Naproxen Sodium for Pain Control With Intrauterine Device Insertion: A Randomized Controlled Trial.

Letters Association of Intended Route of Delivery and Maternal Morbidity in Twin Pregnancy I read the recent article by Easter et al 1 with interest and surprise. The conclu- sion was that women undergoing a trial of labor with twins experience higher odds of serious postpartum hemor- rhage than those electing cesarean delivery. However, the mechanisms leading to increased blood loss after in- tended vaginal delivery of twins was unclear except lacerations. Can the au- thors present other mechanisms leading to the result? In general, cesarean deliv- ery has been recognized to be associ- ated with an increased risk of serious postpartum hemorrhage. The 90th per- centile of bleeding at twin delivery in Japan has been reported to be 1,600 mL for vaginal delivery and 2,300 mL for caesarean delivery. 2 In our previous observation, 3 postpartum hemorrhage requiring transfusion was signiﬁcantly more likely after elective cesarean delivery at term, whereas emergency cesarean delivery at term was not asso- ciated with an increased risk of postpar- tum hemorrhage requiring transfusion. In our article, 3 the mechanisms leading to increased blood loss after delivery of twins was suggested to be associated with uterine atony without contraction. For physician counseling to select the delivery mode of twins, presentation of convincing mechanisms is required. Guidelines for Letters. Letters posing a ques- tion or challenge to an article appearing in Obstetrics & Gynecology should be submitted within 8 weeks of the article’s publication online. Letters received after 8 weeks will rarely be considered. Letters should not exceed 350 words, including signatures and 5 references. A word count should be provided. A corresponding author should be designated (and contact information listed). Let- ters will be published at the discretion of the Editor. The Editor may send the letter to the au- thors of the original article so their comments may be published simultaneously. The Editor reserves the right to edit and shorten letters. A signed author agreement form is required from all au- thors before publication. Letters should be sub- mitted using the Obstetrics & Gynecology online submission and review system, Editorial Manager (http://ong.edmgr.com). VOL. 129, NO. 6, JUNE 2017 Financial Disclosure: The author did not report any potential conﬂicts of interest. Shunji Suzuki, MD Department of Obstetrics and Gynecology, Japanese Red Cross Katsushika Maternity Hospital, Tokyo, Japan REFERENCES 1. Easter SR, Robinson JN, Lieberman E, Carusi D. Association of intended route of delivery and maternal morbidity in twin pregnancy. Obstet Gynecol 2017; 2. Minakami H, Maeda T, Fujii T, Hamada H, Iitsuka Y, Itakura A, et al. Guidelines for obstetrical practice in Japan: Japan Soci- ety of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2014 edition. J Obstet Gynaecol Res 2014;40:1469–99. 3. Suzuki S, Inde Y, Igarashi M, Miyake H. Elective cesarean as a risk factor for transfusion after delivery of twins. J Nippon Med Sch 2008;75:247–9. In Reply: We thank Dr. Suzuki for the opportu- nity to expand on the higher rates of postpartum hemorrhage in mothers at- tempting vaginal birth of twins. 1 A review of our cases of hemorrhage revealed uter- ine atony as the primary causes of post- partum bleeding, which is in line with national data. 2 Fifty percent of hemor- rhages in the elective cesarean group (n514/28) and 48.1% in the labor group (n525/52) were due to atony. Other causes of hemorrhage included retained placenta (25.0% compared with 10.7%), laceration or trauma (15.4% compared with 7.1%), disorders of coagulation (1.9% compared with 3.6%), and unrecog- nized hemorrhage requiring postpartum transfusion (9.6% compared with 28.6%). Although Dr. Suzuki mentions a recog- nized association between cesarean deliv- ery and hemorrhage, this typically applies to labored rather than elective cesarean deliveries in singleton births. 3 Our study extrapolates this ﬁnding to twin deliveries. Notably, 65% of laboring patients who hemorrhaged with cesarean delivery had reached the second stage. 4 This under- scores the role of operative obstetrics to avoid second-stage cesarean deliveries and associated morbidity. Our results emphasize active management of the third stage of labor, protocols for early identiﬁcation and management of post- partum hemorrhage, and skill sets to pri- oritize vaginal delivery for women who attempt labor with twins. 5 Financial Disclosure: The authors did not report any potential conﬂicts of interest. Sarah Rae Easter, MD Julian Robinson, MD Daniela Carusi, MD, MSc Division of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts REFERENCES 1. Easter SR, Robinson JN, Lieberman E, Carusi D. Association of intended route of delivery and maternal morbidity in twin pregnancy. Obstet Gynecol 2017; 2. Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum hemorrhage: United States 1994–2006. Am J Obstet Gynecol 2010;202:363.e1–6. 3. Allen VM, O’Connell CM, Liston RM, Baskett TF. Maternal morbidity associated with cesarean delivery without labor com- pared with spontaneous onset of labor at term. Obstet Gynecol 2003;102:477–82. 4. Alexander JM, Leveno KJ, Rouse DJ, Land- on MB, Gilbert S, Spong CY, et al. Com- parison of maternal and infant outcomes from primary cesarean delivery during the second compared with the ﬁrst stage of labor. Obstet Gynecol 2007;109:917–21. 5. Main EK, Goffman D, Scavone BM, Low LK, Bingham D, Fontaine PL, et al. National Partnership for Maternal Safety: consensus bundle on obstetric hemorrhage. Obstet Gynecol 2015;126:155–62. Naproxen Sodium for Pain Control With Intrauterine Device Insertion: A Randomized Controlled Trial I was very interested in the unex- pected ﬁndings reported by Ngo et al. 1 The double-blind, randomized, placebo-controlled trial was designed to evaluate the effect of naproxen sodium on their primary outcome, OBSTETRICS & GYNECOLOGY Copyright a by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.