Volume 187, Number 3 Letters 819Am J Obstet Gynecol

significantly to the understanding and potential treat-ment to this devastating diagnosis. In reality, spontaneousresealing does occur. To determine the true benefit of re-sealing techniques, prospective randomized trials areneeded of ours and any alternative methods that haveshown definitive instances of fluid reaccumulation.

Anthony C. Sciscione, DODivision of Maternal/Fetal Medicine, Christiana Care Health Services,4755 Ogletown Stanton Rd, Ste 1905, Newark DE 1971; e-mail: ascis-cione@christianacare.org

REFERENCES

1. Quintero RA, Morales WJ, Bornick PW, Allen M, Garabelis N.Surgical treatment of spontaneous rupture of membranes: theamniograft—first experience Am J Obstet Gynecol 2002;186:155-7.

2. Sciscione AC, Manley JS, Pollock MA, Maas B, Shlossman PA,Mulla W, et al. Intracervical fibrin sealants: a potential treatmentfor early preterm premature rupture of the membranes. Am JObstet Gynecol 2001;184:368-73.

3. Hadi HA, Hodson CA, Strickland RT. Premature rupture of themembranes between 20 and 25 weeks gestation: role of amnioticfluid volume and perinatal outcome. Am J Obstet Gynecol1994;170:1139-44.

4. O’Brien J, Barton J, Milligan D. An aggressive, interventionalprotocol for previable premature rupture of the membranes(PROM) [abstract]. Am J Obstet Gynecol 2001;185(Suppl):S99.

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ReplyTo the Editors: We thank Dr Sciscione and collaborators fortheir interest in our publication.

Approximately 106 patients with premature rupture ofthe membranes (PROM) have been treated with tran-scervical fibrin glue since 1979.1,2 Of these 106 patients,reportedly only 4 have had complete cessation of leakageof fluid: 2 in Sciscione’s series and 2 reported by Genz in1979. One of Genz’s patients had iatrogenic PROM aftergenetic amniocentesis and the other after cervical cer-clage. All other authors report inability of the treatmentto stop amniotic fluid leakage per vagina. Dr Sciscionedid not specify whether patients in their series had iatro-genic of spontaneous PROM. This is important because,as we have shown, the clinical behavior of these two formsof PROM is substantially different. For example, we cur-rently have at least a 50% success rate in resealing themembranes after iatrogenic PROM in patients with overtleakage of fluid with the use of our amniopatch, whereasin patients with spontaneous PROM the membranes donot reseal with this technique.3 Thus, we conclude thatthe use of transcervical fibrin glue is inefficient in restor-ing the integrity of the amniotic cavity.

Patients treated at our institution, whether with theamniopatch or the amniograft, are monitored bothclinically and with ultrasound. Each approach has itsbenefits and disadvantages. In our particular am-niograft case, ultrasound did not show the typical in-crease in amniotic fluid volume seen with theamniopatch because of severe compartmentalization of

the amniotic cavity. However, the patient did not reportleakage of fluid during her 10-day hospitalization,which correlated with lack of fluid on the sanitarypads. The report of gross leakage of fluid 14 days afterthe procedure correlated well with the ultrasoundfinding of oligohydramnios.

We do not know whether spontaneous PROM will everbe treatable. However, we certainly believe it is prematureto suggest a randomized clinical trial for the treatment ofpatients with spontaneous PROM. Clinical trials involvingsurgical procedures must first allow for standardization ofthe surgical technique itself and have a reasonable likeli-hood of success. The amniograft technique proposed byus is a first step in the treatment of spontaneous PROM.We have thus extended an invitation to all colleagues toassist us in completing a feasibility trial of 10 patients be-fore we conclude on the potential merits or disadvan-tages of this novel surgical technique for the treatment ofspontaneous PROM.

Rubén A. Quintero, MDSt Joseph’s Women’s Hospital, Florida Institute for Fetal Diagnosis andTherapy, 13601 Bruce B. Downs Blvd, Ste 250, Tampa, FL 33613; e-mail: yvrq@aol.com

REFERENCES

1. Genz H. Die Behandlung des vorzeitigen Blasensprungs durchFibrinklebung. Med Welt 1979;30:1557-9.

2. Baumgarten K. Fibrinklebung bei vorzeitigem Blasensprung.Zentralbl Gynakol 1992;114:74-7.

3. Quintero R, Morales W, Allen M, Bornick P, Arroyo J, LeParc G.Treatment of iatrogenic previable premature rupture of mem-branes with intraamniotic injection of platelets and cryopre-cipitate (amniopatch): preliminary experience. Am J ObstetGynecol 1999;181:744-9.

Additional references available on request.

6/8/126621doi:10.1067/mob.2002.126622

Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortionTo the Editors: Severe hemorrhage after abortion is an un-common event and is usually resolved with uterotonicdrugs or iterative curettage. Life prognosis is exception-ally involved but might lead to hysterectomy. Emboliza-tion should be considered before radical surgery tocontrol hemorrhage.

We read with great interest the paper by Borgatta et al1in the September issue.

We report another case, the only one reported, ofpostabortion hemorrhage with placenta accreta in thefirst trimester of gestation treated by embolization. Asothers, we have a large experience with pelvic emboliza-tion to control postpartum bleeding.2

A 36-year-old woman, gravida 3, para 1, without knowncoagulopathy, had severe hemorrhage during a curet-tage. Several years before she had undergone a cesareandelivery and a curettage for abortion complicated withuterine perforation and uterine synechia. Three surgicalhysteroscopies did not succeed in treating this uterinesynechia, despite which she became pregnant.