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MANAGEMENT OF THE PREGNANT DIABETIC: HOME OR HOSPITAL?
1410 TRIMETHOPRIM RESISTANCE IN BACTERIA ISOLATED INSIDE AND OUTSIDE HOSPITAL
*Excluding intnnsically resistant strains, such as Pseudomonas œruginosa, Candida spp, and Acinetobacter spp. t% of highly resistant strains which transferred resistance shown in parentheses.
in E. coli, Klebsiella spp, Enterobacter spp, and Proteus spp. was 4-3%, and only 10% of these were highly resistant; in the present study 11.7% of these isolates are resistant, and 76% of these are highly ’resistant. Secondly, contrary to our previous prediction,2 the genera most commonly resistant previously (Klebsiella and Enterobacter) have not increased in resistance. Instead, there have been marked increases in the frequency of resistance in E. coli and Proteus spp (5.5 fold and 10-fold, respectively). Most surprising, however, is the finding that staphylococci and Klebsiella spp from domiciliary practice are as commonly resistant as are hospital isolates. Another surprising feature is that E. coli strains carrying R-factors determining
trimethoprim resistance are just as common outside hospital as they are in hospital. Our results highlight the continuing need for periodic studies on bacterial drug resistance using strains isolated from well-defined sources. In this way, information will be gained about trends in drug resistance which is not available by the more popular "league table" approach.3 The survey was complete before trimethoprim alone was put on the market. Thus, the changes in resistance we described occurred while trimethoprim was available in the U.K. for clinical use only in combination with a sulphonamide. Department of Medical Microbiology, Royal Free Hospital, London NW3 2QG
W. BRUMFITT J. M. T. HAMILTON-MILLER A. GOODING
fully understood, signs of asphyxia on fetal heart rate (FHR) records have been reported in up to 21% of cases.2,3 Since the beginning of 1975 245 infants of insulin-dependent diabetics have been delivered in this hospital. Routine obstetric care includes admission from the 32nd week of gestation for metabolic control and fetal monitoring.4 Patients in White’s class F or with other severe problems are generally admitted from the 28th week. The FHR is recorded (non-stressed test for at least 20 min) every other day until the 35th week and daily after that. There have been only 2 intrauterine deaths (at 29 weeks because of premature separation of the placenta, and at 31 weeks, the fetus weighing 3550 g). Neither mother was in hospital at the time. The perinatal mortality was 2% (the 2 stillbirths plus 2 fatal cases of congenital malformation and 1 death due to asphyxia and prematurity). analysed the FHR records in 146 pregnancies (146 fetuses) of insulin-dependent diabetics delivered here in 1977-79. Every FHR record during the last week before labour was screened for short-term variability, reactivity, and late decelerations. 118 records were normal (81.4%); 9 were suspect (6-2%); 18 were abnormal (12.4%); and in 1 case of severe
We have
fetal death FHR was not recorded. All 145 monitored fetuses were born alive. In 13 cases the suspect or abnormal FHR was noted to antepartum: caesarean section was done in 11 of these pregnancies and the FHR changes suggested that at least 3 would have ended in intrauterine without prompt delivery (2 of the 3 infants survived). In the other 14 cases judged suspect or abnormal on FHR the warning came during labour: cæsarean section was resorted to in 7, in 3 vacuum extraction was done, and 4 delivered spontaneously. 10 out of 145 liveborn infants had an Apgar score of 6 or less at 1 min. 3 of these had abnormal FHR record. Thus potentially fatal hazards to the fetus in the last trimester in diabetic pregnancies can be signalled by FHR changes typical of asphyxia seen before labour on non-stressed FHR recordings done every 1 or 2 days. In the case of the insulindependent diabetic in the last weeks of pregnancy fetal monitoring is just as important as good metabolic control. Our experience and that of others3 shows that rapidly progressive antepartum fetal asphyxia can arise even when metabolic control is good. Insulin-dependent diabetics should be admitted routinely from the start of the 32nd week (perhaps even
earlier). Departments I and II of Obstetrics and Gynæcology; and Children’s Hospital, University of Helsinki, 00290 Helsinki 29, Finland
KARI TERAMO PIRKKO ÄMMÄLÄ AARNE N. KUUSISTO KARI O. RAIVIO
MANAGEMENT OF THE PREGNANT DIABETIC: HOME OR HOSPITAL?
SIR,—Dr Stubbs and colleagues (May 24, p. 1122) claim that hospital admission did not improve control in insulindependent diabetics during the last trimester of pregnancy and concluded that insulin-dependent diabetics with no other social or medical indication for hospital care could be managed at home and in the outpatient clinic up to 36 weeks of gestation, Others have come to the same conclusion from self-monitoring of pregnant diabetics at home.’ We should like to argue against home monitoring and outpatient clinic visits in insulin-dependent diabetics after 31 weeks of gestation. Intrauterine fetal death in the last trimester is a typical complication of diabetic pregnancy. Although these deaths are not
2. Brumfitt W, Hamilton-Miller JMT, Grey D. Trimethoprim-resistant coliforms. Lancet, 1979; ii: 926. 3. McAlister TA, Alexander JG, Dulake C, Percival A, Boyce JMH, Wormald PJ. The sensitivities of urinary pathogens: a survey. Multicentre study of sensitivities of urinary tract pathogens. Postgrad Med J 1971; 47: 14. 1. Peacock I, Hunter JC, Walford S, et al. Self-monitoring of blood glucose in diabetic pregnancy. Br Med J 1979; ii: 1333-36.
REVERSAL OF "MILD" DIABETES BY CHLORPROPAMIDE
SIR,—Dr Mutch and Professor Stowers (May 31) claim that with chlorpropamide reversed mild diabetes in children. "Mild diabetes" is a highly ambiguous term which, we had hoped, was consigned to oblivion after the National Diabetes Data Group report.’ Did the children have diabetes of any description? Fasting plasma glucose levels ranged between 3-9and 6-2mmol/1 (70-112 mg/dl) and these would treatment
2.
Ayromlooi J, Mann LI, Weiss RR, et al. Modern management of the diabetic pregnancy. Obstet Gynecol 1977; 49: 137-43. 3. Whittle MJ, Anderson D, Lowensohn RI, et al. Estriol in pregnancy. VI. Experience with unconjugated plasma estriol assays and antepartum fetal heart rate testing in diabetic pregnancies. Am J Obstet Gynecol 1979;
135: 764-72. 4. Teramo K, Kuusisto AN, Raivio KO. Perinatal outcome of insulin-dependent diabetic pregnancies. Ann Clin Res 1979; 11: 146-55. 1. National Diabetes Data Group. Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. Diabetes 1979; 28: 1039-57.
*Excluding intnnsically resistant strains, such as Pseudomonas œruginosa, Candida spp, and Acinetobacter spp. t% of highly resistant strains which transferred resistance shown in parentheses.
in E. coli, Klebsiella spp, Enterobacter spp, and Proteus spp. was 4-3%, and only 10% of these were highly resistant; in the present study 11.7% of these isolates are resistant, and 76% of these are highly ’resistant. Secondly, contrary to our previous prediction,2 the genera most commonly resistant previously (Klebsiella and Enterobacter) have not increased in resistance. Instead, there have been marked increases in the frequency of resistance in E. coli and Proteus spp (5.5 fold and 10-fold, respectively). Most surprising, however, is the finding that staphylococci and Klebsiella spp from domiciliary practice are as commonly resistant as are hospital isolates. Another surprising feature is that E. coli strains carrying R-factors determining
trimethoprim resistance are just as common outside hospital as they are in hospital. Our results highlight the continuing need for periodic studies on bacterial drug resistance using strains isolated from well-defined sources. In this way, information will be gained about trends in drug resistance which is not available by the more popular "league table" approach.3 The survey was complete before trimethoprim alone was put on the market. Thus, the changes in resistance we described occurred while trimethoprim was available in the U.K. for clinical use only in combination with a sulphonamide. Department of Medical Microbiology, Royal Free Hospital, London NW3 2QG
W. BRUMFITT J. M. T. HAMILTON-MILLER A. GOODING
fully understood, signs of asphyxia on fetal heart rate (FHR) records have been reported in up to 21% of cases.2,3 Since the beginning of 1975 245 infants of insulin-dependent diabetics have been delivered in this hospital. Routine obstetric care includes admission from the 32nd week of gestation for metabolic control and fetal monitoring.4 Patients in White’s class F or with other severe problems are generally admitted from the 28th week. The FHR is recorded (non-stressed test for at least 20 min) every other day until the 35th week and daily after that. There have been only 2 intrauterine deaths (at 29 weeks because of premature separation of the placenta, and at 31 weeks, the fetus weighing 3550 g). Neither mother was in hospital at the time. The perinatal mortality was 2% (the 2 stillbirths plus 2 fatal cases of congenital malformation and 1 death due to asphyxia and prematurity). analysed the FHR records in 146 pregnancies (146 fetuses) of insulin-dependent diabetics delivered here in 1977-79. Every FHR record during the last week before labour was screened for short-term variability, reactivity, and late decelerations. 118 records were normal (81.4%); 9 were suspect (6-2%); 18 were abnormal (12.4%); and in 1 case of severe
We have
fetal death FHR was not recorded. All 145 monitored fetuses were born alive. In 13 cases the suspect or abnormal FHR was noted to antepartum: caesarean section was done in 11 of these pregnancies and the FHR changes suggested that at least 3 would have ended in intrauterine without prompt delivery (2 of the 3 infants survived). In the other 14 cases judged suspect or abnormal on FHR the warning came during labour: cæsarean section was resorted to in 7, in 3 vacuum extraction was done, and 4 delivered spontaneously. 10 out of 145 liveborn infants had an Apgar score of 6 or less at 1 min. 3 of these had abnormal FHR record. Thus potentially fatal hazards to the fetus in the last trimester in diabetic pregnancies can be signalled by FHR changes typical of asphyxia seen before labour on non-stressed FHR recordings done every 1 or 2 days. In the case of the insulindependent diabetic in the last weeks of pregnancy fetal monitoring is just as important as good metabolic control. Our experience and that of others3 shows that rapidly progressive antepartum fetal asphyxia can arise even when metabolic control is good. Insulin-dependent diabetics should be admitted routinely from the start of the 32nd week (perhaps even
earlier). Departments I and II of Obstetrics and Gynæcology; and Children’s Hospital, University of Helsinki, 00290 Helsinki 29, Finland
KARI TERAMO PIRKKO ÄMMÄLÄ AARNE N. KUUSISTO KARI O. RAIVIO
MANAGEMENT OF THE PREGNANT DIABETIC: HOME OR HOSPITAL?
SIR,—Dr Stubbs and colleagues (May 24, p. 1122) claim that hospital admission did not improve control in insulindependent diabetics during the last trimester of pregnancy and concluded that insulin-dependent diabetics with no other social or medical indication for hospital care could be managed at home and in the outpatient clinic up to 36 weeks of gestation, Others have come to the same conclusion from self-monitoring of pregnant diabetics at home.’ We should like to argue against home monitoring and outpatient clinic visits in insulin-dependent diabetics after 31 weeks of gestation. Intrauterine fetal death in the last trimester is a typical complication of diabetic pregnancy. Although these deaths are not
2. Brumfitt W, Hamilton-Miller JMT, Grey D. Trimethoprim-resistant coliforms. Lancet, 1979; ii: 926. 3. McAlister TA, Alexander JG, Dulake C, Percival A, Boyce JMH, Wormald PJ. The sensitivities of urinary pathogens: a survey. Multicentre study of sensitivities of urinary tract pathogens. Postgrad Med J 1971; 47: 14. 1. Peacock I, Hunter JC, Walford S, et al. Self-monitoring of blood glucose in diabetic pregnancy. Br Med J 1979; ii: 1333-36.
REVERSAL OF "MILD" DIABETES BY CHLORPROPAMIDE
SIR,—Dr Mutch and Professor Stowers (May 31) claim that with chlorpropamide reversed mild diabetes in children. "Mild diabetes" is a highly ambiguous term which, we had hoped, was consigned to oblivion after the National Diabetes Data Group report.’ Did the children have diabetes of any description? Fasting plasma glucose levels ranged between 3-9and 6-2mmol/1 (70-112 mg/dl) and these would treatment
2.
Ayromlooi J, Mann LI, Weiss RR, et al. Modern management of the diabetic pregnancy. Obstet Gynecol 1977; 49: 137-43. 3. Whittle MJ, Anderson D, Lowensohn RI, et al. Estriol in pregnancy. VI. Experience with unconjugated plasma estriol assays and antepartum fetal heart rate testing in diabetic pregnancies. Am J Obstet Gynecol 1979;
135: 764-72. 4. Teramo K, Kuusisto AN, Raivio KO. Perinatal outcome of insulin-dependent diabetic pregnancies. Ann Clin Res 1979; 11: 146-55. 1. National Diabetes Data Group. Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. Diabetes 1979; 28: 1039-57.