Fatal pulmonary oedema associated with the use of ritodrine in pregnancy

Dear Sir, We were surprised to read that Dr MacLennan and her colleagues [ B r J Obstet Gynaecol(1985), 92, 702-7051 had tried to delay labour in a patient of 32 weeks gestation with ruptured membranes and in whom a diagnosis of, we presume, chorioamnionitis had been made. Surely here the more appropriate management would have been to expedite delivery, thereby removing the focus of infection from the mother and reducing the risk of intra-natal pneumonia in the infant. The use of corticosteroids to accelerate fetal lung maturity remains controversial, although they are generally accepted as being of value between 30 and 32 weeks gestation. However, as rupture of the membranes itself will accelerate lung maturity the need for them in this case is doubtful, the more so since (as the authors acknowledged) there is a 5% risk of pulmonary oedema developing when P2-sympathomimetic agents are given at the same time. Equally controversial is the use of ritodrine or other P2-sympathomimetic agents to stop premature labour. We are not told the state of the cervix until full dilatation had occurred 34 h after admission. Dilatation beyond 4 cm usually means that treatment will fail, and rupture of the membranes (as had occurred here) virtually guarantees it. The presence of superadded infection is, we feel, an absolute contra-indication t o ritodrine therapy. The need to delay delivery, in a hospital with a good special care baby unit, after 32 weeks gestation is also surprising. With regard t o the patient’s death we feel that a chlamydia1 septicaemia may well have been to blame. Neither tetracyclines nor erythromycin were given, despite the isolation of Chlamydia from a high vaginal swab, and in the presence of a persistent pyrexia. That chlamydiae have long been suspected of causing intrauterine infection and premature rupture of the membranes is well known, and would support the concept of this being the main cause of the patient’s problem. In conclusion we would stress that obstetricians should think twice before attempting to stop premature labour in cases like this. I. J. Page Registrar A. Atalla Senior Registrar K. Young Consultant Cambridge Military Hospital Aldershot Hunts G u l l 2AN