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achieved by averaging the dates of delivery predicted by careful examination of fundal height and fetal heart tones.2 Serial examinations during pregnancy are also useful in assessing normal development of the fetus.3 Because deviations from the expected rate of growth can alert the clinician to abnormalities of pregnancy, some measurement of fundal height should be recorded at every antenatal visit. Thus, measurement of the symphysis-fundus height may provide an easy and inexpensive screening test for intrauterine growth retardation, especially if done by the same investigator.4,5 Whether clinical estimates can approach the reliability of ultrasonography is unclear. Chaim Sheba Medical Centre, Tel Hashomer 52621, Israel

M. ROYBURT D. S. SEIDMAN

Jimenez JM, Tyson JE, Reisch JS. Clinical measures of gestational age in normal pregnancies. Obstet Gynecol 1983; 61: 438-43. 2. Andersen HF, Johnson TRB, Flora J, Barclay ML. Gestational age assessment II: prediction from combined clinical observation. Am J Obstet Gynecol 1981; 140: 1.

770-74. 3. Greenhill JP, Friedman EA. Biological principles and modem practice of obstetrics. Philadelphia: Saunders, 1974: 127. 4. Calvert JP, Crean EE, Newcombe RG, Pearson JF. Antenatal screening by measurement of symphysis-fundus height. Br Med J 1982; 285: 846-49. 5. Reece EA, Gabrielli S, Degennaro N, Hobbins JC. Dating through pregnancy: a measure of growing up. Obstet Gynecol Surv 1989; 44: 544-55.

validated. In the absence of a simple and reliable marker of risk for pre-eclampsia, the indications for use of aspirin in nulliparous women certainly remain few. It is difficult to believe that Davies and colleagues’ data do not favour the efficacy of aspirin, for two reasons. The first is the sample size. To have a 95 % chance of detecting a reduction from 25 to 10% in the frequency of hypertension, 256 cases would be needed. To detect a reduction from 25 to 5%, 122 women would be needed. Furthermore, the confidence interval of the difference in frequency of hypertension is — 0 02, + 0 32, which means that the data are compatible with a 2% increase as well as a 32% decrease in the frequency of hypertension in the treated group. The second reason is that the difference in birthweight that Davies et al observed is very similar to that in our study. We agree that the aim of aspirin treatment is not to increase birthweight per se, but rather to decrease the frequency of low birthweight, In this respect, it would be interesting to know if the observed difference in median birthweight was due to a decrease in low birthweight or an increase in high birthweight. Inserm U-149, 123 Bd de Port-Royal, 75014 Paris, France

Hôpital Tenon, Paris

Congenital heart block and maternal SLE SIR,-In your July 13 editorial about systemic lupus erythematosus (SLE) in pregnancy you report that the frequency of

congenital heart block (CHB) is 1 in 60 for all SLE pregnancies and 1 in 20 in mothers with anti-Ro antibodies, citing RamseyGoldman et al,l This estimation seems too pessimistic. RamseyGoldman and colleagues’ study was retrospective, and 3 of the 7 mothers of infants with CHB were diagnosed only because of their infant’s cardiac problem. In the sole prospective study published2 of 91 infants born to women with SLE who were followed up for 4 years had CHB, and 23% of the mothers were anti-Ro positive. During the same period 2 additional babies with CHB were born to mothers not previously known to have SLE. It is now generally agreed that as many as 70% of mothers of infants with neonatal SLE are symptom-free at the time of delivery3 and are identified only by the birth of an affected child,2,4 and for this reason cannot be prospectively identified.2 On the other hand, the estimated risk of having an infant with CHB is not established in women who are known to have SLE, but it should be very low even in women who are anti-Ro positive.2 none

Divisione Medica "Brera" and "De Gasperis",

Department of Cardiology, Niguarda Hospital, 20123 Milan, Italy

A. BRUCATO G. FERRARO M. GASPARINI

1. Ramsey-Goldman R, Hom D, Deng J, et al. Anti SS-A antibodies and fetal outcome in maternal systemic lupus erythematosus. Arthritis Rheum 1986; 29: 1269-73. 2. Lockshin MD, Bonfa E, Elkon K, Druzin ML. Neonatal lupus risk to newboms of mothers with systemic lupus erythematosus. Arthritis Rheum 1988; 31: 697-701. 3. Olson NY, Lindsley CB. Neonatal lupus syndrome. Am J Dis Chest 1987; 141: 908-10. 4.

Buyon JP, Winchester R. Congenital complete heart block. Arthritis Rheum 1990; 33: 609-14.

Low-dose aspirin and nulliparae SIR,-Dr Davies and colleagues (Aug 3, p 324) disagree with the in our report (June 15, p 1427) that "it now seems justifiable to propose aspirin treatment for any patient considered at high risk, even if in her first pregnancy". Their disagreement is based on the results of a trial, which they summarise. We have never proposed an extension of the indications for such treatment, and our clear message is that it is not justifiable to propose aspirin for any patient, unless she is at high risk. Thus, the dispute is about definition of high risk, and not parity. Two studies we discussed1,2 showed prevention of pre-eclampsia with the use of aspirin in nulliparous women. However, the researchers used screening tests that are either not applicable in routine use or not yet statement

1.

2

G. BREART M. BEAUFILS S. UZAN

Wallenburg HCS, Dekker GA, Makowitz JW, Rotmans P. Low-dose aspirin prevents pregnancy-induced hypertension and pre-eclampsia in angiotension-sensitive primigravidae. Lancet 1986; i: 1-3. McParland P, Pearce JM, Chamberlain GVP. Doppler ultrasound and aspirin in recognition and prevention of pregnancy-induced hypertension. Lancet 1990; 335: 1552-55.

Phytophotodermatitis, a botanical view SIR,-Increased awareness of phytophotodermatitis (PPD) has resulted in alarming and sometimes sensational coverage in the press. The front page of the Independent on Sunday on Sept 8 described a controversial case concerning a young child in whom hyperpigmentation had apparently developed after alleged contact with "cow parsley". When PPD is suspected, it is prudent to obtain the opinion of a botanist who has local field experience and can identify plants that might be responsible. The following points may help in the British Isles. Plant contact apart, PPD requires exposure to ultraviolet A in the wavelength range 320-380 nm.1 Many incidents occur in late summer, when high doses of UVA may be available. However, many plants that grow in spring and fruit in early summer have died back by then (eg, cow parsley). The plants responsible contain furocoumarins with a linear, tricyclic structure. Many belong to the Apiaceae (Umbelliferae), a family which contains several vegetables and herbs that have been implicated in contact dermatitis’ (eg, angelica, carrot, celery, fennel, and parsnip). This family also contains giant hogweed (Heradeum mantegazzianum), an enormous plant found on river banks and waste ground in some parts of Britain. PPD from giant hogweed is well known.2 Giant hogweed has spread in Britain but it is still uncommon in many areas. At least two other Apiaceae (hogweed and wild parsnip) could be involved in PPD in Britain. Both grow on roadside verges and in grassy, recreational areas. Hogweed (Hsphondylium) is widespread in Britain but wild parsnip (Pastinaca sativa) is common only in southern Britain, notably the south-east. Both species contain linear furocoumarins and should be suspected if found at the site of a possible PPD incident. Unfortunately, hogweed (H spJwndylium) is sometimes called cow parsnip, an unofficial name that can be confused with cow parsley, a separate species (Anthriscus sylvestris) that may not exhibit a strong phototoxic effect,1 Several Rutaceae, which are grown in parks and gardens, have been implicated in PPD-for example, rue (Ruta graveolens), burning bush (Dictamnus albus), skimmias (Skimmia spp), and citrus species (orange, lemon, lime).3 People who travel to southern Europe or North America may encounter others. During a field course to southern Spain (April, 1981) a student from Swansea had an alarming bullous reaction on the leg after contact with wild rue

Congenital heart block and maternal SLE.

892 achieved by averaging the dates of delivery predicted by careful examination of fundal height and fetal heart tones.2 Serial examinations during...
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