most toxic) is enhanced by injection of epinephrine or by cardiac necrosis or ischemia. When an asthmatic inhales an aerosol medication, he is creating similar circumstances - that is, the sympathomimetic drug is increasing the amount of epinephrine in the body, and the fluorocarbon, as a propellant for the medication, is being inhaled. It may well be that the hazard is increased by the anxiety commonly felt by asthmatics, who are fighting to get air out of the lungs so as to make room for inhaled air and, in the process, are producing more epinephrine. It would seem advisable for physicians to report all deaths in asthmatics, as well as all illness related to inhalation of an aerosol preparation, to an investigating body or a coroner, because we do not yet have enough data regarding the untoward effects (if any) of the use of aerosol preparations in Canada. In the meantime, a caveat is, I believe, in order. S. FOGEL, MB
605 CN Towers Saskatoon, SK
References 1. Standing Medical Advisory Committee: Deaths Irom Asthma, central health services council, Department of Health and Social Security, London, Elephant and Castle, 1973 2. PoKLIs A: Aerosol propellant abuse and toxicity. Can Soc Forensic Sci J 8 (3): 87, 1975 3. BAss M: Sudden sniffing death. JAMA 212: 2075, 1970 4. AvsAoo DM: Toxicity of aerosol propellants in the respiratory and circulatory systems. LX. Summary of the most toxic: trichiorofluoromethane (FC 11). Toxicol 3: 311, 1975
Infection hazard of radio in the OR
To the editor: The increasing use of nonliving substitutes for outworn parts of the human body has resulted in a shocking increase in the number of infections acquired during operation. To combat these, newer and supposedly better anti-infection measures are constantly being introduced - for example, special garments, double gloving, so-called atraumatic techniques for dissecting patients, abstraction of God's air from the operating room and substitution of artificial approximations, even blindfolding hoods instead of the time-honoured operating caps that served Boebler and Watson-Jones and many other creators of modern surgery so well. With all these laborious methods for making the existence of bacteria wellnigh impossible, it comes as a surprise to find that hospitals are busy installing radio equipment in their operating rooms, a measure that can only increase the possibility of infection. The ostensible reason is, of course, to reduce operating tedium but, assuredly, if operating room personnel find operating so tedious, then other outlets
for their talents should be sought. Much more important is the fact that the incessant wiggling accompanying the cacophonous warblings of Basin Street, even if seemingly subtle and relatively quiet, can only help defeat the laborious and painfully contrived anti-infection measures listed above. The bodily contortions inspired by wireless communication must, of necessity, propel bacteria-laden air of the operating room into the interior of wounds. Radio equipment should therefore be removed forthwith from operating rooms. The aseptic millenium will still be far off, but I hope this action may lead to a tiny decrease in the awesome toll of human lives and efficiency taken by hospital infection. PHILIP ETBEL, MD, FRCS[C]
Ste. 370, 5845 C8te des Neiges Montreal, PQ
Failure of continuous fetal heart monitoring to indicate severe fetal distress To the editor: I would like to report an unusual case in which continuous fetal heart monitoring failed to indicate severe intrauterine fetal distress. The patient was an 18-year-old primipara with an uneventful pregnancy, who was admitted in labour at term. The membranes were ruptured when the cervical os was dilated by 3 cm and thick meconium drained. In view of this, fetal heart monitoring was begun with a scalp electrode and a Hewlett-Packard monitor (HewlettPackard Corp., Palo Alto, California). The fetal heart tracing showed a normal baseline with good beat-to-beat variability and deep early decelerations. In view of this, fetal blood sampling was attempted, but the scalp incision did not bleed and therefore no specimen could be obtained for blood gas analysis. The patient was given a continuous epidural anesthetic, after which re-examination showed no progress in labour despite good uterine contractions. Therefore, cesarean section was performed for cephalopelvic disproportion. The fetal heart tracing continued to show deep early decelerations, and for 10 minutes immediately prior to delivery there was also a baseline bradycardia of 115 beats/mm. The infant had an Apgar score of 0 at 1 minute and at 5 minutes and died a few hours later despite intensive resuscitative measures. This case demonstrated that early decelerations in the fetal heart tracing may occur with severe intrauterine fetal hypoxia, and that inability to obtain a fetal blood sample during labour may indicate an absent or grossly deficient peripheral fetal circulation.
672 CMA JOURNAL/APRIL 17, 1976/VOL. 114
Cu-7®
brand of intrauterine copper
Indication - Intrauterine contraception. Contraindications - Cu-7 is contraindicated in the presence of: Pregnancy or suspected pregnancy, abnormal uterine bleeding, bicornuate uterus, uterine hypoplasia, and otherabnormalities of the uterine cavity, uterine fibroids associated with menstrual disorders, active pelvic inflammatory disease, a history of pelvic inflammatory disease within the past three months or a history of repeated episodes of pelvic inflammatory disease, a history of postpartum endometritis or infected abortion within the previous three months, endometrial disease such as hyperplasia, polyps, malignancy or suspected uterine malignancy, dysplasia, suspected or proven carcinoma of the cervix, (papanicolaou smear Class Ill or IV), acute cervicitis, a history nf copper allergy, disorders of copper metabolism (Wilson's disease). Cu-7 should not be inserted within the two months immediately following delivery or abortion. Warnings - If perforation of the uterine wall is diagnosed or suspected during or at any time following insertion, the Cu-7 should be removed immediately. If penetration into the abdominal cavity occurs, laparotomy should be performed and the Cu-7 recovered. Local inflammatory reaction with abscess formation is a possibility ifs device is left in the abdomen. Persistent or excessive cramping or excessive bleeding may .iecessitate the removal of the Cu-7. The Cu-7 should be removed in cases of incomplete expulsion. Reinsertion of another Cu-7 may be considered. In the extremely rare case of pregnancy in which the Cu-7 has remained in utero, removal of the Cu-7 may precipitate abortion. In dys p asia, suspected or proven carcinoma of the cervix (P a panicolaou smear Glass Ill or IV) the Cu-7 should be removed. Precautions - Prior to insertion of Cu-7 a thorough history and physical examination including a pelvic examination and Papanicolaou smear should be performed. It is advisable to insert Cu-7 at the end of menstruation. Sterile technique should be adhered to during insertion of Cu-7. No undue force or pressure is required during proper insertion of Cu-7. Such force or pressure is unwarranted and may lead to complications. The hazard of uterus perforation can be reduced by sounding the uterus before insertion and by aligning the corpus and cervix by traction on a tenaculum. (The uterus should always be sounded prior to insertion.) If pelvic infection occurs which is unresponsive to treatment, consideration should be given to removal of the Cu-7. If treatment of persistent cervical erosion is not successful with conventional treatment, the Cu-7 should be removed. The presence of metallic copper within the uterus should be taken into consideration prior to administration of short wave diathermy or ionizing radiation to the pelvic region. If any patient with a Cu-7 suddenly develops overt clinical hepatitis or abnormal liver function tests, appropriate diagnostic procedures should be initiated, It is advisable to inform the patient that cramping, spotting or light bleeding may occur in the first several days following insertion but ifthese symptoms continue or are severe she should contact her physician. The patient should be advised that should she become aware that the Cu-7 has been expelled, she should contact her physician. The patient should be advised to periodically check the presence of the thread in the vagina. She should be cautioned, however, not to pull the thread. Should she be unable to locate the thread she should contact her physician. Should the physician be unable to locate the thread, the necessary diagnostic steps (uterine sounding, x-ray of the abdominal and pelvic cavity, installation of contrast material into the uterus if necessary) should be undertaken to localize the Cu-7. The patient should be advised to return to her physician at least yearly for Papanicolaou smear and follow-up examination. The Cu-7 should be replaced every twenty-four months to ensure reliable contraception.
Adverse Effects - Perforation of the uterus has occurred. Post insertion cramping, usually of no more than a few minutes duration may occur. However, a few women may experience this for several days and occasionally this cramping is more prolonged. Transient spotting, bleeding or prolongation of menstrual flow may occur in the first few cycles and occasionally these effects may persist longer. Uncommonly, pelvic infection has been reported. Complete or partial expulsion of the Cu-7 occur in some patients particularly those with uteri measuring less than 6.5 cm by sounding. The following adverse reactions have been reported although their relation to the Cu-7 has not been established. Amenorrhea or delayed menstruation, backache, cervical erosion, cystic masses in the pelvis, vaginitis, vaginal discharge, leg pain or soreness, weight loss or gain, nervousness, dyspareunia, cystitis. Packaging of the Cu-7-The Cu-7 will be supplied as a single unit consisting of a labelled carton. Inside the carton will be a hermetically sealed (sterile) paperplastic bag. This bag contains a support card on which is mounted the Cu-7 and the inserter. A package insert giving directions for use is contained within each carton. The entire package is disposable after the Cu-7 is inserted
P.T. HEWLETI-r, MB, FRC5[C]
women's college Hospital 76 Grenville St. Toronto, ON
. Searle Pharmaceuticals Oakville, Ontario L6H 1M5
605 CN Towers Saskatoon, SK
References 1. Standing Medical Advisory Committee: Deaths Irom Asthma, central health services council, Department of Health and Social Security, London, Elephant and Castle, 1973 2. PoKLIs A: Aerosol propellant abuse and toxicity. Can Soc Forensic Sci J 8 (3): 87, 1975 3. BAss M: Sudden sniffing death. JAMA 212: 2075, 1970 4. AvsAoo DM: Toxicity of aerosol propellants in the respiratory and circulatory systems. LX. Summary of the most toxic: trichiorofluoromethane (FC 11). Toxicol 3: 311, 1975
Infection hazard of radio in the OR
To the editor: The increasing use of nonliving substitutes for outworn parts of the human body has resulted in a shocking increase in the number of infections acquired during operation. To combat these, newer and supposedly better anti-infection measures are constantly being introduced - for example, special garments, double gloving, so-called atraumatic techniques for dissecting patients, abstraction of God's air from the operating room and substitution of artificial approximations, even blindfolding hoods instead of the time-honoured operating caps that served Boebler and Watson-Jones and many other creators of modern surgery so well. With all these laborious methods for making the existence of bacteria wellnigh impossible, it comes as a surprise to find that hospitals are busy installing radio equipment in their operating rooms, a measure that can only increase the possibility of infection. The ostensible reason is, of course, to reduce operating tedium but, assuredly, if operating room personnel find operating so tedious, then other outlets
for their talents should be sought. Much more important is the fact that the incessant wiggling accompanying the cacophonous warblings of Basin Street, even if seemingly subtle and relatively quiet, can only help defeat the laborious and painfully contrived anti-infection measures listed above. The bodily contortions inspired by wireless communication must, of necessity, propel bacteria-laden air of the operating room into the interior of wounds. Radio equipment should therefore be removed forthwith from operating rooms. The aseptic millenium will still be far off, but I hope this action may lead to a tiny decrease in the awesome toll of human lives and efficiency taken by hospital infection. PHILIP ETBEL, MD, FRCS[C]
Ste. 370, 5845 C8te des Neiges Montreal, PQ
Failure of continuous fetal heart monitoring to indicate severe fetal distress To the editor: I would like to report an unusual case in which continuous fetal heart monitoring failed to indicate severe intrauterine fetal distress. The patient was an 18-year-old primipara with an uneventful pregnancy, who was admitted in labour at term. The membranes were ruptured when the cervical os was dilated by 3 cm and thick meconium drained. In view of this, fetal heart monitoring was begun with a scalp electrode and a Hewlett-Packard monitor (HewlettPackard Corp., Palo Alto, California). The fetal heart tracing showed a normal baseline with good beat-to-beat variability and deep early decelerations. In view of this, fetal blood sampling was attempted, but the scalp incision did not bleed and therefore no specimen could be obtained for blood gas analysis. The patient was given a continuous epidural anesthetic, after which re-examination showed no progress in labour despite good uterine contractions. Therefore, cesarean section was performed for cephalopelvic disproportion. The fetal heart tracing continued to show deep early decelerations, and for 10 minutes immediately prior to delivery there was also a baseline bradycardia of 115 beats/mm. The infant had an Apgar score of 0 at 1 minute and at 5 minutes and died a few hours later despite intensive resuscitative measures. This case demonstrated that early decelerations in the fetal heart tracing may occur with severe intrauterine fetal hypoxia, and that inability to obtain a fetal blood sample during labour may indicate an absent or grossly deficient peripheral fetal circulation.
672 CMA JOURNAL/APRIL 17, 1976/VOL. 114
Cu-7®
brand of intrauterine copper
Indication - Intrauterine contraception. Contraindications - Cu-7 is contraindicated in the presence of: Pregnancy or suspected pregnancy, abnormal uterine bleeding, bicornuate uterus, uterine hypoplasia, and otherabnormalities of the uterine cavity, uterine fibroids associated with menstrual disorders, active pelvic inflammatory disease, a history of pelvic inflammatory disease within the past three months or a history of repeated episodes of pelvic inflammatory disease, a history of postpartum endometritis or infected abortion within the previous three months, endometrial disease such as hyperplasia, polyps, malignancy or suspected uterine malignancy, dysplasia, suspected or proven carcinoma of the cervix, (papanicolaou smear Class Ill or IV), acute cervicitis, a history nf copper allergy, disorders of copper metabolism (Wilson's disease). Cu-7 should not be inserted within the two months immediately following delivery or abortion. Warnings - If perforation of the uterine wall is diagnosed or suspected during or at any time following insertion, the Cu-7 should be removed immediately. If penetration into the abdominal cavity occurs, laparotomy should be performed and the Cu-7 recovered. Local inflammatory reaction with abscess formation is a possibility ifs device is left in the abdomen. Persistent or excessive cramping or excessive bleeding may .iecessitate the removal of the Cu-7. The Cu-7 should be removed in cases of incomplete expulsion. Reinsertion of another Cu-7 may be considered. In the extremely rare case of pregnancy in which the Cu-7 has remained in utero, removal of the Cu-7 may precipitate abortion. In dys p asia, suspected or proven carcinoma of the cervix (P a panicolaou smear Glass Ill or IV) the Cu-7 should be removed. Precautions - Prior to insertion of Cu-7 a thorough history and physical examination including a pelvic examination and Papanicolaou smear should be performed. It is advisable to insert Cu-7 at the end of menstruation. Sterile technique should be adhered to during insertion of Cu-7. No undue force or pressure is required during proper insertion of Cu-7. Such force or pressure is unwarranted and may lead to complications. The hazard of uterus perforation can be reduced by sounding the uterus before insertion and by aligning the corpus and cervix by traction on a tenaculum. (The uterus should always be sounded prior to insertion.) If pelvic infection occurs which is unresponsive to treatment, consideration should be given to removal of the Cu-7. If treatment of persistent cervical erosion is not successful with conventional treatment, the Cu-7 should be removed. The presence of metallic copper within the uterus should be taken into consideration prior to administration of short wave diathermy or ionizing radiation to the pelvic region. If any patient with a Cu-7 suddenly develops overt clinical hepatitis or abnormal liver function tests, appropriate diagnostic procedures should be initiated, It is advisable to inform the patient that cramping, spotting or light bleeding may occur in the first several days following insertion but ifthese symptoms continue or are severe she should contact her physician. The patient should be advised that should she become aware that the Cu-7 has been expelled, she should contact her physician. The patient should be advised to periodically check the presence of the thread in the vagina. She should be cautioned, however, not to pull the thread. Should she be unable to locate the thread she should contact her physician. Should the physician be unable to locate the thread, the necessary diagnostic steps (uterine sounding, x-ray of the abdominal and pelvic cavity, installation of contrast material into the uterus if necessary) should be undertaken to localize the Cu-7. The patient should be advised to return to her physician at least yearly for Papanicolaou smear and follow-up examination. The Cu-7 should be replaced every twenty-four months to ensure reliable contraception.
Adverse Effects - Perforation of the uterus has occurred. Post insertion cramping, usually of no more than a few minutes duration may occur. However, a few women may experience this for several days and occasionally this cramping is more prolonged. Transient spotting, bleeding or prolongation of menstrual flow may occur in the first few cycles and occasionally these effects may persist longer. Uncommonly, pelvic infection has been reported. Complete or partial expulsion of the Cu-7 occur in some patients particularly those with uteri measuring less than 6.5 cm by sounding. The following adverse reactions have been reported although their relation to the Cu-7 has not been established. Amenorrhea or delayed menstruation, backache, cervical erosion, cystic masses in the pelvis, vaginitis, vaginal discharge, leg pain or soreness, weight loss or gain, nervousness, dyspareunia, cystitis. Packaging of the Cu-7-The Cu-7 will be supplied as a single unit consisting of a labelled carton. Inside the carton will be a hermetically sealed (sterile) paperplastic bag. This bag contains a support card on which is mounted the Cu-7 and the inserter. A package insert giving directions for use is contained within each carton. The entire package is disposable after the Cu-7 is inserted
P.T. HEWLETI-r, MB, FRC5[C]
women's college Hospital 76 Grenville St. Toronto, ON
. Searle Pharmaceuticals Oakville, Ontario L6H 1M5
