240
Value of the obstetric partogram SIR,-Dr Dujardin and colleagues (May 30, p 1336) claim
that their results "show the usefulness and efficacy of the partogram ...". Unfortunately, their study design cannot evaluate efficacy and their results cast some doubt on the partogram’s usefulness. In their case series of 1022 women in labour, crossing the alert line on the partogram was associated with a significantly higher risk of stillbirth and need for resuscitation. However, our interest in partograms is in absolute, not relative, risks. Can partograms substantially reduce the absolute number of poor outcomes? Of the 52 babies needing resuscitation, 73% (38) had normal labours, as did 64% (9/14) of the mothers who had "fresh" stillbirths. Hence, even if the partogram was 100% efficacious, it would have a small impact on the total number of poor outcomes. A major difficulty of uncontrolled case series being used to examine efficacy is that poor outcomes can be explained away as evidence in favour of the intervention. Things would have been worse had the intervention not been carried out, goes the argument. Dujardin et al document that among the labours in which the alert line was crossed, interventions by health workers were associated with a higher risk of the baby needing resuscitation. They argue that this could have been because infants whose deaths were prevented nonetheless needed resuscitation. Or perhaps health workers without a partogram would have left well enough alone and avoided complications altogether. The only way of settling this issue reasonably is by a rigorous, prospective, controlled (if possible, randomised) study of the use versus no use of the partogram. The partogram is meant to help health workers in developing countries who often work alone and in difficult circumstances. As such, it would be tested under similar conditions. Dujardin et al conducted their study in an area where 80% of women chose to deliver in a peripheral maternity clinic. In the Philippines, 80% of women deliver at home. In the Senegal study, each of the maternity clinics was visited every week by a gynaecologist/obstetrician. In the Philippines, not one field supervisor is an obstetrician and few of the district hospitals have one on their staff. In the past, many health interventions were not fully evaluated before they became widely used, and then proved to be of marginal or no use. The controversial history of growth monitoring and the "road to health" approach may be instructive. Until the results of prospective, controlled studies of the partogram, under operational conditions, are available it will be impossible to tell whether the partogram is a good, sound idea or merely an idea that sounds good. Management Sciences for Health, Child Survival Program, Department of Health, Manila, Philippines
BENJAMIN LOEVINSOHN
Partogram presentation and obstetric decision-making SiR,—We agree with Dr Castmill and Dr Thornton’s (June 20, 1520) notion that doctors’ decision-making about slow labour is influenced by the way in which information is presented graphically. Because most deliveries are conducted or supervised by junior doctors, their diagnosis of non-progress or slow progress of labour may be made more frequently if the latent phase is included in the partogram than when it is excluded. We would, however, like to raise some points. Non-progress or slow progress of labour is just one of the many indications for caesarean section. Increased frequency of caesarean section is due to its more liberal use after previous caesarean section, breech presentation, fetal distress, very low birthweight babies, multiple gestation, and early detection of fetal decelerations on intrapartum fetal monitoring.1 O’Driscoll et al2 attributed the lower caesarean section rate in the National Maternity Hospital, Dublin, to more aggressive management of dystocias with oxytocin in nulliparous patients whose uteri they thought to be "almost immune to rupture except by manipulation", to allowing patients with previous low transverse caesarean sections a trial of labour, which proved successful in 60%, and to a liberal trial of labour in breech presentations.
p
A prolonged latent phase on the partogram stimulates the attending obstetrician to augment labour with oxytocin with beneficial effect, rather than doing a caesarean section. We do not
support Castmill and Thomton’s recommendation to omit the latent phase data from the partogram, but advocate that obstetricians, especially junior doctors and midwives, should be more aware of latent phase before making a diagnosis of nonprogress of labour.
J. B. SHARMA E. J. SHAXTED
Acute Services Unit, Northampton General Hospital, Northampton NN1 5BD, UK
G. KHASTGIR
1. Deron R, Patel NB, Thiery M. Implications of increasing rates of caesaraean section. In: Studd J, eds. Progress in obstetrics and gynaecology, vol 6. London Churchill Livingstone, 1987: 175-94. 2. O’Driscoll K, Foley M, MacDonald D. Active management of labour as an alternative to caesarean
section
rates.
Obstet
Gynaecol 1984; 63: 785-91.
Pseudohemiparetic parkinsonism SIR,-Professor De Keyser and colleagues (Jan 18, p 149) describe two patients who are quite similar to the two cases that I had reported in The Lancet in 1976.1 I certainly welcome their confirmatory article for which I have waited some sixteen years. They kindly acknowledge the relation of their report to mine, but suggest that these patients presenting with pseudohemiparetic parkinsonism differ fundamentally from patients with idiopathic Parkinson’s disease. I have had the advantage of a long follow-up in my patients and can report with assurance that the clinical course in at least some patients presenting with pseudohemiparetic parkinsonism evolves into that of typical idiopathic parkinsonism, including bilateral bradykinesia, fixed facies, tremor, and rigidity responsive to antiparkinsonian agents. In one of the cases that I reported,’ there ensued a gradual failure of response to benzhexol and later to levodopa, as is characteristic of idiopathic parkinsonism. No necropsy was done, but in view of the evolution from hemiparetic to typical bilateral parkinsonism, I would question the efforts of De Keyser et al to establish idiopathic hemiparetic parkinsonism as an entity separate from idiopathic parkinsonism. Asymmetrical onset is, in fact, one of the few clinical features that reliably distinguishes idiopathic Parkinson’s disease from other parkinsonian syndrome2 Nor do I believe that their new name for this syndrome is better than my previously coined pseudohemiparetic Parkinson’s disease, since the apparent unilateral weakness of all these patients responded promptly and completely to the use of antiparkinsonian drugs. The main message from these case reports is that patients can have little tremor so that parkinsonism is overlooked, resulting in an extensive diagnostic evaluation for the pseudohemiparesis. My patients were strikingly incapacitated by their hemiparesis, and their prompt response to drugs for Parkinson’s disease was such that they were left with hardly any disability at all. I suspect that similar patients may not be correctly diagnosed and thus left untreated. Neurology and Electroencephalography, 500 Pasadena Avenue South, St Petersburg, Florida 33707, USA
GORDON J. GILBERT
1. Gilbert GJ. A pseudohemiparetic form of Parkinson’s disease. Lancet 1976; ii: 442-43 2. Hughes AJ, Ben-Shlomo Y, Daniel SE, Lees AJ. What features improve the accuracy
of clinical
diagnosis in Parkinson’s disease:
a
clinicopathologic study. Neurology
1992; 42: 1142-46.
Endometriosis and spontaneous rupture of utero-ovarian vessels during pregnancy from intra-abdominal SIR,-Massive haemorrhage spontaneously ruptured utero-ovarian vessels during pregnancy is rare but serious.1,2 The aetiology suggested by Hodgkinson and Christensen3 is dilated utero-ovarian vessels resulting from the physiological demands of pregnancy and muscular activities such as coughing, defaecation, or coitus, which cause a sudden rise in pressure. We suggest that endometriosis may be involved in the rupture of these vessels. A 37-year-old woman was admitted for severe abdominal pain in week 29 of her first pregnancy. A diagnosis of intra-abdominal venous
241
bleeding was confirmed by paracentesis. Because of progressive anaemia, laparotomy was done and revealed 3000 ml of blood clots in the upper abdomen. There was a ruptured vein on the upper anterior surface of the uterus. There were also many thin-walled veins and varicosities on the fundus and anterior surface of the uterus, and hypertrophy of bilateral uterine vessels. In addition, severe endometriosis was present. The fimbriae of the right fallopian tube was tightly attached to the anterior surface of the uterus over the ruptured vein. The bladder was also tightly attached to the lower part. Since it was impossible to ligate the thin and friable wall of the bleeding vein, a 1416 g girl, Apgar score 5 at 5 min, was delivered by caesarean section. Endometriosis was also found in the pelvic cavity. Both ovaries and the rectum adhered tightly to the posterior surface of the uterus, and chronic inflammation was extensive. The postoperative course of the mother was uneventful; the daughter recovered from a difficult course and was discharged at 2 months. There are at least two possible explanations for the involvement of endometriosis in the aetiology of this disease: chronic inflammation due to endometriosis may make utero-ovarian vessels more friable, or the resultant adhesion may give further tension to these vessels when the uterus is enlarged during pregnancy. In our patient, tight adhesion of the right fimbria because of endometriosis was considered to be a dominant factor in the rupture. Two cases of this complication with endometriosis have been reported in Japan.4 Patients with endometriosis are increasing in number and, although endometriosis is one of the causes of infertility, treatments such as in-vitro fertilisation and embryo transfer enable more patients with endometriosis to become pregnant. Therefore, the finding that endometriosis is an important factor for spontaneous rupture of utero-ovarian vessels during pregnancy should be borne in mind. Inazawa
Department of Obstetrics and Gynecology, Municipal Hospital, Inazawa, Aichi 492, Japan
TAKAMI INOUE TAKAYUKI MORIWAKI
Nuffield Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford, UK
ICHIRO NIKI
Intrapelvic hematoma following labor not associated with lesions of the Am J Obstet 1904; 50: 442-45. 2. Ginsburg KA, Valdes C, Schnider G. Spontaneous utero-ovarian vessel rupture during pregnancy three case reports and a review of the literature. Obstet Gynecol 1. Williams JW. uterus.
1987; 69: 474-76 Hodgkinson CP, Christensen RC. Hemorrhage from ruptured uteroovarian veins during pregnancy. Am J Obstet Gynecol 1950; 59: 1112-17. 4. Izumi S, Arai H, Yoshida H, et al. Spontaneous rupture of uterine vessel in the 9th week of pregnancy: case report. Tokyo J Obstet Gynecol 1989; 38: 150-52. 5. Kawabata I, Sawairi M, Furui T, Ichiko S, Tamaya T. A case of spontaneous uterine vessel rupture during pregnancy. Tokai J Obstet Gynecol 1991; 28: 1-4. 3.
Bioavailability of interleukin-2 after reconstitution with albumin SiR,—Mites et all,2 reported that reconstitution of recombinant interleukin-2 (rIL-2) without carrier protein might reduce bioavailability, and hence lead to an underestimate of toxicity, when given by continuous intravenous infusion. The addition of albumin for reconstitution of rIL-2 resulted in increased concentrations of tumour necrosis factor alpha (TNFcx) and neopterin, and also in increased toxicity during the infusion periods. The toxicity was ascribed to rIL-2-induced cytokine release3 from host cells. Serum IL-2 was not measured in these patients. We have assayed serum IL-2 and TNFcx in two groups of patients who received either rIL-2 without protein carrier or rIL-2 reconstituted with 0-5% human serum albumin (HSA) by continuous intravenous infusion from 50 ml plastic syringes. Patients with advanced renal cancer were treated with rIL-2, rIL-2-activated lymphocytes (LAK), and interferon alpha (IFNcx) in a single-institution phase II study. Patients with measurable metastatic renal cancer without central nervous system involvement, with Karnofsky performance status 80 or more, and in whom the primary tumour had been resected were eligible. In part I Proleukin (Eurocetus) was used, reconstituted with sterile water for injection and diluted in 5% dextrose. Part I consisted of a priming phase of rIL-2 18 mU/m2 per day on days 1-5, followed by
SERUM IL-2 AND TNFa IN PATIENTS DURING r!L-2/)FN
Value of the obstetric partogram SIR,-Dr Dujardin and colleagues (May 30, p 1336) claim
that their results "show the usefulness and efficacy of the partogram ...". Unfortunately, their study design cannot evaluate efficacy and their results cast some doubt on the partogram’s usefulness. In their case series of 1022 women in labour, crossing the alert line on the partogram was associated with a significantly higher risk of stillbirth and need for resuscitation. However, our interest in partograms is in absolute, not relative, risks. Can partograms substantially reduce the absolute number of poor outcomes? Of the 52 babies needing resuscitation, 73% (38) had normal labours, as did 64% (9/14) of the mothers who had "fresh" stillbirths. Hence, even if the partogram was 100% efficacious, it would have a small impact on the total number of poor outcomes. A major difficulty of uncontrolled case series being used to examine efficacy is that poor outcomes can be explained away as evidence in favour of the intervention. Things would have been worse had the intervention not been carried out, goes the argument. Dujardin et al document that among the labours in which the alert line was crossed, interventions by health workers were associated with a higher risk of the baby needing resuscitation. They argue that this could have been because infants whose deaths were prevented nonetheless needed resuscitation. Or perhaps health workers without a partogram would have left well enough alone and avoided complications altogether. The only way of settling this issue reasonably is by a rigorous, prospective, controlled (if possible, randomised) study of the use versus no use of the partogram. The partogram is meant to help health workers in developing countries who often work alone and in difficult circumstances. As such, it would be tested under similar conditions. Dujardin et al conducted their study in an area where 80% of women chose to deliver in a peripheral maternity clinic. In the Philippines, 80% of women deliver at home. In the Senegal study, each of the maternity clinics was visited every week by a gynaecologist/obstetrician. In the Philippines, not one field supervisor is an obstetrician and few of the district hospitals have one on their staff. In the past, many health interventions were not fully evaluated before they became widely used, and then proved to be of marginal or no use. The controversial history of growth monitoring and the "road to health" approach may be instructive. Until the results of prospective, controlled studies of the partogram, under operational conditions, are available it will be impossible to tell whether the partogram is a good, sound idea or merely an idea that sounds good. Management Sciences for Health, Child Survival Program, Department of Health, Manila, Philippines
BENJAMIN LOEVINSOHN
Partogram presentation and obstetric decision-making SiR,—We agree with Dr Castmill and Dr Thornton’s (June 20, 1520) notion that doctors’ decision-making about slow labour is influenced by the way in which information is presented graphically. Because most deliveries are conducted or supervised by junior doctors, their diagnosis of non-progress or slow progress of labour may be made more frequently if the latent phase is included in the partogram than when it is excluded. We would, however, like to raise some points. Non-progress or slow progress of labour is just one of the many indications for caesarean section. Increased frequency of caesarean section is due to its more liberal use after previous caesarean section, breech presentation, fetal distress, very low birthweight babies, multiple gestation, and early detection of fetal decelerations on intrapartum fetal monitoring.1 O’Driscoll et al2 attributed the lower caesarean section rate in the National Maternity Hospital, Dublin, to more aggressive management of dystocias with oxytocin in nulliparous patients whose uteri they thought to be "almost immune to rupture except by manipulation", to allowing patients with previous low transverse caesarean sections a trial of labour, which proved successful in 60%, and to a liberal trial of labour in breech presentations.
p
A prolonged latent phase on the partogram stimulates the attending obstetrician to augment labour with oxytocin with beneficial effect, rather than doing a caesarean section. We do not
support Castmill and Thomton’s recommendation to omit the latent phase data from the partogram, but advocate that obstetricians, especially junior doctors and midwives, should be more aware of latent phase before making a diagnosis of nonprogress of labour.
J. B. SHARMA E. J. SHAXTED
Acute Services Unit, Northampton General Hospital, Northampton NN1 5BD, UK
G. KHASTGIR
1. Deron R, Patel NB, Thiery M. Implications of increasing rates of caesaraean section. In: Studd J, eds. Progress in obstetrics and gynaecology, vol 6. London Churchill Livingstone, 1987: 175-94. 2. O’Driscoll K, Foley M, MacDonald D. Active management of labour as an alternative to caesarean
section
rates.
Obstet
Gynaecol 1984; 63: 785-91.
Pseudohemiparetic parkinsonism SIR,-Professor De Keyser and colleagues (Jan 18, p 149) describe two patients who are quite similar to the two cases that I had reported in The Lancet in 1976.1 I certainly welcome their confirmatory article for which I have waited some sixteen years. They kindly acknowledge the relation of their report to mine, but suggest that these patients presenting with pseudohemiparetic parkinsonism differ fundamentally from patients with idiopathic Parkinson’s disease. I have had the advantage of a long follow-up in my patients and can report with assurance that the clinical course in at least some patients presenting with pseudohemiparetic parkinsonism evolves into that of typical idiopathic parkinsonism, including bilateral bradykinesia, fixed facies, tremor, and rigidity responsive to antiparkinsonian agents. In one of the cases that I reported,’ there ensued a gradual failure of response to benzhexol and later to levodopa, as is characteristic of idiopathic parkinsonism. No necropsy was done, but in view of the evolution from hemiparetic to typical bilateral parkinsonism, I would question the efforts of De Keyser et al to establish idiopathic hemiparetic parkinsonism as an entity separate from idiopathic parkinsonism. Asymmetrical onset is, in fact, one of the few clinical features that reliably distinguishes idiopathic Parkinson’s disease from other parkinsonian syndrome2 Nor do I believe that their new name for this syndrome is better than my previously coined pseudohemiparetic Parkinson’s disease, since the apparent unilateral weakness of all these patients responded promptly and completely to the use of antiparkinsonian drugs. The main message from these case reports is that patients can have little tremor so that parkinsonism is overlooked, resulting in an extensive diagnostic evaluation for the pseudohemiparesis. My patients were strikingly incapacitated by their hemiparesis, and their prompt response to drugs for Parkinson’s disease was such that they were left with hardly any disability at all. I suspect that similar patients may not be correctly diagnosed and thus left untreated. Neurology and Electroencephalography, 500 Pasadena Avenue South, St Petersburg, Florida 33707, USA
GORDON J. GILBERT
1. Gilbert GJ. A pseudohemiparetic form of Parkinson’s disease. Lancet 1976; ii: 442-43 2. Hughes AJ, Ben-Shlomo Y, Daniel SE, Lees AJ. What features improve the accuracy
of clinical
diagnosis in Parkinson’s disease:
a
clinicopathologic study. Neurology
1992; 42: 1142-46.
Endometriosis and spontaneous rupture of utero-ovarian vessels during pregnancy from intra-abdominal SIR,-Massive haemorrhage spontaneously ruptured utero-ovarian vessels during pregnancy is rare but serious.1,2 The aetiology suggested by Hodgkinson and Christensen3 is dilated utero-ovarian vessels resulting from the physiological demands of pregnancy and muscular activities such as coughing, defaecation, or coitus, which cause a sudden rise in pressure. We suggest that endometriosis may be involved in the rupture of these vessels. A 37-year-old woman was admitted for severe abdominal pain in week 29 of her first pregnancy. A diagnosis of intra-abdominal venous
241
bleeding was confirmed by paracentesis. Because of progressive anaemia, laparotomy was done and revealed 3000 ml of blood clots in the upper abdomen. There was a ruptured vein on the upper anterior surface of the uterus. There were also many thin-walled veins and varicosities on the fundus and anterior surface of the uterus, and hypertrophy of bilateral uterine vessels. In addition, severe endometriosis was present. The fimbriae of the right fallopian tube was tightly attached to the anterior surface of the uterus over the ruptured vein. The bladder was also tightly attached to the lower part. Since it was impossible to ligate the thin and friable wall of the bleeding vein, a 1416 g girl, Apgar score 5 at 5 min, was delivered by caesarean section. Endometriosis was also found in the pelvic cavity. Both ovaries and the rectum adhered tightly to the posterior surface of the uterus, and chronic inflammation was extensive. The postoperative course of the mother was uneventful; the daughter recovered from a difficult course and was discharged at 2 months. There are at least two possible explanations for the involvement of endometriosis in the aetiology of this disease: chronic inflammation due to endometriosis may make utero-ovarian vessels more friable, or the resultant adhesion may give further tension to these vessels when the uterus is enlarged during pregnancy. In our patient, tight adhesion of the right fimbria because of endometriosis was considered to be a dominant factor in the rupture. Two cases of this complication with endometriosis have been reported in Japan.4 Patients with endometriosis are increasing in number and, although endometriosis is one of the causes of infertility, treatments such as in-vitro fertilisation and embryo transfer enable more patients with endometriosis to become pregnant. Therefore, the finding that endometriosis is an important factor for spontaneous rupture of utero-ovarian vessels during pregnancy should be borne in mind. Inazawa
Department of Obstetrics and Gynecology, Municipal Hospital, Inazawa, Aichi 492, Japan
TAKAMI INOUE TAKAYUKI MORIWAKI
Nuffield Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford, UK
ICHIRO NIKI
Intrapelvic hematoma following labor not associated with lesions of the Am J Obstet 1904; 50: 442-45. 2. Ginsburg KA, Valdes C, Schnider G. Spontaneous utero-ovarian vessel rupture during pregnancy three case reports and a review of the literature. Obstet Gynecol 1. Williams JW. uterus.
1987; 69: 474-76 Hodgkinson CP, Christensen RC. Hemorrhage from ruptured uteroovarian veins during pregnancy. Am J Obstet Gynecol 1950; 59: 1112-17. 4. Izumi S, Arai H, Yoshida H, et al. Spontaneous rupture of uterine vessel in the 9th week of pregnancy: case report. Tokyo J Obstet Gynecol 1989; 38: 150-52. 5. Kawabata I, Sawairi M, Furui T, Ichiko S, Tamaya T. A case of spontaneous uterine vessel rupture during pregnancy. Tokai J Obstet Gynecol 1991; 28: 1-4. 3.
Bioavailability of interleukin-2 after reconstitution with albumin SiR,—Mites et all,2 reported that reconstitution of recombinant interleukin-2 (rIL-2) without carrier protein might reduce bioavailability, and hence lead to an underestimate of toxicity, when given by continuous intravenous infusion. The addition of albumin for reconstitution of rIL-2 resulted in increased concentrations of tumour necrosis factor alpha (TNFcx) and neopterin, and also in increased toxicity during the infusion periods. The toxicity was ascribed to rIL-2-induced cytokine release3 from host cells. Serum IL-2 was not measured in these patients. We have assayed serum IL-2 and TNFcx in two groups of patients who received either rIL-2 without protein carrier or rIL-2 reconstituted with 0-5% human serum albumin (HSA) by continuous intravenous infusion from 50 ml plastic syringes. Patients with advanced renal cancer were treated with rIL-2, rIL-2-activated lymphocytes (LAK), and interferon alpha (IFNcx) in a single-institution phase II study. Patients with measurable metastatic renal cancer without central nervous system involvement, with Karnofsky performance status 80 or more, and in whom the primary tumour had been resected were eligible. In part I Proleukin (Eurocetus) was used, reconstituted with sterile water for injection and diluted in 5% dextrose. Part I consisted of a priming phase of rIL-2 18 mU/m2 per day on days 1-5, followed by
SERUM IL-2 AND TNFa IN PATIENTS DURING r!L-2/)FN
