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DIRECT COOMBS TEST AND METHYLDOPA
97 DIRECT COOMBS TEST AND METHYLDOPA SiR,-We were interested to read the work of Dr. Chan and others (Oct. 16, p. 881). Since our previous report1 we have followed 100 patients on methyldopa (50 Indians and 50 Africans) and found 2 Indian patients with a positive direct Coombs test (D.C.T.). This is similar to the experience of Chan et al., who found an incidence of a positive D.C.T. of 2-8% on methyldopa treatment, a figure2 which is lower than that reported by Carstairs et al.2 (positive D.C.T. in 20% of 202 patients). We have not seen a patient in our hospital develop autoimmune hxmolytic anaemia on methyldopa, despite it being one of the commonly used hypotensive agents. We feel that there is a wide variation in the incidence of a D.c.T. on methyldopa treatment and this is influenced, as stated previously, by racial and environmental factors. We were pleased to read the reports by Chan et al. and by Burns-Cox3 and would be interested to read of other work on the incidence of a D.C.T. on methyldopa from other parts of Asia and Africa. Perhaps a coordinated world project is necessary. The variation in the incidence of a D.C.T. on methyldopa is an important example of how differently various racial groups respond as regards control of blood pressure and side-effects. It seems that besides a genetic factor, environment and the variation of diet and climate may play a part. Hypertension Clinic, Department of Medicine, University of Natal Y. K. SEEDAT and King Edward VIII Hospital, E. I. VAWDA. of South Africa. Durban, Republic
that in every patient who bleeds excessively after a midtrimester abortion (or any other time), an immediate uterine exploration is undertaken. Since simple hysterectomy has been useless in these cases, the surgeon must be skilled in ligation of the hypogastric artery. One of these patients died. Stanford
University Medical Center, Stanford, California 94305, U.S.A.
ABORTION: CHANGING ATTITUDES OF PSYCHIATRISTS
SIR,-During 1967 the Society of Clinical Psychiatrists conducted a survey of its members’ attitudes to therapeutic The result of the first hundred replies was abortion. published in that year.1 During 1971, with an increased membership, an essentially similar questionary was sent to Society members. A statistically significant shift in opinion towards a more " permissive " approach is clearly demonstrated in the replies of that 40% of the Society’s U.K. members who returned the completed questionary. A choice of one of four opinions was sought as to the conditions under which termination of pregnancy was considered advisable: (1) Free choice of abortion by the woman in the first trimester of pregnancy. (2) Termination should be recommended if the woman’s health or life is seriously threatened-the decision to include appraisal of the whole social situation. (3) Termination possible only if the woman’s health or life is seriously threatened-the medical viewpoint before present legislation. (4) Termination insupportable
your comments
(Dec. 4,
p.
1239)
amniotic-fluid or
embolism, myocardial infarction, placenta abruptio being considered instead. It is essential
Seedat, Y. K., Vawda, E. I. Lancet, 1968, i, 427. Carstairs, K. C., Breckenridge, A., Dollery, C. T., Worlledge, S. M. ibid. 1966, ii, 133. 3. Burns-Cox, C. J. ibid. 1970, ii, 673. 4. Goodlin, R. C. Obstet. Gynec. 1969, 34, 891. 1. 2.
any account at any stage.
on
the safety of therapeutic abortions, I should like to describe three cases of uterine rupture in midtrimester abortions which were nearly carbon copies of one another. The patients’ ages ranged from 29 to 34, and they had had between two and five full-term children. Their were abortions with therapeutic accomplished hypertonic saline and oxytocin at approximately the 20th week of gestation (fetal weight 450-510 g.). They all complained of severe pelvic pain and had vaginal bleeding towards the end of their labour. The placentas delivered before the fetuses (which suggested that a placenta prasvia had been present); the fetuses were all in a breech presentation; and there was difficulty in delivering the fetal heads. Immediately post partum, heavy vaginal bleeding occurred, but with maternal shock out of proportion to the external blood-loss. The reason for the bleeding and shock in each case was uterine rupture in the area of the right uterine artery with formation of a large retroperitoneal hasmatoma. Histological examination of the uterus in all three showed a fundal placental implantation site with no suggestion to explain the uterine rupture. Despite considerable speculation, I have no explanation for the association of right-sided uterine rupture and false placenta prxvia in older multigravida undergoing late 2nd trimester abortion. Although I have briefly described such a case, the possibility of uterine rupture at this period in gestation seems to be ignored by most clinicians with such diagnoses as
praevia
on
Analysis of Replies
RISKS OF LEGAL ABORTION
SIR,-Concerning
ROBERT GOODLIN
The most conspicuous change over the four years, as identified from the replies of admittedly limited samples of senior psychiatrists, has been a 75% increase in the proportion of psychiatrists replying in favour of free choice by the woman during the first three months as to whether she wishes or not to carry on with her pregnancy.
J. C. LITTLE,
Crichton Royal,
Dumfries,
Honorary Secretary, Society of Clinical Psychiatrists.
Scotland.
LEVODOPA INEFFECTIVE IN MIGRAINE
al. reported the case of a 56-year-old typical parkinsonian syndrome and, in addition, typical frequent attacks of migraine. She was treated with levodopa 2-5 g. daily for a period of 7 months, during which she was free of migraine attacks and the parkinsonism was improved. The migraine attacks recurred when a placebo was substituted for the levodopa. We have done a pilot study of this treatment in a group of
SiR,-Antunes
woman
who had
et a
patients with otherwise intractable migraine. There were 6 patients (2 men and 4 women aged 25-58 years). All had had typical migraine attacks for at least 10 years, with at least one attack every week. No previous treatment had proved successful. None had symptoms of Parkinson’s disease.
During the study, the patients were seen every month. The initial dose of levodopa was 250 mg. three times daily, 1. 2.
Howells, J. A. Lancet, 1967, i, 728. Antunes, J. L., Macedo, C., Damasio,
A. R. ibid. 1970,
ii,
928.
that in every patient who bleeds excessively after a midtrimester abortion (or any other time), an immediate uterine exploration is undertaken. Since simple hysterectomy has been useless in these cases, the surgeon must be skilled in ligation of the hypogastric artery. One of these patients died. Stanford
University Medical Center, Stanford, California 94305, U.S.A.
ABORTION: CHANGING ATTITUDES OF PSYCHIATRISTS
SIR,-During 1967 the Society of Clinical Psychiatrists conducted a survey of its members’ attitudes to therapeutic The result of the first hundred replies was abortion. published in that year.1 During 1971, with an increased membership, an essentially similar questionary was sent to Society members. A statistically significant shift in opinion towards a more " permissive " approach is clearly demonstrated in the replies of that 40% of the Society’s U.K. members who returned the completed questionary. A choice of one of four opinions was sought as to the conditions under which termination of pregnancy was considered advisable: (1) Free choice of abortion by the woman in the first trimester of pregnancy. (2) Termination should be recommended if the woman’s health or life is seriously threatened-the decision to include appraisal of the whole social situation. (3) Termination possible only if the woman’s health or life is seriously threatened-the medical viewpoint before present legislation. (4) Termination insupportable
your comments
(Dec. 4,
p.
1239)
amniotic-fluid or
embolism, myocardial infarction, placenta abruptio being considered instead. It is essential
Seedat, Y. K., Vawda, E. I. Lancet, 1968, i, 427. Carstairs, K. C., Breckenridge, A., Dollery, C. T., Worlledge, S. M. ibid. 1966, ii, 133. 3. Burns-Cox, C. J. ibid. 1970, ii, 673. 4. Goodlin, R. C. Obstet. Gynec. 1969, 34, 891. 1. 2.
any account at any stage.
on
the safety of therapeutic abortions, I should like to describe three cases of uterine rupture in midtrimester abortions which were nearly carbon copies of one another. The patients’ ages ranged from 29 to 34, and they had had between two and five full-term children. Their were abortions with therapeutic accomplished hypertonic saline and oxytocin at approximately the 20th week of gestation (fetal weight 450-510 g.). They all complained of severe pelvic pain and had vaginal bleeding towards the end of their labour. The placentas delivered before the fetuses (which suggested that a placenta prasvia had been present); the fetuses were all in a breech presentation; and there was difficulty in delivering the fetal heads. Immediately post partum, heavy vaginal bleeding occurred, but with maternal shock out of proportion to the external blood-loss. The reason for the bleeding and shock in each case was uterine rupture in the area of the right uterine artery with formation of a large retroperitoneal hasmatoma. Histological examination of the uterus in all three showed a fundal placental implantation site with no suggestion to explain the uterine rupture. Despite considerable speculation, I have no explanation for the association of right-sided uterine rupture and false placenta prxvia in older multigravida undergoing late 2nd trimester abortion. Although I have briefly described such a case, the possibility of uterine rupture at this period in gestation seems to be ignored by most clinicians with such diagnoses as
praevia
on
Analysis of Replies
RISKS OF LEGAL ABORTION
SIR,-Concerning
ROBERT GOODLIN
The most conspicuous change over the four years, as identified from the replies of admittedly limited samples of senior psychiatrists, has been a 75% increase in the proportion of psychiatrists replying in favour of free choice by the woman during the first three months as to whether she wishes or not to carry on with her pregnancy.
J. C. LITTLE,
Crichton Royal,
Dumfries,
Honorary Secretary, Society of Clinical Psychiatrists.
Scotland.
LEVODOPA INEFFECTIVE IN MIGRAINE
al. reported the case of a 56-year-old typical parkinsonian syndrome and, in addition, typical frequent attacks of migraine. She was treated with levodopa 2-5 g. daily for a period of 7 months, during which she was free of migraine attacks and the parkinsonism was improved. The migraine attacks recurred when a placebo was substituted for the levodopa. We have done a pilot study of this treatment in a group of
SiR,-Antunes
woman
who had
et a
patients with otherwise intractable migraine. There were 6 patients (2 men and 4 women aged 25-58 years). All had had typical migraine attacks for at least 10 years, with at least one attack every week. No previous treatment had proved successful. None had symptoms of Parkinson’s disease.
During the study, the patients were seen every month. The initial dose of levodopa was 250 mg. three times daily, 1. 2.
Howells, J. A. Lancet, 1967, i, 728. Antunes, J. L., Macedo, C., Damasio,
A. R. ibid. 1970,
ii,
928.