1192
serious impairment of pregnancy outcome. These studies showed that the women with polycystic ovary syndrome who hypersecrete LH (perhaps 40% of all patients7) are most predisposed to infertility and early pregnancy loss. Thus, in this issue (p 1141) Miss Regan and her colleagues report that a raised late-follicular phase serum LH concentration is associated with a 20% reduction in the conception rate and a startling increase in the miscarriage rate from 12% in women with normal LH to 65% in women with a raised serum LH concentration. Although there can now be little doubt that hypersecretion of LH is associated with miscarriage, both sporadic and recurrent, the mechanism of the association is unclear. It may be a secondary association, signalling the presence of polycystic ovary syndrome, itself then postulated as the cause of miscarriage; it might be an effect of LH on the ovary, perhaps causing abnormal secretion of testosterone or progesterone; or it may be an effect of LH on oocytes. We think that the most probable cause is an impact of LH on oocyte maturation. the between Whatever the mechanism, association since of LH and is polycystic hypersecretion miscarriage important, ovaries have a prevalence of about 20% in the female population and hypersecretion of LH can be suppressed by gonadotropin releasing hormone agonists,8 ovarian diathermy, and somatostatin.10 Although somatostatin is still being investigated, the other treatments improve conception rates and seem to reduce 8 spontaneous abortion. Department of Reproductive Cobbold Laboratories, Middlesex Hospital, London W1 N 8AA, UK
Holywell Green, Near Halifax, West Yorkshire, UK
R. F. HEYS
1. World Health
Organisation. Recommended obstetric definitions as accepted by the International Federation of Obstetrics and Gynaecology. IntJ Gynaecol Obstet 1976; 14: 570-76. 2. Heys RF. Stillbirth legislation: a case for reform. Obstet Gynaecol Today (in press).
Yoga breathing exercises and bronchial asthma ADAM H. BALEN
SiR,—Dr Singh and colleagues (June 9, p 1381) report the effect of
Endocrinology,
breathing exercises (pranayama) on airway reactivity in subjects with bronchial asthma. They found a significant increase in the dose of histamine needed to provoke a 20% reduction in FEV! during pranayama breathing exercises, compared with controls. Singh et al suggest as possible mechanisms for their findings an increased autonomic control and a reduction in the efferent vagal yoga
LESLEY REGAN
London W2
ELIZABETH J. OWEN HOWARD S. JACOBS
1. Crosignani PG. The defective luteal phase. Hum Reprod 1988; 3: 157-60. 2. Glazener CMA, Kelly NJ, Hull MGR. Luteal deficiency not a persistent cause of infertility Hum Reprod 1988; 3: 213-17. 3. Sagle M, Bishop K, Ridley N, et al. Recurrent early miscarriage and polycystic ovaries. Br Med J 1988; 297: 1027-28. 4. Homburg R, Armar NA, Eshel A, Adams J, Jacobs HS. Influence of serum luteinising hormone concentrations on ovulation, conception and early pregnancy loss in polycystic ovary syndrome Br Med J 1988; 297: 1024-26 5. Stanger JD, Jovich JL Reduced m vitro fertilisation of human oocytes from patients with high basal luteinising hormone levels during the follicular phase. Br J Obstet Gynaecol 1985; 92: 385-90. 6. Howels CM, MacNamee MC, Edwards RG, Goswamy R, Steptoe PC. Effect of high tonic levels of luteinising hormone on outcome of in vitro fertilisation. Lancet 1986; ii: 521-23. 7. Conway GS, Honour JW, Jacobs HS Heterogeneity of polycystic ovary syndrome: clinical, endocrine and ultrasound features in 556 cases. Clin Endocrinol 1989; 30: 459-70. 8. Johnson P, Pearce JM. Recurrent spontaneous abortion and polycystic ovary disease: comparison of two regimes to induce ovulation. Br Med J 1990; 300: 154-56. 9. Armar NA, MacGarrigle HHG, Honour JW, Holownia P, Jacobs HS, Lachelin GCL Laparoscopic ovarian diathermy in the management of anovulatory infertility in women with polycystic ovaries endocrine changes and clinical outcome. Fertil Steril 1990; 53: 45-49. 10. Prelevic GM, Wurzburger MI, Balint-Peric L, Nesic JS. Inhibitory effect of sandostatin on secrenon of luteinising hormone and ovarian steroids in polycystic ovary
Oakes House,
Endocrinology,
Department of Obstetrics and Gynaecology, St Mary’s Hospital, Department of Reproductive Middlesex Hospital
merely because the fetal heart beat stops shortly after, rather than before, delivery. Present legislation also requires fetuses dying in utero before 22-24 weeks’ gestation but not expelled before 28 weeks’ to be registered as stillbirths, rather than being regarded as miscarriages. I have been ordered by the registrar of births and deaths to notify as a stillbirth a fetus papyraceus weighing only 42 g and known to have died at about 16 weeks’.2 Such anomalies could be eliminated by adoption of the WHO recommendation, or by exclusion of fetuses of less than 22 weeks’ gestation at explusion or intrauterine death from notifications of births. This would be possible in view of the now almost universal practice of ultrasound assessment of gestational age at 16-18 weeks’ and the reliability of this technique in the determination of early intrauterine death. The need to monitor the delivery of fetuses between 16-22 weeks’ weighing under 500 g could be met by notification of such cases as miscarriages.
syndrome. Lancet 1990; 336: 900-03.
discharge. We have reported’ that ventilation and rate of breathing were significantly lower and tidal volume and end-tidal pCO significantly higher in a group of advanced practitioners of hatha-yoga than in matched controls. The ventilatory response to CO2, with the rebreathing technique, was significantly lower in the yoga group (p < 001). We suggested that voluntary control of breathing may be a useful adjuvant in the treatment of patients with chronic obstructive lung disease and bronchial asthma. Pulmonary Laboratory and Division, Cliniques Universitaires St Luc, 1200 Brussels, Belgium
D. STANESCU
1. Stanescu DC, Nemery B, Veriter C, Marechal C. Pattern of breathing and ventilatory response to CO2 m subjects practising hatha-yoga J Appl Physiol 1981, 51: 1625-29.
Continuous arteriovenous haemofiltration in hyperammonaemia of newborn babies SIR,-Neonatal haemodialysis, as opposed to peritoneal dialysis exchange transfusion, is the most effective method of
and
the ammonium concentration in hyperammonaemic of the newborn;1,2 however, its application is restricted to centres with special equipment and highly trained personnel. Risks associated with the procedure include disequilibrium and
decreasing
Registration of births at less than 22 weeks’ gestation StR,—Iwrite in support of the suggestion by the Working Group the very-low-birthweight baby (Sept 29, p 782) that the rules governing the registration of births be updated to take account of changes in practice and outcome, especially in the very preterm on
group.
Unlike most European countries, the UK has failed to adopt the world Health Organisation’s recommendation’ that fetuses weighing less than 500 g (corresponding to 22 weeks’ gestation) are not registered as births. As a result, in the UK there is a requirement to notify as births with neonatal death fetuses delivered well before the 24 weeks’ below which therapeutic abortion is now permissible
coma
haemodynamic compromise. We report the successful use of continuous arteriovenous haemofiltration (CAVH) in a baby with hyperammonaemia due to argininosuccinate synthetase deficiency. Inappetence, lethargy, and hyperbilirubinaemia occurred five days after birth. Hyperammonaemia (221 pmol/1) and high concentrations of citrulline (1219 pmol/1) and glutamine (2003 jmol/1) were seen. Despite conservative measures, including protein restriction, high caloric intake, sodium benzoate, carnitine, and arginine supplementation, ammonia increased to 852 fJ1I101jl within a few hours, and metabolic coma and convulsions developed. CAVH was
serious impairment of pregnancy outcome. These studies showed that the women with polycystic ovary syndrome who hypersecrete LH (perhaps 40% of all patients7) are most predisposed to infertility and early pregnancy loss. Thus, in this issue (p 1141) Miss Regan and her colleagues report that a raised late-follicular phase serum LH concentration is associated with a 20% reduction in the conception rate and a startling increase in the miscarriage rate from 12% in women with normal LH to 65% in women with a raised serum LH concentration. Although there can now be little doubt that hypersecretion of LH is associated with miscarriage, both sporadic and recurrent, the mechanism of the association is unclear. It may be a secondary association, signalling the presence of polycystic ovary syndrome, itself then postulated as the cause of miscarriage; it might be an effect of LH on the ovary, perhaps causing abnormal secretion of testosterone or progesterone; or it may be an effect of LH on oocytes. We think that the most probable cause is an impact of LH on oocyte maturation. the between Whatever the mechanism, association since of LH and is polycystic hypersecretion miscarriage important, ovaries have a prevalence of about 20% in the female population and hypersecretion of LH can be suppressed by gonadotropin releasing hormone agonists,8 ovarian diathermy, and somatostatin.10 Although somatostatin is still being investigated, the other treatments improve conception rates and seem to reduce 8 spontaneous abortion. Department of Reproductive Cobbold Laboratories, Middlesex Hospital, London W1 N 8AA, UK
Holywell Green, Near Halifax, West Yorkshire, UK
R. F. HEYS
1. World Health
Organisation. Recommended obstetric definitions as accepted by the International Federation of Obstetrics and Gynaecology. IntJ Gynaecol Obstet 1976; 14: 570-76. 2. Heys RF. Stillbirth legislation: a case for reform. Obstet Gynaecol Today (in press).
Yoga breathing exercises and bronchial asthma ADAM H. BALEN
SiR,—Dr Singh and colleagues (June 9, p 1381) report the effect of
Endocrinology,
breathing exercises (pranayama) on airway reactivity in subjects with bronchial asthma. They found a significant increase in the dose of histamine needed to provoke a 20% reduction in FEV! during pranayama breathing exercises, compared with controls. Singh et al suggest as possible mechanisms for their findings an increased autonomic control and a reduction in the efferent vagal yoga
LESLEY REGAN
London W2
ELIZABETH J. OWEN HOWARD S. JACOBS
1. Crosignani PG. The defective luteal phase. Hum Reprod 1988; 3: 157-60. 2. Glazener CMA, Kelly NJ, Hull MGR. Luteal deficiency not a persistent cause of infertility Hum Reprod 1988; 3: 213-17. 3. Sagle M, Bishop K, Ridley N, et al. Recurrent early miscarriage and polycystic ovaries. Br Med J 1988; 297: 1027-28. 4. Homburg R, Armar NA, Eshel A, Adams J, Jacobs HS. Influence of serum luteinising hormone concentrations on ovulation, conception and early pregnancy loss in polycystic ovary syndrome Br Med J 1988; 297: 1024-26 5. Stanger JD, Jovich JL Reduced m vitro fertilisation of human oocytes from patients with high basal luteinising hormone levels during the follicular phase. Br J Obstet Gynaecol 1985; 92: 385-90. 6. Howels CM, MacNamee MC, Edwards RG, Goswamy R, Steptoe PC. Effect of high tonic levels of luteinising hormone on outcome of in vitro fertilisation. Lancet 1986; ii: 521-23. 7. Conway GS, Honour JW, Jacobs HS Heterogeneity of polycystic ovary syndrome: clinical, endocrine and ultrasound features in 556 cases. Clin Endocrinol 1989; 30: 459-70. 8. Johnson P, Pearce JM. Recurrent spontaneous abortion and polycystic ovary disease: comparison of two regimes to induce ovulation. Br Med J 1990; 300: 154-56. 9. Armar NA, MacGarrigle HHG, Honour JW, Holownia P, Jacobs HS, Lachelin GCL Laparoscopic ovarian diathermy in the management of anovulatory infertility in women with polycystic ovaries endocrine changes and clinical outcome. Fertil Steril 1990; 53: 45-49. 10. Prelevic GM, Wurzburger MI, Balint-Peric L, Nesic JS. Inhibitory effect of sandostatin on secrenon of luteinising hormone and ovarian steroids in polycystic ovary
Oakes House,
Endocrinology,
Department of Obstetrics and Gynaecology, St Mary’s Hospital, Department of Reproductive Middlesex Hospital
merely because the fetal heart beat stops shortly after, rather than before, delivery. Present legislation also requires fetuses dying in utero before 22-24 weeks’ gestation but not expelled before 28 weeks’ to be registered as stillbirths, rather than being regarded as miscarriages. I have been ordered by the registrar of births and deaths to notify as a stillbirth a fetus papyraceus weighing only 42 g and known to have died at about 16 weeks’.2 Such anomalies could be eliminated by adoption of the WHO recommendation, or by exclusion of fetuses of less than 22 weeks’ gestation at explusion or intrauterine death from notifications of births. This would be possible in view of the now almost universal practice of ultrasound assessment of gestational age at 16-18 weeks’ and the reliability of this technique in the determination of early intrauterine death. The need to monitor the delivery of fetuses between 16-22 weeks’ weighing under 500 g could be met by notification of such cases as miscarriages.
syndrome. Lancet 1990; 336: 900-03.
discharge. We have reported’ that ventilation and rate of breathing were significantly lower and tidal volume and end-tidal pCO significantly higher in a group of advanced practitioners of hatha-yoga than in matched controls. The ventilatory response to CO2, with the rebreathing technique, was significantly lower in the yoga group (p < 001). We suggested that voluntary control of breathing may be a useful adjuvant in the treatment of patients with chronic obstructive lung disease and bronchial asthma. Pulmonary Laboratory and Division, Cliniques Universitaires St Luc, 1200 Brussels, Belgium
D. STANESCU
1. Stanescu DC, Nemery B, Veriter C, Marechal C. Pattern of breathing and ventilatory response to CO2 m subjects practising hatha-yoga J Appl Physiol 1981, 51: 1625-29.
Continuous arteriovenous haemofiltration in hyperammonaemia of newborn babies SIR,-Neonatal haemodialysis, as opposed to peritoneal dialysis exchange transfusion, is the most effective method of
and
the ammonium concentration in hyperammonaemic of the newborn;1,2 however, its application is restricted to centres with special equipment and highly trained personnel. Risks associated with the procedure include disequilibrium and
decreasing
Registration of births at less than 22 weeks’ gestation StR,—Iwrite in support of the suggestion by the Working Group the very-low-birthweight baby (Sept 29, p 782) that the rules governing the registration of births be updated to take account of changes in practice and outcome, especially in the very preterm on
group.
Unlike most European countries, the UK has failed to adopt the world Health Organisation’s recommendation’ that fetuses weighing less than 500 g (corresponding to 22 weeks’ gestation) are not registered as births. As a result, in the UK there is a requirement to notify as births with neonatal death fetuses delivered well before the 24 weeks’ below which therapeutic abortion is now permissible
coma
haemodynamic compromise. We report the successful use of continuous arteriovenous haemofiltration (CAVH) in a baby with hyperammonaemia due to argininosuccinate synthetase deficiency. Inappetence, lethargy, and hyperbilirubinaemia occurred five days after birth. Hyperammonaemia (221 pmol/1) and high concentrations of citrulline (1219 pmol/1) and glutamine (2003 jmol/1) were seen. Despite conservative measures, including protein restriction, high caloric intake, sodium benzoate, carnitine, and arginine supplementation, ammonia increased to 852 fJ1I101jl within a few hours, and metabolic coma and convulsions developed. CAVH was
