the urologist will be prepared for this when resecting in the posterior lateral area of the bladder. However, obturator nerve stimulation has not been reported during transcervical endometrial resection. In the case reported here the resectoscope perforated the uterus in the comual area. This prompted us to investigate the electrical resistance of the uterus. Measurements on two hysterectomy specimens showed that the resistance between the endometrium and the tubal ostium is less than that between the endometrium and the peritoneal surface:
(1) Check the Kell status of the partner. If Kell negative, treat the patient as for a normal pregnancy and ignore antibodies. (2) If partner is Kell-positive refer for cordocentesis after 20 weeks’ gestation. If the fetus is Kell-negative treat the patient as for a normal pregnancy and ignore antibodies. (3) If the fetus is Kell-positive, refer the patient for management and treatment to a specialist centre, where cordocentesis and intrauterine intravascular transfusion Good Hope Maternity Hospital, Sutton Coldfield, West Midlands B75 7RR, UK 1. 2.
We suggest that the electrical current followed the fallopian tubes and stimulated the obturator nerve. Perforation and bowel injury have not previously been reported with TCRE, and the serious injuries in this case may have happened because the diathermy was still in the cutting mode when the perforation occurred. This complication of TCRE, with the potential for disastrous consequences, leads us to the following recommendations and
suggestions: (1) Gynaecologists practising TCRE should be prepared for violent adduction of the patient’s thighs, especially when resecting in the comual area. (2) The diatherm should be switched off immediately if the
patient starts moving. (3) Resection in the comual
area should begin at low cutting if nerve stimulation is encountered the usual no obturator power; power may be used. (4) Muscle relaxation may become necessary for TCRE, and it is advisable while the surgeon is familiarising himself with the
procedure. (5) Uterine perforation during TCRE should be investigated with laparotomy rather than laparoscopy. Department of Obstetrics and Gynaecology, Arrowe Park Hospital, Upton, Wirral L49 5PE, UK
RUDIGER PITTROF DARWISH H. DARWISH GIHAD SHABIB
AJ, Glass MR, Well M Patient selection for hysteroscopic endometrial Br J Obstet Gynaecol 1991; 98: 288-30. 2. Magos AL, Bauman R, Lockwood GM, Tumbull AC. Safety of trans-cervical resection.
endometrial resection Lancet 1990; 335: 44. 3.
Magos AL, Bauman R, Lockwood GM, Turnbull AC. Experience with the first 250 endometrial resections for menorrhagia. Lancet 1991; 337: 1074-78.
Anti-Kell in pregnancy SIR,-Your June 1 editorial was no doubt prompted by Leggat and colleagues’ report.’Myself and my colleagues have replied2 to Leggat et al, detailing our experience with anti-Kell antibodies which is somewhat different to theirs. In particular we feel we can address several issues raised by your editorial. You question how seriously anti-Kell antibodies should be regarded in pregnancy. Bearing in mind the epidemiological facts that you discuss, during 1990 we have dealt with two hydropic fetuses of women with anti-Kell antibodies-out of a total of ten such women referred to us. Both fetuses survived, one after an intravascular intrauterine transfusion and one after immediate delivery. Both women were inappropriately managed by their referring general practitioner or consultant who failed to appreciate that in the few women who have a Kell-positive husband, 50% will have a Kell-positive fetus and have the potential to be severely affected. We feel that Leggat and colleagues’ report’ and your editorial may encourage an unwarranted laissez-faire attitude towards anti-Kell antibodies in pregnancy. we agree that antibody titres and amniocentesis you do not mention cordocentesis, which we feel
resolve the crucial difficulty of how to identify the few pregnancies at greatest risk. This seems to be a serious omission and we suggest that a simple protocol as detailed below should be followed in all women with this unpredictable condition.
Leggat HM, Gibson JM, Barron SL, Reid MM. Anti-Kell in pregnancy. Br J Obstet Gynaecol 1991, 98: 162-65. Constantine G, Fitzgibbon N, Weaver JB. Anti-Kell in pregnancy. Br J OBstet Gynaecol (in press).
Before Conn’s classic paper SIR,-Dr Kucharz (June 15, p 1490) notes a case of primary aldosteronism reported in a Polish journal in 1953, two years before Conn’s classic paper. May I mention a similar case reported from Sweden in 1945, published in Swedish in Nordisk Medicin because of the difficulty in reaching international journals during the war. A 55-year-old woman who had consumed a heavy meal of sweet cakes and the like at a birthday party experienced weakness in her feet the same evening and stumbled. Next morning she woke up with her arms almost completely paralysed and a pronounced muscular weakness in her thighs and calves. All tendon reflexes were present but very weak, as were the abdominal reflexes. The facial and upper thoracic muscles were unaffected. Ocular fundi were normal. CSF was normal. She had moderate hypertension. There was no family history of similar illness. Her serum potassium was low at 3 15 mmol/1. We gave her potassium chloride and after two hours the paralysis had partly subsided; after an additional dose next morning the patient could get out of bed by herself and later that day all muscular weakness had gone. Her serum potassium rose to 4 55 mmol/1 after supplementation but 24 hours later it was only 2-55 mmol/1. Clearly there was rapid transport of potassium from serum to potassiumdepleted tissues. After 3 days potassium chloride 10-20 g per day, her serum potassium became consistently normal. Intravenous pyelography (renal angiography was not available at that time in the small county where she was admitted) revealed no sign of renal or adrenal tumour. Androgens in a 24 h urine specimen were normal. On discharge the patient was advised to take 3 g potassium chloride daily for some weeks. When supplementation was discontinued she remained healthy. At follow-up 7 years later she reported that she had occassionally taken potassium chloride for a few days but she had had no paroxysmal paralytic attacks. She was offered admission to hospital for close observation and a laboratory check-up, but refused. A renewed offer of admission when Conn’s report had appeared was also declined. This case lacks final proof as an example of hyperaldosteronism but the diagnosis seems
probable. Gravsten Sateri, 585 93 Linkoping, Sweden
1. Berlin R. Myoplegia
kaliopenica. Nord Med 1945; 30: 1099-2006.
CORRECTIONS Preoperative fisk assessment In coronary artery revascularisation, In the letter by Dr A. Deloche and colleagues (May 11, p 1157) the last column of the second table should have been headed "No events". Cytotoxic cross-matching for organ transplantation. In the letter by P. K. Donnelly and A. R. Simpson (June 22, p 1553) the passage beginning "57% of units routinely" should have continued "give renal donors drug treatment before organ retrieval. Six transplant units routinely saved the whole spleen...".