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CHORIONIC BIOPSY AND MISCARRIAGE IN FIRST TRIMESTER
562 Our study suggests that acute chlorine exposure, even when repeated, requires medical support for only a short time and does not induce any late sequelae even in patients with abnormal respiratory function tests or blood gases on admission. Internal Medicine and Toxicology CHU Grenoble, 38043 Grenoble, France
Service,
L. BARRET
J. FAURE
RECOVERY AFTER POTENTIALLY LETHAL AMOUNT OF ANTI-FREEZE
SiR,-Following the communication of Dr Saus and colleagues (Jan 2, p 158) we would like to report a case of full recovery after deliberate ingestion of potentially lethal amounts of methanol and ethyleneglycol. Toxicity is related to hepatic metabolism of the two agents to formic and oxalic acids and their aldehydes. Treatments recommended for both have been the use of ethanol (to inhibit the action of alcohol dehydrogenase in the production of toxic metabolites)1 and haemodialysis2or peritoneal dialysis3for the quick removal of the chemicals. A 36-year-old man was admitted 6 h after deliberately swallowing 500 ml of an antifreeze mixture of methanol and ethyleneglycol. He was drowsy but rousable, and hyperventilating. He had a respiratory alkalosis compensating the underlying metabolic acidosis (arterial pH 7-51, pC02 22 -5mm Hg, actual bicarbonate 18’5mmol/1), and normal renal function. Methanol and ethyleneglycol levels were 113 g/1 and 199 g/1, respectively (toxic levels 0 -2g/l and 0 - 5 g/1). Gastric lavage was done and ethanol was administered by mouth, followed by an infusion maintaining serum ethanol levels above 1 g/1. Haemodialysis was started within 12 h of ingestion, and continued for 10 of the first 14 h of admission. Postdialysis, ethyleneglycol was no longer detected in the serum and methanol levels were below the toxic range, falling to zero 8 h later. During and after therapy diuresis was maintained, and there were no neurological or ophthalmic sequelae. We believe that early correction of acidosis and effective and thorough removal of toxic metabolites within 24 h resulted in the successful
outcome.
Departments of Medicine and Renal Medicine, Manchester Royal Infirmary, Manchester M13 9WL
N. P. VITES C. R. PAYNE R. GOKAL
NEUROLOGICAL DEFICIT MORE THAN THIRTY YEARS AFTER CHRONIC THALLIUM INTOXICATION
SiR,-Thallium poisoning is now very rare in Britain and recent have usually been deliberate (ie, suicide or homicide) 4 Thallium acetate used to be administered as a depilatory agent for ringworm of the scalp but this use stopped when reports of serious After acute ingestion of thallium the outcome toxicity is usually death or full clinical recovery, and reports of long-term sequelae are rare.7,8 However, Reedfollowed up 48 children six months to seven years after an episode of thallotoxicosis and found residual neurological deficits in 26 (54%). The abnormalities were not fully defined but "mental retardation" and "psychosis" were the commonest findings, followed by ataxia and tremor. We have seen a 43-year-old man who was given oral thallium acetate for scalp ringworm at the age of 7. A few days later he began to lose his scalp hair and at the same time a progressive ataxia, painful parasthesiae in both legs, and increasing confusion and cases
appeared.s°6
drowsiness
developed. Over the next few months he gradually improved but was left with a residual ataxia, mild spastic paraparesis, and intellectual impairment. He attended a special school and was eventually able to find employment with the Forestry Commission. His disability remained static until over the past 3 years when he has been experiencing increasing problems with mobility. In August, 1982, he was referred to the department of neurology. By then he had a spastic paraparesis combined with a painful peripheral sensorimotor neuropathy. His full scale IQ was 74’but there was no other defect in higher mental function. Investigations included normal biochemical and haematological screening, normal CSF, and normal evoked potentials. Myelography was not done since it would not have influenced the management of his longstanding disability. We can find no alternative cause for his problems and suggest that his neurological disabilities are secondary to thallium ingestion in childhood. We cannot prove this or explain his recent functional decline but we would be interested in any other accounts of the long-term sequelae of thallium poisoning. M. P. BARNES K. MURRAY P. J. B. TILLEY
Department of Neurology, Middlesbrough General Hospital, Middlesbrough, Cleveland
CHORIONIC BIOPSY AND MISCARRIAGE IN FIRST TRIMESTER 42 women scheduled for diagnostic chorionic biopsyl at SIR,-Of our department, 4 aborted spontaneously before the sampling and 4 had a dead fetus when examined by ultrasound (ie, a fetal loss rate of 19%). These 8 women, aged 39-45 years, were in the 7th to l lth week of pregnancy. 5 had been checked by ultrasound 6-11 days earlier, when normal fetal heart activity was recorded. Indications for sampling were maternal age (6 cases), sexing of a fetus at risk for haemophilia A (1 case), and balanced translocation in the father (I case). I know of no published report on the probability that a woman of a given age and in a given gestational week will abort spontaneously before the end of the 28th week. Such data are presented here in table form, having been extracted from the medical records of women treated for spontaneous abortion (547) or intrauterine fetal death (59) in the 7th week of gestation or later at our department during 1980 and 1981, when altogether 5731 women gave birth. Pregnancies terminated legally are not included. Most notably, 1 out of every 3 women aged 40 and over aborted in the 8th week or later. Among women of this age group who reached the 11 th week, the risk of aborting before the end of the 28th week was reduced to 13 - 6%. By the 14th week, there was little difference between the rates for women aged 40 or more and those under 30
(2’8%
vs
2’1%).
The contents of the table may prove useful when choosing a time for chorionic biopsy. We now usually do biopsies in the 11th week. Among the 31 pregnancies allowed to continue after biopsy, there has so far been only 1 abortion. Department of Obstetrics and Gynaecology, University of Lund, S-22185 Lund, Sweden
BJÖRN GUSTAVII
1. Gustavii B. First-trimester chromosomal
vision
technique.
Lancet 1983;
ii:
analysis of
chorionic villi obtained by direct
507-08.
FETAL LOSSES AT GIVEN GESTATIONAL PERIODS, RELATED TO AGE OF MOTHER*
1. Bergeron R, Cardinal J, Gredah D. Prevention of methanol poisoning by ethanol therapy. N Engl J Med 1982; 306: 1528. 2. Vale JA, Widdop B, Bluett NH. Ethylene glycol poisoning. Postgrad Med J 1976; 52: 598-602 3. Vale JA, Prior JG, O’Hare JP, Flanagan RJ, Feehally J. Treatment of ethylene glycol poisoning with peritoneal dialysis. Br Med J 1982; 284: 557. 4. Cavanagh JB, Fuller NH, Johnson HRM, Rudge P. The effects of thallium salts, with particular reference to the nervous system changes. Quart J Med 1974; 43: 293-319. 5. Stein MD, Perlstein MA. Thallium poisoning. Am J Dis Child 1959; 98: 80-85. 6. Munch JC. Human thallotoxicosis. JAMA 1934; 102: 1929-34. 7. Reed D, Crawley J, Faro SN, Pieper SJ, Kurland LT. Thallotoxicosis. Acute manifestations and sequelae. JAMA 1963; 183: 516-22. 8. Bank WJ, Pleasure DE, Suzuki K, Nigro M, Katz R. Thallium poisoning. Arch Neural 1972; 26: 456-64.
*These loss rates are cumulative: for example, of 3787 fetuses at the 7th week in women under 30 a total of 294 (7 - 8%) were lost, 14 between weeks 7 and 8, leaving 3773 fetuses at the 8th week of which a total of 280(7-4%) were lost, and so on.
Service,
L. BARRET
J. FAURE
RECOVERY AFTER POTENTIALLY LETHAL AMOUNT OF ANTI-FREEZE
SiR,-Following the communication of Dr Saus and colleagues (Jan 2, p 158) we would like to report a case of full recovery after deliberate ingestion of potentially lethal amounts of methanol and ethyleneglycol. Toxicity is related to hepatic metabolism of the two agents to formic and oxalic acids and their aldehydes. Treatments recommended for both have been the use of ethanol (to inhibit the action of alcohol dehydrogenase in the production of toxic metabolites)1 and haemodialysis2or peritoneal dialysis3for the quick removal of the chemicals. A 36-year-old man was admitted 6 h after deliberately swallowing 500 ml of an antifreeze mixture of methanol and ethyleneglycol. He was drowsy but rousable, and hyperventilating. He had a respiratory alkalosis compensating the underlying metabolic acidosis (arterial pH 7-51, pC02 22 -5mm Hg, actual bicarbonate 18’5mmol/1), and normal renal function. Methanol and ethyleneglycol levels were 113 g/1 and 199 g/1, respectively (toxic levels 0 -2g/l and 0 - 5 g/1). Gastric lavage was done and ethanol was administered by mouth, followed by an infusion maintaining serum ethanol levels above 1 g/1. Haemodialysis was started within 12 h of ingestion, and continued for 10 of the first 14 h of admission. Postdialysis, ethyleneglycol was no longer detected in the serum and methanol levels were below the toxic range, falling to zero 8 h later. During and after therapy diuresis was maintained, and there were no neurological or ophthalmic sequelae. We believe that early correction of acidosis and effective and thorough removal of toxic metabolites within 24 h resulted in the successful
outcome.
Departments of Medicine and Renal Medicine, Manchester Royal Infirmary, Manchester M13 9WL
N. P. VITES C. R. PAYNE R. GOKAL
NEUROLOGICAL DEFICIT MORE THAN THIRTY YEARS AFTER CHRONIC THALLIUM INTOXICATION
SiR,-Thallium poisoning is now very rare in Britain and recent have usually been deliberate (ie, suicide or homicide) 4 Thallium acetate used to be administered as a depilatory agent for ringworm of the scalp but this use stopped when reports of serious After acute ingestion of thallium the outcome toxicity is usually death or full clinical recovery, and reports of long-term sequelae are rare.7,8 However, Reedfollowed up 48 children six months to seven years after an episode of thallotoxicosis and found residual neurological deficits in 26 (54%). The abnormalities were not fully defined but "mental retardation" and "psychosis" were the commonest findings, followed by ataxia and tremor. We have seen a 43-year-old man who was given oral thallium acetate for scalp ringworm at the age of 7. A few days later he began to lose his scalp hair and at the same time a progressive ataxia, painful parasthesiae in both legs, and increasing confusion and cases
appeared.s°6
drowsiness
developed. Over the next few months he gradually improved but was left with a residual ataxia, mild spastic paraparesis, and intellectual impairment. He attended a special school and was eventually able to find employment with the Forestry Commission. His disability remained static until over the past 3 years when he has been experiencing increasing problems with mobility. In August, 1982, he was referred to the department of neurology. By then he had a spastic paraparesis combined with a painful peripheral sensorimotor neuropathy. His full scale IQ was 74’but there was no other defect in higher mental function. Investigations included normal biochemical and haematological screening, normal CSF, and normal evoked potentials. Myelography was not done since it would not have influenced the management of his longstanding disability. We can find no alternative cause for his problems and suggest that his neurological disabilities are secondary to thallium ingestion in childhood. We cannot prove this or explain his recent functional decline but we would be interested in any other accounts of the long-term sequelae of thallium poisoning. M. P. BARNES K. MURRAY P. J. B. TILLEY
Department of Neurology, Middlesbrough General Hospital, Middlesbrough, Cleveland
CHORIONIC BIOPSY AND MISCARRIAGE IN FIRST TRIMESTER 42 women scheduled for diagnostic chorionic biopsyl at SIR,-Of our department, 4 aborted spontaneously before the sampling and 4 had a dead fetus when examined by ultrasound (ie, a fetal loss rate of 19%). These 8 women, aged 39-45 years, were in the 7th to l lth week of pregnancy. 5 had been checked by ultrasound 6-11 days earlier, when normal fetal heart activity was recorded. Indications for sampling were maternal age (6 cases), sexing of a fetus at risk for haemophilia A (1 case), and balanced translocation in the father (I case). I know of no published report on the probability that a woman of a given age and in a given gestational week will abort spontaneously before the end of the 28th week. Such data are presented here in table form, having been extracted from the medical records of women treated for spontaneous abortion (547) or intrauterine fetal death (59) in the 7th week of gestation or later at our department during 1980 and 1981, when altogether 5731 women gave birth. Pregnancies terminated legally are not included. Most notably, 1 out of every 3 women aged 40 and over aborted in the 8th week or later. Among women of this age group who reached the 11 th week, the risk of aborting before the end of the 28th week was reduced to 13 - 6%. By the 14th week, there was little difference between the rates for women aged 40 or more and those under 30
(2’8%
vs
2’1%).
The contents of the table may prove useful when choosing a time for chorionic biopsy. We now usually do biopsies in the 11th week. Among the 31 pregnancies allowed to continue after biopsy, there has so far been only 1 abortion. Department of Obstetrics and Gynaecology, University of Lund, S-22185 Lund, Sweden
BJÖRN GUSTAVII
1. Gustavii B. First-trimester chromosomal
vision
technique.
Lancet 1983;
ii:
analysis of
chorionic villi obtained by direct
507-08.
FETAL LOSSES AT GIVEN GESTATIONAL PERIODS, RELATED TO AGE OF MOTHER*
1. Bergeron R, Cardinal J, Gredah D. Prevention of methanol poisoning by ethanol therapy. N Engl J Med 1982; 306: 1528. 2. Vale JA, Widdop B, Bluett NH. Ethylene glycol poisoning. Postgrad Med J 1976; 52: 598-602 3. Vale JA, Prior JG, O’Hare JP, Flanagan RJ, Feehally J. Treatment of ethylene glycol poisoning with peritoneal dialysis. Br Med J 1982; 284: 557. 4. Cavanagh JB, Fuller NH, Johnson HRM, Rudge P. The effects of thallium salts, with particular reference to the nervous system changes. Quart J Med 1974; 43: 293-319. 5. Stein MD, Perlstein MA. Thallium poisoning. Am J Dis Child 1959; 98: 80-85. 6. Munch JC. Human thallotoxicosis. JAMA 1934; 102: 1929-34. 7. Reed D, Crawley J, Faro SN, Pieper SJ, Kurland LT. Thallotoxicosis. Acute manifestations and sequelae. JAMA 1963; 183: 516-22. 8. Bank WJ, Pleasure DE, Suzuki K, Nigro M, Katz R. Thallium poisoning. Arch Neural 1972; 26: 456-64.
*These loss rates are cumulative: for example, of 3787 fetuses at the 7th week in women under 30 a total of 294 (7 - 8%) were lost, 14 between weeks 7 and 8, leaving 3773 fetuses at the 8th week of which a total of 280(7-4%) were lost, and so on.