819
examinations of the fetuses were normal. Spiramycin was given to seroconverted women. Toxoplasma IgM in the card blood was negative in all cases, and the babies were healthy after birth and
during follow-up. We believe that, in
terms
of cost,
our
programme may be
regarded as a model for underdeveloped countries. The HA test is the cheapest screening test, and requires little equipment. Sera from seroconverted cases can be sent to a central reference laboratory for
IgM testing. Supported by the Turkish (TAG 596).
Scientific and Technical Research Organisation
Departments of Neonatology, Microbiology and Obstetrics, Turkish Health and Therapy Foundation,
U. DILMEN I. S. KAYA U. Ç&Ibreve;FTÇÍ E. GÖKŞ9IN
Medical Centre Hospital, 06510 Emek, Ankara, Turkey 1. Dilmen
U, Kaya
IS, Çift&c edil;i U, Gökşin E. Toxoplasmosis and rubella infections in
pregnancy, still births and abortions.
Doğa Tr J Med Sci 1990;
14: 290-300.
SIR,-With reference to your Aug 11 editorial on toxoplasmosis and correspondence in The Lancet of Sept 8 surely the relevant
the
figure is the number of new maternal infections with toxoplasmosis? Research at the Swansea Public Health Laboratory1 has put this at 2 per 1000 pregnancies, and this is confirmed by Ho-Yen.2 This suggests 1200 maternal infections a year in Britain and 480 infected babies. Data held by public health laboratories are more indicative of the incidence of toxoplasma infection since current levels of reporting are low and do not reflect the true incidence. Since its formation in May, 1989, the Toxoplasmosis Trust has been in contact with 124 patients with congenital toxoplasmosis and a further 70 women who acquired toxoplasmosis during pregnancy. There will be many instances where subclinical toxoplasmosis is not recognised in a child at birth, as well as in children presenting with eye disease, epilepsy, brain damage, and hydrocephalus. 90% of children with a subclinical infection will go onto acquire often serious symptoms within the first 20 years of life, if untreated.3,4 Your editorial questions the efficacy of the testing procedures used. No action is going to be taken on the basis of one blood test alone. Further tests will be done to establish levels and changes in IgG and IgM. Cordocentesis is also available to test the baby for signs of infection, as are scans to examine the fetus for severe damage. This eliminates any question that healthy women are at risk of losing healthy babies. It is our experience that few women (less than one-third) whose babies are diagnosed as affected will opt for termination. Most choose to continue the pregnancy, with treatment.
The Toxoplasmosis Trust believes that a large-scale campaign on the dangers of toxoplasmosis and avoidance measures during pregnancy is urgent. There have been proposals for health education projects since 1984.4,5 Why have these not been acted upon? The only attempts at health education are being provided by the Toxoplasmosis Trust, with little support from statutory bodies. Preventive health education is one of our most important aims. Screening for rubella and syphilis continues, which is valuable. The number of cases per year is 20 for rubella and even fewer for syphilis. Toxoplasmosis affects 480 cases per year. Toxoplasmosis Trust, Garden Studios, 11-15 Betterton Street, London WC2H 9BP, UK
1
BEATRICE
TEUTEN,
Chairman
Joynson DHM, Payne R Screening for toxoplasmosis in pregnancy. Lancet 1988; ii:
795. 2 Ho-Yen D. Screening for toxoplasmosis in pregnancy. Lancet 1988, ii: 795-96. 3. Koppe JG, Rothova A. Congenital toxoplasmosis: a longterm follow-up of 20 years Int Ophthalmol 1989; 13: 387-90. 4 wilson CB, Remington JS, Stagno S, et al. Development of adverse sequelae in children born with subclinical toxoplasma infection. Pediatrics 1990, 66: 767-74. 5.Henderson JB, Beattie CP, Bale EG, Wright T The evaluation of new services. possibilities for preventing congenital toxoplasmosis IntJ Epidemiol 1984; 13: 65-72.
Caesarean section for fetal distress SIR,-In their article on inconsistencies in obstetric decisions, Dr Barrett and colleagues (Sept 1, p 549) describe the difficulties clinicians have in making decisions in areas of practice where there are no clear objective criteria. However, to conclude that 30% of emergency caesarean sections were unnecessary is misleading. Barrett et al do not tell us whether there was any agreement between the assessors and if this agreement could have occurred by chance. They could have done this by the use of the kappa statistic, a measure of reliability that corrects for chance agreement.1 Percentage agreement on repeated assessment by the same assessor ranged from 60 to 82-5%. The expected agreement by chance alone would be at least 50%. If the proportion of decisions to operate was larger or smaller than 50%, the expected chance agreement would be even greater. Thus the repeatability of the assessors is not statistically greater than would be produced by chance alone. This reflects the uncertainty of action for these
patients. With any group of people assessed as positive by an assessment which has some uncertainty, it is not surprising to find that some are not reassessed as positive. This arises purely because of the uncertainty and is an example of regression towards the mean.3 The study would have contributed more if it had included a control group of women who did not have a caesarean section despite fetal distress. The expected lack of agreement between the assessors in such a control group may suggest that some of these women should have had caesarean sections. We would not, however, conclude that women were denied necessary surgery. All the study shows us is that decisions as to whether women should have emergency surgery for fetal distress are difficult. Department of Public Health Sciences, St George’s Hospital Medical School, London SW17 ORE, UK
ANEEZ ESMAIL MARTIN BLAND
1. Cohen
AJ. A coefficient of agreement for nominal scales Educ Psychol Measure 1960; 20: 37-66. 2. Healy MJR, Goldstein H. Regression towards the mean Arch Hum Biol 1978; 5: 277-80.
Fetal
haemorrhage after fetal scalp blood sampling
SIR,—Fetal scalp blood sampling is increasingly being used in the diagnosis of fetal distress during labour, and it is recommended to exclude or confirm fetal acidosis when cardiotocography (CTG) is abnormal. Persistent bleeding from the sampling site is rare and is usually due to coagulation abnormalities.We report bleeding from the sampling site necessitating immediate delivery by caesarean section in an infant with a normal coagulation profile. A 28-year-old woman in her third pregnancy was noted at 41 weeks’ gestation to have intermittent fetal bradycardia on auscultation. This was confirmed by CTG and she was therefore admitted for induction of labour. Clear liquor was drained after artificial rupture of the membranes and a fetal scalp electrode was applied. CTG at this time was normal. Labour was augmented with oxytocin (’Syntocinon’) infusion because of slow progress. Late fetal heart decelerations were noticed at 6 cm cervical dilatation. Fetal scalp blood sampling was done, and the pH was 7.28. An emergency lower segment caesarean section was done because of continued bleeding from the sampling site despite application of pressure. A live, male infant weighing 3550 g was delivered. The Apgar score was 2 at 1 and 5 minutes, cord blood pH was 725, and cord blood gases were PC02 5-88 KPa, P02 8-6 KPa, and bicarbonate 18.0mmol/1. The acid-base deficit was 7-5 mmol/1 and oxygen saturation was 85%. The baby required intermittent positive-pressure ventilation. Insertion of a single stitch was required to achieve haemostasis from the sampling site, which was 3 mm long. The baby’s haemoglobin concentration was 117g/dl and he needed a transfusion of 130 ml whole blood. His recovery was satisfactory and he was extubated on day 1. He was -
examinations of the fetuses were normal. Spiramycin was given to seroconverted women. Toxoplasma IgM in the card blood was negative in all cases, and the babies were healthy after birth and
during follow-up. We believe that, in
terms
of cost,
our
programme may be
regarded as a model for underdeveloped countries. The HA test is the cheapest screening test, and requires little equipment. Sera from seroconverted cases can be sent to a central reference laboratory for
IgM testing. Supported by the Turkish (TAG 596).
Scientific and Technical Research Organisation
Departments of Neonatology, Microbiology and Obstetrics, Turkish Health and Therapy Foundation,
U. DILMEN I. S. KAYA U. Ç&Ibreve;FTÇÍ E. GÖKŞ9IN
Medical Centre Hospital, 06510 Emek, Ankara, Turkey 1. Dilmen
U, Kaya
IS, Çift&c edil;i U, Gökşin E. Toxoplasmosis and rubella infections in
pregnancy, still births and abortions.
Doğa Tr J Med Sci 1990;
14: 290-300.
SIR,-With reference to your Aug 11 editorial on toxoplasmosis and correspondence in The Lancet of Sept 8 surely the relevant
the
figure is the number of new maternal infections with toxoplasmosis? Research at the Swansea Public Health Laboratory1 has put this at 2 per 1000 pregnancies, and this is confirmed by Ho-Yen.2 This suggests 1200 maternal infections a year in Britain and 480 infected babies. Data held by public health laboratories are more indicative of the incidence of toxoplasma infection since current levels of reporting are low and do not reflect the true incidence. Since its formation in May, 1989, the Toxoplasmosis Trust has been in contact with 124 patients with congenital toxoplasmosis and a further 70 women who acquired toxoplasmosis during pregnancy. There will be many instances where subclinical toxoplasmosis is not recognised in a child at birth, as well as in children presenting with eye disease, epilepsy, brain damage, and hydrocephalus. 90% of children with a subclinical infection will go onto acquire often serious symptoms within the first 20 years of life, if untreated.3,4 Your editorial questions the efficacy of the testing procedures used. No action is going to be taken on the basis of one blood test alone. Further tests will be done to establish levels and changes in IgG and IgM. Cordocentesis is also available to test the baby for signs of infection, as are scans to examine the fetus for severe damage. This eliminates any question that healthy women are at risk of losing healthy babies. It is our experience that few women (less than one-third) whose babies are diagnosed as affected will opt for termination. Most choose to continue the pregnancy, with treatment.
The Toxoplasmosis Trust believes that a large-scale campaign on the dangers of toxoplasmosis and avoidance measures during pregnancy is urgent. There have been proposals for health education projects since 1984.4,5 Why have these not been acted upon? The only attempts at health education are being provided by the Toxoplasmosis Trust, with little support from statutory bodies. Preventive health education is one of our most important aims. Screening for rubella and syphilis continues, which is valuable. The number of cases per year is 20 for rubella and even fewer for syphilis. Toxoplasmosis affects 480 cases per year. Toxoplasmosis Trust, Garden Studios, 11-15 Betterton Street, London WC2H 9BP, UK
1
BEATRICE
TEUTEN,
Chairman
Joynson DHM, Payne R Screening for toxoplasmosis in pregnancy. Lancet 1988; ii:
795. 2 Ho-Yen D. Screening for toxoplasmosis in pregnancy. Lancet 1988, ii: 795-96. 3. Koppe JG, Rothova A. Congenital toxoplasmosis: a longterm follow-up of 20 years Int Ophthalmol 1989; 13: 387-90. 4 wilson CB, Remington JS, Stagno S, et al. Development of adverse sequelae in children born with subclinical toxoplasma infection. Pediatrics 1990, 66: 767-74. 5.Henderson JB, Beattie CP, Bale EG, Wright T The evaluation of new services. possibilities for preventing congenital toxoplasmosis IntJ Epidemiol 1984; 13: 65-72.
Caesarean section for fetal distress SIR,-In their article on inconsistencies in obstetric decisions, Dr Barrett and colleagues (Sept 1, p 549) describe the difficulties clinicians have in making decisions in areas of practice where there are no clear objective criteria. However, to conclude that 30% of emergency caesarean sections were unnecessary is misleading. Barrett et al do not tell us whether there was any agreement between the assessors and if this agreement could have occurred by chance. They could have done this by the use of the kappa statistic, a measure of reliability that corrects for chance agreement.1 Percentage agreement on repeated assessment by the same assessor ranged from 60 to 82-5%. The expected agreement by chance alone would be at least 50%. If the proportion of decisions to operate was larger or smaller than 50%, the expected chance agreement would be even greater. Thus the repeatability of the assessors is not statistically greater than would be produced by chance alone. This reflects the uncertainty of action for these
patients. With any group of people assessed as positive by an assessment which has some uncertainty, it is not surprising to find that some are not reassessed as positive. This arises purely because of the uncertainty and is an example of regression towards the mean.3 The study would have contributed more if it had included a control group of women who did not have a caesarean section despite fetal distress. The expected lack of agreement between the assessors in such a control group may suggest that some of these women should have had caesarean sections. We would not, however, conclude that women were denied necessary surgery. All the study shows us is that decisions as to whether women should have emergency surgery for fetal distress are difficult. Department of Public Health Sciences, St George’s Hospital Medical School, London SW17 ORE, UK
ANEEZ ESMAIL MARTIN BLAND
1. Cohen
AJ. A coefficient of agreement for nominal scales Educ Psychol Measure 1960; 20: 37-66. 2. Healy MJR, Goldstein H. Regression towards the mean Arch Hum Biol 1978; 5: 277-80.
Fetal
haemorrhage after fetal scalp blood sampling
SIR,—Fetal scalp blood sampling is increasingly being used in the diagnosis of fetal distress during labour, and it is recommended to exclude or confirm fetal acidosis when cardiotocography (CTG) is abnormal. Persistent bleeding from the sampling site is rare and is usually due to coagulation abnormalities.We report bleeding from the sampling site necessitating immediate delivery by caesarean section in an infant with a normal coagulation profile. A 28-year-old woman in her third pregnancy was noted at 41 weeks’ gestation to have intermittent fetal bradycardia on auscultation. This was confirmed by CTG and she was therefore admitted for induction of labour. Clear liquor was drained after artificial rupture of the membranes and a fetal scalp electrode was applied. CTG at this time was normal. Labour was augmented with oxytocin (’Syntocinon’) infusion because of slow progress. Late fetal heart decelerations were noticed at 6 cm cervical dilatation. Fetal scalp blood sampling was done, and the pH was 7.28. An emergency lower segment caesarean section was done because of continued bleeding from the sampling site despite application of pressure. A live, male infant weighing 3550 g was delivered. The Apgar score was 2 at 1 and 5 minutes, cord blood pH was 725, and cord blood gases were PC02 5-88 KPa, P02 8-6 KPa, and bicarbonate 18.0mmol/1. The acid-base deficit was 7-5 mmol/1 and oxygen saturation was 85%. The baby required intermittent positive-pressure ventilation. Insertion of a single stitch was required to achieve haemostasis from the sampling site, which was 3 mm long. The baby’s haemoglobin concentration was 117g/dl and he needed a transfusion of 130 ml whole blood. His recovery was satisfactory and he was extubated on day 1. He was -
