1096 Letters

of clinical parameters is operative at the time of the next delivery (e.g., macrosomia, glucose intolerance).

To date, 34 cases of cephalic replacement have been collected from around this country with only one fail­ure and one major maternal complication. We agree that the McRoberts maneuver is most effective.

James A. O'Leary, MD Department of Obstetrics and Gynecology, St. Luke's Hospital, Bethlehem, PA 18015

Measurement of cardiac output with impedance cardiography

To the Editors: An interesting article was published in the September 1989 issue of the JOURNAL (Masaki DI, Greenspoon JS, Ouzounian JG. Measurement of car­diac output in pregnancy by thoracic electrical bioimpedance and thermodilution. AM J OBSTET Gy­NECOL 1989; 161 :680-4) concerning the measurement of cardiac output in patients with cardiac problems, pancreatitis, septic shock, and pregnancy-induced hy­pertension. More than 10 years ago, in 1978, we in­vestigated cardiac output and stroke volume index in pregnant women with threatening premature birth compared with normal pregnancies in the standing, supine, and left lateral positions using a Minnesota impedance cardiograph. We found a statistically highly (p < O.OOS) significant reduction of cardiac output in the standing position in patients with premature labor that disappeared in the lying positions and a significant (p < 0.02S) reduction in stroke volume, which disap­peared in the supine position but persisted in the left lateral position.

The absolute values of cardiac output were in the same range as in the investigations by Masaki et al.

W. Lechner, MD Department of Obstetrics and Gynecology, University of 1nnsbruck, Anichstrasse 35, A-6020 1nnsbruck, Austria

Response declined

Labor epidural analgesia and dystocia-related cesarean section

To the Editors: Does labor epidural analgesia increase the need for obstetric intervention? Most published studies addressing this question, some that implicate and others that exonerate labor epidural analgesia, have design flaws. The same is true of two recent re­ports claiming that labor epidural analgesia increases the rate of dystocia-related cesarean section." 2 In the first, parturients chose their methods of pain relief and altered it at will.' In the second report involv­ing "matched" subjects, the anesthesiologist and obste­trician prescribed analgesia.2 Furthermore, their pa­tients were not matched for height and weight, factors that are likely to influence pelvic bony and soft tissue anatomy.3

September 1990 Am J Obstet Gynecol

Thorp et al.' argue that a controlled, randomized comparison between labor epidural analgesia and par­enteral narcotics would be unethical and liable to pa­tient dropout.' However, Philipsen and Jensen' have prospectively compared labor epidural analgesia and intramuscular meperidine in a randomized study and found no differences in obstetric interference rates. Cesarean section was performed for management of cephalopelvic disproportion in nine of 10 and three of six parturients, and malrotation was present in three of nine and none of a group of three patients, respec­tively. Their cesarean section rates (labor epidural an­algesia, 7.8% or 4/S1 and meperidine, S.9% or 3/S1) are thus commensurate with those of others.'

Thorp et al.' gave patients a bolus dose of 0.2S% bupivacaine and infused 0.12S%. Diro and Beydoun2

and Philipsen and Jensen' used intermittent injections of 0.2S% and 0.37S% bupivacaine, respectively. La­mont et al. 5 compared bupivacaine infusion with inter­mittent "top-ups" but "allowed a passive phase of sec­ond stage of up to 3 hours in each group." Newer labor epidural analgesia techniques that offer optimal ma­ternal analgesia without muscle weakness, and loss of perineal pressure sensation6-8 may thus favor sponta­neous vaginal delivery.

Thorp et al.' stress the current medicolegally inspired reluctance of some obstetricians to use forceps. Are their results perhaps related more to obstetric prefer­ence rather than labor epidural analgesia? Diro and Beydoun2 delivered nine patients who had received epi­dural anesthesia with forceps, within 2 hours of reach­ing 10 cm dilatation. Prolonging the second stage up to 3 hours might have changed the clinical situations.5

Forty percent of nulliparous women suffer severe pain with childbirth.9 This may jeopardize the fe­tus.'o, II Labor epidural analgesia provides maternal analgesia with improved transplacental exchange.'2, I3

A large, controlled, prospective multicenter study in­corporating newer labor epidural analgesia and labor management techniques6-8 could resolve the issue.'4, '5

Patients could be randomized to receive either la­bor epidural analgesia with intravenous saline solution or intravenous meperidine with epidural saline solu­tion, allowing escape to labor epidural analgesia for unbearable pain. When the grave accusations being leveled at labor epidural analgesia are considered," 2 this approach would be ethical in our view.

John W. Downing, FFARCS (Eng) Division of Obstetric Anesthesia, Department of Anesthesiology, Vanderbilt University School of Medicine, 526 Medical Arts Building, Nashville, TN 37232-2125

Norman Herman, MD, PhD, Farkhanda Husain, MD, and Kelly C. Knape, MD

Division of Obstetric Anesthesia, Department of Anesthesiology, University of Texas Health Science Center, 7703 Floyd Curl Dr" San Antonio, TX 78284-7838

REFERENCES 1. ThorpjA, Parisi VM, Boylan PC,johnson DA. The effect

of continuous epidural analgesia on cesarean section for dystocia in nulliparous women. AM j OBSTET GYNECOL

1989;161:670-5.

Volume 163 Number 3

2. Diro M, Beydoun SN. Segmental epidural analgesia in labor: a matched control study. ] Nat! Med Assoc 1985; 78:569-73.

3. Perkins RP. Fetal dystocia. Clin Obstet Gynecol 1987;30: 56-68.

4. Philipsen T, Jensen N-H. Epidural block or parenteral pethidine as analgesic in labour; a randomized study con­cerning progress in labour and instrumental deliveries. Eur] Obstet Gynecol 1989;30:27-33.

5. Lamont RF, Pinney D, Rodgers P, Bryant TN. Continuous versus intermittent epidural analgesia: a randomised trial to observe obstetric outcome. Anaesthesiology 1989;44: 893-6.

6. Chestnut DH, Owen CL, Bates]N, Ostman LG, Choi WW, Geiger MW. Continuous infusion epidural analgesia dur­ing labor: a randomized, double-blind comparison of 0.0625% bupivacaine/0.0002% fentanyl versus 0.125% bupivacaine. Anesthesiology 1988;68:754-9.

7. Chestnut DH, Pollack KL, Laszewski L], Bates ]N, Choi WW. Continuous epidural infusion of bupivacaine­fentanyl during the second stage of labor. Anesthesiology 1989;71:A841.

8. Vandemeulen E, Vertommen], Van Aken H, Noordwin H, Van Steenberge A. Epidural bupivacaine with. sufen­tanil in labor. Anesthesiology 1989;71 :A844.

9. Melzack R. The myth of painless childbirth. (The John J. Bonica Lecture). Pain 1984;19:321-37.

10. Myers RE, Myers SE. Use of sedative, analgesic, and an­esthetic drugs during labor and delivery: bane or boon? AM] OBSTET GYNECOL 1979;133:83-104.

II. Myers RE, Williams MY. Lost opportunities for the pre­vention of fetal asphyxia: sedation, analgesia and general anaesthesia. Clin Obstet Gynecol 1982;9(2):369-414.

12. Pearson ]F, Davies P. The effect of continuous lumbar epidural analgesia on maternal acid-base balance and ar­teriallactate concentration during the second stage of la­bour.] Obstet Gynaecol Br Commonw 1973;80:225-9.

13. Pearson ]F, Davies P. The effect of continuous lumbar epidural analgesia upon fetal acid-base status during the second stage of labour. ] Obstet Gynaecol Br Commonw 1974;81:975-9.

14. Forrest ]B, Rehder K, Goldsmith CH, et al. Multicenter study of general anesthesia. I. Design and patient de­mography. Anesthesiology 1990;72:252-61.

15. Forrest ]B, Calahan MK, Rehder K, et al. Multicenter study of general anesthesia. II. Results. Anesthesiology 1990;71:262-8.

Pemphigus in pregnancy To the Editors: We read with interest the report by Kan­war et al. of another case of pemphigus vulgaris in pregnancy (Kanwar AJ, Kaur S, Abraham A, Nanda A. Pemphigus in pregnancy. AM J OBSTET GYNECOL 1989; 161 :995-6). We heartily support the authors' con­clusion that "it is important that physicians and obste­tricians be aware of the problem" and "consider as problematic the treatment of pemphigus during preg­nancy." Pemphigus vulgaris during pregnancy that af­fects the fetus is very rare. The authors erroneously mentioned 48 such cases l

; however, this figure also in­cludes cases of pemphigus foliaceus, which does not affect the neonate and thus does not pose a difficult therapeutic problem during pregnancy.

We did express our opinion2 that pemphigus vulgaris may severely endanger the fetus because the stillbirth rate for the reported infants born to mothers with this immune-mediated disease during pregnancy is 23%.

Letters 1097

This is probably a result of the effect of treatment. It may be the result of high doses of corticosteroid ther­apy, masking a possibly overwhelming infection or caus­ing placental insufficiency. We might find support for this in the report by Kanwar et al. of a newborn with a birth weight of 1800 gm at 36 weeks' gestation, who was obviously small for gestational age, possibly because of placental insufficiency, after the mother had been treated with 60 mg prednisolone per day for some time.

We recommend repeated plasmapheresis as an al­ternative treatment to improve the precarious state of a patient or fetus with pemphigus vulgaris, thus avoid­ing high doses of corticosteroids when a high titer of circulating pemphigus antibodies is present.3 Plasma­pheresis should contribute to the alleviation of risk to the infants of pregnant women with pemphigus vul­garis.

A. Metzker, MD, and P. Merlob, MD Departments of Pediatric Dermatology and Neonatology, Beilinson Medical Center, Petah Tiqva, 49 100 Israel

REFERENCES I. Kaufman A], Ahmed AR, Kaplan RP. Pemphigus, myas­

thenia gravis, and pregnancy. ] Am Acad Dermatol 1988; 19:414-8.

2. Merlob P, Metzker A, Hazaz B, Rogovin H, Reisner SH. Neonatal pemphigus vulgaris. Pediatrics 1986;78: 1102-5.

3. Metzker A, Merlob P. Pemphigus in pregnancy: a reeval­uation of fetal risk. AM] OBSTET GYNECOL 1987;157: 1012-3.

Reply To the Editors: We thank Drs. Metzker and Merlob for their comments on our article. Although we did men­tion that only 48 patients in whom pemphigus devel­oped or who had recurrent pemphigus during preg­nancy have been reported in the literature, it was not specified that all these cases were of pemphigus vul­garis. Because transplacental transfer of IgG antibodies does occur in pemphigus, why pemphigus foliaceus does not affect the newborn is a matter of conjecture. The milder form of the disease, low levels of circulating antibodies, and smaller doses of corticosteroids re­quired for control of the disease perhaps protect the fetus.

We do not agree with their suggestion that repeated plasmapheresis is an alternative treatment to improve the precarious state of a patient or fetus with pemphi­gus vulgaris. At best plasmapheresis is still an experi­mental procedure in treatment of pemphigus and its use is presently restricted to severe corticosteroid­resistant cases of pemphigus. I. 2 In our opinion it is not worthwhile to subject the mother and fetus to the ex­tensive stress of this repeated procedure with the risks and ill effects of its own. Amrinder J. Kanwar, MD, and Surrinder Kaur, MD, FAMS Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

REFERENCES 1. Roujeau]C. Plasmapheresis therapy of pemphigus and

bullous pemphigoid. Semin Dermatol 1988;7:195-200. 2. Bystryn ]C. Plasmapheresis therapy of pemphigus. Arch

Dermatol 1988; 124: 1702-4.