47 laborative Study was instituted, and it is regrettable that participating members of that study should publish preliminary data leading to conclusions which may turn out to be mislead-

ingly optimistic. Department of Human Genetics, Western General Hospital, Edinburgh EH4 2HU.

D.

J. H. BROCK

AMNIOTIC ALPHA-FETOPROTEIN AND OMPHALOCELE

SIR,-A transabdominal amniocentesis was performed for genetic reasons in the 15th week of pregnancy in a 27-year-old patient, whose third child had had Down syndrome. The ocfetoprotein (A.F.P.) concentration in the amniotic fluid was very high, 110 µg/ml at first and 115 µg/ml a week later (upper limit of normal 50 µg/ml). The raised A.F.P. level suggested that the fetus had an open neural-tube,defect and the patient decided to have a termination, which was carried out by intravenous infusion of prostaglandin E. A female fetus with an extensive omphalocele was delivered. The liver and small intestine were in the omphalocele, but there was no skin defect. This is the second case, to our knowledge, of a raised amniotic-fluid A.F.P. concentration early in pregnancy associated with an omphalocele. Nevin and Armstrong’ reported the first. Omphalocele may be a further malformation associated with raised A.F.P. levels. Department of Obstetrics and Gynæcology, University of Zurich, 8006 Zürich,

stayed under 10 mvmin, with blood-creatinine values between 6.5 and 8.5 mg/dl. At the end of September she had slight hypogastric malaise, especially at night, but without signs of uterine irritability. On Oct. 17 she spontaneously had a high rupture of membranes. Delivery was induced with oral synthetic oxytocin. The fetal sounds were normal and there were no signs of fetal hypoxia. Delivery was normal, and a male of 35 weeks’ gestational age and 2200 g body-weight, with an Apgar score of 8 (10 after 3 min) was born. There were no visible congenital anomalies. The post-partum course was normal until amenorrhoea developed. At that time her blood-urea was 250 mg/dl, creatinine 10.9 mg/dl, and creatinine clearance 4-5 mvmin. She has since been on periodic haemodialysis. The infant’s development has been normal. This case shows conservative management can be successful in a pregnant woman with poor renal function and hypertension. Nevertheless we feel conservative treatment should only be tried in a centre with dialysis facilities and under close supervision. The control of the hypertension must have been the chief reason for the successful outcome of pregnancy, since fetal prognosis is related more to maternal blood-pressure than to uraemia. A detailed account of this case is given elsewhere.3 J. EGIDO DE LOS RíOS Nephrology Service, J. J. PLAZA PEREZ Fundación Jiménez Diaz, S. CASADO PÉREZ Avda. Reyes Católicos 2, L. HERNANDO AVENDANO. Madrid 3, Spain

JÜRG KUNZ JOSEF SCHMID

Switzerland.

PSYCHOGERIATRIC PATIENTS WHO DIE IN HOSPITAL

SUCCESSFUL PREGNANCY AND ADVANCED

SIR— You point out (Oct. 25, p.801) that the chances of a successful pregnancy are slim if the mother’s plasma-urea exceeds 60 mg/dl, especially if she is hypertensive. In Mackay’s large experience2 they were nil. We have successfully managed a pregnancy despite advanced renal failure and hypertension. A 33-year-old woman, six-months pregnant, entered the nephrology service in August 1973, when her blood-urea was found to be raised. Her first pregnancy 8 years previously had been complicated by palpebral and ankle oedema, proteinuria, and hypertension. She was treated with salt restriction and hypotensive drugs, and gave birth to a normal infant. She has since presented with polyuria, polydipsia, and nocturia, high blood-pressure (diastolic 90-100 mm Hg), and proteinuria up

to 3 g/l. Her second pregnancy had started with

vomiting and ankle cedema during the first 3 months. When we saw the patient her blood-pressure was 155/90 mm Hg; pulse 88/min, slight systolic on the basal area. Uterus palpable at height of umbilicus. Fetal heart sounds normal. Slight ankle oedema. Eye fundus normal. Laboratory assessment included Hb 6.5 g/dl, urea 160

mg/dl, creatinine 6.5 mg/dl with a clearance of 10 ml/min. Urinalysis revealed 2.7g protein/24h white and 60 red bloodcells high-power field, and evidence of urinary infection (Escherichia coly. The E.C.G. showed left-ventricular burden. She was ordered complete rest and checked daily. The diet contained 2500 kcal and 40 g proteins with supplements of calcium, iron, and vitamins. Aluminium hydroxide was added and 500 mg of progesterone were administered weekly. Packed red blood-cells were transfused to maintain the hsematocht above 20%. Blood-pressure was controlled with reserpine and

hydrallazine. Her acidosis was corrected and she was maintained in adequate salt and water balance. Creatinine clearance persistently 1.

Nevin, N. C., Armstrong, M. J. J. Obstet. Gynœc.

Br. Commonw.

826. 2.

McKay, E. V.

Aust. N.

SIR,—Stone House is the main, though

not the only, psychihospital serving the Danford and Gravesham Health District, which has a population of about 250 000. The population is not exceptional-in particular, there is no special geriatric loading such as may happen on the south coast. We have about 27 000 people over the age of 65 in our district. Between January, 1970, and June, 1975, 155 patients from

atric

RENAL FAILURE

Z. Jl Obstet. Gynœc. 1963, 3, 21.

1975, 82,

the district over the age of 65 died. Less than half had been in hospital for more than a year: Years

Up to

Up to 2 2-5 6-10 11-15 16-20 Total

Total 86 51 10

M F 36 50 12 39 3 7 22 1 3 54 101

36

86

50

4 4

155

37 had been in hospital for a month or less before they died 14 survived a week or less in hospital). The causes of death of these 14 were: bronchopneumonia (3), pulmonary embolus (3), congestive cardiac failure (3), myocardial infarction (2), cerebrovascular accident (1), cor pulmonale (1), carcinoma with metastasis (1). Of the 155 patients only 7 were admitted on this final occasion before the age of 65, and among these 7 by far the larger part of their stay occurred over the age of 65. It can be concluded therefore that district patients admitted before the age of 65 seldom remain in psychiatric hospital up to or after that age without a break until their death there. Only 32 patients had previously been admitted to this psychiatric hospital within the last 15 years or more, for an earlier episode of illness. 127 were considered at the time of their final admission to have a cerebral organic state (e.g., dementia or confusion). These patients were, on average, in their late 70s (males) or early 80s (females), and most of them had been in hospital a year or less when they died. The direct cause of death in most instances was certified as bronchopneumonia or car-

(and

3.

de los Rios, J., Plaza, J. J., Fernandez Revta. clin. esp. 1975, 137, 363.

Egido

Aparicio,

M.

A., Hernando, L.

Letter: Amniotic alpha-fetoprotein and omphalocele.

47 laborative Study was instituted, and it is regrettable that participating members of that study should publish preliminary data leading to conclusi...
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