1594
this patient the incubation time would seem to be more than 17 years. We are aware of two patients with infective dermatitis who died before age 20 years with what was considered to be pre-ATL, on the basis of a persistent lymphocytosis.! The case reported here therefore represents the first instance of overt ATL found in a patient with infective dermatitis. Whether infective dermatitis defines a group of individuals at increased risk of ATL will require further follow-up of large numbers of cases.
Supported by National Institutes of Health, contract
National Cancer Institute
NOI-CP-31006.
University of the West Indies, Kingston, Jamaica
BARRIE HANCHARD LOIS LAGRENADE CHRISTINE CARBERRY VALERIE FLETCHER ELAINE WILLIAMS BEVERLEY CRANSTON
National Institutes of Health,
Bethesda, Maryland
WILLIAM A. BLATTNER
Viral Epidemiology Section, National Institutes of Health,
Bethesda, Maryland 20892, USA
ANGELA MANNS
1. LaGrenade L, Hanchard B, Fletcher V, et al. Infective dermatitis of Jamaican children: a marker for HTLV-I infection. Lancet 1990; 336: 1345-47. 2. Sweet RD. A pattern of eczema m Jamaica. Br J Dermatol 1966; 78: 93-100. 3. Walshe MM. Infective dermatitis in Jamaican children. Br J Dermatol 1967; 79: 229-36. 4. Takatsuki K, Yamaguchi K, Kawano F, et al. Clinical aspects of adult T-cell leukemia/lymphoma (ATL): In: Miwa M, et al, eds. Retroviruses in human lymphoma/leukemia. Tokyo. Japan Scientific Society Press, 1985: 51-57. 5. Gibbs WN, Lofters W, Campbell M, et al. Non-Hodgkin’s lymphoma in Jamaica and its relationship to ATL: a study in Jamaica. Ann Intern Med 1987; 106: 331-68. 6. Hanoaka M, Sasaki M, Matsumoto H, et al. Adult T-cell leukemia: histological classification and characteristics. Acta Pathol Jpn 1979; 29: 723-38. 7. Hanchard B, Gibbs WN, Lofters W, et al. Adult T-cell leukemia/lymphoma in Jamaica. In: Blattner W, ed. Human retrovirology. New York: Raven Press, 1990: 173-83. 8. Suchi T, Lennert K, Tu L-Y, et al. Histopathology and immunohistochemistry of peripheral T-cell lymphomas: a proposal for their classification. J Clin Pathol 1987; 40: 995-1015. 9. Murphy E, Hanchard B, Figueroa JP, et al. Modelling the risk of adult T-cell leukemia/lymphoma in persons infected with HTLV-I. Int J Cancer 1989; 43: 250-53.
training. A critical issue is whether the pregnancy will be recognised early enough. Will women always be able to understand and follow the two-stage treatment schedule and to assess whether the abortion is complete-and will they be able to seek and receive help if complications ensue (haemorrhage, incomplete abortion, uterine infection)? The implication by Norman and colleagues that oral abortifacients may compensate for the lack of access to health facilities seems naive to us. Improved access to family planning and to health care (including surgical abortion by vacuum aspiration) is perhaps a safer and more effective alternative in developing countries. Advances in drug technology do have a part to play in improving the efficiency and safety of drug-induced abortions but the central issue in developing countries is the right of women to free (or affordable), safe, and legal abortion. As in the developed world, the issues raised stretch far beyond medicine into political, cultural, and religious areas. We thank Nazneen Kanji for her
Department of Social Medicine, Federal University of Pelotas, Pelotas (RS), Brazil
WALTER FONSECA
Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine
CHIZURU MISAGO
Health Policy Unit, London School of Hygiene and Tropical Medicine
NAJMI KANJI
*Present address Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1 E 7HT, UK
1. Fonseca W, Alencar AJC, Mota FSB, Coelho HLL. Misoprostol and congenital malformations. Lancet 1991; 338: 56. 2. Pons JC, Elefant E, Hersckorn P, Papiernik E. Development after exposure to mifepristone in early pregnancy. Lancet 1991; 338: 763. 3. Coelho HLL, Misago C, Fonseca W, Souza DSC, Araujo JML. Selling abortifacients over
the
counter
in pharmacies in Fortaleza, Brazil.
SIR,-Dr Norman and colleagues (Nov 16, p 1233) reporting on use of misoprostol plus mifepristone for terminating early pregnancy say that "an orally active prostaglandin in tablet form would be more acceptable to women and could be important in the
developing countries where access to medical facilities is limited". Their clinical results are encouraging but the small numbers of women in the three study groups call into question the extrapolation to larger populations of these findings on efficacy and safety. We question the promotion of this method as an acceptable familyplanning alternative for women in developing countries. Safety needs to be assured. Congenital malformations have been reported in five babies bom to women exposed to misoprostol early in pregnancy in unsuccessful abortion attempts.l 1 case of abnormal development of a fetus after exposure to mifepristone in early pregnancy has been reportedA deleterious effect of misoprostol plus mifepristone on the development of the fetus cannot be ruled out. Firm evidence on freedom from congenital malformations is needed before this drug can be promoted for use in pregnancy termination. In many developing countries women with unwanted pregnancies face not only poor access to medical care but also the illegality of abortion unless medically indicated. In such circumstances, it is likely that these drugs will only be available on the black-market, at a price, and proper information on drugs will not be available. For example, a study of over-the-counter selling of abortifacients in pharmacies in Fortaleza, Brazil, revealed that 80% of pharmacy personnel recommended misoprostol. However, only 7% of pharmacies mentioned the side-effects of the drug and advised women that they may need medical attention after its use.3 In developing countries, even where abortion is legal, women still face difficulties over access to medical care. Furthermore drugs are often administered by primary level health workers with limited
Lancet 1 991; 338: 247.
Management of intrahepatic cholestasis in pregnancy SIR,-lntrahepatic
Misoprostol plus mifepristone
comments.
cholestasis in pregnancy is characterised
by
jaundice) and raised maternal serum occurs in most patients during the third aminotransferases, trimester, and resolves after delivery. Although maternal outcome is invariably good, an increased fetal risk associated with cholestasis in pregnancy has been reported. No treatment improves liver function tests in cholestasis of pregnancy.2 Ursodeoxycholic acid (UDCA) is effective in the treatment of other cholestatic liver diseases such as primary biliary cirrhosis 3 A 30-year-old primigravida was referred at 34 weeks’ gestation because of cholestasis. She had a history of abnormal liver tests after oral contraceptive use. On admission she had hypertransaminasaemia, increased alkaline phosphatase, and normal serum gamma glutamyl transpeptidase. Viral markers for hepatitis A, B, and C, and for cytomegalovirus, Epstein-Barr virus, and herpesvirus were negative. Ultrasound examination revealed a morphologically normal fetus with an estimated weight between the 5th and 10th percentile for gestational age. Amniotic fluid was only slightly reduced and the non-stress test was reactive. Lecithin/ sphingomyelin ratio in amniotic fluid indicated fetal immaturity. The patient was treated with UDCA (600 mg daily in two divided doses) after informed consent. Alanine aminotransferase (ALT), alkaline phosphatase, bilirubin, and gamma glutamyl transpeptidase were measured twice a week. Conjugated bile acids
pruritus (with
or
without
evaluated every week in serum and amniotic fluid before and the start of therapy. ALT was 438 mU/ml before treatment and rapidly decreased with treatment, reaching normal values after two weeks. Alkaline phosphatase decreased more slowly from 408 mU/ml pretreatment to 330 mU/mI on the day of delivery. Conjugated cholic acid was 22-5 umol/1 (normal < 1 lunol/1) before UDCA treatment and decreased to 2-3 lunol/1 after one week of therapy. Serum conjugated chenodeoxycolic acid was 4-9 limol/I (normal
this patient the incubation time would seem to be more than 17 years. We are aware of two patients with infective dermatitis who died before age 20 years with what was considered to be pre-ATL, on the basis of a persistent lymphocytosis.! The case reported here therefore represents the first instance of overt ATL found in a patient with infective dermatitis. Whether infective dermatitis defines a group of individuals at increased risk of ATL will require further follow-up of large numbers of cases.
Supported by National Institutes of Health, contract
National Cancer Institute
NOI-CP-31006.
University of the West Indies, Kingston, Jamaica
BARRIE HANCHARD LOIS LAGRENADE CHRISTINE CARBERRY VALERIE FLETCHER ELAINE WILLIAMS BEVERLEY CRANSTON
National Institutes of Health,
Bethesda, Maryland
WILLIAM A. BLATTNER
Viral Epidemiology Section, National Institutes of Health,
Bethesda, Maryland 20892, USA
ANGELA MANNS
1. LaGrenade L, Hanchard B, Fletcher V, et al. Infective dermatitis of Jamaican children: a marker for HTLV-I infection. Lancet 1990; 336: 1345-47. 2. Sweet RD. A pattern of eczema m Jamaica. Br J Dermatol 1966; 78: 93-100. 3. Walshe MM. Infective dermatitis in Jamaican children. Br J Dermatol 1967; 79: 229-36. 4. Takatsuki K, Yamaguchi K, Kawano F, et al. Clinical aspects of adult T-cell leukemia/lymphoma (ATL): In: Miwa M, et al, eds. Retroviruses in human lymphoma/leukemia. Tokyo. Japan Scientific Society Press, 1985: 51-57. 5. Gibbs WN, Lofters W, Campbell M, et al. Non-Hodgkin’s lymphoma in Jamaica and its relationship to ATL: a study in Jamaica. Ann Intern Med 1987; 106: 331-68. 6. Hanoaka M, Sasaki M, Matsumoto H, et al. Adult T-cell leukemia: histological classification and characteristics. Acta Pathol Jpn 1979; 29: 723-38. 7. Hanchard B, Gibbs WN, Lofters W, et al. Adult T-cell leukemia/lymphoma in Jamaica. In: Blattner W, ed. Human retrovirology. New York: Raven Press, 1990: 173-83. 8. Suchi T, Lennert K, Tu L-Y, et al. Histopathology and immunohistochemistry of peripheral T-cell lymphomas: a proposal for their classification. J Clin Pathol 1987; 40: 995-1015. 9. Murphy E, Hanchard B, Figueroa JP, et al. Modelling the risk of adult T-cell leukemia/lymphoma in persons infected with HTLV-I. Int J Cancer 1989; 43: 250-53.
training. A critical issue is whether the pregnancy will be recognised early enough. Will women always be able to understand and follow the two-stage treatment schedule and to assess whether the abortion is complete-and will they be able to seek and receive help if complications ensue (haemorrhage, incomplete abortion, uterine infection)? The implication by Norman and colleagues that oral abortifacients may compensate for the lack of access to health facilities seems naive to us. Improved access to family planning and to health care (including surgical abortion by vacuum aspiration) is perhaps a safer and more effective alternative in developing countries. Advances in drug technology do have a part to play in improving the efficiency and safety of drug-induced abortions but the central issue in developing countries is the right of women to free (or affordable), safe, and legal abortion. As in the developed world, the issues raised stretch far beyond medicine into political, cultural, and religious areas. We thank Nazneen Kanji for her
Department of Social Medicine, Federal University of Pelotas, Pelotas (RS), Brazil
WALTER FONSECA
Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine
CHIZURU MISAGO
Health Policy Unit, London School of Hygiene and Tropical Medicine
NAJMI KANJI
*Present address Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1 E 7HT, UK
1. Fonseca W, Alencar AJC, Mota FSB, Coelho HLL. Misoprostol and congenital malformations. Lancet 1991; 338: 56. 2. Pons JC, Elefant E, Hersckorn P, Papiernik E. Development after exposure to mifepristone in early pregnancy. Lancet 1991; 338: 763. 3. Coelho HLL, Misago C, Fonseca W, Souza DSC, Araujo JML. Selling abortifacients over
the
counter
in pharmacies in Fortaleza, Brazil.
SIR,-Dr Norman and colleagues (Nov 16, p 1233) reporting on use of misoprostol plus mifepristone for terminating early pregnancy say that "an orally active prostaglandin in tablet form would be more acceptable to women and could be important in the
developing countries where access to medical facilities is limited". Their clinical results are encouraging but the small numbers of women in the three study groups call into question the extrapolation to larger populations of these findings on efficacy and safety. We question the promotion of this method as an acceptable familyplanning alternative for women in developing countries. Safety needs to be assured. Congenital malformations have been reported in five babies bom to women exposed to misoprostol early in pregnancy in unsuccessful abortion attempts.l 1 case of abnormal development of a fetus after exposure to mifepristone in early pregnancy has been reportedA deleterious effect of misoprostol plus mifepristone on the development of the fetus cannot be ruled out. Firm evidence on freedom from congenital malformations is needed before this drug can be promoted for use in pregnancy termination. In many developing countries women with unwanted pregnancies face not only poor access to medical care but also the illegality of abortion unless medically indicated. In such circumstances, it is likely that these drugs will only be available on the black-market, at a price, and proper information on drugs will not be available. For example, a study of over-the-counter selling of abortifacients in pharmacies in Fortaleza, Brazil, revealed that 80% of pharmacy personnel recommended misoprostol. However, only 7% of pharmacies mentioned the side-effects of the drug and advised women that they may need medical attention after its use.3 In developing countries, even where abortion is legal, women still face difficulties over access to medical care. Furthermore drugs are often administered by primary level health workers with limited
Lancet 1 991; 338: 247.
Management of intrahepatic cholestasis in pregnancy SIR,-lntrahepatic
Misoprostol plus mifepristone
comments.
cholestasis in pregnancy is characterised
by
jaundice) and raised maternal serum occurs in most patients during the third aminotransferases, trimester, and resolves after delivery. Although maternal outcome is invariably good, an increased fetal risk associated with cholestasis in pregnancy has been reported. No treatment improves liver function tests in cholestasis of pregnancy.2 Ursodeoxycholic acid (UDCA) is effective in the treatment of other cholestatic liver diseases such as primary biliary cirrhosis 3 A 30-year-old primigravida was referred at 34 weeks’ gestation because of cholestasis. She had a history of abnormal liver tests after oral contraceptive use. On admission she had hypertransaminasaemia, increased alkaline phosphatase, and normal serum gamma glutamyl transpeptidase. Viral markers for hepatitis A, B, and C, and for cytomegalovirus, Epstein-Barr virus, and herpesvirus were negative. Ultrasound examination revealed a morphologically normal fetus with an estimated weight between the 5th and 10th percentile for gestational age. Amniotic fluid was only slightly reduced and the non-stress test was reactive. Lecithin/ sphingomyelin ratio in amniotic fluid indicated fetal immaturity. The patient was treated with UDCA (600 mg daily in two divided doses) after informed consent. Alanine aminotransferase (ALT), alkaline phosphatase, bilirubin, and gamma glutamyl transpeptidase were measured twice a week. Conjugated bile acids
pruritus (with
or
without
evaluated every week in serum and amniotic fluid before and the start of therapy. ALT was 438 mU/ml before treatment and rapidly decreased with treatment, reaching normal values after two weeks. Alkaline phosphatase decreased more slowly from 408 mU/ml pretreatment to 330 mU/mI on the day of delivery. Conjugated cholic acid was 22-5 umol/1 (normal < 1 lunol/1) before UDCA treatment and decreased to 2-3 lunol/1 after one week of therapy. Serum conjugated chenodeoxycolic acid was 4-9 limol/I (normal
