- Email: [email protected]
TREATMENT OF CERVICAL DYSPLASIA WITH BROMOCRIPTINE
157
Letters
to
the Editor
TREATMENT OF CERVICAL DYSPLASIA WITH BROMOCRIPTINE
SIR,-Like workers in the UK, Scandinavia, and the United States have observed an increase in the prevalence of preinvasive lesions of the cervix during the past ten years, especially in women below the age of 30. And we too are convinced that these young patients with cervical intraepithelial neoplasia need very conservative treatment. Conisation can, in these very young and often nulliparous women, lead to problems with fertility and pregnancy. In 1982 Guthrie reported a positive effect of bromo1 criptme in cases of advanced and fully treated cancer of the cervix, and Forsberg and Breistein’s experiments on ovariectomised mice showed that bromocriptine reduced the induction of cervical carcinoma by carcinogens.2Both studies point to a possible effect of bromocriptine on cervical neoplasia. We have done a pilot clinical we
study. In March, 1983, we began a trial of bromocriptine in women in whom we wished to avoid surgery for cervical dysplasia. Most of them were outpatients with primary or secondary sterility. So far twenty-two women, with an average age of 32, have been studied. Before therapy with bromocriptine the lesions found were CIN I in eleven, CIN II in ten, and CIN III in one. All patients had been seen at our colposcopy clinic because of their dysplasia for at least 6 months (average 13 months). Women with such persistent intraepithelial neoplasia have little chance of spontaneous remission.3-5 Before therapy began all patients had microbiological, cytological, and colposcopic examinations, if possible with colposcopically directed punch biopsy. The women took bromocriptine 2x2-55 mg daily for betwen 3 and 8 months and plasma prolactin levels were measured before and during therapy, the object (as reported by Guthrie’) being to lower the plasma prolactin below 2 ng/ml. The therapeutic response was checked by 3-monthly cytological and colposcopic examinations. Where possible we tried to get a final histological examination. Eleven patients underwent complete remission, in one case we observed a partial remission, and in ten cases the lesions progressed. Although we cannot offer a conclusive explanation for our results, they do suggest a positive influence of bromocriptine on cervical intraepithelial neoplasia. A prospective, randomised study is now
required. Department of Gynaecology and Obstetrics, University of Tübingen, D7400 Tubingen, West Germany
EVA M. DONATH A. E. SCHINDLER
1 Guthrie D Treatment of carcinoma of the cervix with bromocriptine. Br J Obstet Gynaecol 1982; 89: 853-55. 2 Forsberg J, Breistein L Prolactin and 3-methylcholanthrene induced cervical
Effect of bromocriptine. Acta Pathol Microbiol Scand SA 1979; 87: 151-56 3. Kraus H. Schneider A. Häufigkeit, Ursachen und Verlauf zweifelhafter Abstrichbefunde (Gruppe Papanicolaou III). Geburtsh Frauenheilk 1984, 44: 87-90 4 Nasiell K, Nasiell M, Vaclavinkova V. Behaviour of moderate cervical dysplasia during long-term follow-up Obstet Gynecol 1983; 61: 609-14. 5. Richart R, Barren B. A follow-up study of patients with cervical dysplasia. Am J Obst Gynecol 1969; 105: 386-93 carcinoma.
IMPACT OF INTEGRATED CHILD DEVELOPMENT SERVICES ON INFANT MORTALITY RATE IN INDIA
SIR,-A coordinated approach to child development through integrated child development services (ICDS)1 was started in India on Oct 2, 1975, as an experiment. Its successful implementation2,3 resulted in fast expansion, and by March, 1Q85; nearly one-fifth of the
population of India will be covered by this scheme. ICDS provides health care, nutrition, and non-formal education to preschool children and care to pregnant and lactating women, as a package, at village centres through village level female workers (known as Anganwadi workers). One objective of ICDS is to reduce the infant mortality rate (IMR). A sample registration system44 periodically collects demographic data, including IMR, on a sample
of about 1%. 1980 estimates of IMR provided in this way are 124 per 1000 in the rural and tribal sample and 65 per 1000 in the urban
sample. We have studied infant mortality in ICDS projects which have been implemented for at least a year. We did this via a two-stage stratified random sampling procedure: a 20% sample of projects was selected and then within each project a 6% sample of villages and urban slums (137 villages and 90 slums) was drawn. About 1-5% (230 000) of the population covered by two hundred ICDS projects in, different parts of India was surveyed. Continuous follow-up of births and deaths for a period of 12 months during the year 1982-83 was achieved by teams supervised by senior faculty members of nearby medical colleges (ICDS consultants). The infrastructure of the primary health centres, including the ICDS village female worker and local informants, was utilised to record events. The design of data forms and the analysis of results was done at the AllIndia Institute of Medical Sciences, New Delhi. The IMR (per 1000) was significantly lower (86) for the 1982-83 ICDS sample survey than for the country as a whole, as provided by the sample registration system (114). Since ICDS projects are located in socioeconomically backward villages the IMR would be expected to be higher than the national average in those areas. Indeed a 1978 survey had shown the IMR in backward communities to be 159 (rural) and 90 (urban) compared with national estimates of 136 and 70, respectively. ICDS seems to have achieved a considerable decline in female IMR, the male to female ratio in the rural population being 919 vs 86 -8. Sex is not referred to in the 1980 sample registration study but the 1978 study had shown an IMR in females (142) much higher than that in males (130). We believe that the coordinated approach to the delivery of services in ICDS, providing better delivery of health and nutrition services to infants and expectant and nursing mothers, is the major factor responsible for lower IMRs in ICDS projects compared with IMRs nationwide. The lower IMR in ICDS projects was obvious in rural and tribal populations. The IMR for the rural and tribal population as calculated by sample registration survey data is 124 compared with 89 - 5 for ICDS projects. However, we did not find a similar impact of ICDS in urban projects: compared with an IMR of 65 at the national level in ICDS projects it was 80. However, the urban ICDS projects are in the slum populations ofbig towns where malnutrition and infection due to poverty, overcrowding, lack of water, and poor sanitation are highly prevalent. The samples for the IMR study were drawn from this selectively disadvantaged population while the sample registration survey sampled the whole urban population in which slums had a very low representation. Furthermore, the ICDS infrastructure in urban projects is meagre compared with what has been provided for rural and tribal projects. We conclude that a coordinated approach to the delivery of health, nutrition, and non-informal education to mothers and infants through the ICDS model has helped in reducing infant mortality in India. We thank all the consultants who contributed to this births and deaths study. Office of Central Technical Committee, Integrated Child Development Service,
Department of Gastroenterology and Human Nutrition, All-India Institute of Medical Sciences, New Delhi 110029, India child
B. N. TANDON
AJIT SAHAI ASHOK VARDHAN scheme. New Delhi:
1.
Integrated
2.
Welfare, 1975. Integrated child development service. A coordinated approach India Lancet 1981; i: 650-53.
3. 4.
development
services
Department to
of Social
children’s health in
Integrated child development services. A coordinated approach to children’s health in India Progress report after five years (1975-1980). Lancet 1983; i: 109-11. Vital Statistics Division, Registrar General, New Delhi. Sample registration system. New Delhi: Department of Home Affairs.
CHORIONIC BIOPSY IN MANAGEMENT OF SEVERE RHESUS ISOIMMUNISATION
SIR,—Determination of the fetal Rh(D) factor in early pregnancy would be of great benefit for severely sensitised women with a D antigen heterozygous partner. In some women it would prevent unnecessary diagnostic and therapeutic procedures; for others
Letters
to
the Editor
TREATMENT OF CERVICAL DYSPLASIA WITH BROMOCRIPTINE
SIR,-Like workers in the UK, Scandinavia, and the United States have observed an increase in the prevalence of preinvasive lesions of the cervix during the past ten years, especially in women below the age of 30. And we too are convinced that these young patients with cervical intraepithelial neoplasia need very conservative treatment. Conisation can, in these very young and often nulliparous women, lead to problems with fertility and pregnancy. In 1982 Guthrie reported a positive effect of bromo1 criptme in cases of advanced and fully treated cancer of the cervix, and Forsberg and Breistein’s experiments on ovariectomised mice showed that bromocriptine reduced the induction of cervical carcinoma by carcinogens.2Both studies point to a possible effect of bromocriptine on cervical neoplasia. We have done a pilot clinical we
study. In March, 1983, we began a trial of bromocriptine in women in whom we wished to avoid surgery for cervical dysplasia. Most of them were outpatients with primary or secondary sterility. So far twenty-two women, with an average age of 32, have been studied. Before therapy with bromocriptine the lesions found were CIN I in eleven, CIN II in ten, and CIN III in one. All patients had been seen at our colposcopy clinic because of their dysplasia for at least 6 months (average 13 months). Women with such persistent intraepithelial neoplasia have little chance of spontaneous remission.3-5 Before therapy began all patients had microbiological, cytological, and colposcopic examinations, if possible with colposcopically directed punch biopsy. The women took bromocriptine 2x2-55 mg daily for betwen 3 and 8 months and plasma prolactin levels were measured before and during therapy, the object (as reported by Guthrie’) being to lower the plasma prolactin below 2 ng/ml. The therapeutic response was checked by 3-monthly cytological and colposcopic examinations. Where possible we tried to get a final histological examination. Eleven patients underwent complete remission, in one case we observed a partial remission, and in ten cases the lesions progressed. Although we cannot offer a conclusive explanation for our results, they do suggest a positive influence of bromocriptine on cervical intraepithelial neoplasia. A prospective, randomised study is now
required. Department of Gynaecology and Obstetrics, University of Tübingen, D7400 Tubingen, West Germany
EVA M. DONATH A. E. SCHINDLER
1 Guthrie D Treatment of carcinoma of the cervix with bromocriptine. Br J Obstet Gynaecol 1982; 89: 853-55. 2 Forsberg J, Breistein L Prolactin and 3-methylcholanthrene induced cervical
Effect of bromocriptine. Acta Pathol Microbiol Scand SA 1979; 87: 151-56 3. Kraus H. Schneider A. Häufigkeit, Ursachen und Verlauf zweifelhafter Abstrichbefunde (Gruppe Papanicolaou III). Geburtsh Frauenheilk 1984, 44: 87-90 4 Nasiell K, Nasiell M, Vaclavinkova V. Behaviour of moderate cervical dysplasia during long-term follow-up Obstet Gynecol 1983; 61: 609-14. 5. Richart R, Barren B. A follow-up study of patients with cervical dysplasia. Am J Obst Gynecol 1969; 105: 386-93 carcinoma.
IMPACT OF INTEGRATED CHILD DEVELOPMENT SERVICES ON INFANT MORTALITY RATE IN INDIA
SIR,-A coordinated approach to child development through integrated child development services (ICDS)1 was started in India on Oct 2, 1975, as an experiment. Its successful implementation2,3 resulted in fast expansion, and by March, 1Q85; nearly one-fifth of the
population of India will be covered by this scheme. ICDS provides health care, nutrition, and non-formal education to preschool children and care to pregnant and lactating women, as a package, at village centres through village level female workers (known as Anganwadi workers). One objective of ICDS is to reduce the infant mortality rate (IMR). A sample registration system44 periodically collects demographic data, including IMR, on a sample
of about 1%. 1980 estimates of IMR provided in this way are 124 per 1000 in the rural and tribal sample and 65 per 1000 in the urban
sample. We have studied infant mortality in ICDS projects which have been implemented for at least a year. We did this via a two-stage stratified random sampling procedure: a 20% sample of projects was selected and then within each project a 6% sample of villages and urban slums (137 villages and 90 slums) was drawn. About 1-5% (230 000) of the population covered by two hundred ICDS projects in, different parts of India was surveyed. Continuous follow-up of births and deaths for a period of 12 months during the year 1982-83 was achieved by teams supervised by senior faculty members of nearby medical colleges (ICDS consultants). The infrastructure of the primary health centres, including the ICDS village female worker and local informants, was utilised to record events. The design of data forms and the analysis of results was done at the AllIndia Institute of Medical Sciences, New Delhi. The IMR (per 1000) was significantly lower (86) for the 1982-83 ICDS sample survey than for the country as a whole, as provided by the sample registration system (114). Since ICDS projects are located in socioeconomically backward villages the IMR would be expected to be higher than the national average in those areas. Indeed a 1978 survey had shown the IMR in backward communities to be 159 (rural) and 90 (urban) compared with national estimates of 136 and 70, respectively. ICDS seems to have achieved a considerable decline in female IMR, the male to female ratio in the rural population being 919 vs 86 -8. Sex is not referred to in the 1980 sample registration study but the 1978 study had shown an IMR in females (142) much higher than that in males (130). We believe that the coordinated approach to the delivery of services in ICDS, providing better delivery of health and nutrition services to infants and expectant and nursing mothers, is the major factor responsible for lower IMRs in ICDS projects compared with IMRs nationwide. The lower IMR in ICDS projects was obvious in rural and tribal populations. The IMR for the rural and tribal population as calculated by sample registration survey data is 124 compared with 89 - 5 for ICDS projects. However, we did not find a similar impact of ICDS in urban projects: compared with an IMR of 65 at the national level in ICDS projects it was 80. However, the urban ICDS projects are in the slum populations ofbig towns where malnutrition and infection due to poverty, overcrowding, lack of water, and poor sanitation are highly prevalent. The samples for the IMR study were drawn from this selectively disadvantaged population while the sample registration survey sampled the whole urban population in which slums had a very low representation. Furthermore, the ICDS infrastructure in urban projects is meagre compared with what has been provided for rural and tribal projects. We conclude that a coordinated approach to the delivery of health, nutrition, and non-informal education to mothers and infants through the ICDS model has helped in reducing infant mortality in India. We thank all the consultants who contributed to this births and deaths study. Office of Central Technical Committee, Integrated Child Development Service,
Department of Gastroenterology and Human Nutrition, All-India Institute of Medical Sciences, New Delhi 110029, India child
B. N. TANDON
AJIT SAHAI ASHOK VARDHAN scheme. New Delhi:
1.
Integrated
2.
Welfare, 1975. Integrated child development service. A coordinated approach India Lancet 1981; i: 650-53.
3. 4.
development
services
Department to
of Social
children’s health in
Integrated child development services. A coordinated approach to children’s health in India Progress report after five years (1975-1980). Lancet 1983; i: 109-11. Vital Statistics Division, Registrar General, New Delhi. Sample registration system. New Delhi: Department of Home Affairs.
CHORIONIC BIOPSY IN MANAGEMENT OF SEVERE RHESUS ISOIMMUNISATION
SIR,—Determination of the fetal Rh(D) factor in early pregnancy would be of great benefit for severely sensitised women with a D antigen heterozygous partner. In some women it would prevent unnecessary diagnostic and therapeutic procedures; for others