240
Value of the obstetric partogram SIR,-Dr Dujardin and colleagues (May 30, p 1336) claim
that their results "show the usefulness and efficacy of the partogram ...". Unfortunately, their study design cannot evaluate efficacy and their results cast some doubt on the partogram’s usefulness. In their case series of 1022 women in labour, crossing the alert line on the partogram was associated with a significantly higher risk of stillbirth and need for resuscitation. However, our interest in partograms is in absolute, not relative, risks. Can partograms substantially reduce the absolute number of poor outcomes? Of the 52 babies needing resuscitation, 73% (38) had normal labours, as did 64% (9/14) of the mothers who had "fresh" stillbirths. Hence, even if the partogram was 100% efficacious, it would have a small impact on the total number of poor outcomes. A major difficulty of uncontrolled case series being used to examine efficacy is that poor outcomes can be explained away as evidence in favour of the intervention. Things would have been worse had the intervention not been carried out, goes the argument. Dujardin et al document that among the labours in which the alert line was crossed, interventions by health workers were associated with a higher risk of the baby needing resuscitation. They argue that this could have been because infants whose deaths were prevented nonetheless needed resuscitation. Or perhaps health workers without a partogram would have left well enough alone and avoided complications altogether. The only way of settling this issue reasonably is by a rigorous, prospective, controlled (if possible, randomised) study of the use versus no use of the partogram. The partogram is meant to help health workers in developing countries who often work alone and in difficult circumstances. As such, it would be tested under similar conditions. Dujardin et al conducted their study in an area where 80% of women chose to deliver in a peripheral maternity clinic. In the Philippines, 80% of women deliver at home. In the Senegal study, each of the maternity clinics was visited every week by a gynaecologist/obstetrician. In the Philippines, not one field supervisor is an obstetrician and few of the district hospitals have one on their staff. In the past, many health interventions were not fully evaluated before they became widely used, and then proved to be of marginal or no use. The controversial history of growth monitoring and the "road to health" approach may be instructive. Until the results of prospective, controlled studies of the partogram, under operational conditions, are available it will be impossible to tell whether the partogram is a good, sound idea or merely an idea that sounds good. Management Sciences for Health, Child Survival Program, Department of Health, Manila, Philippines
BENJAMIN LOEVINSOHN
Partogram presentation and obstetric decision-making SiR,—We agree with Dr Castmill and Dr Thornton’s (June 20, 1520) notion that doctors’ decision-making about slow labour is influenced by the way in which information is presented graphically. Because most deliveries are conducted or supervised by junior doctors, their diagnosis of non-progress or slow progress of labour may be made more frequently if the latent phase is included in the partogram than when it is excluded. We would, however, like to raise some points. Non-progress or slow progress of labour is just one of the many indications for caesarean section. Increased frequency of caesarean section is due to its more liberal use after previous caesarean section, breech presentation, fetal distress, very low birthweight babies, multiple gestation, and early detection of fetal decelerations on intrapartum fetal monitoring.1 O’Driscoll et al2 attributed the lower caesarean section rate in the National Maternity Hospital, Dublin, to more aggressive management of dystocias with oxytocin in nulliparous patients whose uteri they thought to be "almost immune to rupture except by manipulation", to allowing patients with previous low transverse caesarean sections a trial of labour, which proved successful in 60%, and to a liberal trial of labour in breech presentations.
p
A prolonged latent phase on the partogram stimulates the attending obstetrician to augment labour with oxytocin with beneficial effect, rather than doing a caesarean section. We do not
support Castmill and Thomton’s recommendation to omit the latent phase data from the partogram, but advocate that obstetricians, especially junior doctors and midwives, should be more aware of latent phase before making a diagnosis of nonprogress of labour.
J. B. SHARMA E. J. SHAXTED
Acute Services Unit, Northampton General Hospital, Northampton NN1 5BD, UK
G. KHASTGIR
1. Deron R, Patel NB, Thiery M. Implications of increasing rates of caesaraean section. In: Studd J, eds. Progress in obstetrics and gynaecology, vol 6. London Churchill Livingstone, 1987: 175-94. 2. O’Driscoll K, Foley M, MacDonald D. Active management of labour as an alternative to caesarean
section
rates.
Obstet
Gynaecol 1984; 63: 785-91.
Pseudohemiparetic parkinsonism SIR,-Professor De Keyser and colleagues (Jan 18, p 149) describe two patients who are quite similar to the two cases that I had reported in The Lancet in 1976.1 I certainly welcome their confirmatory article for which I have waited some sixteen years. They kindly acknowledge the relation of their report to mine, but suggest that these patients presenting with pseudohemiparetic parkinsonism differ fundamentally from patients with idiopathic Parkinson’s disease. I have had the advantage of a long follow-up in my patients and can report with assurance that the clinical course in at least some patients presenting with pseudohemiparetic parkinsonism evolves into that of typical idiopathic parkinsonism, including bilateral bradykinesia, fixed facies, tremor, and rigidity responsive to antiparkinsonian agents. In one of the cases that I reported,’ there ensued a gradual failure of response to benzhexol and later to levodopa, as is characteristic of idiopathic parkinsonism. No necropsy was done, but in view of the evolution from hemiparetic to typical bilateral parkinsonism, I would question the efforts of De Keyser et al to establish idiopathic hemiparetic parkinsonism as an entity separate from idiopathic parkinsonism. Asymmetrical onset is, in fact, one of the few clinical features that reliably distinguishes idiopathic Parkinson’s disease from other parkinsonian syndrome2 Nor do I believe that their new name for this syndrome is better than my previously coined pseudohemiparetic Parkinson’s disease, since the apparent unilateral weakness of all these patients responded promptly and completely to the use of antiparkinsonian drugs. The main message from these case reports is that patients can have little tremor so that parkinsonism is overlooked, resulting in an extensive diagnostic evaluation for the pseudohemiparesis. My patients were strikingly incapacitated by their hemiparesis, and their prompt response to drugs for Parkinson’s disease was such that they were left with hardly any disability at all. I suspect that similar patients may not be correctly diagnosed and thus left untreated. Neurology and Electroencephalography, 500 Pasadena Avenue South, St Petersburg, Florida 33707, USA
GORDON J. GILBERT
1. Gilbert GJ. A pseudohemiparetic form of Parkinson’s disease. Lancet 1976; ii: 442-43 2. Hughes AJ, Ben-Shlomo Y, Daniel SE, Lees AJ. What features improve the accuracy
of clinical
diagnosis in Parkinson’s disease:
a
clinicopathologic study. Neurology
1992; 42: 1142-46.
Endometriosis and spontaneous rupture of utero-ovarian vessels during pregnancy from intra-abdominal SIR,-Massive haemorrhage spontaneously ruptured utero-ovarian vessels during pregnancy is rare but serious.1,2 The aetiology suggested by Hodgkinson and Christensen3 is dilated utero-ovarian vessels resulting from the physiological demands of pregnancy and muscular activities such as coughing, defaecation, or coitus, which cause a sudden rise in pressure. We suggest that endometriosis may be involved in the rupture of these vessels. A 37-year-old woman was admitted for severe abdominal pain in week 29 of her first pregnancy. A diagnosis of intra-abdominal venous
Value of the obstetric partogram SIR,-Dr Dujardin and colleagues (May 30, p 1336) claim
that their results "show the usefulness and efficacy of the partogram ...". Unfortunately, their study design cannot evaluate efficacy and their results cast some doubt on the partogram’s usefulness. In their case series of 1022 women in labour, crossing the alert line on the partogram was associated with a significantly higher risk of stillbirth and need for resuscitation. However, our interest in partograms is in absolute, not relative, risks. Can partograms substantially reduce the absolute number of poor outcomes? Of the 52 babies needing resuscitation, 73% (38) had normal labours, as did 64% (9/14) of the mothers who had "fresh" stillbirths. Hence, even if the partogram was 100% efficacious, it would have a small impact on the total number of poor outcomes. A major difficulty of uncontrolled case series being used to examine efficacy is that poor outcomes can be explained away as evidence in favour of the intervention. Things would have been worse had the intervention not been carried out, goes the argument. Dujardin et al document that among the labours in which the alert line was crossed, interventions by health workers were associated with a higher risk of the baby needing resuscitation. They argue that this could have been because infants whose deaths were prevented nonetheless needed resuscitation. Or perhaps health workers without a partogram would have left well enough alone and avoided complications altogether. The only way of settling this issue reasonably is by a rigorous, prospective, controlled (if possible, randomised) study of the use versus no use of the partogram. The partogram is meant to help health workers in developing countries who often work alone and in difficult circumstances. As such, it would be tested under similar conditions. Dujardin et al conducted their study in an area where 80% of women chose to deliver in a peripheral maternity clinic. In the Philippines, 80% of women deliver at home. In the Senegal study, each of the maternity clinics was visited every week by a gynaecologist/obstetrician. In the Philippines, not one field supervisor is an obstetrician and few of the district hospitals have one on their staff. In the past, many health interventions were not fully evaluated before they became widely used, and then proved to be of marginal or no use. The controversial history of growth monitoring and the "road to health" approach may be instructive. Until the results of prospective, controlled studies of the partogram, under operational conditions, are available it will be impossible to tell whether the partogram is a good, sound idea or merely an idea that sounds good. Management Sciences for Health, Child Survival Program, Department of Health, Manila, Philippines
BENJAMIN LOEVINSOHN
Partogram presentation and obstetric decision-making SiR,—We agree with Dr Castmill and Dr Thornton’s (June 20, 1520) notion that doctors’ decision-making about slow labour is influenced by the way in which information is presented graphically. Because most deliveries are conducted or supervised by junior doctors, their diagnosis of non-progress or slow progress of labour may be made more frequently if the latent phase is included in the partogram than when it is excluded. We would, however, like to raise some points. Non-progress or slow progress of labour is just one of the many indications for caesarean section. Increased frequency of caesarean section is due to its more liberal use after previous caesarean section, breech presentation, fetal distress, very low birthweight babies, multiple gestation, and early detection of fetal decelerations on intrapartum fetal monitoring.1 O’Driscoll et al2 attributed the lower caesarean section rate in the National Maternity Hospital, Dublin, to more aggressive management of dystocias with oxytocin in nulliparous patients whose uteri they thought to be "almost immune to rupture except by manipulation", to allowing patients with previous low transverse caesarean sections a trial of labour, which proved successful in 60%, and to a liberal trial of labour in breech presentations.
p
A prolonged latent phase on the partogram stimulates the attending obstetrician to augment labour with oxytocin with beneficial effect, rather than doing a caesarean section. We do not
support Castmill and Thomton’s recommendation to omit the latent phase data from the partogram, but advocate that obstetricians, especially junior doctors and midwives, should be more aware of latent phase before making a diagnosis of nonprogress of labour.
J. B. SHARMA E. J. SHAXTED
Acute Services Unit, Northampton General Hospital, Northampton NN1 5BD, UK
G. KHASTGIR
1. Deron R, Patel NB, Thiery M. Implications of increasing rates of caesaraean section. In: Studd J, eds. Progress in obstetrics and gynaecology, vol 6. London Churchill Livingstone, 1987: 175-94. 2. O’Driscoll K, Foley M, MacDonald D. Active management of labour as an alternative to caesarean
section
rates.
Obstet
Gynaecol 1984; 63: 785-91.
Pseudohemiparetic parkinsonism SIR,-Professor De Keyser and colleagues (Jan 18, p 149) describe two patients who are quite similar to the two cases that I had reported in The Lancet in 1976.1 I certainly welcome their confirmatory article for which I have waited some sixteen years. They kindly acknowledge the relation of their report to mine, but suggest that these patients presenting with pseudohemiparetic parkinsonism differ fundamentally from patients with idiopathic Parkinson’s disease. I have had the advantage of a long follow-up in my patients and can report with assurance that the clinical course in at least some patients presenting with pseudohemiparetic parkinsonism evolves into that of typical idiopathic parkinsonism, including bilateral bradykinesia, fixed facies, tremor, and rigidity responsive to antiparkinsonian agents. In one of the cases that I reported,’ there ensued a gradual failure of response to benzhexol and later to levodopa, as is characteristic of idiopathic parkinsonism. No necropsy was done, but in view of the evolution from hemiparetic to typical bilateral parkinsonism, I would question the efforts of De Keyser et al to establish idiopathic hemiparetic parkinsonism as an entity separate from idiopathic parkinsonism. Asymmetrical onset is, in fact, one of the few clinical features that reliably distinguishes idiopathic Parkinson’s disease from other parkinsonian syndrome2 Nor do I believe that their new name for this syndrome is better than my previously coined pseudohemiparetic Parkinson’s disease, since the apparent unilateral weakness of all these patients responded promptly and completely to the use of antiparkinsonian drugs. The main message from these case reports is that patients can have little tremor so that parkinsonism is overlooked, resulting in an extensive diagnostic evaluation for the pseudohemiparesis. My patients were strikingly incapacitated by their hemiparesis, and their prompt response to drugs for Parkinson’s disease was such that they were left with hardly any disability at all. I suspect that similar patients may not be correctly diagnosed and thus left untreated. Neurology and Electroencephalography, 500 Pasadena Avenue South, St Petersburg, Florida 33707, USA
GORDON J. GILBERT
1. Gilbert GJ. A pseudohemiparetic form of Parkinson’s disease. Lancet 1976; ii: 442-43 2. Hughes AJ, Ben-Shlomo Y, Daniel SE, Lees AJ. What features improve the accuracy
of clinical
diagnosis in Parkinson’s disease:
a
clinicopathologic study. Neurology
1992; 42: 1142-46.
Endometriosis and spontaneous rupture of utero-ovarian vessels during pregnancy from intra-abdominal SIR,-Massive haemorrhage spontaneously ruptured utero-ovarian vessels during pregnancy is rare but serious.1,2 The aetiology suggested by Hodgkinson and Christensen3 is dilated utero-ovarian vessels resulting from the physiological demands of pregnancy and muscular activities such as coughing, defaecation, or coitus, which cause a sudden rise in pressure. We suggest that endometriosis may be involved in the rupture of these vessels. A 37-year-old woman was admitted for severe abdominal pain in week 29 of her first pregnancy. A diagnosis of intra-abdominal venous
