1262
reasoning should apply to inhaled lectins and bronchial carcinoma, though here the bronchospasm that widespread mastcell activation would undoubtedly cause might impose a strict limit to usage. Department of Bacteriology & Virology,
DAVID L.
J. FREED
Department of Pathology, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT.
FRANCIS H. Y. GREEN
STABILISER FOR LONG-TERM INDWELLING CATHETERS catheters or intra-arterial catheters are placed in the laboratory animal and in the human for long periods, for parenteral alimentation’ or long-term pressure monitoring.2The permanent fixation of the catheter has given us great difficulties. After the first two weeks a numbet of catheters have gradually slipped out. This was particularly true for catheters used in dogs in long-term parenteral nutrition. Fixation with sutures to muscle or fascia or with tissue-
SIR,-Central
into the middle of the plate. They are used to fasten the catheter(s) to the stabiliser with no. 5-0 steel suture and no. 2-0 silk suture. To prevent the steel suture from damaging or cutting into the intravenous catheter, the silk suture should always be placed distal to the metal suture. When the stabiliser plate has been positioned about 2 cm away from the catheter entry into the skin, mechanical dislodgement or loss of the catheter has always been prevented even in unusually active animals. At the same time the necessary wound care can be
given without difficulties. This technique, which has proved very useful in animal studies, probably can find occasional application in man. Department of Pediatrics, University of Texas, Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, Texas 75235, U.S.A.
EKKEHARD W. REIMOLD
venous
CONGENITAL ANOMALIES AND CLOMIPHENE
SIR,—Dr Berman’s letter (Nov. 1, p. 879) prompts me to report a further case of congenital anomalies associated with maternal clomiphene treatment. The mother, aged 26, visited me because of primary sterility of 3 years’ duration. Temperature charts over 6 months indicated that she did not ovulate regularly, and treatment with clomiphene 50 mg daily from the 5th to 9th day of cycle was started in May, 1975. After the first course she ovulated, but menstrual bleeding started on June 22. After the second course the ovulation occurred on the 15th day of cycle (July 7). On July 30 slight bleeding appeared which the patient put down to menstruation, and the third course of clomiphene was taken during Aug. 4-8. On Sept. 3, a pregnancy test was positive; the size of the uterus corresponded to a 9 weeks’ gestation, and the temperature had been constantly high (37-2-4°C) from July 7. These findings confirmed that the patient had conceived around July 7 and that the last course of clomiphene had been taken during very early pregnancy. In addition, the patient had been treated with 250 mg methyldopa twice daily because of mild hypertension, and the same therapy was continued throughout the pregnancy. During the 38th week of pregnancy the mother was admitted to hospital because of a pre-eclampsia and hydramnion. 1 week later labour was induced by amniotomy, 3600 ml of liquor was obtained, and a male infant, weight 2500 g, Apgar scores 3/5/7, was delivered. The infant was operated on at the age of 8 h because of an oesophageal atresia, but he died at the age of 48 h. Necropsy revealed the following anomalies: oesophageal atresia with broncho-oesophageal fistula, patent ductus arteriosus, atrial and ventricular septal defects, absence of left kidney, hydronephrotic right kidney and ureter, and
hypospadias. The stabiliser in
use.
glue (’Histoacryl-blue’, butyl-cyanoacrylate, B. Braun, Melsungen), or external fixation with various suturing techniques including a suture to adhesive tape, has not prevented loss of catheters in more than 20% of cases. We are now using a stabiliser plate (see figure) which can be made easily and with very little expense. This plate has prevented loss of an indwelling catheter in every instance. A small piece of hard polystyrene plastic or soft silicone rubber is cut to the appropriate size (1.5x 3 cm) and the corners are rounded. Four large holes are drilled into the four corners which are used to suture the stabiliser plate to the skin. Four additional holes (for 2 catheters six additional holes) are drilled 1. Broviac, J. W., Scribner, B. H. in Total Parenteral Nutrition (edited by P. L. White and M. E. Nagy); p. 409. Acton, Mass. 1974 2. Berk, J. L. Surg. Clins N. Am. 1975, 55, 713. 3. Kitterman, J. A., Phibbs, R. H., Tooley, W. H. Pediat. Clins N. Am. 1970, 17, 895.
Abnormal fetal development and subfertility may be related but a possible teratogenic effect of the drug(s) taken by my patient cannot be ruled out. I know of no data on the teratogenicity of methyldopa but there are several reports of neural-tube defects in children of mothers treated with clomiphene.2-J Other anomalies (e.g., absence of kidney in my case and Dr Berman’s) have also been reported. As in one out of two cases reported by Dyson and Kohler2 and by Sandler3(who speculated that "the patient must have been under its [clomiphene’s] influence when conception took place") my patient was still
taking clomiphene after conception. These limited observations may indicate a possible causal relationship between fetal anomalies and maternal clomiphene ingestion. The danger can be further increased if clomiphene is taken inadvertently at or after conception. Mistakes can be 1. 2. 3. 4. 5.
James, W. H. Lancet, 1973, ii, 916. Dyson, J. L., Kohler, H. G. ibid. 1973, i, 1256. Sandler, B. ibid. 1973, ii, 379. Barret, C., Hakim, C. ibid. p. 916. Field, B., Kerr, C. ibid. 1974, ii, 1511.
reasoning should apply to inhaled lectins and bronchial carcinoma, though here the bronchospasm that widespread mastcell activation would undoubtedly cause might impose a strict limit to usage. Department of Bacteriology & Virology,
DAVID L.
J. FREED
Department of Pathology, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT.
FRANCIS H. Y. GREEN
STABILISER FOR LONG-TERM INDWELLING CATHETERS catheters or intra-arterial catheters are placed in the laboratory animal and in the human for long periods, for parenteral alimentation’ or long-term pressure monitoring.2The permanent fixation of the catheter has given us great difficulties. After the first two weeks a numbet of catheters have gradually slipped out. This was particularly true for catheters used in dogs in long-term parenteral nutrition. Fixation with sutures to muscle or fascia or with tissue-
SIR,-Central
into the middle of the plate. They are used to fasten the catheter(s) to the stabiliser with no. 5-0 steel suture and no. 2-0 silk suture. To prevent the steel suture from damaging or cutting into the intravenous catheter, the silk suture should always be placed distal to the metal suture. When the stabiliser plate has been positioned about 2 cm away from the catheter entry into the skin, mechanical dislodgement or loss of the catheter has always been prevented even in unusually active animals. At the same time the necessary wound care can be
given without difficulties. This technique, which has proved very useful in animal studies, probably can find occasional application in man. Department of Pediatrics, University of Texas, Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, Texas 75235, U.S.A.
EKKEHARD W. REIMOLD
venous
CONGENITAL ANOMALIES AND CLOMIPHENE
SIR,—Dr Berman’s letter (Nov. 1, p. 879) prompts me to report a further case of congenital anomalies associated with maternal clomiphene treatment. The mother, aged 26, visited me because of primary sterility of 3 years’ duration. Temperature charts over 6 months indicated that she did not ovulate regularly, and treatment with clomiphene 50 mg daily from the 5th to 9th day of cycle was started in May, 1975. After the first course she ovulated, but menstrual bleeding started on June 22. After the second course the ovulation occurred on the 15th day of cycle (July 7). On July 30 slight bleeding appeared which the patient put down to menstruation, and the third course of clomiphene was taken during Aug. 4-8. On Sept. 3, a pregnancy test was positive; the size of the uterus corresponded to a 9 weeks’ gestation, and the temperature had been constantly high (37-2-4°C) from July 7. These findings confirmed that the patient had conceived around July 7 and that the last course of clomiphene had been taken during very early pregnancy. In addition, the patient had been treated with 250 mg methyldopa twice daily because of mild hypertension, and the same therapy was continued throughout the pregnancy. During the 38th week of pregnancy the mother was admitted to hospital because of a pre-eclampsia and hydramnion. 1 week later labour was induced by amniotomy, 3600 ml of liquor was obtained, and a male infant, weight 2500 g, Apgar scores 3/5/7, was delivered. The infant was operated on at the age of 8 h because of an oesophageal atresia, but he died at the age of 48 h. Necropsy revealed the following anomalies: oesophageal atresia with broncho-oesophageal fistula, patent ductus arteriosus, atrial and ventricular septal defects, absence of left kidney, hydronephrotic right kidney and ureter, and
hypospadias. The stabiliser in
use.
glue (’Histoacryl-blue’, butyl-cyanoacrylate, B. Braun, Melsungen), or external fixation with various suturing techniques including a suture to adhesive tape, has not prevented loss of catheters in more than 20% of cases. We are now using a stabiliser plate (see figure) which can be made easily and with very little expense. This plate has prevented loss of an indwelling catheter in every instance. A small piece of hard polystyrene plastic or soft silicone rubber is cut to the appropriate size (1.5x 3 cm) and the corners are rounded. Four large holes are drilled into the four corners which are used to suture the stabiliser plate to the skin. Four additional holes (for 2 catheters six additional holes) are drilled 1. Broviac, J. W., Scribner, B. H. in Total Parenteral Nutrition (edited by P. L. White and M. E. Nagy); p. 409. Acton, Mass. 1974 2. Berk, J. L. Surg. Clins N. Am. 1975, 55, 713. 3. Kitterman, J. A., Phibbs, R. H., Tooley, W. H. Pediat. Clins N. Am. 1970, 17, 895.
Abnormal fetal development and subfertility may be related but a possible teratogenic effect of the drug(s) taken by my patient cannot be ruled out. I know of no data on the teratogenicity of methyldopa but there are several reports of neural-tube defects in children of mothers treated with clomiphene.2-J Other anomalies (e.g., absence of kidney in my case and Dr Berman’s) have also been reported. As in one out of two cases reported by Dyson and Kohler2 and by Sandler3(who speculated that "the patient must have been under its [clomiphene’s] influence when conception took place") my patient was still
taking clomiphene after conception. These limited observations may indicate a possible causal relationship between fetal anomalies and maternal clomiphene ingestion. The danger can be further increased if clomiphene is taken inadvertently at or after conception. Mistakes can be 1. 2. 3. 4. 5.
James, W. H. Lancet, 1973, ii, 916. Dyson, J. L., Kohler, H. G. ibid. 1973, i, 1256. Sandler, B. ibid. 1973, ii, 379. Barret, C., Hakim, C. ibid. p. 916. Field, B., Kerr, C. ibid. 1974, ii, 1511.
