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ENALAPRIL-INDUCED COUGH
918 RITODRINE DOSE AND ECG FINDINGS
for which they may persist has not been investigated. A 53-year-old woman presented with a 2 week history of a pink vaginal discharge. 14 years previously she had undergone a total abdominal hysterectomy and right salpingo-oophorectomy for a non-malignant condition. 6 weeks before being referred to the gynaecologist she had had what seemed to be a pulmonary embolism and had been prescribed anticoagulants. On speculum examination of the vagina there was obvious granulation tissue at the vault. This was avulsed. Histopathological examination confirmed the presence of granulation tissue only. The vault was then cauterised and was seen to be well healed on subsequent review. This case shows not only that vault granulation tissue can take very much longer to resolve spontaneously than is currently thought but also that symptoms attributable to this may develop after a long quiescence, the trigger here being anticoagulation. It may be important to ensure adequate follow-up for women who have vault granulations cauterised to confirm complete eradication. University Department of Obstetrics and Gynaecology, Leicester Royal Infirmary,
PAUL WOOD
Leicester LE2 7LX
In pregnancy the intravascular volume increases, peripheral vascular resistance falls, and cardiac output rises,3 in combination with relative anaemia and increased oxygen consumption. Thus, the addition of 0 receptor stimulation, further increasing oxygen consumption, may induce myocardial ischaemia. 1,4 Even so myocardial ischaemia is thought of as a rare, albeit potentially serious, complication of (3z sympathomimetic treatment. We found significant ST segment depression in the anteroseptal leads in 73 % of patients receiving ritodrine. This change is highly suggestive of myocardial ischaemia.s Furthermore, in three out of four patients echocardiography revealed septal hypokinesia, an independent indicator of myocardial ischaemia. These findings question the advisability of using &bgr;2-sympathomimetic drugs in the treatment of premature uterine contractions. Although acute myocardial necrosis is rare,’ silent ischaemia could contribute to the cardiomyopathy that has been reported after prolonged ritodrine treatment.6 Hendricks et alreporting similar ECG findings in ritodrine-treated women, suggest that these changes are not likely to represent mycocardial ischaemia, but this view is not supported by the parallel echocardiographic recordings reported here. Departments of Obstetrics and Gynaecology, Rebecca Sieff Government Hospital
Department of Cardiology, Rebecca Sieff Government Hospital, Safed, Safed 13100, Israel
IZHAR BEN-SHLOMO
SHIFRA ZOHAR ALON MARMOR* DAVID S. BLONDHEIM TALI SHARIR
*Faculty of Medicine, Technion, Haifa, Israel. 1. Katz M, Robertson P, Creasy RK. Cardiovascular complications associated with terbutaline treatment for preterm labor. Am J Obstet Gynecol 1981; 139: 605-08. 2. Cohn PF Silent myocardial ischemia in patients with a defective anginal warning system. Am J Cardiol 1980; 45: 697-702. 3. Sullivan JM, Ramanthan KB. Management of medical problems in pregnancy— severe cardiac disease. N Engl J Med 1985; 313: 304-08. 4. Benedetti TJ Maternal complications of parenteral beta-sympathomimetic therapy for premature labor. Am J Obstet Gynecol 1983; 145: 1-6. 5. Rijneke RD, Ascoop CA, Talmon JL. Clinical significance of upsloping S-T segment in exercise ECG. Circulation
1980; 61: 671-78. 6. Dhmaut JF, Boutonnet G, Weber S, et al Responsabilite des betamimetiques presents au cours de la grossesse dans la genese d’une cardiomyopathie du post-partum. Nouv Presse Méd 1978; 7: 4058-62. 7. Hendricks SK, Keroes J, Katz M. Electrocardiographic changes associated with ritodrin-induced maternal tachycardia and hypokalemia Am J Obstet Gynecol 1986; 154: 921-23
1. Greenhalf
JO. Vaginal vault granulation tissue following total abdominal hysterectomy. Br J Clin Pract 1972; 26: 247-49. 2. Howkins J, Williams DK. Vault granulations after total abdominal hysterectomy.J Obstet Gynaecol Br Commonw 1968; 75: 84-86.
ENALAPRIL-INDUCED COUGH
SIR,--Cough and wheeze have been described as possible undesirable side-effects of angiotensin-converting enzyme (ACE) inhibitors.l°2 The first report of this complication was with captopril. Bronchospasm has also been reported in this context, in patients with or without a history of asthma. 2,3 We describe here a patient who had a chronic cough while taking enalapril. A 61-year-old woman who had never smoked had been taking enalapril 10 mg daily for a year because of hypertension. Soon after the start of treatment she had a severe dry cough, sometimes accompanied by nausea and vomiting. No environmental or predisposing factors could be found. The patient had no personal or family history of atopy. She was in good general condition, with no respiratory symptoms apart from the cough and no sign of left heart failure or oesophageal reflux. Her blood pressure was 130/80 mm Hg. Chest X-ray, lung function tests (no change was observed after 5000 ug acetylcholine), and fibreoptic bronchoscopy were normal. On the assumption that the patient’s cough was due to enalapril, the drug was withdrawn; the symptoms soon disappeared and have not reappeared. The timing of symptoms in relation to treatment and the exclusion of other causes of cough strongly argue that enalapril was responsible. The mechanism is unclear, though kinins3 may be involved: plasma kinin levels rise during ACE inhibition3 and kinins can provoke bronchoconstriction in patients with asthma. However, our patient had no background of bronchial hyperreactivity. Whatever the mechanism, cough should be added to the list of side-effects of enalapril. Department of Lung Diseases, Hôpital Laennec, 75007 Pans, France
D. ISRAEL-BIET C. DELAISEMENTS J. CHRETIEN
1. Sesoko
S, Kaneko Y. Cough associated with the use of captopril. Arch Intern Med 1985; 145: 1524. 2. Semple P, Herd G. Cough and wheeze caused by inhibitors of angiotensin-converting enzyme. N Engl J Med 1986; 314: 61. 3. Gavras H, Brunner H, Turini G, et al. Antihypertensive effect of the oral angiotensinconverting enzyme inhibitors SQ14225 in man. N Engl J Med 1978; 298: 991-95.
PERSISTENCE OF VAGINAL VAULT GRANULATION
SIR,-Vault granulation after total abdominal hysterectomy is a common postoperative finding, having been identified in up to 37 % of hysterectomised patients 8 weeks after surgery.’ Of these, 63% had symptoms attributable to the granulations, and these can vary from postcoital bleeding to vaginal discharge. The prevalence of vault granulation may depend on operative technique, being higher if the vault is left open at the time of surgery.2 Spontaneous resolution is thought to take weeks or months, but the length of time
ASTHMA DEATHS AND INHALER TYPE
SIR,-Dr Bumey (Aug 9, p 323) states that asthma mortality rose sharply in several countries, including England and Wales in the 1960s and that asthma mortality may be rising in the United States, which was unaffected by the previous epidemic. May I offer possible explanations. (1) Until the mid-1960s the most widely used method of controlling acute asthma attacks was by an aqueous solution of
for which they may persist has not been investigated. A 53-year-old woman presented with a 2 week history of a pink vaginal discharge. 14 years previously she had undergone a total abdominal hysterectomy and right salpingo-oophorectomy for a non-malignant condition. 6 weeks before being referred to the gynaecologist she had had what seemed to be a pulmonary embolism and had been prescribed anticoagulants. On speculum examination of the vagina there was obvious granulation tissue at the vault. This was avulsed. Histopathological examination confirmed the presence of granulation tissue only. The vault was then cauterised and was seen to be well healed on subsequent review. This case shows not only that vault granulation tissue can take very much longer to resolve spontaneously than is currently thought but also that symptoms attributable to this may develop after a long quiescence, the trigger here being anticoagulation. It may be important to ensure adequate follow-up for women who have vault granulations cauterised to confirm complete eradication. University Department of Obstetrics and Gynaecology, Leicester Royal Infirmary,
PAUL WOOD
Leicester LE2 7LX
In pregnancy the intravascular volume increases, peripheral vascular resistance falls, and cardiac output rises,3 in combination with relative anaemia and increased oxygen consumption. Thus, the addition of 0 receptor stimulation, further increasing oxygen consumption, may induce myocardial ischaemia. 1,4 Even so myocardial ischaemia is thought of as a rare, albeit potentially serious, complication of (3z sympathomimetic treatment. We found significant ST segment depression in the anteroseptal leads in 73 % of patients receiving ritodrine. This change is highly suggestive of myocardial ischaemia.s Furthermore, in three out of four patients echocardiography revealed septal hypokinesia, an independent indicator of myocardial ischaemia. These findings question the advisability of using &bgr;2-sympathomimetic drugs in the treatment of premature uterine contractions. Although acute myocardial necrosis is rare,’ silent ischaemia could contribute to the cardiomyopathy that has been reported after prolonged ritodrine treatment.6 Hendricks et alreporting similar ECG findings in ritodrine-treated women, suggest that these changes are not likely to represent mycocardial ischaemia, but this view is not supported by the parallel echocardiographic recordings reported here. Departments of Obstetrics and Gynaecology, Rebecca Sieff Government Hospital
Department of Cardiology, Rebecca Sieff Government Hospital, Safed, Safed 13100, Israel
IZHAR BEN-SHLOMO
SHIFRA ZOHAR ALON MARMOR* DAVID S. BLONDHEIM TALI SHARIR
*Faculty of Medicine, Technion, Haifa, Israel. 1. Katz M, Robertson P, Creasy RK. Cardiovascular complications associated with terbutaline treatment for preterm labor. Am J Obstet Gynecol 1981; 139: 605-08. 2. Cohn PF Silent myocardial ischemia in patients with a defective anginal warning system. Am J Cardiol 1980; 45: 697-702. 3. Sullivan JM, Ramanthan KB. Management of medical problems in pregnancy— severe cardiac disease. N Engl J Med 1985; 313: 304-08. 4. Benedetti TJ Maternal complications of parenteral beta-sympathomimetic therapy for premature labor. Am J Obstet Gynecol 1983; 145: 1-6. 5. Rijneke RD, Ascoop CA, Talmon JL. Clinical significance of upsloping S-T segment in exercise ECG. Circulation
1980; 61: 671-78. 6. Dhmaut JF, Boutonnet G, Weber S, et al Responsabilite des betamimetiques presents au cours de la grossesse dans la genese d’une cardiomyopathie du post-partum. Nouv Presse Méd 1978; 7: 4058-62. 7. Hendricks SK, Keroes J, Katz M. Electrocardiographic changes associated with ritodrin-induced maternal tachycardia and hypokalemia Am J Obstet Gynecol 1986; 154: 921-23
1. Greenhalf
JO. Vaginal vault granulation tissue following total abdominal hysterectomy. Br J Clin Pract 1972; 26: 247-49. 2. Howkins J, Williams DK. Vault granulations after total abdominal hysterectomy.J Obstet Gynaecol Br Commonw 1968; 75: 84-86.
ENALAPRIL-INDUCED COUGH
SIR,--Cough and wheeze have been described as possible undesirable side-effects of angiotensin-converting enzyme (ACE) inhibitors.l°2 The first report of this complication was with captopril. Bronchospasm has also been reported in this context, in patients with or without a history of asthma. 2,3 We describe here a patient who had a chronic cough while taking enalapril. A 61-year-old woman who had never smoked had been taking enalapril 10 mg daily for a year because of hypertension. Soon after the start of treatment she had a severe dry cough, sometimes accompanied by nausea and vomiting. No environmental or predisposing factors could be found. The patient had no personal or family history of atopy. She was in good general condition, with no respiratory symptoms apart from the cough and no sign of left heart failure or oesophageal reflux. Her blood pressure was 130/80 mm Hg. Chest X-ray, lung function tests (no change was observed after 5000 ug acetylcholine), and fibreoptic bronchoscopy were normal. On the assumption that the patient’s cough was due to enalapril, the drug was withdrawn; the symptoms soon disappeared and have not reappeared. The timing of symptoms in relation to treatment and the exclusion of other causes of cough strongly argue that enalapril was responsible. The mechanism is unclear, though kinins3 may be involved: plasma kinin levels rise during ACE inhibition3 and kinins can provoke bronchoconstriction in patients with asthma. However, our patient had no background of bronchial hyperreactivity. Whatever the mechanism, cough should be added to the list of side-effects of enalapril. Department of Lung Diseases, Hôpital Laennec, 75007 Pans, France
D. ISRAEL-BIET C. DELAISEMENTS J. CHRETIEN
1. Sesoko
S, Kaneko Y. Cough associated with the use of captopril. Arch Intern Med 1985; 145: 1524. 2. Semple P, Herd G. Cough and wheeze caused by inhibitors of angiotensin-converting enzyme. N Engl J Med 1986; 314: 61. 3. Gavras H, Brunner H, Turini G, et al. Antihypertensive effect of the oral angiotensinconverting enzyme inhibitors SQ14225 in man. N Engl J Med 1978; 298: 991-95.
PERSISTENCE OF VAGINAL VAULT GRANULATION
SIR,-Vault granulation after total abdominal hysterectomy is a common postoperative finding, having been identified in up to 37 % of hysterectomised patients 8 weeks after surgery.’ Of these, 63% had symptoms attributable to the granulations, and these can vary from postcoital bleeding to vaginal discharge. The prevalence of vault granulation may depend on operative technique, being higher if the vault is left open at the time of surgery.2 Spontaneous resolution is thought to take weeks or months, but the length of time
ASTHMA DEATHS AND INHALER TYPE
SIR,-Dr Bumey (Aug 9, p 323) states that asthma mortality rose sharply in several countries, including England and Wales in the 1960s and that asthma mortality may be rising in the United States, which was unaffected by the previous epidemic. May I offer possible explanations. (1) Until the mid-1960s the most widely used method of controlling acute asthma attacks was by an aqueous solution of