- Email: [email protected]
Naloxone hydrochloride
982
Correspondence
Table I. Comparison control groups
December Am. J. Obstet.
of drug
exposures
in care and
I
Bendectin only Bendectin and other drugs Other drum onlv No drugs ”
2 2
22.2 22.2
5 3
3 2 i3
33.3
26 28 62
22.2 99.9
8.1 4.8 41.9 45.2
15, 1983 Gynecol.
REFERENCES
1. Schlesselman, 1. 1.: Gase-Control Studies, New York, 1982, Oxford Unive%y Press, p. 13 1. 2. Eskenazi, B., and Bracken, M. B.: Bendectin (Debendox) as a risk factor for pyloric stenosis, AM. J. OBSTET. GYNECOL. l&919, 1982. 3. Bracken, M. B., and Berg, A.: Bendectin (Debendox) and congenital diaphragniatic hernia, Lancet 1:586, 1983. 4. Heinonen, 0. P., Slone, D., and Shapiro, S.: Birth Defects and Drugs in Pregnancy, Littleton, Massachusetts, 1977, Publishing Sciences Group. 5. Dodge, J. A., Laurence, K. M., and Webb, A. R.: Unprecedented increase of infantile hypertrophic pyloric stenosis, Br. Med. J. 281:1069, 1980.
-100.0
Naloxone hydrochloride To the Editor.,:
rates, a comparison of the rates of twins among cases and controls (not Bendectin exposure and nonexposure) were included (see Table I in article). Of course, a higher frequency of congenital malformations is expected among twins. Dr. Fleming also notes that, among his 21 cases of pyloric stenosis, 11 were exposed to a wide assortment of antacids and antiemetics. He concludes that pyloric stenosis may be caused by maternal vomiting rather than directly from Bendectin. Although this conclusion may be valid (as we suggested in the original article), Dr. Fleming has overinterpreted his data. Since eight of the 11 drugs contain an antihistamine, an alternative conclusion might be that this component is associated with pyloric stenosis. Interestingly, we have recently noticed that the Collaborative Perinatal Project“ data suggest a significant association between pyloric stenosis and doxylamine, the antihistamine component which remains in the two-component Bendectin formulation (cOR = 2.28, 95% CL = 1.05, 4.93). Dr. Fleming took issue with our suggestion that a sharp rise in incidence of pyloric stenosis in Britain may be linked to a concomitant increased use of Bendectin (Debendox). Although we cited only the increased incidence in Scotland, a rise in pyloric stenosis was also noted in Wales.’ Additionally, it is likely that the concurrent increase in prescriptions of Bendectin in Northern Ireland occurred also throughout Britain. We reemphasize the conclusions to our original article: (1) further studies are needed to clarify whether a direct casual relationship exists between Bendectin and pyloric stenosis, and (2) the hazards of maternal vomiting should be weighed against the risk of a treatable malformation. Brenda Eskenuzi, John B. Pierce Foundation Laboratory Department of Epidemiology and Public Health Yale University School of Medicine New Haven, Connecticut 06519 Michael B. Bracken, Perinatal Epidemiology Unit Departments of Epidemiology and Public Health and Obstetrics and Gynecology Yale University School of Medicine New Haven, Connecticut 06519
Ph.D.
Ph.D.
I wish to thank Dr. Sylvain Fribourg, Southern California Permanence Medical Group, Panorama City, California, for calling attention to the misspelling of naloxone hydrochloride (Narcan, Endo Laboratories, inc., Garden City, New York) as maloxone in my informal discussion of the article by Drs. Sandberg and Pelligra (AM. J. OBSTET. GYNECOL. 146:519, 1983). Charles
D. Kimball,
M.D.
b’irginia Mason Research Center 1000 Senecu Street Scuttle, Washington 98101
Amniotic fluid embolism To the Editor.\:
In their article, entitled “Hemodynamic observations in a patient with intrapartum amniotic fluid embolism” (AM. J. OBSTET. GYNECOL 146:112, 1983), Dr. Duff and co-workers chronicled important hemodynamic parameters in a patient with clinical amniotic fluid embolism. They report finding keratin and fat cells on microscopic examination of maternal pulmonary arterial blood. This is, of course, consistent with amniotic fluid embolism, as the authors stated. On two occasions, however, we have incidentally found fetal squames and other amniotic fluid detritus in blood drawn from the Schwann-Ganz catheter in patients who were delivered of their infants while undergoing hemodynamic monitoring. Neither patient had any clinical or hemodynamic changes to support a diagnosis of amniotic fluid embolism. My questions to the authors are: (1) How often can amniotic fluid material be found in the pulmonary arterial blood after vaginal delivery? (2) Could “amniotic fluid embolism” be a common phenomenon in small quantities and only produce a clinical disorder when the inoculum is large? Thank you for the opportunity to comment on this interesting subject. Warren C. Plauchd, Department Obstetrics and Gynecoloa School of Medicine in New Orleans Louisiana State University Medical Cente? 1542 Tulane Avenue New Orleans, Louisiana 70112-2822
qf
M.D.
Correspondence
Table I. Comparison control groups
December Am. J. Obstet.
of drug
exposures
in care and
I
Bendectin only Bendectin and other drugs Other drum onlv No drugs ”
2 2
22.2 22.2
5 3
3 2 i3
33.3
26 28 62
22.2 99.9
8.1 4.8 41.9 45.2
15, 1983 Gynecol.
REFERENCES
1. Schlesselman, 1. 1.: Gase-Control Studies, New York, 1982, Oxford Unive%y Press, p. 13 1. 2. Eskenazi, B., and Bracken, M. B.: Bendectin (Debendox) as a risk factor for pyloric stenosis, AM. J. OBSTET. GYNECOL. l&919, 1982. 3. Bracken, M. B., and Berg, A.: Bendectin (Debendox) and congenital diaphragniatic hernia, Lancet 1:586, 1983. 4. Heinonen, 0. P., Slone, D., and Shapiro, S.: Birth Defects and Drugs in Pregnancy, Littleton, Massachusetts, 1977, Publishing Sciences Group. 5. Dodge, J. A., Laurence, K. M., and Webb, A. R.: Unprecedented increase of infantile hypertrophic pyloric stenosis, Br. Med. J. 281:1069, 1980.
-100.0
Naloxone hydrochloride To the Editor.,:
rates, a comparison of the rates of twins among cases and controls (not Bendectin exposure and nonexposure) were included (see Table I in article). Of course, a higher frequency of congenital malformations is expected among twins. Dr. Fleming also notes that, among his 21 cases of pyloric stenosis, 11 were exposed to a wide assortment of antacids and antiemetics. He concludes that pyloric stenosis may be caused by maternal vomiting rather than directly from Bendectin. Although this conclusion may be valid (as we suggested in the original article), Dr. Fleming has overinterpreted his data. Since eight of the 11 drugs contain an antihistamine, an alternative conclusion might be that this component is associated with pyloric stenosis. Interestingly, we have recently noticed that the Collaborative Perinatal Project“ data suggest a significant association between pyloric stenosis and doxylamine, the antihistamine component which remains in the two-component Bendectin formulation (cOR = 2.28, 95% CL = 1.05, 4.93). Dr. Fleming took issue with our suggestion that a sharp rise in incidence of pyloric stenosis in Britain may be linked to a concomitant increased use of Bendectin (Debendox). Although we cited only the increased incidence in Scotland, a rise in pyloric stenosis was also noted in Wales.’ Additionally, it is likely that the concurrent increase in prescriptions of Bendectin in Northern Ireland occurred also throughout Britain. We reemphasize the conclusions to our original article: (1) further studies are needed to clarify whether a direct casual relationship exists between Bendectin and pyloric stenosis, and (2) the hazards of maternal vomiting should be weighed against the risk of a treatable malformation. Brenda Eskenuzi, John B. Pierce Foundation Laboratory Department of Epidemiology and Public Health Yale University School of Medicine New Haven, Connecticut 06519 Michael B. Bracken, Perinatal Epidemiology Unit Departments of Epidemiology and Public Health and Obstetrics and Gynecology Yale University School of Medicine New Haven, Connecticut 06519
Ph.D.
Ph.D.
I wish to thank Dr. Sylvain Fribourg, Southern California Permanence Medical Group, Panorama City, California, for calling attention to the misspelling of naloxone hydrochloride (Narcan, Endo Laboratories, inc., Garden City, New York) as maloxone in my informal discussion of the article by Drs. Sandberg and Pelligra (AM. J. OBSTET. GYNECOL. 146:519, 1983). Charles
D. Kimball,
M.D.
b’irginia Mason Research Center 1000 Senecu Street Scuttle, Washington 98101
Amniotic fluid embolism To the Editor.\:
In their article, entitled “Hemodynamic observations in a patient with intrapartum amniotic fluid embolism” (AM. J. OBSTET. GYNECOL 146:112, 1983), Dr. Duff and co-workers chronicled important hemodynamic parameters in a patient with clinical amniotic fluid embolism. They report finding keratin and fat cells on microscopic examination of maternal pulmonary arterial blood. This is, of course, consistent with amniotic fluid embolism, as the authors stated. On two occasions, however, we have incidentally found fetal squames and other amniotic fluid detritus in blood drawn from the Schwann-Ganz catheter in patients who were delivered of their infants while undergoing hemodynamic monitoring. Neither patient had any clinical or hemodynamic changes to support a diagnosis of amniotic fluid embolism. My questions to the authors are: (1) How often can amniotic fluid material be found in the pulmonary arterial blood after vaginal delivery? (2) Could “amniotic fluid embolism” be a common phenomenon in small quantities and only produce a clinical disorder when the inoculum is large? Thank you for the opportunity to comment on this interesting subject. Warren C. Plauchd, Department Obstetrics and Gynecoloa School of Medicine in New Orleans Louisiana State University Medical Cente? 1542 Tulane Avenue New Orleans, Louisiana 70112-2822
qf
M.D.