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Cicatricial pemphigoid of the vulva
916 Correspondence
2. Griffin D, Bilardo K, Masini L, et al. Doppler blood flow waveforms in the descending thoracic aorta of the human fetus. Br J Obstet GynaecoI1984;91 :997. 3. Jouppila P, Kirkinen P. Increased vascular resistance in the descending aorta of the human fetus in hypoxia. Br J Obstet Gynaecol 1984;91 :853. Reply
To the Editors: We appreciate that Dr. Spinnato commented on our recent publication on umbilical artery velocity waveforms. Most investigators now believe that there is a definable diastolic velocity component in the descending aorta of the average-for-gestational age fetus. We would not disagree with this contention; however, the diastolic signal is frequently quite noisy or turbulent, hence we had decided not to use it as a useful site for fetal evaluation. This concern seems to have been reinforced by the reports of normal aortic flow. For example in Griffin et al. I normal rates of 246 ml/kg/min are reported, but others suggest values averaging 168 to 216 mllkg/min! Dr. Spin nato's illustrations highlight how disagreements may arise. As he mentioned, their equipment differs from ours. The spectral analysis may differ, and the time-frame freeze appears to be different. Furthermore, a fetal tachycardia may also influence the diastolic component. Hence comparisons are problematic. We have had the opportunity of studying more than a thousa nd fetuses and are convinced that our hypothesis is reasonable; that is, in most circumstances it is easy to differentiate aortic signals from umbilical. Aortic systotic/diastolic ratios are normally around 7 to 8 whereas umbilical ratios are -2.5 to 3 and rarely >6. The advantage of a continuous-wave system without linear-array imaging is that repetitive studies can be carried out without exceeding current established safety guidelines and that a powerful diagnostic tool is available at the bedside or in the office rather than in an expensive laboratory. Adiel Fleischer, M.D . clo Harold Schulman, M .D. Department of Obstetrics and Gynecology Nassau if ospital 249 First Street Mineola, New York 11501
REFERENCES I. Griffin D, Bilardo K, Masini L, et al. Doppler blood flow waveforms in the descending thoracic aorta of the human fetus . Br J Obstet Gynaecol 1984;91 :997. 2. Van Lierde M, Oberweis D, Thomas K. Ultrasonic measurement of aortic and umbilical blood flow in the human fetus . Obstet Gynecol 1984;63:801. Cicatricial pemphigoid of the vulva To the Editors: I was interested to read the report "Bullous pemphigoid of the vulva: A case report" by Stage et al. (AM J OBSTET GVNECOL 1984;150:169).
August 1, 1985 Am J Obstet Gynecol
The fact that the patient had lesions on the scalp and in the mouth and pharynx makes it likely that she had cicatricial pemphigoid rather than bullous pemphigoid . The latter condition very rarely affects mucosal surfaces whereas such involvement and also lesions of the scalp and vulva are common in the cicatricial type. It may therefore be highly relevant that the patient was taking a ~-blocking agent since, as the authors point out, there is a previous reference in the literature to the particular relationship of a ~-blocker to anogenital cicatricial pemphigoid. C. M. Ridley Whittington Hospital St. Mary's Wing Highgate Hill London, England N19 5NF
Reply
To the Editors: Dr. Ridley'S comments on our report "Bullous pemphigoid of the vulva" are indeed pertinent and appreciated. The format of this presentation required brevity and did not allow for any discussion of bullous diseases in depth . Bullous pemphigoid is a chronic, benign, vesicular disease of the skin and mucous membranes. Lesions of the vulva may occur, but vaginal lesions are rare. The bullae are subepidermal, and a linear deposit of IgG, IgM, and/or complement can be demonstrated by immunofluorescent studies along the basement membrane zone in 90% of patients. In addition to subepidermal bullae, dense eosinophilic and perivascular Iymphohistiocytic infiltration of the dermis is noted microscopically. Benign mucous membrane pemphigoid, or cicatricial pemphigoid, is a variant of bullous pemphigoid involving mainly the mucous membranes including the buccal membranes, nasal mucosa, larynx, esophagus, genitalia, and anal area. Skin lesions occur in only 10% to 30% of such patients. Chronic erosions of the mucous membranes in benign mucous membrane pemphigoid can often lead to symblepharon of the eye and blindness, and adhesions and strictures of the larynx and esophagus as well as in the vagina. Benign mucous membrane pemphigoid tends to run a more chronic course and is at times less responsive to therapy. Circulating antibodies to the basement membrane zone antigens are present in 90% of patients with bullous pemphigoid, but contrary to what was previously thought, differentiation between bullous pemphigoid and benign mucous membrane pemphigoid cannot be made by the presence or absence of circulating antibodies. I In one study, mucous membrane involvement was especially noted in patients with bullous pemphigoid when indirect immunofluorescent studies were negative! The pathologic picture is identical in both, but there is a lower incidence of circulating antibodies in benign mucous membrane pemphigoid as well as a tendency to ocular involvement, slow healing, and scar formation. No consistent laboratory d ata ex-
2. Griffin D, Bilardo K, Masini L, et al. Doppler blood flow waveforms in the descending thoracic aorta of the human fetus. Br J Obstet GynaecoI1984;91 :997. 3. Jouppila P, Kirkinen P. Increased vascular resistance in the descending aorta of the human fetus in hypoxia. Br J Obstet Gynaecol 1984;91 :853. Reply
To the Editors: We appreciate that Dr. Spinnato commented on our recent publication on umbilical artery velocity waveforms. Most investigators now believe that there is a definable diastolic velocity component in the descending aorta of the average-for-gestational age fetus. We would not disagree with this contention; however, the diastolic signal is frequently quite noisy or turbulent, hence we had decided not to use it as a useful site for fetal evaluation. This concern seems to have been reinforced by the reports of normal aortic flow. For example in Griffin et al. I normal rates of 246 ml/kg/min are reported, but others suggest values averaging 168 to 216 mllkg/min! Dr. Spin nato's illustrations highlight how disagreements may arise. As he mentioned, their equipment differs from ours. The spectral analysis may differ, and the time-frame freeze appears to be different. Furthermore, a fetal tachycardia may also influence the diastolic component. Hence comparisons are problematic. We have had the opportunity of studying more than a thousa nd fetuses and are convinced that our hypothesis is reasonable; that is, in most circumstances it is easy to differentiate aortic signals from umbilical. Aortic systotic/diastolic ratios are normally around 7 to 8 whereas umbilical ratios are -2.5 to 3 and rarely >6. The advantage of a continuous-wave system without linear-array imaging is that repetitive studies can be carried out without exceeding current established safety guidelines and that a powerful diagnostic tool is available at the bedside or in the office rather than in an expensive laboratory. Adiel Fleischer, M.D . clo Harold Schulman, M .D. Department of Obstetrics and Gynecology Nassau if ospital 249 First Street Mineola, New York 11501
REFERENCES I. Griffin D, Bilardo K, Masini L, et al. Doppler blood flow waveforms in the descending thoracic aorta of the human fetus . Br J Obstet Gynaecol 1984;91 :997. 2. Van Lierde M, Oberweis D, Thomas K. Ultrasonic measurement of aortic and umbilical blood flow in the human fetus . Obstet Gynecol 1984;63:801. Cicatricial pemphigoid of the vulva To the Editors: I was interested to read the report "Bullous pemphigoid of the vulva: A case report" by Stage et al. (AM J OBSTET GVNECOL 1984;150:169).
August 1, 1985 Am J Obstet Gynecol
The fact that the patient had lesions on the scalp and in the mouth and pharynx makes it likely that she had cicatricial pemphigoid rather than bullous pemphigoid . The latter condition very rarely affects mucosal surfaces whereas such involvement and also lesions of the scalp and vulva are common in the cicatricial type. It may therefore be highly relevant that the patient was taking a ~-blocking agent since, as the authors point out, there is a previous reference in the literature to the particular relationship of a ~-blocker to anogenital cicatricial pemphigoid. C. M. Ridley Whittington Hospital St. Mary's Wing Highgate Hill London, England N19 5NF
Reply
To the Editors: Dr. Ridley'S comments on our report "Bullous pemphigoid of the vulva" are indeed pertinent and appreciated. The format of this presentation required brevity and did not allow for any discussion of bullous diseases in depth . Bullous pemphigoid is a chronic, benign, vesicular disease of the skin and mucous membranes. Lesions of the vulva may occur, but vaginal lesions are rare. The bullae are subepidermal, and a linear deposit of IgG, IgM, and/or complement can be demonstrated by immunofluorescent studies along the basement membrane zone in 90% of patients. In addition to subepidermal bullae, dense eosinophilic and perivascular Iymphohistiocytic infiltration of the dermis is noted microscopically. Benign mucous membrane pemphigoid, or cicatricial pemphigoid, is a variant of bullous pemphigoid involving mainly the mucous membranes including the buccal membranes, nasal mucosa, larynx, esophagus, genitalia, and anal area. Skin lesions occur in only 10% to 30% of such patients. Chronic erosions of the mucous membranes in benign mucous membrane pemphigoid can often lead to symblepharon of the eye and blindness, and adhesions and strictures of the larynx and esophagus as well as in the vagina. Benign mucous membrane pemphigoid tends to run a more chronic course and is at times less responsive to therapy. Circulating antibodies to the basement membrane zone antigens are present in 90% of patients with bullous pemphigoid, but contrary to what was previously thought, differentiation between bullous pemphigoid and benign mucous membrane pemphigoid cannot be made by the presence or absence of circulating antibodies. I In one study, mucous membrane involvement was especially noted in patients with bullous pemphigoid when indirect immunofluorescent studies were negative! The pathologic picture is identical in both, but there is a lower incidence of circulating antibodies in benign mucous membrane pemphigoid as well as a tendency to ocular involvement, slow healing, and scar formation. No consistent laboratory d ata ex-