done, and I wish them success in their evaluation and fur-
ther improvement of this technique.
Jorge O. Escamilla, MD
204 Sunset Dr, Brooksville, FL 34601
6/8/100637
Reply
To the Editors: We thank Escamilla for his kind words and
interest in our article. His proposal that a minilaparo-
tomy be defined by the length of the fascial incision is in-
teresting. On the basis of his clinical experience, he be-
lieves that this is more applicable to patient outcomes.
We do not have experience with Escamilla’s “funnel-like
incision,” and it would be difficult to measure our ex-
tended fascial incision. I do think that Escamilla has a
valid clinical point in that recovery may correlate better
with the size of the fascial and peritoneal incisions than
with the skin incision. This may explain why we had a dif-
ficult time discharging patients before day 3. Our small
skin incisions were quite cosmetic, and the patients did
seem to appreciate that.
We continue to use chromic catgut sutures during hys-
terectomy for the same reason stated by Escamilla. This
seems to be especially true in the teaching setting. The
delayed absorbable suture is used on the vaginal cuff in
an effort to reduce the formation of granulation tissue.
Again, we thank Escamilla for his comments and urge
him to report his experience with the “funnel-like inci-
sion.”
Mitchel S. Hoffman, MD, and Catherine Lynch, MD
Department of Obstetrics and Gynecology, University of South Florida,
College of Medicine, Harbor Side Medical Tower, 4 Columbia Dr #554,
Tampa, FL 33606
6/8/100638
Determinants of abdominal circumference
To the Editors: We were very interested in the recent article
by Roberts et al (Roberts AB, Mitchell JM, McCowan LM,
Barker S. Ultrasonographic measurement of liver length
in the small-for-gestational-age fetus. Am J Obstet
Gynecol 1999;180:634-8). In it the authors demonstrate
that liver size does not appear to be responsible for the
majority of the change in abdominal circumference that
is observed in the small-for-gestational-age fetus. They
postulate that alternative mechanisms for the change in
abdominal circumference include decreased subcuta-
neous fat deposition and an elevation of the diaphragm
resulting from reduced lung size. Kehl et al
1
have
demonstrated in the fetus of the diabetic mother, where
overgrowth rather than undergrowth is the primary con-
cern, that subcutaneous fat accounts for a significantly
greater proportion of the variance in abdominal circum-
ference than does liver size when the fetus is large for
gestational age. Whereas this evidence is indirect as it ap-
plies to the small-for-gestational-age fetus, we believe that
it supports the subcutaneous fat hypothesis for the al-
tered abdominal circumference in the small-for-gesta-
tional-age fetus. In addition, there may be an influence
of the central or visceral adiposity in altering the abdom-
inal circumference. Approximately 80% of total body fat
in the newborn is subcutaneous whereas the remaining
fat is deep and predominantly intra-abdominal.
2
Alterations in this deep fat store might further influence
the abdominal circumference measurement.
Ira M. Bernstein, MD
Division of Maternal-Fetal Medicine, Department of Obstetrics and
Gynecology, University of Vermont, Fletcher Allen Health Care,
Shepardson 331, 111 Colchester Ave, Burlington, VT 05401-1435
Patrick Catalano, MD
Department of Obstetrics and Gynecology, MetroHealth Medical Center,
2500 Metrohealth Dr, Cleveland, OH 44109-1998
REFERENCES
1. Kehl RJ, Krew MA, Thomas A, Catalano PM. Fetal growth and
body composition in infants of women with diabetes mellitus
during pregnancy. J Matern Fetal Med 1996;5:273-80.
2. Sparks JW. Human intrauterine growth and accretion. Semin
Perinatol 1984;8:74-93.
6/8/100636
Response declined
Neurobiology of infants born to women who exer-
cise regularly throughout pregnancy
To the Editors: Clapp et al (Clapp JF III, Lopez B, Harcar-
Sevcik R. Neonatal behavioral profile of the offspring of
women who continued to exercise regularly throughout
pregnancy. Am J Obstet Gynecol 1999;180:91-4) found
that 5-day-old offspring of women who continued to ex-
ercise by running, performing aerobics, swimming, or
using stair-climbing machines regularly throughout preg-
nancy were better able to orient to environmental stimuli
and regulate their state to quiet themselves after light
and sound stimuli. They suggested that this may have
been a learned response to an intermittent arousal stim-
ulus such as the vibration and sound stimuli produced in
utero by both maternal rhythmic motion and the music
that usually accompanies sustained recreational aerobic
activity.
Neurobiologic features are suggested by a study in
which constant braking power was used as a model for
describing both the changes of tempo in final ritardandi
of musical performance and the changes of velocity in
runners’ decelerations.
1
This hypothesis is supported by
short-term laboratory experience demonstrating that
adult female speech production is sufficient to influence
infant’s speech production occurring in the silent inter-
vals between the adult’s vocalizations (average, 3.37 sec-
onds) and by a report that the microvascular response to
the onset of neural activity is consistently delayed by sev-
eral seconds. It is also supported by the association of the
reduction of blood pressure with longer, less recurrent
speech hesitation pauses on the order of 2 seconds that
1038 Letters
October 1999
Am J Obstet Gynecol