- Email: [email protected]
ARE ACE INHIBITORS SAFE IN PREGNANCY?
750
hampered by physicians; some doctors objected to what they saw as a loss of sovereignty over patients. Low-income patients may have been deterred by the 120 Baht premium; the fee charged at routine antenatal clinic visits is typically 10 Baht and never more than 40 Baht. On the other hand, the self-selected patient population of a university hospital may lead to over-representation of those who can easily pay for HBIG and HBV vaccine and so would be less likely to participate in an insurance scheme. 18 months after the insurance programme began the hospital adopted a policy of routine antenatal HBsAg testing, and the insurance programme enrolled its last patient 2 months later. During the 20 months of the programme vaccine costs fell by 40-50%, lessening the financial necessity for a risk-sharing scheme. However, despite the low acceptance rate, we think that the programme provided benefits by making both patients and staff more aware of HBV infection and its consequences. Prophylaxis is now considered routine for infants born to HBeAg-positive mothers; the hospital will provide vaccine free of charge in cases of economic necessity (but so far no family has asked for free vaccine). Many members of the hospital’s obstetric and paediatric staff now recommend HBV vaccine for infants of HBsAg-positive/HBeAgnegative mothers whose family can afford it. As vaccine costs decrease, schemes of universal childhood vaccination against HBV may be tenable in endemic areas such as Thailand. Until that time, however, imaginative ways to educate doctors, nurses, and the lay public about the threat of HBV and of assisting with payment for vaccine when required will be needed to stem HBV-related morbidity and mortality.
Faculty of Medicine, Prince of Songkla University, Hat Yai 90112, Thailand
VIRASAKDI CHONGSUVIVATWONG PISESPONG PATAMASUCON VERAPOL CHANDEYING
PRASIN CHANVITAN
Department of Family Medicine, University of Rochester, New York, USA
Department of Obstetrics and Gynaecology, St Mary’s Hospital Medical School,
JASON GARDOSI
London W2 1PG 1.
Gupta JK, Brayshaw E, Lilford RJ. An experiment of squatting birth. Eur J Obstet Gynecol Reprod Biol 1989; 30: 217-20.
SIR,—Ihave read with interest Dr Gupta and colleagues’ report the Gardosi birth cushion. I was amused at the suggestion that the female population of Leeds might differ in some way from that of Milton Keynes, but say with conviction that the women of on
Gateshead bear greater resemblance to the latter. The Gardosi birth cushion was loaned to the Queen Elizabeth Hospital, Gateshead, for a short trial period, and the response from mothers and midwives was so positive that one has now been purchased (despite the prevalence of non-height adjustable beds in our labour ward). The opinions of the midwives echo the Gardosi study: pushing effort is better coordinated and thus delivery expedited, control of perineum and fetal head is facilitated, and potential instrumental delivery is avoided. We are fortunate in Gateshead: flexibility of attitude to research and innovation not only exists amongst the "young and trendy" midwives but also prevails in the most experienced. I am sad for the midwives of Leeds, whose own medical staff decry their lack of motivation, but I am pleased to report that elsewhere the clinical application and benefits of this birth aid are proving to be most acceptable to mothers and midwives alike. 12 Harthope Close, Washington, Tyne and Wear NE38 9DZ
S. J. BROWN
JOSEPH FINETTI
Punyagupta S, Olson LC, Harinasuta U, et al. The epidemiology of hepatitis B antigen in a high prevalence area. Am J Epidemiol 1973; 97: 349-54. 2. Thongcharoen P, Panpatana P, Wasi C, et al. The incidence of hepatitis B surface antigen in tropical infection and liver diseases in Thailand. J Med Assoc Thai 1976; 1.
59: 546-49. 3.
The birth cushion is a simple new obstetric aid that increases the woman’s choices in childbirth, and it is already used in a number of centres in the UK and elsewhere to provide the option of squatting for delivery.
Beasley RP, Hwang L-Y, Lee GC-Y, et al. Prevention of perinatally transmitted hepatitis B virus infections with hepatitis B immune globulin and hepatitis B
vaccine. Lancet 1983; ii: 1099-102. 4. Kanai K, Takehiro A, Noto H, et al. Prevention of perinatal transmission of hepatitis B virus (HBV) to children of e antigen-positive HBV carrier mothers by hepatitis B immune globulin and HBV vaccine. J Infect Dis 1985; 151: 287-90. 5. Chunhasithiwat S. Cost-effectiveness analysis of hepatitis B control program in Thailand. In: Sitprija V, et al, eds. Hepatitis B virus: direction of research and control strategy. Bangkok: Medipress, 1966: 159-68. 6. Mowat AP. Viral hepatitis in infancy and childhood. Clin Gastroenterol 1980; 9: 191-200. 7. Bunyaratvej S, Varavidhya W, Chiewsilp P, et al. Studies in Ramathibodi Hospital. In: Wasi C, Thongcharoen P, eds. Viral hepatitis in Thailand. Bangkok Aksornsamai Press, 1983: 174.
SQUATTING IN SECOND STAGE OF LABOUR SIR,-While commending the Milton Keynes trial (July 8, p 74) for its large sample size, Dr Gupta and colleagues (Sept 2 p 561) report their contrasting experiences obtained from a total of 13 women. They also felt able to conclude, from an earlier trial,’ which had only 11women (6 primipara) squatting, that this position "does not appear to facilitate birth". Surely adequate sample sizes are as important in perinatal research, as in any other clinical specialty, before valid conclusions can be reached? There is hardly a shortage of appropriate subjects (women in labour). The Milton Keynes birth cushion trial was begun after a pilot study during which the midwives became familiar with the use of this new equipment and the management of delivery in the squatting position. The trial showed clear benefits of squatting over recumbent positions. It also showed that although most of the parturients had not even thought about birth positions before admission in labour, they easily maintained the supported squatting position and usually also stayed on the cushion during third stage, while already holding the baby. This position can also be adopted when epidural analgesia is used.
ARE ACE INHIBITORS SAFE IN PREGNANCY?
SiR,—Your Aug 26 editorial reminds obstetricians and physicians as well as neonatologists that angiotensin-convertingenzyme (ACE) inhibitors taken during pregnancy may not be safe for the fetus. Oligohydramnios, neonatal anuria, birthweight below the 10th centile, skull ossification defects, and persistent ductus arteriosus are recorded. We report a patient who took ACE inhibitors through four pregnancies. In 1981 an Asian girl, aged 14 years, proved to have a blood pressure of 260/160 mm Hg, with papilloedema. After control of the hypertension, a congenitally small right kidney (33 g) was removed. At that time, proteinuria was moderate (0-9 g/1) and the plasma urea 9-2 mmol/1. The hypertension remained difficult to control and compliance was poor. In 1983, when her blood pressure was 240/155 mm Hg she had a right hemiplegia due to an intracerebral haematoma, from which she made an excellent recovery and was discharged taking hydralazine, propranolol, and captopril. She attended in 1985,
ten
weeks pregnant, with
a
blood pressure of
Hg and still taking the three drugs. Following admission, hydralazine and captopril were discontinued. Control was so poor that by the tenth week, captopril 37 mg daily, atenolol 100 mg daily, and nifedipine retard 20 mg twice daily were given: later the captopril was increased to 75 mg daily. She had moderate proteinuria (1-5 g/1), plasma creatinine was 130 Ilffiol/l, and creatinine clearance was 54 ml/min. Hypoproteinaemia was treated by intravenous albumen. Serial scanning revealed intrauterine growth retardation. A healthy girl (1 -59 kg) was delivered by caesarean section at 30 weeks, and survived. The patient was discharged on atenolol 100 mg daily and enalapril 10 mg as well as nifedipine 20 mg twice daily, and failed to attend regularly to receive parenteral medroxyprogesterone acetate for contraception. By December, 1986, she was 13 weeks pregnant with unchanged antihypertensive therapy: plasma creatinine was 148 Ilffiolfl with heavy proteinuria and blood pressure was 130/100 mm Hg. Fetal
160/100
mm
death occurred at eighteen weeks: a macerated otherwise normal 340 g male fetus with an 85 g placenta delivered spontaneously. Again contraception was avoided and the patient returned in 1988 at
751 weeks’ gestation taking enalapril, nifedipine, and atenolol in unchanged dosage: blood pressure was 130/100 mm Hg with heavy proteinuria (5 g per 24 h). Patient compliance was ensured by her husband: the medication remained unaltered except that soluble aspirin (75 mg) was added from the tenth week. Plasma creatinine was 201 timol/1. A healthy girl 1 17 kg was delivered abdominally at the twenty-ninth week, and she survived. Again the patient failed to attend for postnatal examination and returned pregnant for the fourth time. Management in this pregnancy was similar to the third, except that there was doubt about compliance and the dose of nifedipine was only 20 mg daily. Creatinine varied between 354 Eunol/1 and 342 Ilffiol/l with hypoalbuminaemia (20 g/1). By the twenty-ninth week, the hypertension became uncontrolled, blood pressure was 240/140 mm Hg, and proteinuria was greater than ever, associated with diminished fetal movements. After controlling the hypertension with intravenous hydralazine a healthy boy (154 kg) was delivered by repeat section, and he has survived so far. The antihypertensive therapy is being controlled and contraception may now be acceptable. That this patient, with severe renal hypertension and now early renal failure, has had three successful pregnancies out of four, is attributable to early delivery and skilled neonatal intensive care, and, arguably, to ACE inhibitors combined with other antihypertensives. It may not therefore always be practical or wise to discontinue ACE inhibitors in early pregnancy. ten
These data indicate that meningoencephalitic untoward reactions associated with both Jeryl Lynn and Urabe Am 9 mumps vaccines. Data from Canada’ and Sweden8 support this conclusion. However, the benefit/risk ratio remains in favour of mumps vaccination, since the frequency of these untoward reactions is low and all children with mumps meningitis recovered without are
sequelae. Am Kroog 6, D-2000 Hamburg 73, West Germany 1.
W. EHRENGUT
Ehrengut W, Zastrow K. Komplikationen "nach" Mumpsschutzimpfungen in der Bundesrepublik Deutschland (einschliesslich Mehrfachschutzimpfungen) Monatsschr Kinderheilkd 1989; 137: 398-402
Ehrengut W, Georges AM, André FE. The reactogenicity and inimunogenicity of the Urabe-Am-9 live mumps vaccine and persistence of the vaccine induced antibodies in healthy young children. Biol J Standard 1983; 11: 105-09. 3. von Muhlendahl KE. Nebenwirkungen und Komplikationen der Masem-MumpsImpfung. Monatsschr Kinderheilkd 1989; 137: 440-46. 4. Jorch G, Kleine M, Erwig H Koinzidenz von Virusenzephalitis und MasernMumps-Impfung Monatsschr Kinderheilkd 1984; 132: 299-300. 5. Forster J, Urbanek R. Encephalitis nach Masern-Mumps-Impfung und gleichzeitiger EBV-Infektion. Klin Paediatr 1982; 194: 29-30. 6. Quast U, Hennessen W, Widmark RM. Vaccine induced mumps-like disease. Dev
2.
Biol Stand 1979; 43: 269-72. 7. Furesz J, Hockin JC. Mumps meningitis, possibly vaccine related. Can Dis Wkly Rep 1988; 14-40: 209-11. 8. Bottiger M, Christenson B, Romanus V, Tatanger J, Strandell A. Swedish experience of two dose vaccination programme aiming at eliminating measles, mumps and rubella. Br Med J 1987; 295: 264-67.
New Cross Hospital, Wolverhampton, ALAN M. SMITH
West Midlands WV10 0QP
Plouin P-F, Tchobroutsky C, Boutroy M-J. angiotensin-converting enzyme inhibitors during pregnancy: a survey of 22 patients given captopril and nine given enalapril. Br J Obstet Gynaecol 1988; 95: 420-22.
HISPANIC REGISTRY OF GRAFT PROCEDURES FOR PARKINSON’S DISEASE
1. Kreft-Jais C,
SiR,—The first results with adrenal medulla autografts and fetal grafts to the caudate nucleus in Parkinson’s diseasel,2 were encouraging3 and prompted other Hispanic groups to try this approach." To collate results obtained in Spanish-speaking countries we have set up a Hispanic registry of adrenal medulla and fetal brain graft procedures, seeking information from Chile, Cuba, and Spain to add to experience in Mexico. Table I summarises information on 135 patients given implants with the same technique.7 Of the 117 autotransplants 106 have been followed up for more than 6 months. The patients have been scored preoperatively and postoperatively on commonly used rating scales for parkinsonim such as Hoehn and Yahr. 31-6% of the patients have shown a good response (50-90% improvement), 27-4% have had a moderate response (30-50%), 14-5% have had a poor response (5-30%), and 9-4% have not responded. Table 11 lists the postoperative complications; there were 10 deaths (7-4%). Of the fetal brain grafts (all in Mexico or Cuba) with a follow-up of at least 6 months, the response to ventral mesencephalon implantation was good in 13 cases and moderate in 1 case; there was 1 death. 3 patients received fetal adrenal grafts with 1 good, 1 moderate, and 1 poor response.
tissue MUMPS VACCINE AND MENINGITIS
SIR,-Dr Gray and Dr Burns (July 8, p 98) and Professor von Muhlendahl (Aug 12, p 394) report cases of mumps meningitis with onset three weeks after administration of mumps vaccine. In a recent review of untoward reactions to mumps-containing vaccines reported to the Bundesgesundheitsamt in West Germany and my own reports 27 temporally-related neurological untoward reactions were
reported:
No
Onset of symptoms
of
(day
Vaccine* reports post-vaccination) C 1 14 Absence epilepsy B 1 13 Ataxia 1 A 12 Encephalitis 2 B 9,10 Encephalitis 1 8 B Encephalopathy 1 B 8 Epilepsy B 9 Febrile convulsion 1,7,9,9,9,9,9,9,10 C 19 Febrile convulsion 1 8 C Hemiparesis 1 B 14 Hennparesisl encephalitis 12 4 D Meningitis J3 21 E Meningitis A 3 8,9,21 Meningitis 27 B 1 Meningitis 19 B Meningoencephalitis 14 7 B Menmgoencephalitis (fatal) A=’Mumpsvax’ (Jeryl Lynn), B=’MM-Vax’ (Moraten/Jeryl Lynn), C=’MMR-Vax’ (Moraten/Jeryl Lynn/RA27/3), D= ’Parionx’ (UrabeAm 9), E = ’Rmipanx’ (Schwarz/Urabe Am 9). Reaction
Since the introduction of mumps vaccines in West Germany, 6 of meningitis and 2 of meningoencephalitis have been published. In 2 instances mumps virus was isolated from the cerebrospinal fluid (CSF). In a personally observed case mumps virus was isolated from the CSF of a 6-year-old boy who had meningitis 21 days after administration of JerylLynn mumps vaccine. He recovered without sequelae. The other case was the one described by von Miihlendahl.3 The above cases apart, the development of meningoencephalitis 9 days after measles-mumps (Moraten/Jeryl Lynn) vaccination in a child with a concurrent symptom-free Epstein-Barr virus infection was also reported. 4 other cases of meningitis following ‘Mumpsvax’ (Jeryl Lynn) were reported in another review in 1979.6
TABLE I-ADRENAL MEDULLA AUTOGRAFTS REGISTERED IN HISPANIC REGISTRY OF GRAFT PROCEDURES IN TREATMENT OF PARKINSON’S DISEASE: FOLLOW-UP SIX MONTHS OR MORE
cases
G
=
good, M
=
moderate, P poor, NR
=
no
response, D
=
death.
hampered by physicians; some doctors objected to what they saw as a loss of sovereignty over patients. Low-income patients may have been deterred by the 120 Baht premium; the fee charged at routine antenatal clinic visits is typically 10 Baht and never more than 40 Baht. On the other hand, the self-selected patient population of a university hospital may lead to over-representation of those who can easily pay for HBIG and HBV vaccine and so would be less likely to participate in an insurance scheme. 18 months after the insurance programme began the hospital adopted a policy of routine antenatal HBsAg testing, and the insurance programme enrolled its last patient 2 months later. During the 20 months of the programme vaccine costs fell by 40-50%, lessening the financial necessity for a risk-sharing scheme. However, despite the low acceptance rate, we think that the programme provided benefits by making both patients and staff more aware of HBV infection and its consequences. Prophylaxis is now considered routine for infants born to HBeAg-positive mothers; the hospital will provide vaccine free of charge in cases of economic necessity (but so far no family has asked for free vaccine). Many members of the hospital’s obstetric and paediatric staff now recommend HBV vaccine for infants of HBsAg-positive/HBeAgnegative mothers whose family can afford it. As vaccine costs decrease, schemes of universal childhood vaccination against HBV may be tenable in endemic areas such as Thailand. Until that time, however, imaginative ways to educate doctors, nurses, and the lay public about the threat of HBV and of assisting with payment for vaccine when required will be needed to stem HBV-related morbidity and mortality.
Faculty of Medicine, Prince of Songkla University, Hat Yai 90112, Thailand
VIRASAKDI CHONGSUVIVATWONG PISESPONG PATAMASUCON VERAPOL CHANDEYING
PRASIN CHANVITAN
Department of Family Medicine, University of Rochester, New York, USA
Department of Obstetrics and Gynaecology, St Mary’s Hospital Medical School,
JASON GARDOSI
London W2 1PG 1.
Gupta JK, Brayshaw E, Lilford RJ. An experiment of squatting birth. Eur J Obstet Gynecol Reprod Biol 1989; 30: 217-20.
SIR,—Ihave read with interest Dr Gupta and colleagues’ report the Gardosi birth cushion. I was amused at the suggestion that the female population of Leeds might differ in some way from that of Milton Keynes, but say with conviction that the women of on
Gateshead bear greater resemblance to the latter. The Gardosi birth cushion was loaned to the Queen Elizabeth Hospital, Gateshead, for a short trial period, and the response from mothers and midwives was so positive that one has now been purchased (despite the prevalence of non-height adjustable beds in our labour ward). The opinions of the midwives echo the Gardosi study: pushing effort is better coordinated and thus delivery expedited, control of perineum and fetal head is facilitated, and potential instrumental delivery is avoided. We are fortunate in Gateshead: flexibility of attitude to research and innovation not only exists amongst the "young and trendy" midwives but also prevails in the most experienced. I am sad for the midwives of Leeds, whose own medical staff decry their lack of motivation, but I am pleased to report that elsewhere the clinical application and benefits of this birth aid are proving to be most acceptable to mothers and midwives alike. 12 Harthope Close, Washington, Tyne and Wear NE38 9DZ
S. J. BROWN
JOSEPH FINETTI
Punyagupta S, Olson LC, Harinasuta U, et al. The epidemiology of hepatitis B antigen in a high prevalence area. Am J Epidemiol 1973; 97: 349-54. 2. Thongcharoen P, Panpatana P, Wasi C, et al. The incidence of hepatitis B surface antigen in tropical infection and liver diseases in Thailand. J Med Assoc Thai 1976; 1.
59: 546-49. 3.
The birth cushion is a simple new obstetric aid that increases the woman’s choices in childbirth, and it is already used in a number of centres in the UK and elsewhere to provide the option of squatting for delivery.
Beasley RP, Hwang L-Y, Lee GC-Y, et al. Prevention of perinatally transmitted hepatitis B virus infections with hepatitis B immune globulin and hepatitis B
vaccine. Lancet 1983; ii: 1099-102. 4. Kanai K, Takehiro A, Noto H, et al. Prevention of perinatal transmission of hepatitis B virus (HBV) to children of e antigen-positive HBV carrier mothers by hepatitis B immune globulin and HBV vaccine. J Infect Dis 1985; 151: 287-90. 5. Chunhasithiwat S. Cost-effectiveness analysis of hepatitis B control program in Thailand. In: Sitprija V, et al, eds. Hepatitis B virus: direction of research and control strategy. Bangkok: Medipress, 1966: 159-68. 6. Mowat AP. Viral hepatitis in infancy and childhood. Clin Gastroenterol 1980; 9: 191-200. 7. Bunyaratvej S, Varavidhya W, Chiewsilp P, et al. Studies in Ramathibodi Hospital. In: Wasi C, Thongcharoen P, eds. Viral hepatitis in Thailand. Bangkok Aksornsamai Press, 1983: 174.
SQUATTING IN SECOND STAGE OF LABOUR SIR,-While commending the Milton Keynes trial (July 8, p 74) for its large sample size, Dr Gupta and colleagues (Sept 2 p 561) report their contrasting experiences obtained from a total of 13 women. They also felt able to conclude, from an earlier trial,’ which had only 11women (6 primipara) squatting, that this position "does not appear to facilitate birth". Surely adequate sample sizes are as important in perinatal research, as in any other clinical specialty, before valid conclusions can be reached? There is hardly a shortage of appropriate subjects (women in labour). The Milton Keynes birth cushion trial was begun after a pilot study during which the midwives became familiar with the use of this new equipment and the management of delivery in the squatting position. The trial showed clear benefits of squatting over recumbent positions. It also showed that although most of the parturients had not even thought about birth positions before admission in labour, they easily maintained the supported squatting position and usually also stayed on the cushion during third stage, while already holding the baby. This position can also be adopted when epidural analgesia is used.
ARE ACE INHIBITORS SAFE IN PREGNANCY?
SiR,—Your Aug 26 editorial reminds obstetricians and physicians as well as neonatologists that angiotensin-convertingenzyme (ACE) inhibitors taken during pregnancy may not be safe for the fetus. Oligohydramnios, neonatal anuria, birthweight below the 10th centile, skull ossification defects, and persistent ductus arteriosus are recorded. We report a patient who took ACE inhibitors through four pregnancies. In 1981 an Asian girl, aged 14 years, proved to have a blood pressure of 260/160 mm Hg, with papilloedema. After control of the hypertension, a congenitally small right kidney (33 g) was removed. At that time, proteinuria was moderate (0-9 g/1) and the plasma urea 9-2 mmol/1. The hypertension remained difficult to control and compliance was poor. In 1983, when her blood pressure was 240/155 mm Hg she had a right hemiplegia due to an intracerebral haematoma, from which she made an excellent recovery and was discharged taking hydralazine, propranolol, and captopril. She attended in 1985,
ten
weeks pregnant, with
a
blood pressure of
Hg and still taking the three drugs. Following admission, hydralazine and captopril were discontinued. Control was so poor that by the tenth week, captopril 37 mg daily, atenolol 100 mg daily, and nifedipine retard 20 mg twice daily were given: later the captopril was increased to 75 mg daily. She had moderate proteinuria (1-5 g/1), plasma creatinine was 130 Ilffiol/l, and creatinine clearance was 54 ml/min. Hypoproteinaemia was treated by intravenous albumen. Serial scanning revealed intrauterine growth retardation. A healthy girl (1 -59 kg) was delivered by caesarean section at 30 weeks, and survived. The patient was discharged on atenolol 100 mg daily and enalapril 10 mg as well as nifedipine 20 mg twice daily, and failed to attend regularly to receive parenteral medroxyprogesterone acetate for contraception. By December, 1986, she was 13 weeks pregnant with unchanged antihypertensive therapy: plasma creatinine was 148 Ilffiolfl with heavy proteinuria and blood pressure was 130/100 mm Hg. Fetal
160/100
mm
death occurred at eighteen weeks: a macerated otherwise normal 340 g male fetus with an 85 g placenta delivered spontaneously. Again contraception was avoided and the patient returned in 1988 at
751 weeks’ gestation taking enalapril, nifedipine, and atenolol in unchanged dosage: blood pressure was 130/100 mm Hg with heavy proteinuria (5 g per 24 h). Patient compliance was ensured by her husband: the medication remained unaltered except that soluble aspirin (75 mg) was added from the tenth week. Plasma creatinine was 201 timol/1. A healthy girl 1 17 kg was delivered abdominally at the twenty-ninth week, and she survived. Again the patient failed to attend for postnatal examination and returned pregnant for the fourth time. Management in this pregnancy was similar to the third, except that there was doubt about compliance and the dose of nifedipine was only 20 mg daily. Creatinine varied between 354 Eunol/1 and 342 Ilffiol/l with hypoalbuminaemia (20 g/1). By the twenty-ninth week, the hypertension became uncontrolled, blood pressure was 240/140 mm Hg, and proteinuria was greater than ever, associated with diminished fetal movements. After controlling the hypertension with intravenous hydralazine a healthy boy (154 kg) was delivered by repeat section, and he has survived so far. The antihypertensive therapy is being controlled and contraception may now be acceptable. That this patient, with severe renal hypertension and now early renal failure, has had three successful pregnancies out of four, is attributable to early delivery and skilled neonatal intensive care, and, arguably, to ACE inhibitors combined with other antihypertensives. It may not therefore always be practical or wise to discontinue ACE inhibitors in early pregnancy. ten
These data indicate that meningoencephalitic untoward reactions associated with both Jeryl Lynn and Urabe Am 9 mumps vaccines. Data from Canada’ and Sweden8 support this conclusion. However, the benefit/risk ratio remains in favour of mumps vaccination, since the frequency of these untoward reactions is low and all children with mumps meningitis recovered without are
sequelae. Am Kroog 6, D-2000 Hamburg 73, West Germany 1.
W. EHRENGUT
Ehrengut W, Zastrow K. Komplikationen "nach" Mumpsschutzimpfungen in der Bundesrepublik Deutschland (einschliesslich Mehrfachschutzimpfungen) Monatsschr Kinderheilkd 1989; 137: 398-402
Ehrengut W, Georges AM, André FE. The reactogenicity and inimunogenicity of the Urabe-Am-9 live mumps vaccine and persistence of the vaccine induced antibodies in healthy young children. Biol J Standard 1983; 11: 105-09. 3. von Muhlendahl KE. Nebenwirkungen und Komplikationen der Masem-MumpsImpfung. Monatsschr Kinderheilkd 1989; 137: 440-46. 4. Jorch G, Kleine M, Erwig H Koinzidenz von Virusenzephalitis und MasernMumps-Impfung Monatsschr Kinderheilkd 1984; 132: 299-300. 5. Forster J, Urbanek R. Encephalitis nach Masern-Mumps-Impfung und gleichzeitiger EBV-Infektion. Klin Paediatr 1982; 194: 29-30. 6. Quast U, Hennessen W, Widmark RM. Vaccine induced mumps-like disease. Dev
2.
Biol Stand 1979; 43: 269-72. 7. Furesz J, Hockin JC. Mumps meningitis, possibly vaccine related. Can Dis Wkly Rep 1988; 14-40: 209-11. 8. Bottiger M, Christenson B, Romanus V, Tatanger J, Strandell A. Swedish experience of two dose vaccination programme aiming at eliminating measles, mumps and rubella. Br Med J 1987; 295: 264-67.
New Cross Hospital, Wolverhampton, ALAN M. SMITH
West Midlands WV10 0QP
Plouin P-F, Tchobroutsky C, Boutroy M-J. angiotensin-converting enzyme inhibitors during pregnancy: a survey of 22 patients given captopril and nine given enalapril. Br J Obstet Gynaecol 1988; 95: 420-22.
HISPANIC REGISTRY OF GRAFT PROCEDURES FOR PARKINSON’S DISEASE
1. Kreft-Jais C,
SiR,—The first results with adrenal medulla autografts and fetal grafts to the caudate nucleus in Parkinson’s diseasel,2 were encouraging3 and prompted other Hispanic groups to try this approach." To collate results obtained in Spanish-speaking countries we have set up a Hispanic registry of adrenal medulla and fetal brain graft procedures, seeking information from Chile, Cuba, and Spain to add to experience in Mexico. Table I summarises information on 135 patients given implants with the same technique.7 Of the 117 autotransplants 106 have been followed up for more than 6 months. The patients have been scored preoperatively and postoperatively on commonly used rating scales for parkinsonim such as Hoehn and Yahr. 31-6% of the patients have shown a good response (50-90% improvement), 27-4% have had a moderate response (30-50%), 14-5% have had a poor response (5-30%), and 9-4% have not responded. Table 11 lists the postoperative complications; there were 10 deaths (7-4%). Of the fetal brain grafts (all in Mexico or Cuba) with a follow-up of at least 6 months, the response to ventral mesencephalon implantation was good in 13 cases and moderate in 1 case; there was 1 death. 3 patients received fetal adrenal grafts with 1 good, 1 moderate, and 1 poor response.
tissue MUMPS VACCINE AND MENINGITIS
SIR,-Dr Gray and Dr Burns (July 8, p 98) and Professor von Muhlendahl (Aug 12, p 394) report cases of mumps meningitis with onset three weeks after administration of mumps vaccine. In a recent review of untoward reactions to mumps-containing vaccines reported to the Bundesgesundheitsamt in West Germany and my own reports 27 temporally-related neurological untoward reactions were
reported:
No
Onset of symptoms
of
(day
Vaccine* reports post-vaccination) C 1 14 Absence epilepsy B 1 13 Ataxia 1 A 12 Encephalitis 2 B 9,10 Encephalitis 1 8 B Encephalopathy 1 B 8 Epilepsy B 9 Febrile convulsion 1,7,9,9,9,9,9,9,10 C 19 Febrile convulsion 1 8 C Hemiparesis 1 B 14 Hennparesisl encephalitis 12 4 D Meningitis J3 21 E Meningitis A 3 8,9,21 Meningitis 27 B 1 Meningitis 19 B Meningoencephalitis 14 7 B Menmgoencephalitis (fatal) A=’Mumpsvax’ (Jeryl Lynn), B=’MM-Vax’ (Moraten/Jeryl Lynn), C=’MMR-Vax’ (Moraten/Jeryl Lynn/RA27/3), D= ’Parionx’ (UrabeAm 9), E = ’Rmipanx’ (Schwarz/Urabe Am 9). Reaction
Since the introduction of mumps vaccines in West Germany, 6 of meningitis and 2 of meningoencephalitis have been published. In 2 instances mumps virus was isolated from the cerebrospinal fluid (CSF). In a personally observed case mumps virus was isolated from the CSF of a 6-year-old boy who had meningitis 21 days after administration of JerylLynn mumps vaccine. He recovered without sequelae. The other case was the one described by von Miihlendahl.3 The above cases apart, the development of meningoencephalitis 9 days after measles-mumps (Moraten/Jeryl Lynn) vaccination in a child with a concurrent symptom-free Epstein-Barr virus infection was also reported. 4 other cases of meningitis following ‘Mumpsvax’ (Jeryl Lynn) were reported in another review in 1979.6
TABLE I-ADRENAL MEDULLA AUTOGRAFTS REGISTERED IN HISPANIC REGISTRY OF GRAFT PROCEDURES IN TREATMENT OF PARKINSON’S DISEASE: FOLLOW-UP SIX MONTHS OR MORE
cases
G
=
good, M
=
moderate, P poor, NR
=
no
response, D
=
death.