- Email: [email protected]
URINARY CALCULI IN CHRONIC DIALYSIS PATIENTS
1024
superior. Cefotaxime (and all the aminoglycosides) are ineffective against Strep.faecalis. Cefotaxime is more active against Enterobacteriaceae than are other cephalosporins, acylureido-penicillins, and aminoglycosides. Further clinical studies are necessary the excellent in-vitro properties of cefotaxime replace the aminoglycosides.
to
show whether that it can
mean
Institute of Medical Microbiology, Technical University, D-8000 Munich 80, West Germany
I. BRAVENY H. DICKERT
PRIMARY CARPAL STENOSIS AS A CAUSE OF "IDIOPATHIC" CARPAL-TUNNEL SYNDROME
SIR,-The carpal-tunnel syndrome is the
most common
nerve-entrapment syndrome and may be caused by widely differing lesions. In about 50% of patientsthe aetiology is not clear. Such patients with "idiopathic" carpal-tunnel syndrome are often females approaching the menopause. The symptoms tend to be bilateral but commonly more severe in the dominant limb.’ Stenosis of the carpal canal as a result of trauma, osteoarthritis of the wrist joint, and neoplasms have all been recorded as leading to carpal tunnel syndrome.2 We therefore examined the cross-sectional areas of the carpal canal in seven female patients with "idiopathic" carpal-tunnel syndrome and in a group of twelve age-matched female and six male controls by computerised axial tomography (CT 1010 F3C). The diagnosis of carpal-tunnel syndrome was based on clinical history and findings and electrodiagnostic studies. Patients who may have had one of the recognised lesions leading to the carpal-tunnel syndrome were excluded. Both hands of each patient and of controls were examined. The radiographs of the cross-sections were mounted and projected to a table digitiser connected to a computer (Digital Equipment Corporation PDP 31/34). Because the flexor retinaculum was not always clearly visible on the radiographs, a line was drawn from the scaphoid tubercle to the pisiform bone and from the trapezium to the hook of the hemate corresponding to the anatomical attachments of the carpal ligament. The area enclosed by the carpal bones and this line was measured from the radiographs. The proximal carpal-tunnel cross-sectional area (pisiform bone to the tubercle of the scaphoid) of the female patients was 1428±4.6 mm2 (mean+SEM), and this was significantly smaller (p<0-001) than the cross-sectional area of female controls (1938±8.3 mm2). The cross-sectional area of the proximal carpal tunnel in female controls were significantly smaller (p. 005 ) than the corresponding area in male controls (239.8112.3 mm2). The distal cross-sectional area (hook of the hamate to the tubercle of the trapezium) did not differ significantly between female patients (162.5±12.4 mm2) and controls (182.9±9-2 mm2) but was significantly different (p<0-05) between female and male controls (216±11-0 mm2). These results suggest an association between a small carpaltunnel canal and symptoms of carpal-tunnel syndrome. The smaller carpal canal in control females compared with control males may explain the female propensity for this condition. The main difference between the three groups examined is in the proximal cross-sectional area of the carpal tunnel. This suggests the stenosis of this particular part may account forI the symptoms. The familial tendency of idiopathic carpal-tunnel syndrome has been noted,2 and it may be that carpal stenosis has a genetic basis. The symptoms only appearing in late life due to degenerative changes in the content or of the walls of the carpal canal. Nuffield Department of Orthopædic Nuffield Orthopædic Centre, Headington, Oxford OX3 7LD
Surgery,
S. DEKEL R. COATES
1. Phalen GS. The carpal tunnel syndrome. Clin Orthoped 1972; 83: 29-40. 2. Sunderland S. Nerves and nerve injuries. Edinburgh: Churchill Livingstone, 1978:711. 3. Warwick R, Williams PL, eds. Gray’s anatomy. London: Longman, 1973: 551.
URINARY CALCULI IN CHRONIC DIALYSIS PATIENTS
SiR,—The mechanism responsible for urolithiasis is usually increase in concentration or amount of solutes, leading to precipitation and the formation of calculi. In end-stage kidney an
disease neither condition is met and a high incidence of urinary calculi in chronic dialysis patients is difficult to
explain. our patients on chronic hmmodialysis are enrolled integrated hsemodialysis-transplant programme, and usually they have to wait for months or even years for a kidney graft. The nephropathies of these patients are the usual ones found in chronic renal failure-glomerulonephritis, pyelonephritis, polycystic kidney disease, hypertension, diabetes,
Most of
in
an
and so on. Our surgeons do a unilateral nephrectomy and then reconstruct the urinary tract using whole ureter and renal pelvis that are anastomosed to the renal pelvis of the graft.l The excised kidney is studied routinely and sometimes slides are examined under polarised light. Urinary calculi are examined by infra-red spectrophotometer or under a polarised-light microscope if the calculus is very small. In one group of patients with advanced chronic renal insufficiency we measured the oxalic acid in the urine.2 12 of the 160 patients on chronic haemodialysis (7.5%) have passed one or more calculi since their inclusion in the programme. This figure is higher than that for the general population in western countries (2-3%3). 6 other patients (3-7%) had one or more episodes of renal pain without calculus being passed. No patients had a history of urinary lithiasis. The expulsion of calculi never occurred before the patient had been on dialysis for six months. The diagnoses in those so affected were typical of the population studied. The urine was usually sterile. Some of the calculi were examined and found to be formed of calcium oxalate. The upper urinary tracts of 15 kidneys removed at the time of a kidney transplant were studied and small calcium oxalate calculi were found in 3 of them (20%). The calculi could be seen on plain abdominal X-ray films taken before transplantation. The frequency of renal and ureteral calculi found at necropsy is only 1 %.4 2 patients with no history of urinary calculi who were on chronic haemodialysis at another hospital and who were transferred to our unit for transplantation had calculi in the ureter used for the reconstruction of the urinary tract. Both calculi were visible in the plain abdominal film, done before transplantation, but the images were misinterpreted. In 1 patient the calculus was in the upper ureter and was easily removed during transplantation, but the other one was in the lower ureter and manifest as urinary obstruction 48 h after trans-
plantation, ureterolithotomy being required.
The
composition
of both calculi was calcium oxalate. We now recommend plain abdominal films immediately before transplantation. We think that the calcium-oxalate lithiasis seen in chronic dialysis patients is related to the hyperoxaluria that we have found in advanced chronic renal insufficiency and to the renal deposition of calcium oxalate in chronic renal failure.s We measured urinary calcium, uric acid, and oxalic acid excretion in 24 h in 17 patients with advanced chronic renal insufficiency of diverse setiology, creatinine clearances of 10-30 ml/min, and no history of urinary lithiasis: the urinary calcium (mean 86 mg), and uric acid (413 mg) values were lower
Caralps A. Human renal homotransplantation: A new surgical technique. Urologia Int 1968; 23: 201-23. 2. Hodgkinson A, Williams A. An improved colorimetric procedure for urine oxalate. Clin Chim Acta 1972; 26: 127-32. 3. Nordin BEC, Hodgkinson A. Urinary tract calculi. In: Black D, ed. Renal disease. Oxford: Blackwell, 1972: 759-80. 4. Bell ET. Renal disease. London: Kimpton, 1950: 414. 5. Salyer WR, Keren D. Oxalosis as a complication of chronic renal failure. Kidney Int 1973; 4: 61-66. 1. Gil-Vernet JM,
1025 than in individuals with normal creatinine clearances, but 24 urinary oxalic acid values were raised (mean 53-5 mg, the normal maximum level being 35 mg) and 2 patients excreted more than 70 mg. In 23 out of 27 kidneys removed at the time of transplantation calcium oxalate dihydrate deposits were observed inside and in the wall of the cortex or the medulla tubules and to a lesser extent in the interstitium. We also discovered crystals inside the renal pelvis, which shows that these crystalline collections can be excreted with the urine. h
A. CARALPS J. LLOVERAS J. ANDREU A. BRULLES J. MASRAMON M. LLORACH M. T. VIDAL M. FERNANDEZ CONDE J. AUBIA
Transplant Unit, Hospital Clinico, Barcelona, Spain; and Nephrology Service, Hospital de la Esperanza,
Renal
Barcelona
HAZARDS OF MOUTH-TO-MOUTH RESUSCITATION
SIR,-Professor Davies (Sept. 15,
p. 593) has raised imporquestions about the risk to operators of mouth-to-mouth breathing. Most people who acquire meningococcal infection do so from a carrier, and patients with meningococcal infection are thought to pose no great risk to hospital contacts.’1 However, transmission of meningococcal infection from patients to hospital staffsand other patients’ has been described. Meningococcal infection has been acquired after tant
mouth-to-mouth resuscitationbut there is no agreement as to the management of such contacts. Jacobson and Fraser5 recommended that mouth-to-mouth contacts be given the same chemoprophylaxis with rifampicin, sulfadiazine, or minocycline as are other close contacts. My concerns with this approach are that there may be a very brief period of colonisation of the upper respiratory tract before the onset of meningococcal infection6 and such infection may be very rapidly fatal.2 To eradicate a potential bacterxmia in the operator immediately after mouth-to-mouth resuscitation, Artenstein recommended procaine penicillin intramuscularly, 500 000 units three times daily for two days, followed by orally administered penicillin V 500 mg three times daily for eight days. However, Artenstein’s regimen may be ineffective because meningococcal infection has been reported in close, but not mouth-to-mouth, contacts receiving intramuscular procaine penicillin and benzathine penicillin for chemoprophylaxis.8 When faced with this dilemma I have recommended that the mouth-to-mouth contact be admitted to hospital and started on 12 million units of penicillin G intravenously in divided doses over 24 h after blood has been drawn for culture. The patients are discharged 2 days later if they remain symptom-free and if blood cultures are sterile. None of these recommendations have been evaluated formally and I would be interested in having other phys1. Artenstein MS, Ellis RE. The risk of exposure to a patient with meningococcal meningitis. Military Med 1968; 133: 474-77. 2. Fieldman HA. Some recollections of the meningococcal diseases: The first Harry F. Dowling lecture. JAMA 1972; 220: 1107-112. 3. Anonymous. Nosocomial meningococcemia—Wisconsin. Morbid Mortal
Weekly Rep 1978; 27: 358-63. 4. Cohen MS, Steere AC, Baltimore R, Von Graevenitz A, Pantelick E, Camp B, Root RK, Possible nosocomial transmission of Group Y Neisseria meningitidis among oncology patients. Ann Intern Med 1979; 91: 7-12. 5. Jacobson JA, Fraser DW. A simplified approach to meningococcal disease prophylaxis. JAMA 1976; 236: 1053-54. 6. Edwards EA, Devine LF, Sengbusch CH, Ward HW, et al. Immunological investigations of meningococcal disease. III Brevity of group C acquisition prior to disease occurrence. Scand J Infect Dis 1977; 9: 105-10. 7. Artenstein MS. Prophylaxis for meningococcal disease. JAMA 1975; 231:
1035-37. 8. Anonymous. 17: 178.
Meningococcal meningitis.
Morbid Mortal
Weekly Rep 1968;
icians’ views
on
the management of mouth-to-mouth
contacts
of patients with meningococcal infection. Clinical Pharmacology Service, St. Joseph’s Hospital, Hamilton, Ontario L8N 1Y4, Canada
MICHAEL R. ACHONG
OVARIAN OVERRIPENESS AND INTRAUTERINE GROWTH RETARDATION
SIR,-Intrauterine growth retardation (IUGR) leading to small-for-dates babies is usually related to a maternal or fetal disturbance. However, about 50% of cases of IUGR remain unexplained. Such IUGR could be similar to delayed fetal growth observed when the luteinising-hormone peak is delayed by 48 h in the rat or by 60 h in the rabbit. Overripeness of the ovum, which is the consequence of an overlong follicular phase, is difficult to study in women but an indication can be had from basal body-temperature charts (BBT). The BBT charts for 289 conception cycles have been studied. 159 (55%) were from women seeking advice after cessation of oral contraception or who were using BBT as a contraceptive method and 130 (45%) were from women who had had
previous subfertility problems. PROPORTION OF SMALL-FOR-DATES BABIES ACCORDING TO CYCLE DAY AND LENGTH OF TEMPERATURE RISE
The BBT curves were read by two independent observers who measured several items, notably the "nadir" point (the last day of hypothermia) and the duration of the temperature rise. The charts of women showing an obvious maternal factor for IUGR were discarded (53 cases), as were those with twin pregnancies (6), malformed infants (4), and stillbirths (1). 20 curves were unreadable, leaving 205 for analysis. A baby was defined as small-for-dates when the birthweight was under the tenth centile for gestational age.3 The proportion of small-for-date babies was 13% when the nadir took place between day 11 and day 16 of the cycle and 27% when it was after day 16 (p <0-02). This increase was more striking when nadir occurred between days 17 and 23 (table). This could correspond to a long follicular phase. The relation between IUGR and the duration of the temperature rise suggests an association between a long follicular phase and slowness of temperature rise, but the numbers were small. The results were the same for women with or without fertility problems and for different age-groups. Ovulation between day 17 and 23 in the cycle can be compared to experimentally delayed ovulation in the rat and rab1.
Fugo NW,
Butcher RL.
Overripeness and the mammalian
ova.
Fertil Steril
1967; 18: 294-302. 2. Bomsel-Helmrich O. Effets de l’ovulation retardée
sur
le
développement des
blastocystes de lapine. Int Congr Animel Reprod 1972; 11: 205-12. 3. Leroy B, Lefort F. A propos du poids et de la taille des nouveau-nés à la naissance. Revue Fr Gynecol 1971: 391-96.
superior. Cefotaxime (and all the aminoglycosides) are ineffective against Strep.faecalis. Cefotaxime is more active against Enterobacteriaceae than are other cephalosporins, acylureido-penicillins, and aminoglycosides. Further clinical studies are necessary the excellent in-vitro properties of cefotaxime replace the aminoglycosides.
to
show whether that it can
mean
Institute of Medical Microbiology, Technical University, D-8000 Munich 80, West Germany
I. BRAVENY H. DICKERT
PRIMARY CARPAL STENOSIS AS A CAUSE OF "IDIOPATHIC" CARPAL-TUNNEL SYNDROME
SIR,-The carpal-tunnel syndrome is the
most common
nerve-entrapment syndrome and may be caused by widely differing lesions. In about 50% of patientsthe aetiology is not clear. Such patients with "idiopathic" carpal-tunnel syndrome are often females approaching the menopause. The symptoms tend to be bilateral but commonly more severe in the dominant limb.’ Stenosis of the carpal canal as a result of trauma, osteoarthritis of the wrist joint, and neoplasms have all been recorded as leading to carpal tunnel syndrome.2 We therefore examined the cross-sectional areas of the carpal canal in seven female patients with "idiopathic" carpal-tunnel syndrome and in a group of twelve age-matched female and six male controls by computerised axial tomography (CT 1010 F3C). The diagnosis of carpal-tunnel syndrome was based on clinical history and findings and electrodiagnostic studies. Patients who may have had one of the recognised lesions leading to the carpal-tunnel syndrome were excluded. Both hands of each patient and of controls were examined. The radiographs of the cross-sections were mounted and projected to a table digitiser connected to a computer (Digital Equipment Corporation PDP 31/34). Because the flexor retinaculum was not always clearly visible on the radiographs, a line was drawn from the scaphoid tubercle to the pisiform bone and from the trapezium to the hook of the hemate corresponding to the anatomical attachments of the carpal ligament. The area enclosed by the carpal bones and this line was measured from the radiographs. The proximal carpal-tunnel cross-sectional area (pisiform bone to the tubercle of the scaphoid) of the female patients was 1428±4.6 mm2 (mean+SEM), and this was significantly smaller (p<0-001) than the cross-sectional area of female controls (1938±8.3 mm2). The cross-sectional area of the proximal carpal tunnel in female controls were significantly smaller (p. 005 ) than the corresponding area in male controls (239.8112.3 mm2). The distal cross-sectional area (hook of the hamate to the tubercle of the trapezium) did not differ significantly between female patients (162.5±12.4 mm2) and controls (182.9±9-2 mm2) but was significantly different (p<0-05) between female and male controls (216±11-0 mm2). These results suggest an association between a small carpaltunnel canal and symptoms of carpal-tunnel syndrome. The smaller carpal canal in control females compared with control males may explain the female propensity for this condition. The main difference between the three groups examined is in the proximal cross-sectional area of the carpal tunnel. This suggests the stenosis of this particular part may account forI the symptoms. The familial tendency of idiopathic carpal-tunnel syndrome has been noted,2 and it may be that carpal stenosis has a genetic basis. The symptoms only appearing in late life due to degenerative changes in the content or of the walls of the carpal canal. Nuffield Department of Orthopædic Nuffield Orthopædic Centre, Headington, Oxford OX3 7LD
Surgery,
S. DEKEL R. COATES
1. Phalen GS. The carpal tunnel syndrome. Clin Orthoped 1972; 83: 29-40. 2. Sunderland S. Nerves and nerve injuries. Edinburgh: Churchill Livingstone, 1978:711. 3. Warwick R, Williams PL, eds. Gray’s anatomy. London: Longman, 1973: 551.
URINARY CALCULI IN CHRONIC DIALYSIS PATIENTS
SiR,—The mechanism responsible for urolithiasis is usually increase in concentration or amount of solutes, leading to precipitation and the formation of calculi. In end-stage kidney an
disease neither condition is met and a high incidence of urinary calculi in chronic dialysis patients is difficult to
explain. our patients on chronic hmmodialysis are enrolled integrated hsemodialysis-transplant programme, and usually they have to wait for months or even years for a kidney graft. The nephropathies of these patients are the usual ones found in chronic renal failure-glomerulonephritis, pyelonephritis, polycystic kidney disease, hypertension, diabetes,
Most of
in
an
and so on. Our surgeons do a unilateral nephrectomy and then reconstruct the urinary tract using whole ureter and renal pelvis that are anastomosed to the renal pelvis of the graft.l The excised kidney is studied routinely and sometimes slides are examined under polarised light. Urinary calculi are examined by infra-red spectrophotometer or under a polarised-light microscope if the calculus is very small. In one group of patients with advanced chronic renal insufficiency we measured the oxalic acid in the urine.2 12 of the 160 patients on chronic haemodialysis (7.5%) have passed one or more calculi since their inclusion in the programme. This figure is higher than that for the general population in western countries (2-3%3). 6 other patients (3-7%) had one or more episodes of renal pain without calculus being passed. No patients had a history of urinary lithiasis. The expulsion of calculi never occurred before the patient had been on dialysis for six months. The diagnoses in those so affected were typical of the population studied. The urine was usually sterile. Some of the calculi were examined and found to be formed of calcium oxalate. The upper urinary tracts of 15 kidneys removed at the time of a kidney transplant were studied and small calcium oxalate calculi were found in 3 of them (20%). The calculi could be seen on plain abdominal X-ray films taken before transplantation. The frequency of renal and ureteral calculi found at necropsy is only 1 %.4 2 patients with no history of urinary calculi who were on chronic haemodialysis at another hospital and who were transferred to our unit for transplantation had calculi in the ureter used for the reconstruction of the urinary tract. Both calculi were visible in the plain abdominal film, done before transplantation, but the images were misinterpreted. In 1 patient the calculus was in the upper ureter and was easily removed during transplantation, but the other one was in the lower ureter and manifest as urinary obstruction 48 h after trans-
plantation, ureterolithotomy being required.
The
composition
of both calculi was calcium oxalate. We now recommend plain abdominal films immediately before transplantation. We think that the calcium-oxalate lithiasis seen in chronic dialysis patients is related to the hyperoxaluria that we have found in advanced chronic renal insufficiency and to the renal deposition of calcium oxalate in chronic renal failure.s We measured urinary calcium, uric acid, and oxalic acid excretion in 24 h in 17 patients with advanced chronic renal insufficiency of diverse setiology, creatinine clearances of 10-30 ml/min, and no history of urinary lithiasis: the urinary calcium (mean 86 mg), and uric acid (413 mg) values were lower
Caralps A. Human renal homotransplantation: A new surgical technique. Urologia Int 1968; 23: 201-23. 2. Hodgkinson A, Williams A. An improved colorimetric procedure for urine oxalate. Clin Chim Acta 1972; 26: 127-32. 3. Nordin BEC, Hodgkinson A. Urinary tract calculi. In: Black D, ed. Renal disease. Oxford: Blackwell, 1972: 759-80. 4. Bell ET. Renal disease. London: Kimpton, 1950: 414. 5. Salyer WR, Keren D. Oxalosis as a complication of chronic renal failure. Kidney Int 1973; 4: 61-66. 1. Gil-Vernet JM,
1025 than in individuals with normal creatinine clearances, but 24 urinary oxalic acid values were raised (mean 53-5 mg, the normal maximum level being 35 mg) and 2 patients excreted more than 70 mg. In 23 out of 27 kidneys removed at the time of transplantation calcium oxalate dihydrate deposits were observed inside and in the wall of the cortex or the medulla tubules and to a lesser extent in the interstitium. We also discovered crystals inside the renal pelvis, which shows that these crystalline collections can be excreted with the urine. h
A. CARALPS J. LLOVERAS J. ANDREU A. BRULLES J. MASRAMON M. LLORACH M. T. VIDAL M. FERNANDEZ CONDE J. AUBIA
Transplant Unit, Hospital Clinico, Barcelona, Spain; and Nephrology Service, Hospital de la Esperanza,
Renal
Barcelona
HAZARDS OF MOUTH-TO-MOUTH RESUSCITATION
SIR,-Professor Davies (Sept. 15,
p. 593) has raised imporquestions about the risk to operators of mouth-to-mouth breathing. Most people who acquire meningococcal infection do so from a carrier, and patients with meningococcal infection are thought to pose no great risk to hospital contacts.’1 However, transmission of meningococcal infection from patients to hospital staffsand other patients’ has been described. Meningococcal infection has been acquired after tant
mouth-to-mouth resuscitationbut there is no agreement as to the management of such contacts. Jacobson and Fraser5 recommended that mouth-to-mouth contacts be given the same chemoprophylaxis with rifampicin, sulfadiazine, or minocycline as are other close contacts. My concerns with this approach are that there may be a very brief period of colonisation of the upper respiratory tract before the onset of meningococcal infection6 and such infection may be very rapidly fatal.2 To eradicate a potential bacterxmia in the operator immediately after mouth-to-mouth resuscitation, Artenstein recommended procaine penicillin intramuscularly, 500 000 units three times daily for two days, followed by orally administered penicillin V 500 mg three times daily for eight days. However, Artenstein’s regimen may be ineffective because meningococcal infection has been reported in close, but not mouth-to-mouth, contacts receiving intramuscular procaine penicillin and benzathine penicillin for chemoprophylaxis.8 When faced with this dilemma I have recommended that the mouth-to-mouth contact be admitted to hospital and started on 12 million units of penicillin G intravenously in divided doses over 24 h after blood has been drawn for culture. The patients are discharged 2 days later if they remain symptom-free and if blood cultures are sterile. None of these recommendations have been evaluated formally and I would be interested in having other phys1. Artenstein MS, Ellis RE. The risk of exposure to a patient with meningococcal meningitis. Military Med 1968; 133: 474-77. 2. Fieldman HA. Some recollections of the meningococcal diseases: The first Harry F. Dowling lecture. JAMA 1972; 220: 1107-112. 3. Anonymous. Nosocomial meningococcemia—Wisconsin. Morbid Mortal
Weekly Rep 1978; 27: 358-63. 4. Cohen MS, Steere AC, Baltimore R, Von Graevenitz A, Pantelick E, Camp B, Root RK, Possible nosocomial transmission of Group Y Neisseria meningitidis among oncology patients. Ann Intern Med 1979; 91: 7-12. 5. Jacobson JA, Fraser DW. A simplified approach to meningococcal disease prophylaxis. JAMA 1976; 236: 1053-54. 6. Edwards EA, Devine LF, Sengbusch CH, Ward HW, et al. Immunological investigations of meningococcal disease. III Brevity of group C acquisition prior to disease occurrence. Scand J Infect Dis 1977; 9: 105-10. 7. Artenstein MS. Prophylaxis for meningococcal disease. JAMA 1975; 231:
1035-37. 8. Anonymous. 17: 178.
Meningococcal meningitis.
Morbid Mortal
Weekly Rep 1968;
icians’ views
on
the management of mouth-to-mouth
contacts
of patients with meningococcal infection. Clinical Pharmacology Service, St. Joseph’s Hospital, Hamilton, Ontario L8N 1Y4, Canada
MICHAEL R. ACHONG
OVARIAN OVERRIPENESS AND INTRAUTERINE GROWTH RETARDATION
SIR,-Intrauterine growth retardation (IUGR) leading to small-for-dates babies is usually related to a maternal or fetal disturbance. However, about 50% of cases of IUGR remain unexplained. Such IUGR could be similar to delayed fetal growth observed when the luteinising-hormone peak is delayed by 48 h in the rat or by 60 h in the rabbit. Overripeness of the ovum, which is the consequence of an overlong follicular phase, is difficult to study in women but an indication can be had from basal body-temperature charts (BBT). The BBT charts for 289 conception cycles have been studied. 159 (55%) were from women seeking advice after cessation of oral contraception or who were using BBT as a contraceptive method and 130 (45%) were from women who had had
previous subfertility problems. PROPORTION OF SMALL-FOR-DATES BABIES ACCORDING TO CYCLE DAY AND LENGTH OF TEMPERATURE RISE
The BBT curves were read by two independent observers who measured several items, notably the "nadir" point (the last day of hypothermia) and the duration of the temperature rise. The charts of women showing an obvious maternal factor for IUGR were discarded (53 cases), as were those with twin pregnancies (6), malformed infants (4), and stillbirths (1). 20 curves were unreadable, leaving 205 for analysis. A baby was defined as small-for-dates when the birthweight was under the tenth centile for gestational age.3 The proportion of small-for-date babies was 13% when the nadir took place between day 11 and day 16 of the cycle and 27% when it was after day 16 (p <0-02). This increase was more striking when nadir occurred between days 17 and 23 (table). This could correspond to a long follicular phase. The relation between IUGR and the duration of the temperature rise suggests an association between a long follicular phase and slowness of temperature rise, but the numbers were small. The results were the same for women with or without fertility problems and for different age-groups. Ovulation between day 17 and 23 in the cycle can be compared to experimentally delayed ovulation in the rat and rab1.
Fugo NW,
Butcher RL.
Overripeness and the mammalian
ova.
Fertil Steril
1967; 18: 294-302. 2. Bomsel-Helmrich O. Effets de l’ovulation retardée
sur
le
développement des
blastocystes de lapine. Int Congr Animel Reprod 1972; 11: 205-12. 3. Leroy B, Lefort F. A propos du poids et de la taille des nouveau-nés à la naissance. Revue Fr Gynecol 1971: 391-96.