 6-cm dilated and the patient is in a great deal of pain.
This concept of administering an analgesic after the onset of pain is very different from the one where anesthesia is provided to patients prior to surgical procedures. No physician would begin a scheduled surgical procedure before confirming administration of adequate anesthesia. Why should labor be any different?
The pain of labor caused by uterine contractions and cervical dilatation is transmitted through visceral afferent nerves entering the spinal cord from T10 through L1. Perineal stretching transmits pain through the pudendal and sacral nerves. Epidural analgesia for labor and delivery involves injection of a local anesthetic agent and an opioid analgesic into the lumbar epidural space. The injected agents gradually diffuse across the dura into the subarachnoid cavity. In spinal analgesia, which is often combined with epidural analgesia, the medication is injected directly into the subarachnoid cavity, resulting in a more rapid effect.2
