- Email: [email protected]
INTERPRETATION OF FETAL BREATHING MOVEMENTS IN OLIGOHYDRAMNIOS DUE TO MEMBRANE RUPTURE
182
probable identification of this toxin as p-N-methylamino-L-alanine and the development of a primate model may have important implications in neuroscience research.1 It would seem appropriate to ban or strongly discourage the use of cycad products, especially seeds, as foods or traditional medicines, and to look for similar exposure to cycad products in patients with motoneurone disease in other regions in the tropics. However, readers may be confused to be told that cycads have been used as food, as "types of sago and arrowroot". Sago is usually prepared from the starchy pith of the trunk of the sago palm Metroxylon sagu just before flowering, and it is still the food staple of several groups of people, especially in the Fly and Sepik river areas of Papua New Guinea. It is the only common staple prepared from a tree, in a very labour-intensive process, and is poorly nutritious. When alternatives such as rice or sweet potato are available it is readily abandoned. It is commercially grown in Malaysia, where it is usually produced for human consumption as pearl sago from which a delicious milk pudding can be prepared. Sago from the pith of the cycad palm (Japanese sago) is not now commercially produced. Arrowroot, traditionally used to poultice arrow wounds, is usually prepared from the rhizome of the West Indian arrowroot herb (Maranta arundinacea).It is these days used for cooking, especially in sauces, and most of it comes from the Caribbean. The usual sources of sago and arrowroot should be appreciated before people with motoneurone disease are closely questioned about annual consumption of sago pudding or the use of arrowroot, and before these products are banned from the kitchen or dining table. Tropical Medicine Unit, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford OX3 9DU CHARLES F. GILKS 1. Spencer PS, Nunn PB, Hugson J, et al. Guam amyotrophic lateral sclerosisParkinsonism-dementia linked to a plant excitant neurotoxia. Science 1987; 237:
TABLE II-HEAD-INJURY CASES SEEN (ARR) AND ADMITTED (HOSP) TO HOSPITAL FOR HEAD INJURY IN MOTORCYCLE OR MOPED ACCIDENTS IN SEPTEMBER TO OCTOBER, 1985, AND IN THE SAME MONTHS IN 1986 .
the
SAFETY HELMET LAW IN ITALY
SIR,---.:.on July 18, 1986, a law making compulsory the wearing of safety helmet by motorcyclists and moped riders came into force in Italy. Italy has about 1700 000 motorcycles and 3500 000 mopeds
a
her roads; and some 2500 riders die every year, with another 80 000 injuries. To evaluate the effects of the safety helmet legislation we have been monitoring the prevalence of helmet use on Italian urban roads and the incidence of head injury in accidents involving two-wheel vehicles seen in casualty departments. Full details will be reported elsewhere (in Italian) but’we thought that a summary might be helpful. Table I reports the frequency of helmet use before the law came into force and afterwards in a stratified sample survey of two hundred locations throughout Italy. The rate is now about 100% for motorcyclists; it is only 50% for moped users because the legislation here applies to teenagers only. We confined our study to urban zones because on motorways and non-urban roads we had noted that the percentage of safety helmet wearing was already over 90% and more than 85% of all two-wheeler accidents in Italy happen on urban roads. Unfortunately Italy has no systematic reporting system for road-traffic accidents. Instead we collected data on head injuries from two-wheeler accidents in September, October, and November, 1985 (before the law), and in 1986 from thirty hospitals in fifteen cities. There has been a fall of about half in hospital admissions for head trauma in motorcyclists and of about 30 % for on
TABLE I-SAFETY HELMET USE BEFORE LEGISLATION AND AFTER .
JULY
18, 1986
figures
contain
the upper data and data where
we
had
no
information about the
.
moped users (table n). We used a mathematical model,l taking into account the prevalence of safety helmet wearing before and after the legislation and relative risk of unhelmeted/helmeted people, and estimated a decrease of 48-9% for motorcyclists and of 24-7% for moped riders. This model yields a reduction in mortality of around 33 %, confirming the figure of about 30 % suggested by preliminary data from the police. Also confirming the validity of our mathematical model is the agreement between prediction and observation for all injuries. Marchi et al2 reported a decrease in head injuries (as the model forecasts) but not in injuries to legs, arms, and so on. We are confident that the observed reduction in mortality and morbidity is due to the safety helmet use. Italian legislation on the compulsory use of safety helmet use has had a great impact on injuries, amounting, we estimate, to 600 deaths avoided and 15 000 injuries spared in a year. In our opinion the legislation should be extended to all moped users and we hope that our findings will help to speed up the approval of safety-belts legislation, now under discussion in the Italian Parliament. This study has been a cooperative one between the Italian National Health Institute (Istituto Superiore di Sanita’) and urban police officers (Associazione Nazionale tra Comandanti ed Ufficiali dei Corpi di Polizia
517-22.
ITS INTRODUCTION IN
*These user.
Municipale, Viareggio). Epidemiology and Biostatistics Laboratory, Istituto Superiore di Sanita’, 00161, Rome, Italy F. A mathematical model
FRANCO TAGGI
evaluate the mortality variation by before-after Taggi prevalence of the use of safety helmet (in Italian) Med Trasporti 1984; 5: 51-60. 2. Marchi AG, et al. Effectiveness of the safety helmet in teenagers (in Italian). Med Bambino 1987, 2: 6. 1
to
INTERPRETATION OF FETAL BREATHING MOVEMENTS IN OLIGOHYDRAMNIOS DUE TO MEMBRANE RUPTURE
SIR,-Dr Moessinger and colleagues (Dec 5, p 1296) support our clinical findings (July 18, p 129, and ref 1) that oligohydramnios due to premature and prolonged rupture of the membranes (PROM) does not necessarily have an unfavourable outcome. In The Lancet, we reported 11 such pregnancies, 5 of which were associated with pulmonary hypoplasia, compared with 4 of 10 by Moessinger et al. We have now investigated a larger series of 35 such pregnancies1 all with PROM for longer than 1 week, membrane rupture occurring at 15-32 weeks. In none of the 35 was there evidence of antenatal infection or any other pregnancy complication. 13 of the 35 cases were associated with intrauterine or neonatal death, but in only 8 was there necropsy evidence of pulmonary hypoplasia. All 35 cases were regularly scanned for fetal breathing movements (FBM).2 In 24 cases FBM persisted: 20 infants suvived and 4 infants, all premature deliveries, died (3 of severe respiratory distress syndrome and 1 of septicaemia). In 9 cases FBM were not found, despite a total of 84 h of ultrasound examination. Necropsies in 8 of the 9 revealed pulmonary hypoplasia.3,4 These results confirm our earlier fmdings that the absence of FBM is a reliable indicator of unfavourable outcome due to abnormal lung growth. Moessinger and colleagues, however, apparently detected FBM in all pregnancies irrespective of outcome. This discrepancy may be explained by differences in the definition of FBM. Moessinger et al defined fetuses to be breathing if at least three breaths were detected within a 6 s period; this
183
"epoch" of breathing activity ended when less than three valid breaths occurred within this timeframe. We, however, considered fetuses to be breathing only if an episode of movements was continuous for at least 60 s during a 30 min observation period, which was extended for up to 2 h if no such episodes were seen. A breath-to-breath interval of more than 6 s was taken to indicate cessation of breathing. Our definition has been used extensively before and emphasises the importance of sustained respiratory effort for a defined time.2,5,6 Although Castle and Tumbulf suggested 20 s or more may be sufficient, most investigators use at least 30 or 60 S.2,5,6,8,9 "Breathing activity" may occur before death in utero from a variety of insults, but usually as gasps or brief episodes of abnormal breathing."* Moessinger and colleagues’ use of a short period such as 6 s could include such activity and we believe this could be incorrectly interpreted as "FBM present". Indeed, in our series, fetuses who subsequently died of pulmonary hypoplasia did make breathing movements which we interpreted as gasps, as none of these episodes were sustained for a 60 s period with a breath-tobreath interval of less than 6 s. Our results suggest that "sustained" breathing activity rather than the short epochs described by Moessinger et al is important for continuing antenatal lung growth in cases of oligohydramnios due to PROM. ANNE GREENOUGH Department of Child Health, MARGARET BLOTT King’s College School of K. NICOLAIDES Medicine-and Dentistry, STUART CAMPBELL London SE5 9PJ 1. Blott M,
Greenough A. Oligohydramnios in the second trimester of pregnancy: Fetal breathing and normal lung growth. Early Hum Devel (in press). 2 Roberts AD, Griffin D, Mooney R, Cooper DJ, Campbell S. Fetal activity in 100 normal third trimester pregnancies. Br J Obstet Gynaecol 1980; 87: 480-84. 3. Cooney TP, Thurlbeck WM. Pulmonary hypoplasia in Down’s syndrome. N Engl J Med 1982; 207: 1170-73.
Emery JL, Mithal A. The alveoli in the terminal respiratory unit of man during late intrauterine life and childhood. Arch Dis Child 1960; 35: 544-47. 5. Manning FA, Platt LD, Sipos L. Antepartum fetal evaluation: Development of a fetal biophysical profile. Am J Obstet Gynecol 1980; 136: 787-95. 6. Vintzileos AM, Campbell WA, Ingardia CJ, Nochimson DJ. The fetal biophysical profile and its predictive value. Obstet Gynecol 1983; 62: 271-78. 7. Castle BM, Turnbull AC. The presence or absence of fetal breathing movements predicts the outcome of preterm labour. Lancet 1983; ii: 471-73. 8. Vintzileos AM, Campbell WA, Nochimson DJ, Weinbaum PJ. Fetal breathing as a predictor of infection in premature rupture ofthe membranes. Obstet Gynecol 1986; 4.
67: 813-17.
Manning FA, Platt LD. Fetal breathing movements and the abnormal contraction stress test. Am J Obstet Gynecol 1979; 133: 590-93. 10. Patrick JE, Dalton KJ, Dawes GS. Breathing patterns before detah in fetal lambs. Am J Obstet Gynecol 1976; 125: 73-78. 9.
FETAL VIABILILTY IN MULTIPLE PREGNANCY
SIR,-Dr Stabile and colleagues (Nov 28, p 1237) report that early ultrasound examination will identify a large proportion of pregnancies destined to continue when spontaneous abortion threatens. At 5-8 weeks, identification of a live fetus rarely results in spontaneous abortion. We have observed the effect of identification of the fetal heart at 5-8 weeks in multiple gestations resulting from in-vitro fertilisation. After transfer of 3 or 4 embryos all patients were offered ultrasound examination, primarily to identify the number of embryos implanted and to aid diagnosis of ectopic pregnancy. Multiple gestation sacs (2-4) were observed at 6-8 weeks’ gestation in 106 patients between September, 1984, and April, 1987. 5 patients had no demonstrable live fetus in any sac (all twin sacs). All miscarried and were excluded from further analysis. Of the 101patients in which one or more fetal hearts were identified, 98 (97%) have either now delivered one or more live infants or have one or more ongoing pregnancies above 28 weeks’ gestation. A fetal heart was identified in 178 gestation sacs. 172 (96 6%) of these are either ongoing (containing a live fetus over 28 weeks’ gestation, n = 38) or have resulted in delivery of a live infant (n= 134). A fetal heart was not identified in 53 sacs (22-9% of the total). 52 of these resulted in the demise of the sac and 1(19 %) in a live birth. The number of fetal hearts seen was less than the number of gestation sacs in 31 % patients with 2 sacs, 53 % patients with 3 sacs
miscarried a live fetus. The miscarriage rate was similar to the group in which all sacs contained a live fetus (7-8%). That an empty sac does not affect eventual outcome is therefore true for higher order
pregnancies too. The positive reassurance of ongoing pregnancy when a fetal heart is identified by ultrasonography at 6-8 weeks can be extended to multiple pregnancies where 2-4 sacs are present. Academic Department of Obstetrics and Gynaecology, King’s College School of Medicine and Dentistry, London SE5 8RX
JULIAN S. PAMPIGLIONE
Hallam Medical Centre, London WIN 5LR
BRIDGETT A. MASON LIMITATIONS OF GIFT
SIR,-We have completed more than 1700 gamete intrafallopian (GIFT) operations and consider this treatment to be an important part of any comprehensive fertility service. However, despite the promotion of GIFT as a simpler alternative to in-vitro fertilisation (IVF) for use in district general hospitals, we are cautious in recommending it as a first option for most patients with open fallopian tubes who are resistant to conventional treatment. GIFT may fail to fulfil the hopes of both specialists and infertile couples. transfer
The main difference between GIFT and IVF is that fertilisation in vivo rather than in vitro. Both require the same organisational work-up. There are advantages to GIFT in patients with a record of fertilisation (ie, a previous pregnancy or IVF) but there are limitations to GIFT alone in those in whom fertilisation has not been proven, especially when sperm counts are thought to be equivocal or suboptimum. GIFT should, ideally, be undertaken in conjunction with, rather than in isolation from, IVF. If the technical skill needed to handle gametes and culture media that is necessary with GIFT is available then IVF is also possible. The use of both techniques together provides a clearer understanding of the nature of difficult cases of infertility and their management. This has particular relevance to some patients with "unexplained" infertility or endometriosis and in some with polycystic ovaries who have failed to conceive by alternative means. They may have lower fertilisation and pregnancy occurs
potential. We do not recommend GIFT as the primary treatment in patients with suboptimum sperm counts. Analysis of our first 1000 procedures shows that GIFT with poor sperm has a significantly reduced chance of success. Similarly, there are limitations to GIFT in certain groups if no more than four oocytes are transferred. Your Oct 24 editorial refers to IVF and GIFT as if they were totally separate entities. They are not. If the ability to do both is not available some patients treated unsuccessfully by GIFT may remain unaware of the cause of their infertility and of its potential resolution. The question whether fertilisation is possible will not have been answered. GIFT is a welcome addition to a range of fertility options but it is no panacea. It is not ideal to use this method of assisted reproduction on an empirical basis without the provision of IVF.
.
and all
patients with 4 sacs.
In these
patients only 2 out of 36 (6%)
Fertility & IVF Unit, Humana Hospital Wellington, London NW8 9LE
IAN CRAFT PETER R. BRINSDEN ERIC G. SIMONS PAUL M. LEWIS
NEEDLE SIZE AND RISK OF MISCARRIAGE AFTER
AMNIOCENTESIS
SiR,—In our randomised controlled trial of genetic amniocentesis in low-risk women1 we stated that an 18G needle (outer diameter 1-2 mm) was used. Others2" have correlated this needle size with the 1 -0 % miscarriage rate (95 % confidence interval 0-3-1-5) we found. We now know that the amniocenteses were done with a 20G needle (1-0 mm). Embarrassing though it is we felt that this information had to be made available because we found a higher miscarriage rate after amniocentesis than most other workers had done. Ours is the only randomised controlled trial to have been published and, with the above amendment, it now fulfils all the
probable identification of this toxin as p-N-methylamino-L-alanine and the development of a primate model may have important implications in neuroscience research.1 It would seem appropriate to ban or strongly discourage the use of cycad products, especially seeds, as foods or traditional medicines, and to look for similar exposure to cycad products in patients with motoneurone disease in other regions in the tropics. However, readers may be confused to be told that cycads have been used as food, as "types of sago and arrowroot". Sago is usually prepared from the starchy pith of the trunk of the sago palm Metroxylon sagu just before flowering, and it is still the food staple of several groups of people, especially in the Fly and Sepik river areas of Papua New Guinea. It is the only common staple prepared from a tree, in a very labour-intensive process, and is poorly nutritious. When alternatives such as rice or sweet potato are available it is readily abandoned. It is commercially grown in Malaysia, where it is usually produced for human consumption as pearl sago from which a delicious milk pudding can be prepared. Sago from the pith of the cycad palm (Japanese sago) is not now commercially produced. Arrowroot, traditionally used to poultice arrow wounds, is usually prepared from the rhizome of the West Indian arrowroot herb (Maranta arundinacea).It is these days used for cooking, especially in sauces, and most of it comes from the Caribbean. The usual sources of sago and arrowroot should be appreciated before people with motoneurone disease are closely questioned about annual consumption of sago pudding or the use of arrowroot, and before these products are banned from the kitchen or dining table. Tropical Medicine Unit, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford OX3 9DU CHARLES F. GILKS 1. Spencer PS, Nunn PB, Hugson J, et al. Guam amyotrophic lateral sclerosisParkinsonism-dementia linked to a plant excitant neurotoxia. Science 1987; 237:
TABLE II-HEAD-INJURY CASES SEEN (ARR) AND ADMITTED (HOSP) TO HOSPITAL FOR HEAD INJURY IN MOTORCYCLE OR MOPED ACCIDENTS IN SEPTEMBER TO OCTOBER, 1985, AND IN THE SAME MONTHS IN 1986 .
the
SAFETY HELMET LAW IN ITALY
SIR,---.:.on July 18, 1986, a law making compulsory the wearing of safety helmet by motorcyclists and moped riders came into force in Italy. Italy has about 1700 000 motorcycles and 3500 000 mopeds
a
her roads; and some 2500 riders die every year, with another 80 000 injuries. To evaluate the effects of the safety helmet legislation we have been monitoring the prevalence of helmet use on Italian urban roads and the incidence of head injury in accidents involving two-wheel vehicles seen in casualty departments. Full details will be reported elsewhere (in Italian) but’we thought that a summary might be helpful. Table I reports the frequency of helmet use before the law came into force and afterwards in a stratified sample survey of two hundred locations throughout Italy. The rate is now about 100% for motorcyclists; it is only 50% for moped users because the legislation here applies to teenagers only. We confined our study to urban zones because on motorways and non-urban roads we had noted that the percentage of safety helmet wearing was already over 90% and more than 85% of all two-wheeler accidents in Italy happen on urban roads. Unfortunately Italy has no systematic reporting system for road-traffic accidents. Instead we collected data on head injuries from two-wheeler accidents in September, October, and November, 1985 (before the law), and in 1986 from thirty hospitals in fifteen cities. There has been a fall of about half in hospital admissions for head trauma in motorcyclists and of about 30 % for on
TABLE I-SAFETY HELMET USE BEFORE LEGISLATION AND AFTER .
JULY
18, 1986
figures
contain
the upper data and data where
we
had
no
information about the
.
moped users (table n). We used a mathematical model,l taking into account the prevalence of safety helmet wearing before and after the legislation and relative risk of unhelmeted/helmeted people, and estimated a decrease of 48-9% for motorcyclists and of 24-7% for moped riders. This model yields a reduction in mortality of around 33 %, confirming the figure of about 30 % suggested by preliminary data from the police. Also confirming the validity of our mathematical model is the agreement between prediction and observation for all injuries. Marchi et al2 reported a decrease in head injuries (as the model forecasts) but not in injuries to legs, arms, and so on. We are confident that the observed reduction in mortality and morbidity is due to the safety helmet use. Italian legislation on the compulsory use of safety helmet use has had a great impact on injuries, amounting, we estimate, to 600 deaths avoided and 15 000 injuries spared in a year. In our opinion the legislation should be extended to all moped users and we hope that our findings will help to speed up the approval of safety-belts legislation, now under discussion in the Italian Parliament. This study has been a cooperative one between the Italian National Health Institute (Istituto Superiore di Sanita’) and urban police officers (Associazione Nazionale tra Comandanti ed Ufficiali dei Corpi di Polizia
517-22.
ITS INTRODUCTION IN
*These user.
Municipale, Viareggio). Epidemiology and Biostatistics Laboratory, Istituto Superiore di Sanita’, 00161, Rome, Italy F. A mathematical model
FRANCO TAGGI
evaluate the mortality variation by before-after Taggi prevalence of the use of safety helmet (in Italian) Med Trasporti 1984; 5: 51-60. 2. Marchi AG, et al. Effectiveness of the safety helmet in teenagers (in Italian). Med Bambino 1987, 2: 6. 1
to
INTERPRETATION OF FETAL BREATHING MOVEMENTS IN OLIGOHYDRAMNIOS DUE TO MEMBRANE RUPTURE
SIR,-Dr Moessinger and colleagues (Dec 5, p 1296) support our clinical findings (July 18, p 129, and ref 1) that oligohydramnios due to premature and prolonged rupture of the membranes (PROM) does not necessarily have an unfavourable outcome. In The Lancet, we reported 11 such pregnancies, 5 of which were associated with pulmonary hypoplasia, compared with 4 of 10 by Moessinger et al. We have now investigated a larger series of 35 such pregnancies1 all with PROM for longer than 1 week, membrane rupture occurring at 15-32 weeks. In none of the 35 was there evidence of antenatal infection or any other pregnancy complication. 13 of the 35 cases were associated with intrauterine or neonatal death, but in only 8 was there necropsy evidence of pulmonary hypoplasia. All 35 cases were regularly scanned for fetal breathing movements (FBM).2 In 24 cases FBM persisted: 20 infants suvived and 4 infants, all premature deliveries, died (3 of severe respiratory distress syndrome and 1 of septicaemia). In 9 cases FBM were not found, despite a total of 84 h of ultrasound examination. Necropsies in 8 of the 9 revealed pulmonary hypoplasia.3,4 These results confirm our earlier fmdings that the absence of FBM is a reliable indicator of unfavourable outcome due to abnormal lung growth. Moessinger and colleagues, however, apparently detected FBM in all pregnancies irrespective of outcome. This discrepancy may be explained by differences in the definition of FBM. Moessinger et al defined fetuses to be breathing if at least three breaths were detected within a 6 s period; this
183
"epoch" of breathing activity ended when less than three valid breaths occurred within this timeframe. We, however, considered fetuses to be breathing only if an episode of movements was continuous for at least 60 s during a 30 min observation period, which was extended for up to 2 h if no such episodes were seen. A breath-to-breath interval of more than 6 s was taken to indicate cessation of breathing. Our definition has been used extensively before and emphasises the importance of sustained respiratory effort for a defined time.2,5,6 Although Castle and Tumbulf suggested 20 s or more may be sufficient, most investigators use at least 30 or 60 S.2,5,6,8,9 "Breathing activity" may occur before death in utero from a variety of insults, but usually as gasps or brief episodes of abnormal breathing."* Moessinger and colleagues’ use of a short period such as 6 s could include such activity and we believe this could be incorrectly interpreted as "FBM present". Indeed, in our series, fetuses who subsequently died of pulmonary hypoplasia did make breathing movements which we interpreted as gasps, as none of these episodes were sustained for a 60 s period with a breath-tobreath interval of less than 6 s. Our results suggest that "sustained" breathing activity rather than the short epochs described by Moessinger et al is important for continuing antenatal lung growth in cases of oligohydramnios due to PROM. ANNE GREENOUGH Department of Child Health, MARGARET BLOTT King’s College School of K. NICOLAIDES Medicine-and Dentistry, STUART CAMPBELL London SE5 9PJ 1. Blott M,
Greenough A. Oligohydramnios in the second trimester of pregnancy: Fetal breathing and normal lung growth. Early Hum Devel (in press). 2 Roberts AD, Griffin D, Mooney R, Cooper DJ, Campbell S. Fetal activity in 100 normal third trimester pregnancies. Br J Obstet Gynaecol 1980; 87: 480-84. 3. Cooney TP, Thurlbeck WM. Pulmonary hypoplasia in Down’s syndrome. N Engl J Med 1982; 207: 1170-73.
Emery JL, Mithal A. The alveoli in the terminal respiratory unit of man during late intrauterine life and childhood. Arch Dis Child 1960; 35: 544-47. 5. Manning FA, Platt LD, Sipos L. Antepartum fetal evaluation: Development of a fetal biophysical profile. Am J Obstet Gynecol 1980; 136: 787-95. 6. Vintzileos AM, Campbell WA, Ingardia CJ, Nochimson DJ. The fetal biophysical profile and its predictive value. Obstet Gynecol 1983; 62: 271-78. 7. Castle BM, Turnbull AC. The presence or absence of fetal breathing movements predicts the outcome of preterm labour. Lancet 1983; ii: 471-73. 8. Vintzileos AM, Campbell WA, Nochimson DJ, Weinbaum PJ. Fetal breathing as a predictor of infection in premature rupture ofthe membranes. Obstet Gynecol 1986; 4.
67: 813-17.
Manning FA, Platt LD. Fetal breathing movements and the abnormal contraction stress test. Am J Obstet Gynecol 1979; 133: 590-93. 10. Patrick JE, Dalton KJ, Dawes GS. Breathing patterns before detah in fetal lambs. Am J Obstet Gynecol 1976; 125: 73-78. 9.
FETAL VIABILILTY IN MULTIPLE PREGNANCY
SIR,-Dr Stabile and colleagues (Nov 28, p 1237) report that early ultrasound examination will identify a large proportion of pregnancies destined to continue when spontaneous abortion threatens. At 5-8 weeks, identification of a live fetus rarely results in spontaneous abortion. We have observed the effect of identification of the fetal heart at 5-8 weeks in multiple gestations resulting from in-vitro fertilisation. After transfer of 3 or 4 embryos all patients were offered ultrasound examination, primarily to identify the number of embryos implanted and to aid diagnosis of ectopic pregnancy. Multiple gestation sacs (2-4) were observed at 6-8 weeks’ gestation in 106 patients between September, 1984, and April, 1987. 5 patients had no demonstrable live fetus in any sac (all twin sacs). All miscarried and were excluded from further analysis. Of the 101patients in which one or more fetal hearts were identified, 98 (97%) have either now delivered one or more live infants or have one or more ongoing pregnancies above 28 weeks’ gestation. A fetal heart was identified in 178 gestation sacs. 172 (96 6%) of these are either ongoing (containing a live fetus over 28 weeks’ gestation, n = 38) or have resulted in delivery of a live infant (n= 134). A fetal heart was not identified in 53 sacs (22-9% of the total). 52 of these resulted in the demise of the sac and 1(19 %) in a live birth. The number of fetal hearts seen was less than the number of gestation sacs in 31 % patients with 2 sacs, 53 % patients with 3 sacs
miscarried a live fetus. The miscarriage rate was similar to the group in which all sacs contained a live fetus (7-8%). That an empty sac does not affect eventual outcome is therefore true for higher order
pregnancies too. The positive reassurance of ongoing pregnancy when a fetal heart is identified by ultrasonography at 6-8 weeks can be extended to multiple pregnancies where 2-4 sacs are present. Academic Department of Obstetrics and Gynaecology, King’s College School of Medicine and Dentistry, London SE5 8RX
JULIAN S. PAMPIGLIONE
Hallam Medical Centre, London WIN 5LR
BRIDGETT A. MASON LIMITATIONS OF GIFT
SIR,-We have completed more than 1700 gamete intrafallopian (GIFT) operations and consider this treatment to be an important part of any comprehensive fertility service. However, despite the promotion of GIFT as a simpler alternative to in-vitro fertilisation (IVF) for use in district general hospitals, we are cautious in recommending it as a first option for most patients with open fallopian tubes who are resistant to conventional treatment. GIFT may fail to fulfil the hopes of both specialists and infertile couples. transfer
The main difference between GIFT and IVF is that fertilisation in vivo rather than in vitro. Both require the same organisational work-up. There are advantages to GIFT in patients with a record of fertilisation (ie, a previous pregnancy or IVF) but there are limitations to GIFT alone in those in whom fertilisation has not been proven, especially when sperm counts are thought to be equivocal or suboptimum. GIFT should, ideally, be undertaken in conjunction with, rather than in isolation from, IVF. If the technical skill needed to handle gametes and culture media that is necessary with GIFT is available then IVF is also possible. The use of both techniques together provides a clearer understanding of the nature of difficult cases of infertility and their management. This has particular relevance to some patients with "unexplained" infertility or endometriosis and in some with polycystic ovaries who have failed to conceive by alternative means. They may have lower fertilisation and pregnancy occurs
potential. We do not recommend GIFT as the primary treatment in patients with suboptimum sperm counts. Analysis of our first 1000 procedures shows that GIFT with poor sperm has a significantly reduced chance of success. Similarly, there are limitations to GIFT in certain groups if no more than four oocytes are transferred. Your Oct 24 editorial refers to IVF and GIFT as if they were totally separate entities. They are not. If the ability to do both is not available some patients treated unsuccessfully by GIFT may remain unaware of the cause of their infertility and of its potential resolution. The question whether fertilisation is possible will not have been answered. GIFT is a welcome addition to a range of fertility options but it is no panacea. It is not ideal to use this method of assisted reproduction on an empirical basis without the provision of IVF.
.
and all
patients with 4 sacs.
In these
patients only 2 out of 36 (6%)
Fertility & IVF Unit, Humana Hospital Wellington, London NW8 9LE
IAN CRAFT PETER R. BRINSDEN ERIC G. SIMONS PAUL M. LEWIS
NEEDLE SIZE AND RISK OF MISCARRIAGE AFTER
AMNIOCENTESIS
SiR,—In our randomised controlled trial of genetic amniocentesis in low-risk women1 we stated that an 18G needle (outer diameter 1-2 mm) was used. Others2" have correlated this needle size with the 1 -0 % miscarriage rate (95 % confidence interval 0-3-1-5) we found. We now know that the amniocenteses were done with a 20G needle (1-0 mm). Embarrassing though it is we felt that this information had to be made available because we found a higher miscarriage rate after amniocentesis than most other workers had done. Ours is the only randomised controlled trial to have been published and, with the above amendment, it now fulfils all the