First-Trimester Growth and the Risk of Low Birth Weight

Abstract

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 massive 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 cannot 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 distended. 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 anaesthetic teams should be dedicated to monitor blood loss and replacement. 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. 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

Discordance of First-Trimester Crown-Rump Length Is a Predictor of Adverse Outcomes in Structurally Normal Euploid Dichorionic Twins

“…Bartha et al 8 found that firsttrimester discordant twins had an increased risk of intrauterine growth restriction and growth discordance later in pregnancy. Smith et al 7 confirmed the relationship between first-trimester growth and term birth weight in a large cohort of singleton pregnancies.…”

Familial resemblance and diversity in bone mass and strength in the population are established during the first year of postnatal life

“…(16) Smith and colleagues implied that tracking occurred during gestation because smaller-than-expected crown-rump length in the first trimester doubled the risk for a low weight at birth. (17) However, only 38 of 1289 smaller-than-expected fetuses remained small throughout gestation, whereas 1251 did not, suggesting that tracking is uncommon during gestation.…”

Investigation of the Effects of First and Second Trimester Biochemical Markers and Ultrasonographic Measurements on Infant Birth Weight

“…Biophysical measurements of the fetuses during second trimester were comparable between genders. [31] This outcome suggested that PAPP-A secreted from trophoblasts might be related to premature development of fetus and placentation. However, in studies performed separately by Dugoff et al and Krantz et al, a relatively prominent correlation between low birth weight and PAPP-A levels was not seen.…”