PREGNANCY WITH ANENCEPHALY

679 of the 4th costal cartilage, was mobilised and decorticated. A small collection of pleural fluid, similar to the pericardial fluid, was found in a posterior space. The chest was closed and convalescence was uneventful. Histologically the pericardium and pleura were infiltrated with a small number of lymphocytes and occasional polymorphs, but they gave no clue to the aetiology of the condition. Both samples of fluid were sterile on culture, and no organisms were seen on microscopy. The fluid contained 5-2 g. of protein per 100 ml., and only 100 mg. per 100 ml. of cholesterol-probably because of the rapid reaccumulation of fluid following almost complete aspiration of the pericardial fluid seventeen days earlier. At that time cholesterol crystals were profuse, but unfortunately no chemical estimation was carried out.

We are grateful to Dr. Neville J. Roussak for permission to publish this case; to Miss Ann-Marie Courtney and Mrs. Jean Prosser for secretarial assistance; and to the Medical Illustration Department, Wvthenshawe Hosoital. REFERENCES

Alexander, J. S. (1919) Brit. med. J. ii, 463. Genecin, A. (1959) Amer. J. Med. 26, 496. Griffin, S. G., Swan, W. G. A. (1963) Brit. Heart J. 25, 825. Haming, R. B., Haining, R. G. (1961) Ann. intern. Med. 54, 300. Moe, A. S., Campos, F. J. (1957) ibid. 47, 817. Szatkowski, J., Toshihiko, I. (1963) Amer. J. Cardiol. 12, 730. Addendum

The patient remains well. Chest radiography on Feb. no change from that on Nov. 5, 1964.

Progress The patient was discharged from hospital on Sept. 9. When seen again on Oct. 7 he was well. There was no evidence of heart-failure. An electrocardiogram showed T-wave inversion in the early V leads and T-wave flattening in the later V leads. Chest radiography (fig. 3) now showed good expansion of the left lung with slight diaphragmatic elevation. Pericardial

Aspiration

The main hazards of this relatively uncommon procedure are damage to the lung or pleura causing pneumothorax, or to the coronary vessels or cardiac chambers causing cardiac tamponade, and the introduction of infection. The use of a needle, with an anterior intercostal or subcostal approach, is dangerous, and complete emptying is impossible. Either approach using a bardic intracath permits free aspiration and, if indicated, air replacement, without anxiety. After skin preparation and local anxsthetic infiltration in the 6th.left intercostal space well within the area of cardiac dullness, the bardic needle and catheter (no. 1614.R) were inserted slowly. As soon as pericardial fluid flowed into it, the catheter was advanced deeply into the pericardium and the needle was withdrawn and secured. At the end of aspiration air was introduced to permit contrast radiography of the heart and pericardium (fig. 2). This excluded tumour of either structures and showed the pericardium to be thin. The bardic intracath is a presterilised, readily available unit. Its use for pericardial aspiration should avoid any of the complications listed above and greatly diminish the physician’s anxiety in this investigation. Discussion

i

found

no evidence of tuberculosis, patient hypothyroidism, collagen disease, hypoproteinaemia, or familial disease. The patient originally attended hospital solely because of increasing breathlessness and intractable cedema-both mechanical effects of the massive pericardial effusion. After the first aspiration of the effusion he had a massive diuresis, and was able to return to his heavy work. When the effusion recurred, the symptoms returned. Pericardectomy left the patient symptom-free and extremely well. Summary In a case of chronic pericardial effusion with cholesterol crystals, the patient’s only symptoms were dyspnoea and oedema. The physical signs could have led to a wrong diagnosis of a large heart due to unspecified cardiomyopathy, and an unnecessarily poor prognosis. After aspiration he was well for some months. When the effusion recurred, he was cured by pericardectomy. The condition, and therefore the need for such treatment, may be more common than is generally supposed. With theBardic Intracath’, aspiration and air replacement of pericardial effusion is a safe and simple procedure.

In

our

we

5,

1965, showed

PREGNANCY WITH ANENCEPHALY

JAMES B. COMERFORD M.B., M.A.O. N.U.I., M.R.C.O.G., D.C.H. RESEARCH

ASSISTANT,

THE NATIONAL MATERNITY

HOSPITAL, DUBLIN, 2

ANENCEPHALY may give rise to obstetrical complications. The purpose of this paper is to establish their nature. During the period 1956-61, 150 mothers were delivered of an anencephalic foetus, of more than 28 weeks’ maturity, at this hospital. The incidence was 6-5 per 1000 births.

Complications There were three main obstetrical complications. These were hydramnios, accidental antepartum haemorrhage, and postmaturity associated with dystocia.

Hydramniosz Hydramnios was diagnosed in 135 of the patients (90%). The signs were gross in 52, moderate in 58, and slight in 25

cases.

Transabdominal amniotomy was performed on 78 patients. The operation was repeated once on 16 patients, twice on 5, and three times on 1. 26 had more than 5 litres of liquor amnii removed. Transabdominal amniotomy was followed in 18 cases by accidental hxmorrhage, and in 1 by a fatal amniotic-fluid infusion, previously reported (Geoghegan et al. 1964). This was the only maternal death in the series. Accidental Antepartum Hcemorrhage 30 patients (20%) had accidental haemorrhage, which was severe in 4 cases, moderate in 11, and slight in 15. Of these 30 patients, 2 had hypofibrinogenxmia, and all but 1 had hydramnios. Accidental haemorrhage followed artificial rupture of the membranes in 3 of 12 patients so treated. It followed spontaneous rupture of the membranes in 9 instances, and transabdominal amniotomy in 18.

Postmaturity and Dystocia Of the 15 patients without hydramnios, 5 had extreme prolongation of pregnancy. They were delivered after 43, 47, 49, 50, and 53 weeks’ gestation. None responded to oxytocin-drip stimulation. They had attained a degree of such as is seldom encountered. There were 2 instances of serious shoulder dystocia, at 43 and 53 weeks’ maturity. The lst patient, a nullipara, was delivered after embryotomy of an infant weighing 6 lb. 10 oz. (3 kg.). The 2nd patient had extreme rigidbaby dystocia at 53 weeks and was delivered after embryotomy of an infant weighing 7 lb. 14 oz. (3-6 kg.). A year later she had a spontaneous delivery of a living infant weighing 7 lb. 12 oz. (3-5kg.). 112 (74°°) of the infants were female.

postmaturity

47

(31%)

were not

diagnosed

until

delivery.

68(

There

1 uniovular twin pregnancy, and both infants

was

anencephalic.:. 10 (10%) of 103 anencephalus.

parous mothers had had

8 (5%) had pre-eclamptic toxaemia. 13 of 61 tested had abnormal glucose tolerance Induction of Labour

Labour

a

ISONIAZID-INDUCED ENCEPHALOPATHY

were

PETER ADAMS

previous

M.B. Wales, M.R.C.P. REGISTRAR

(21 %).

CHESTER WHITE M.A., B.M., B.Sc. Oxon. LATE HOUSE-PHYSICIAN

successfully induced in 36 patients, by means of oxytocin in 27 and surgical induction in the remaining 9. Oxytocin failed to induce labour in 21 patients (44%). It is remarkable that patients with an anencephalic foetus do not readily respond to oxytocin even when hydramnios is absent. was

ADDENBROOKE’S HOSPITAL,

use;

damage

Congenital malformation is the main cause of perinatal mortality, and anencephaly is the most common gross malformation. From the obstetrical viewpoint, anencephaly is peculiar in that the foetal prognosis is hopeless and management is governed solely by maternal interests. This study shows the high incidence of hydramnios and associated hxmorrhage. The haemorrhage was directly related to the spontaneous or artificial release of liquor amnii. Transabdominal amniotomy did not prevent accidental haemorrhage, the incidence of which was 23% in patients so treated and 19% in the remainder. Macafee (1950) noted shoulder dystocia at delivery of anencephalic infants, and advocated bipolar version with rupture of the membranes. O’Driscoll and Meagher (1962) reported 3 instances of ruptured uterus during delivery of the shoulders of anencephalic infants. Rigidbaby dystocia is a hazardous obstetrical problem, and is a particular complication of postmature anencephalic pregnancy. It can be avoided only by early induction of section. Conclusion

The presence or absence of hydramnios decides the clinical course of the anencephalic pregnancy. If hydramnios is present, there is a tendency to accidental separation of the placenta. If hydramnios is not present there is a remarkable predisposition to postmaturity, with consequent rigid-baby dystocia. A gestational age of more than 44 weeks suggests a diagnosis of anencephalus.

Summary Observations were made on 150 anencephalic pregnancies. Analysis of the material was limited to obstetrical considerations. 90% of the patients had hydramnios, leading in 18 cases to accidental haemorrhage, and in 1 to a fatal infusion of amniotic fluid. Accidental antepartum haemorrhage occurred in 20% of the patients. Transabdominal amniotomy could not be shown to reduce the incidence of this complication when hydramnios was present. Postmaturity and rigid-baby

dystocia were common in the absence of hydramnios. Both oxytocin and transabdominal amniotomy often failed to induce labour. Shoulder dystocia may an anencephalic infant.

complicate vaginal delivery

optic atrophy, convulsions, and major psychoses

have also been described (British Medical Journal 1958). Severe to the central nervous system is much less but Korsakov’s usual; psychosis (Hunter 1952), toxic and Nimitz 1954, Adams and encephalopathy (Biehl Davies 1961), neuromyelitis optica (Dixon et al. 1956), and myelopathy (Money 1959) have been reported in

Commentary

or caesarean

CAMBRIDGE

THE neurotoxic effects of isoniazid are well known. Peripheral neuropathy is the commonest but not the only important neurological disturbance that complicates its

Artificial rupture of the membranes was undertaken in 12 patients. It failed to induce labour in 3, who were delivered vaginally more than 48 hours after rupture of the membranes. Transabdominal amniotomy failed to induce labour in 39 patients (50%).

labour

*

of

REFERENCES

REFERENCES

Geoghegan, F., O’Driscoll, K., Comerford, J. (1964) J. Obstet. Gynœc. Brit. Cwlth, 71, 673. Macafee, C. H. G. (1950) ibid. 57, 171. O’Driscoll, K., Meagher, D. (1962) ibid. 69, 248.

patients receiving isoniazid. We here describe the

of a patient in whom severe encephalopathy developed while she was receiving conventional doses of isoniazid and sodium p-aminosalicylic acid (P.A.S.) for renal tuberculosis. case

Case-report In 1947, the patient, a woman then aged 20, developed pulmonary tuberculosis. In 1951 tubercle bacilli were found in the sputum; she was treated with P.A.s. alone for 2 months, and 6 months later was given another course of this treatment for 2 months. In 1957 she complained of pain in the left hip and osteoarthritis was diagnosed. Her symptoms became progressively worse, and 4 years later movement of the left hip In 1961 she developed frequency of was severely limited. micturition, nocturia, and hoematuria; she was found to have bilateral renal tuberculosis. In March, 1962, treatment was begun with isoniazid 300 mg. daily and P.A.S. 12 g. daily. In April, 1963, she was experiencing severe pain in the left hip and was unable to walk without assistance. At about the same time she complained of poor vision and became querulous, irritable, and apathetic. A few weeks later she had a major convulsion. On July 9, 1963, a left psoas tenotomy was performed in an attempt to correct the flexion deformity of the left hip. On the 3rd postoperative day the patient was confused, paranoid, and agitated. The next day she had a major convulsion with involuntary movements of the right side of the face and the right arm. On recovery she was incontinent of urine and fxces, and in a drowsy muttering delirium. There was no evidence of meningitis; the legs were spastic and there was hyperreflexia. The cerebrospinal fluid (C.S.F.) was normal. On July 29 the patient was admitted to Addenbrooke’s Hospital for further investigation. She was pale but wellnourished (weight 75 kg.). She was conscious but inaccessible, and there were involuntary movements of the face, lips, arms, and hands. Tone was increased in all muscles; there was paraplegia in flexion with adduction at both hips. Tendon reflexes were increased in the arms and legs with ankle clonus; the abdominal reflexes were absent and the plantar responses extensor. The cranial nerves were normal and the jaw-jerk was brisk. There was no papilloedema. The sensory system was normal. It was concluded that the patient had either a neurological complication of tuberculosis or a major metabolic disturbance possibly related to isoniazid therapy. The normal c.s.F. was considered to exclude tuberculosis. Investigations.-The hoemoglobin was 11.7 g. per 100 ml., and the leucocyte-count 8200 per c.mm. with a normal differential count. The platelet-count was 400,000 per c.mm. and the erythrocyte-sedimentation rate 56 mm. in the lst hour (Westergren). Other investigations showed no evidence of * Present address: Department of Medicine, University of Cambridge.