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VACUUM VERSUS FORCEPS
575 the ventouse accounted for only 6% of the 683 assisted vaginal deliveries which occurred. In contrast, experience of its use in Brecon GP maternity unit is relevant. The unit is one of the small number of GP units undertaking most of the abnormal obstetrics of the population served, and has always enjoyed full consultant support for this policy. The ventouse has been used to assist 215 vaginal deliveries (almost exactly 50% of assisted vaginal deliveries) over the past 23 years, and perinatal mortality due to the method of delivery has been nil. Analysis of the last 100 cases, which gives a better comparison with modern obstetric practice, is as follows:
concluded that the presence of lupus anticoagulant and the of arterial and/or venous thrombosis were significantly associated. During the past three years we have observed 15 further patients, bringing our series to 29 (25 female, 4 male) with the lupus anticoagulant. All had severe forms of the disease, and 26 had clinical evidence of renal involvement. Renal biopsy (in 22 patients) revealed proliferative glomerular lesions in 15 (diffuse 9, focal 6), arteriolar lesions with glomerular ischaemia in 3, membranous nephropathy in 2, and mesangial immunoglobulin deposits in 2. Renal biopsy was not done in 4 patients because of thrombocytopenia. Severe extrarenal manifestations of SLE were noted in 25 patients, associated with renal involvement in 22. Central nervous system disease was present in 14 (48%) of patients. High-dose corticosteroid therapy was used in 27 patients and was combined with cyclophosphamide in 12. Thrombocytopenia (<150x 109/1) was recorded in 22 patients and 10 had counts below 100 x 109/1. False positive serological test for syphilis was observed in 17 patients (59%). DNA binding was above 30% in the active phase of the disease in 18 of 22 patients tested with the Farr
development
Dilatation of cervix.-lO cm (81 cases), 9 cm (13), cm(4),7 cm (1), 6 cm (1). Application distance (since advent of Bird’s cupsJ.->3 cm in 32 cases,> cm in 9
General anaesthesia.-2 cases. of head in pelvis.-At or above spines in 22 cases, below in 78. Position of occiput.-Anterior in 57, posterior in 27, and lateral in 16. Failure of vacuum.-With delivery by caesarean section in 6 cases and forceps in 2.
Position
technique. Thrombotic episodes were observed in 20 patients. On the assumption that cerebral infarction resulted from arterial thrombosis, as proposed by Harris et al,’ 15 patients had a history of one or more arterial thrombotic episodes: 9 had CNS involvement, 2 coronary artery thrombosis, 2 lower limb artery occlusion, 1 central retinal artery stenosis, and 2 visceral infarctions, pancreatic or splenic. 7 patients had one or more episodes of deep vein thrombosis, with recurrent pulmonary embolism in 1 patient who also had pulmonary hypertension. Both arterial and venous complications occurred, simultaneously or successively, in 3 patients. Of the 10 female patients who became pregnant, 3 had a history of one to three spontaneous abortions. Only 9 patients with the lupus anticoagulant never exhibited clinical evidence of vascular thrombosis. Evolution of lupus anticoagulant was assessed in 23 patients. In 13, anticoagulant level decreased (it even disappeared in 2) after corticosteroid therapy, in parallel with the reduction in clinical activity. In 5 of these patients, recurrence (1 case) or increase in anticoagulant level (4 cases) preceded or accompanied clinical reexacerbation of lupus disease. In 10 other patients, lupus anticoagulant persisted despite corticosteroid therapy; all but 1 of these patients exhibited persistent clinical SLE activity. The concordance between the findings of the Hammersmith Hospital group and our own strongly suggest that the lupus anticoagulant is a useful marker for SLE patients at risk of thromboembolic complications. Nephrology Unit, Necker Hospital,
P. JUNGERS
75743 Paris, France
F. LIOTE
Haematology Unit, Necker Hospital
M. D. DAUTZENBERG C. GAZENGEL
Rheumatology Unit, Cochin Hospital, Paris
M. DOUGADOS
Immunology Unit, Necker Hospital
J.
VACUUM VERSUS FORCEPS
SIR,-Your Jan 21 editorial re-emphasises the value and safety of the ventouse 25 years after its successful introduction to Britain by J. A. Chalmers.5 It says something for the conservatism of obstetric practice in the UK that it is necessary for his son to assist in recapitulating his findings a generation later.Comparative neglect of this instrument extends to general practitioner obstetricians, who are more likely than any others to derive benefit from its use-but since GPs learn their practical obstetrics in consultant units this neglect may be inevitable. In 1982 in isolated GP maternity units
Obstet
years’
experience with the
Wyatt G, Chalmers Gynaecol 1983; 90: 1107-12.
vacuum extractor.
I. Portsmouth
Br Med J
by
The safety of the instrument and the rare need for anaesthesia, together with the vacuum extractor’s ability to deal with malrotations of the occiput, mean that it has much to offer to GP obstetricians, few of whom will be skilled at delivery with Kielland’s forceps. Ability to perform assisted vaginal deliveries on the spot is associated with significantly lower transfer-in-labour rates from isolated GP maternity units, and more widespread use of this instrument will increase this capability. But a change in consultant attitudes will be necessary, for they are our teachers. Our results confirm the preliminary findings of the use of the ventouse in general practice,7 and I only hope it will not be necessary for anyone in my children’s generation to repeat these twenty years hence. Ruperra House, Brecon, Powys LD3 7AA
A. J. M. CAVENAGH
SEVERE HYPOKALAEMIA SECONDARY TO OVERINDULGENCE IN ALCOHOL-FREE "PASTIS"
SiR,-Pseudo primary aldosteronism is a well known complication of chronic liquorice ingestion. Glycyrrhizinic acid, the active component of liquorice, has mineralocorticoid effects, leading to potassium deficiency and hypertension. 1,2 A new source for this potentially serious intoxication is pastis sans alcool, soft drinks marketed in France that have liquorice to mimick the taste of pastis and contain 0 -. 6-135g/l of glycyrrhizinic acid.3,4 Here is another warning against the potential hazards of this type of drink. A 32-year-old man, a chronic alcoholic who was drinking between 3 and 6 litres of red wine daily, had an attack of alcoholic hepatitis, confirmed by liver enzyme studies on Aug 17, 1983. On advice of his family doctor the patient decided to stop drinking alcohol and he began to imbibe a soft drink (’Pacific’) containing 0-6 g/1 of glycyrrhizinic acid. His intake progressively increased to 0 . 30 g glycyrrhizinic acid by the beginning of November, the total amount of glycyrrhizinic acid absorbed was about 23 g. On Nov 26 his blood was 180/110 mm Hg. A few days later diffuse muscle pain occurred, associated with a generalised weakness which developed into tetraparesis. On Dec 10 the patient sustained a prolonged cardiac arrest at home. Life support was initiated by the fire brigade and continued by the family doctor. When the emergency medical team saw him 40 min later he was comatose, with absent motor responses, dilated and fixed pupils, a blood pressure of 120/90 mm Hg, and an irregular pulse. The ECG disclosed bigeminal premature ventricular beats (cardiac rhythm of 130 beats/min) with a Q-T interval of 0-45 s (normal 0 -32 s). His serum potassium (before any intravenous infusion) was 1’88 mmol/1. A potassium infusion was immediately
{pressure
F. TRON F. BACH
5. Chalmers JA. Five 1216-20. 6. Vacca A, Grant A,
cases.
7.
2.
1964; i:
3.
Br
4.
operative delivery trial.
J
Cavenagh AJM. The ventouse in general practice. Practitioner 1965; 194: 396-99. B, Ginsburg R, Shneerson J. Cardiac arrest due to liquorice-induced hypokalaemia. Br Med J 1977; ii: 738-39. Epstein MT, Espiner EA, Donald RA, Hughes H Effect of eating liquorice on the renin-angiotensins in aldosterone axis in normal subjects. Br Med J 1977; i: 488-89. Bauer D, Piette AM, Chapman A. Hypokaliémie majeure avec rhabdomyolyse secondaire à l’ingestion de pastis non alcoolisé. Nouv Presse Méd 1982; 11: 2638-39. Cereda JM, Trono D, Schifferli J. Liquorice intoxication caused by alcohol-free pastis.
1. Bannister
Lancet
1983,
i: 1442.
concluded that the presence of lupus anticoagulant and the of arterial and/or venous thrombosis were significantly associated. During the past three years we have observed 15 further patients, bringing our series to 29 (25 female, 4 male) with the lupus anticoagulant. All had severe forms of the disease, and 26 had clinical evidence of renal involvement. Renal biopsy (in 22 patients) revealed proliferative glomerular lesions in 15 (diffuse 9, focal 6), arteriolar lesions with glomerular ischaemia in 3, membranous nephropathy in 2, and mesangial immunoglobulin deposits in 2. Renal biopsy was not done in 4 patients because of thrombocytopenia. Severe extrarenal manifestations of SLE were noted in 25 patients, associated with renal involvement in 22. Central nervous system disease was present in 14 (48%) of patients. High-dose corticosteroid therapy was used in 27 patients and was combined with cyclophosphamide in 12. Thrombocytopenia (<150x 109/1) was recorded in 22 patients and 10 had counts below 100 x 109/1. False positive serological test for syphilis was observed in 17 patients (59%). DNA binding was above 30% in the active phase of the disease in 18 of 22 patients tested with the Farr
development
Dilatation of cervix.-lO cm (81 cases), 9 cm (13), cm(4),7 cm (1), 6 cm (1). Application distance (since advent of Bird’s cupsJ.->3 cm in 32 cases,> cm in 9
General anaesthesia.-2 cases. of head in pelvis.-At or above spines in 22 cases, below in 78. Position of occiput.-Anterior in 57, posterior in 27, and lateral in 16. Failure of vacuum.-With delivery by caesarean section in 6 cases and forceps in 2.
Position
technique. Thrombotic episodes were observed in 20 patients. On the assumption that cerebral infarction resulted from arterial thrombosis, as proposed by Harris et al,’ 15 patients had a history of one or more arterial thrombotic episodes: 9 had CNS involvement, 2 coronary artery thrombosis, 2 lower limb artery occlusion, 1 central retinal artery stenosis, and 2 visceral infarctions, pancreatic or splenic. 7 patients had one or more episodes of deep vein thrombosis, with recurrent pulmonary embolism in 1 patient who also had pulmonary hypertension. Both arterial and venous complications occurred, simultaneously or successively, in 3 patients. Of the 10 female patients who became pregnant, 3 had a history of one to three spontaneous abortions. Only 9 patients with the lupus anticoagulant never exhibited clinical evidence of vascular thrombosis. Evolution of lupus anticoagulant was assessed in 23 patients. In 13, anticoagulant level decreased (it even disappeared in 2) after corticosteroid therapy, in parallel with the reduction in clinical activity. In 5 of these patients, recurrence (1 case) or increase in anticoagulant level (4 cases) preceded or accompanied clinical reexacerbation of lupus disease. In 10 other patients, lupus anticoagulant persisted despite corticosteroid therapy; all but 1 of these patients exhibited persistent clinical SLE activity. The concordance between the findings of the Hammersmith Hospital group and our own strongly suggest that the lupus anticoagulant is a useful marker for SLE patients at risk of thromboembolic complications. Nephrology Unit, Necker Hospital,
P. JUNGERS
75743 Paris, France
F. LIOTE
Haematology Unit, Necker Hospital
M. D. DAUTZENBERG C. GAZENGEL
Rheumatology Unit, Cochin Hospital, Paris
M. DOUGADOS
Immunology Unit, Necker Hospital
J.
VACUUM VERSUS FORCEPS
SIR,-Your Jan 21 editorial re-emphasises the value and safety of the ventouse 25 years after its successful introduction to Britain by J. A. Chalmers.5 It says something for the conservatism of obstetric practice in the UK that it is necessary for his son to assist in recapitulating his findings a generation later.Comparative neglect of this instrument extends to general practitioner obstetricians, who are more likely than any others to derive benefit from its use-but since GPs learn their practical obstetrics in consultant units this neglect may be inevitable. In 1982 in isolated GP maternity units
Obstet
years’
experience with the
Wyatt G, Chalmers Gynaecol 1983; 90: 1107-12.
vacuum extractor.
I. Portsmouth
Br Med J
by
The safety of the instrument and the rare need for anaesthesia, together with the vacuum extractor’s ability to deal with malrotations of the occiput, mean that it has much to offer to GP obstetricians, few of whom will be skilled at delivery with Kielland’s forceps. Ability to perform assisted vaginal deliveries on the spot is associated with significantly lower transfer-in-labour rates from isolated GP maternity units, and more widespread use of this instrument will increase this capability. But a change in consultant attitudes will be necessary, for they are our teachers. Our results confirm the preliminary findings of the use of the ventouse in general practice,7 and I only hope it will not be necessary for anyone in my children’s generation to repeat these twenty years hence. Ruperra House, Brecon, Powys LD3 7AA
A. J. M. CAVENAGH
SEVERE HYPOKALAEMIA SECONDARY TO OVERINDULGENCE IN ALCOHOL-FREE "PASTIS"
SiR,-Pseudo primary aldosteronism is a well known complication of chronic liquorice ingestion. Glycyrrhizinic acid, the active component of liquorice, has mineralocorticoid effects, leading to potassium deficiency and hypertension. 1,2 A new source for this potentially serious intoxication is pastis sans alcool, soft drinks marketed in France that have liquorice to mimick the taste of pastis and contain 0 -. 6-135g/l of glycyrrhizinic acid.3,4 Here is another warning against the potential hazards of this type of drink. A 32-year-old man, a chronic alcoholic who was drinking between 3 and 6 litres of red wine daily, had an attack of alcoholic hepatitis, confirmed by liver enzyme studies on Aug 17, 1983. On advice of his family doctor the patient decided to stop drinking alcohol and he began to imbibe a soft drink (’Pacific’) containing 0-6 g/1 of glycyrrhizinic acid. His intake progressively increased to 0 . 30 g glycyrrhizinic acid by the beginning of November, the total amount of glycyrrhizinic acid absorbed was about 23 g. On Nov 26 his blood was 180/110 mm Hg. A few days later diffuse muscle pain occurred, associated with a generalised weakness which developed into tetraparesis. On Dec 10 the patient sustained a prolonged cardiac arrest at home. Life support was initiated by the fire brigade and continued by the family doctor. When the emergency medical team saw him 40 min later he was comatose, with absent motor responses, dilated and fixed pupils, a blood pressure of 120/90 mm Hg, and an irregular pulse. The ECG disclosed bigeminal premature ventricular beats (cardiac rhythm of 130 beats/min) with a Q-T interval of 0-45 s (normal 0 -32 s). His serum potassium (before any intravenous infusion) was 1’88 mmol/1. A potassium infusion was immediately
{pressure
F. TRON F. BACH
5. Chalmers JA. Five 1216-20. 6. Vacca A, Grant A,
cases.
7.
2.
1964; i:
3.
Br
4.
operative delivery trial.
J
Cavenagh AJM. The ventouse in general practice. Practitioner 1965; 194: 396-99. B, Ginsburg R, Shneerson J. Cardiac arrest due to liquorice-induced hypokalaemia. Br Med J 1977; ii: 738-39. Epstein MT, Espiner EA, Donald RA, Hughes H Effect of eating liquorice on the renin-angiotensins in aldosterone axis in normal subjects. Br Med J 1977; i: 488-89. Bauer D, Piette AM, Chapman A. Hypokaliémie majeure avec rhabdomyolyse secondaire à l’ingestion de pastis non alcoolisé. Nouv Presse Méd 1982; 11: 2638-39. Cereda JM, Trono D, Schifferli J. Liquorice intoxication caused by alcohol-free pastis.
1. Bannister
Lancet
1983,
i: 1442.