- Email: [email protected]
"THE SAFETY OF ORAL CONTRACEPTIVES"
1163
WARMING EMERGENCY BLOOD-TRANS FUSIONS SIR,-It was encouraging to read (April 8, p. 782) the letter
emphasising the value of warming emergency blood-transfusions. The point is one which needs reiteration. The effect of rapidly infusing cold blood is not only " shivering and much apprehension "--often it is cardiac arrest or from Dr. Tacchi
ventricular fibrillation. That such effects are not due to factors besides temperature (e.g., citrate intoxication, or pH or
electrolyte changes) was shown by Boyan and Howland1 in a study of matched groups of patients who received large volumes of rapidly transfused blood. Whereas over half of 36 patients receiving cold blood developed cardiac arrest, only 1 out of 40 patients who received warmed blood did so. My own observations have borne this
When the infusion-rate is low (less than 10 ml. per minute), there is no problem, since the body can warm the blood before it reaches the heart. But with rapid flow-rates (50-100 ml. per minute), cold blood can upset a delicate balance and cause irreversible shock or cardiac out.
arrest.
Such rapid infusion-rates are common in postpartum and gastrointestinal haemorrhage or after large blood-losses during major surgery. In such cases the simple device illustrated by Dr. Tacchi is quite effective. (Often, if several units are to be given, one may be warmed via the submerged tubing while a
second bottle is set in another warm water-bath.) I have used convenient modification of the technique in the form of an electric blood-bank water-bath with an adjustable thermostat. With the thermostat set at about 40C and six ft. of coiled tubing (two extension-sets tightly coupled and taped together) in the water, rapidly infused blood can be warmed to body temperature. Toppenish, Washington, U.S.A. JOSEPH B. VANDERVEER, JR. a
agreeing with Lady Summerskill that the committee’s terms of reference, though " wider ", included thrombosis, added: I should think that that investigation may well take quite a long time."lo "
On Sept. 1, 1966, the steroid sex hormones committee still existed but, according to a personal communication, had published no report. The January, 1966, body is clearly continuing a part of that committee’s function. Summerfield Hospital, ROBERT J. HETHERINGTON. Birmingham 18.
EFFECTS OF ORAL CONTRACEPTIVES SIR,-Wynn and Doar’s report 11 of the incidence of abnormal glucose-tolerance tests in women taking oral contraceptives prompts us to give here the results of a similar investigation which confirms their findings. Our study was carried out in 161 women who had been submitted to various treatments: mestranol, ethinyloestradiol, norethisterone acetate combined with mestranol and norethisterone combined with ethinyloestradiol. Prednisone/glucosetolerance tests (P.G.T.T.) showed abnormal responses in 53% of the women who had received contraceptives containing mestranol, whereas previously the incidence of pathological responses was 9-4%-a difference of statistical significance. On the other hand the results in patients treated with ethinylcestradiol, norethisterone, or both combined, did not reveal any significant variations of P.G.T.T. The proportion of abnormal P.G.T.T.S in women who had received mestranol had no special relation to age, personal history linked with diabetes, obesity index, or obstetric history, but an increased proportion of diabetic curves was observed in women with a family history of diabetes or with incidence of early menarche. A paper
"THE SAFETY OF ORAL CONTRACEPTIVES" SIR,-Professor Morrison last week (p. 1097) uses the history of the oral-contraceptive-safety question as an example of medical administration. Unfortunately, by accepting the Doll report’s account he has omitted the first three years: " In January 1966, at the request of the Committee on Safety of Drugs, the Ministry of Health asked the Medical Research Council for their views. The Council accordingly set up a subcommittee ..."2 In 1961 was reported the first British case of thromboembolism associated with oral-contraceptive medication.3 On June 6, 1962, in the House of Lords, Lord Brain, president of the Family Planning Association, said: I would urge the government to hold a watching brief on the clinical tests of oral contraceptives or, better still, to sponsor such tests themselves." 4Lord Brain was also chairman of the Medical Advisory Council of the" F.P.A., which on July 26, 1962, issued a press statement that: the Council considers that the Medical Research Council should also accept the responsibility for investigating their possible ill-effects." 56 On Aug. 4, 1962, the British Medical Journal in a strongly worded annotation on this statement singled out thromboembolism as the main risk,6 and attracted wide attention.7 In November, 1962, the Medical Research Council appointed a committee on steroid sex hormones to study " the possible long-term effects of administration of steroid sex hormones ". 8a Lord Brain accepted this as a fulfilment of his June 6 speech.9 In December, 1962, in the House of Lords, Lord Newton, "
1. Boyan, C. P., Howland, W. S. J. Am. med. Ass. 1963, 183, 58. 2. Medical Research Council Subcommittee Report. Br. med. J. May 6, 3. 4. 5. 6. 7. 8. 9.
1967, p. 355. Jordan, W. M. Lancet, 1961, ii, ibid. 1962, i, 1295. ibid. 1962, ii, 236. Br. med. J. 1962, ii, 315. ibid. p. 426.
1146.
ibid. p. 1268.
Brain, Lord, Parkes,
A.
S., Bishop, P. M. F. Lancet, 1964, ii, 1329.
on our
1st Chair of
findings
is about to be
published. GUILLERMO DI PAOLA F. PUCHULU M. ROBIN R. NICHOLSON M. MARTIN.
Gynæcology,
2149 Córdoba, Buenos Aires, Argentina.
ORAL CONTRACEPTION AFTER DELIVERY SIR,-It is thought important to draw attention to certain facts concerning the use of oral contraceptives in the postpartum period. The main point concerns the physiology of ovulation after delivery. I have discussed this 12 with particular reference to how long a mother should wait after having a baby before starting oral contraception. From extensive studies,13 I have emphasised that the earliest day for which there is presumptive evidence of ovulation is the 42nd day post partum. I have also evidence that ovulation occurred premenstrually in some women-two women in a large series investigated had not menstruated until 10 weeks after ovulation. Moreover, I have described a post-partum follow-up in a large number of cases in which three non-lactating mothers became pregnant 6 weeks after delivery, but none became pregnant earlier; in these three mothers menstruation had not been re-established. There is therefore considerable doubt whether taking " the pill " as a contraceptive measure should be postponed until after the first menstrual period, as is widely suggested-e.g., Kistner,14 who stated that it is generally recommended that oral contraception should be started on day 5 after the first spontaneous period. There is little unanimity of advice given by the various manufacturers : one advertises: For convenience of timing, it may "
10. ibid. 1962, ii, 1231. 11. Wynn, V., Doar, J. W. H. ibid. 1966, ii, 715. 12. Sharman, A. 5th World Congress of the International Fertility Assotion, Stockholm, June, 1966 (in the press); International Symposium on Oral Gestogens, Folkestone, October, 1966 (in the press). 13. Sharman, A. Reproductive Physiology of the Post-Partum Period. Edinburgh, 1966. 14. Kistner, R. W. Postgrad. Med. 1966, 39, 207.
WARMING EMERGENCY BLOOD-TRANS FUSIONS SIR,-It was encouraging to read (April 8, p. 782) the letter
emphasising the value of warming emergency blood-transfusions. The point is one which needs reiteration. The effect of rapidly infusing cold blood is not only " shivering and much apprehension "--often it is cardiac arrest or from Dr. Tacchi
ventricular fibrillation. That such effects are not due to factors besides temperature (e.g., citrate intoxication, or pH or
electrolyte changes) was shown by Boyan and Howland1 in a study of matched groups of patients who received large volumes of rapidly transfused blood. Whereas over half of 36 patients receiving cold blood developed cardiac arrest, only 1 out of 40 patients who received warmed blood did so. My own observations have borne this
When the infusion-rate is low (less than 10 ml. per minute), there is no problem, since the body can warm the blood before it reaches the heart. But with rapid flow-rates (50-100 ml. per minute), cold blood can upset a delicate balance and cause irreversible shock or cardiac out.
arrest.
Such rapid infusion-rates are common in postpartum and gastrointestinal haemorrhage or after large blood-losses during major surgery. In such cases the simple device illustrated by Dr. Tacchi is quite effective. (Often, if several units are to be given, one may be warmed via the submerged tubing while a
second bottle is set in another warm water-bath.) I have used convenient modification of the technique in the form of an electric blood-bank water-bath with an adjustable thermostat. With the thermostat set at about 40C and six ft. of coiled tubing (two extension-sets tightly coupled and taped together) in the water, rapidly infused blood can be warmed to body temperature. Toppenish, Washington, U.S.A. JOSEPH B. VANDERVEER, JR. a
agreeing with Lady Summerskill that the committee’s terms of reference, though " wider ", included thrombosis, added: I should think that that investigation may well take quite a long time."lo "
On Sept. 1, 1966, the steroid sex hormones committee still existed but, according to a personal communication, had published no report. The January, 1966, body is clearly continuing a part of that committee’s function. Summerfield Hospital, ROBERT J. HETHERINGTON. Birmingham 18.
EFFECTS OF ORAL CONTRACEPTIVES SIR,-Wynn and Doar’s report 11 of the incidence of abnormal glucose-tolerance tests in women taking oral contraceptives prompts us to give here the results of a similar investigation which confirms their findings. Our study was carried out in 161 women who had been submitted to various treatments: mestranol, ethinyloestradiol, norethisterone acetate combined with mestranol and norethisterone combined with ethinyloestradiol. Prednisone/glucosetolerance tests (P.G.T.T.) showed abnormal responses in 53% of the women who had received contraceptives containing mestranol, whereas previously the incidence of pathological responses was 9-4%-a difference of statistical significance. On the other hand the results in patients treated with ethinylcestradiol, norethisterone, or both combined, did not reveal any significant variations of P.G.T.T. The proportion of abnormal P.G.T.T.S in women who had received mestranol had no special relation to age, personal history linked with diabetes, obesity index, or obstetric history, but an increased proportion of diabetic curves was observed in women with a family history of diabetes or with incidence of early menarche. A paper
"THE SAFETY OF ORAL CONTRACEPTIVES" SIR,-Professor Morrison last week (p. 1097) uses the history of the oral-contraceptive-safety question as an example of medical administration. Unfortunately, by accepting the Doll report’s account he has omitted the first three years: " In January 1966, at the request of the Committee on Safety of Drugs, the Ministry of Health asked the Medical Research Council for their views. The Council accordingly set up a subcommittee ..."2 In 1961 was reported the first British case of thromboembolism associated with oral-contraceptive medication.3 On June 6, 1962, in the House of Lords, Lord Brain, president of the Family Planning Association, said: I would urge the government to hold a watching brief on the clinical tests of oral contraceptives or, better still, to sponsor such tests themselves." 4Lord Brain was also chairman of the Medical Advisory Council of the" F.P.A., which on July 26, 1962, issued a press statement that: the Council considers that the Medical Research Council should also accept the responsibility for investigating their possible ill-effects." 56 On Aug. 4, 1962, the British Medical Journal in a strongly worded annotation on this statement singled out thromboembolism as the main risk,6 and attracted wide attention.7 In November, 1962, the Medical Research Council appointed a committee on steroid sex hormones to study " the possible long-term effects of administration of steroid sex hormones ". 8a Lord Brain accepted this as a fulfilment of his June 6 speech.9 In December, 1962, in the House of Lords, Lord Newton, "
1. Boyan, C. P., Howland, W. S. J. Am. med. Ass. 1963, 183, 58. 2. Medical Research Council Subcommittee Report. Br. med. J. May 6, 3. 4. 5. 6. 7. 8. 9.
1967, p. 355. Jordan, W. M. Lancet, 1961, ii, ibid. 1962, i, 1295. ibid. 1962, ii, 236. Br. med. J. 1962, ii, 315. ibid. p. 426.
1146.
ibid. p. 1268.
Brain, Lord, Parkes,
A.
S., Bishop, P. M. F. Lancet, 1964, ii, 1329.
on our
1st Chair of
findings
is about to be
published. GUILLERMO DI PAOLA F. PUCHULU M. ROBIN R. NICHOLSON M. MARTIN.
Gynæcology,
2149 Córdoba, Buenos Aires, Argentina.
ORAL CONTRACEPTION AFTER DELIVERY SIR,-It is thought important to draw attention to certain facts concerning the use of oral contraceptives in the postpartum period. The main point concerns the physiology of ovulation after delivery. I have discussed this 12 with particular reference to how long a mother should wait after having a baby before starting oral contraception. From extensive studies,13 I have emphasised that the earliest day for which there is presumptive evidence of ovulation is the 42nd day post partum. I have also evidence that ovulation occurred premenstrually in some women-two women in a large series investigated had not menstruated until 10 weeks after ovulation. Moreover, I have described a post-partum follow-up in a large number of cases in which three non-lactating mothers became pregnant 6 weeks after delivery, but none became pregnant earlier; in these three mothers menstruation had not been re-established. There is therefore considerable doubt whether taking " the pill " as a contraceptive measure should be postponed until after the first menstrual period, as is widely suggested-e.g., Kistner,14 who stated that it is generally recommended that oral contraception should be started on day 5 after the first spontaneous period. There is little unanimity of advice given by the various manufacturers : one advertises: For convenience of timing, it may "
10. ibid. 1962, ii, 1231. 11. Wynn, V., Doar, J. W. H. ibid. 1966, ii, 715. 12. Sharman, A. 5th World Congress of the International Fertility Assotion, Stockholm, June, 1966 (in the press); International Symposium on Oral Gestogens, Folkestone, October, 1966 (in the press). 13. Sharman, A. Reproductive Physiology of the Post-Partum Period. Edinburgh, 1966. 14. Kistner, R. W. Postgrad. Med. 1966, 39, 207.