- Email: [email protected]
Plasma estradiol, estriol, and progesterone in human pregnancy
OBSTETRICS
Plasma estradiol, estriol, and progesterone in human pregnancy II. Clinical
DAN
applications
TULCHINSKY,
CALVIN
J.
ELIZABETH
HOBEL,
in Rh-isoimmunization
M.D. M.D.
YEAGER,
JOHN
R.
MARSHALL,
Torrance,
California
disease
B.S. M.D.
The plasma concentrations of unconjugated estradiol (El), estriol (EJ), and progesterone (P) were measured by radioligand and radioimmunoassay in 8 patients with severe and 4 patients with mild Rh-isoimmunization disease. An abnormal ratio of either EJE, or P/ES was found to precede each of 5 perinatal deaths attributed to hemolytic disease. Normal ratios of both EJES and P/E, were found in 6 of 12 patients and were associated with good fetal prognosis. A normal ratio of only one of either Et/E, or P/Es was associated with 2 and I, respectively, of the 5 perinatal deaths attributed to the hemolytic disease. Determining both Es/Es and P/E, ratios is necessary for predicting fetal well-being in patients with Rh-isoimmunization disease. The method may be helpful in the follow-up of patients who undergo intrauterine fetal transfusion and may provide a more thorough assessment of fetoplacental function.
From the Department of Obstetrics Gynecology, University of California Los Angeles School of Medicine, and the Division of Reproductive Biology, Department of Obstetrics and Gynecology, Harbor General Hospital.
IN A PaEvro u s communication,1 we described the plasma estrogen/progesterone relationships of normal pregnancy. Becausein late pregnancy progesterone (P) is mainly derived from maternal cholesterol2 while estradiol (E2) is derived from both fetal and maternal precursors and estriol (ES) is mostly from fetal precursoq3 we suggested that the relationships existing between these 3 hormones may provide additional means for assessing the over-all function of the fetoplacental unit. The purpose of this study is to describe the relationships between Es, E,, and P in Rh-
and
Supported in part by Grant No. 404 from the California State Department of Health and by Harbor General Hospital Research Support Grant RR 0551 from the National Institutes of Health. ;9e$ved for publication January 12, Accepted for publication March 20, 1972. Reprint re uests: Dr. D. Tulchinsky, Dept. Ob. 7 Gyn., Harbor General Hospital, 1000 W. Carson St., Torrance, California 90509.
766
Volume Number
113 6
Estradiol,
estriol, and progesterone
in pregnancy.
II
767
Table I. The plasma E,, E,, and P concentrations of 8 patients with severe Rh-isoimmunization disease* --______--Patient No.
Weeks of
No. of
gestation
: 3 4 5 6 7 8
Fetal outcome
IUFly
1
35 36 34 35 28 30 32 30
(lo
Good
! 1 1
Neonatal Stillborn Stillborn
These values tIntrauterine 8ince the mean
are fetal
the last ones transfusions.
obtained
the plasma L, Ea. and P levels no&d value’- i at ;he corresponding
8A value l[Borderline
above normal
the
95 per
167 2 34.0 > 0.05 < 0.10
75 + 14.1 > 0.10
death
Stillborn
Value whencomparedto normalmean
cent
confidence
prior
to intrauterine
chame with the stage week of gestation. interval
fetal
EJS of normal)
100 ‘q 5511 65 50 65 50
Neonataldeath :
(%
135 ‘:,“I/ 160 300s 17011 3053 55
Premature-died
Mean k S.E. p
Ed of normal)
death
of gestation,
(q0
PS of normal)
2558 140
115 150 375s
100 1955 3508 210 k 42.0 < 0.05
or delivery. values
have
been
expressed
as the
per
cent
of
limit.
value.
isoimmunization diseasewhere the combination of an abnormally large placenta and an affected fetus may result in abnormal hormonal relationships, Measurement of these hormones and calculation of the E,/E, and E,/P ratios appear to offer important information which may be useful clinically in the management of patients with Rh disease. Material and methods Twelve patients with Rh-isoimmunization diseaseand anti-Rh titers of l/16 or greater provided serial plasma specimens for this study. The severity of the hemolytic disease was determined by spectrophotometric analysis of amniotic fluid according to the method of Liley.4 Four patients had mild diseasewith amniotic fluid optical densities at 450 rnp which fell within Zone A. E,ight had severe diseasewith amniotic fluid optical densities at 450 rnp which fell either in the upper portion of Zone B or within Zone C. All 8 patients underwent intrauterine fetal transfusion. Plasma P and unconjugated E, were measured by radioimmunoassay.5*e Plasma unconjugated E, was measuredby a radioligand assay with the use of uterine cytosol as a specific binder.’ The coefficient of variation of the 3 methods is lessthan 10 per cent for
values above 5 ng. per milliliter. Normal valueswere determined from 150 to 300 patients at various stagesof gestati0n.l Results The plasma concentrations of P and unconjugated E, and E, in 8 patients severely affected with Rh-isoimmunization diseaseare shown in Table I. Since the plasma E,, ES, and P levels change with the stage of gestation, values have been expressed as a percentage of the mean normal value at the corresponding week of gestation, The mean plasma P level in this severely affected group averaged 210 per cent of the mean normal and was significantly elevated (p < 0.05). Plasma E, levels were less consistent, with only 2 of the patients having values significantly above the mean, whereas the mean E, value, 160 per cent, was not significantly elevated (p < 0.05). The mean E, concentration averaged 75 per cent of normal but was not significantly low. In no case did the plasma E, levels fall below the 95 per cent confidence limit for normal pregnancies. Four patients with mild Rh-isoimmunization disease were studied for comparison (Table II). Their plasma E,, Es, and P concentrations did not differ sigrmicantly from the mean normal values. The relationship between E,/E, ratios and
768
Tulchinsky
July 15, 1972 Am. J. Obstet. Gyned.
et al.
........................ ........................ ........................ ........................ :::::::::::::::::::::::: ........................ ........................ ........................ ........................ ......................... ......................... ......................... ......................... ......................... .........................
........................ .................... .... .... .................... ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ................................................ ........................ ........................ ........................
L 20
I 22
I I 24 26 WEEKS
I, 20 30
I 32
I, 34
36
I 30
, 40
, 42
OF PREGNANCY
Fig. 1. E2/E3 ratios in Rh-isoimmunization disease. The shaded area represents the 95 per cent confidence interval for normal patients.1 The individual patients are numbered 1 to 12. T represents intrauterine fetal transfusion. The black squares indicate the time of fetal death and do not indicate actual E,/E, values.
gestational age for the 12 patients with Rhisoimmunization disease is presented in Fig. 1. The shaded area represents the 95 per cent confidence interval for normal patients. Of the 12 patients, three demonstrated EJE, ratios outside the 95 per cent confidence interval, and all three ended in either intrauterine fetal death (Nos. 5 and 6) or neonatal death (No. 7) which was attributed to the hemolytic disease and not to prematurity. Of the 9 patients with normal &/ES ratios, three sustained perinatal deaths and six were delivered of babies who survived. The 3 perinatal deaths included an intrauterine fetal death (No. 8) and a neonatal death, both attributed to hemolytic disease (No. 4), as well as a neonatal death attributed to prematurity (No. 3). The P/E, relationships for all 12 patients with Rh-isoimmunization disease is presented in Fig. 2. Six of the 12 patients showed rising P/E, values reaching ranges
I 20
I, 22
24
I 26
I 26
I 30
I 32
I 34
I 36
I 30
I 40
I 42
WEEKS OF PREGNANCY
Fig. 2. P/ES ratios in Rh-immunization disease. The shaded area represents the 95 per cent confidence interval for normal P/E2 values, and the upper dashed line indicates the 99 per cent confidence limit for high values. T represents intrauterine fetal transfusion. The black squares indicate fetal death and do not indicate actual P/E8 values. outside the 95 per cent confidence interval. Four of the six resulted in either stillbirths (Nos. 5 and 8) or neonatal deaths (Nos. 4 and 7) which were directly attributed to the hemolytic disease. One of the two others (No. 1) was delivered of a vigorous baby who survived, and the other (No. 3) was delivered of a premature baby who died of hyaline membrane disease. The observations made in Figs. 1 and 2 of the predictive value of determining P/E, and E,/E, ratios have been expressed in percentages and contrasted with infant survival and perinatal death, respectively (Table III). As can be seen, it is quite likely that the fetus may die if both the E,/E, and the P/E, ratios are abnormal, and the fetus appears to be safe as long as both ratios remain normal.
Volume Number
113 6
Estradiol,
estriol, and progesterone
in pregnancy.
II
769
Table II. The plasma E,, E, and P concentrations of 4 patients with mild Rh-isoimmunization disease* Patient No. 9 10 11 12 Means
No. of
Weeks of gestation
Fetal outcome
IUFTt
37 38 37 38
0 0 0 0
Good Good Good Good
2 S.E.
*These values +Intrauterine SSince the mean
are the last ones fetal transfusions.
obtained
the plasma E?, E3, and P levels ~OCUXAI VAL+ I at the corresponding
Ed of normal)
(70
prior
to intrauterine
fetal
change with the stage week of gestation.
Ed (TO of normal)
PS of normal)
(%
135 160 85 70
70 65 95 85
100 85 80 100
112 + 21.0
79 f 6.9
91 k 5.6
death
or delivery.
of gestation,
values
have
been
expressed
m the
per
cent
of
Table III. The usefulnessof determining the E,/E, and P/E, ratios in assessing fetal prognosisin Rh-isoimmunization disease Perinatal deaths erythroblastosis
Es/ES
and P/ES
ratios Both abnormal P/ES abnormal EJEs abnormal Either abnormal Either normal P/E, EJE, Both
normal normal normal
Total
Deaths in the tested group
(96)
No. of patients
100 67 100 83 30
2 4 3 5 3
17 22 0
12 0
due to fetalis
Alive
% of 5 deaths associated with an abnormal test
5
Comment
Plasma P/E, and E,/E, ratios appear to be useful in evaluating the fetal prognosis in patients with Rh-isoimmunization disease.In not 1 of the 6 caseswhere both the EJE, and the P/E, ratios were normal did a fetus or infant die from erythroblastosis fetalis (Table III). Each of the 5 perinatal deaths attributed to Rh-isoimmunization diseasewas preceded by a rise of at least one of the two ratios, in each case reaching values above the 95 per cent confidence limit. The 2 ratios should both be examined in each case, since in 3 of the 5 perinatal deaths attributed to hemolytic diseaseabnormality of only 1 of the 2 ratios was found (Table III) . Spectroscopic analysis of amniotic fluid is a simple and accurate procedure for assessing the severity of hemolytic disease.Once intrauterine fetal transfusion has been performed,
40 80
or died of cause other erythroblastosis fetalis
Alive of the tested group (%) 0 33 0 17 70 ;i 100
No. of
patients
than
70 of 7 survivals associated with normal test
0
Total No.
i 1 7
100
2 6 3 6 10
; 6
71 100 86
: 6
-
7
12
however, spectroanalysisof the amniotic fluid is difficult to interpret. Determination of the E,/E, and P/E, ratios may well be more helpful in assessing fetal well-being. With the use of presently available techniques, results of the 3 hormone determinations can be obtained by 2 technicians in one working day. Previous tests with the use of serial determinations of individual hormones, including urinary Es* and total conjugated plasma E,,g have not been found generally useful in the assessmentof fetal well-being in Rh-isoimmunization disease.In our previous study with the use of serial determinations of unconjugated estriol in plasma, we have shown that the E, levels did not fall or increase significantly until the fetuses died.10 In contrast, plasma progesterone (Table I) and plasma unconjugated estradioY kept increasing as pregnancy progressed, in several in-
770
Tulchinsky
July 15, 1972 Am. J. Obstet. Gynecol.
et al.
stances reaching values outside the 95 per cent confidence limit (Table I). These resulted in abnormal P/E, or E,/E, ratios. Perhaps one of the reasonsthat individual hormone determinations have not been very reliable in predicting fetal well-being in Rhisoimmunization diseaseis that no consideration has been given to the two- to three-fold increase in placental masswhich is so often observed.‘l This may account for the increased plasma human chorionic gonadotropin’* and progesterone (Table I) as well as an increased conversion rate of estrogen precursors.13This, in turn, could result in normal plasma E, concentration in the presence of a diminished supply of E, precursors. It may well be that for predicting fetal wellbeing in Rh-isoimmunization diseasedetermination of the actual plasma levels of E, precursors would be more helpful than measuring plasma E, itself. It is possible that abnormally high E,/E, ratios could be indicative of diminished availability of E, precursors. E, is partially (50 per cent) derived from maternal adrenal precursors whereas E3 is primarily of fetal origin3 If one assumesthat the conversion rate of E, and E, precursors would both be affected similarly in Rh-isoimmunization disease, then an abnormal E,/E, ratio could indicate a diminished supply of fetal precursors to the placenta. This could result from a diminished fetal adrenal production of E, precursors, impaired fetal circulation,
or impaired 16cr-hydroxylation by the fetal liver. The latter is substantiated by a report of intrauterine fetal cirrhosis which was associated with an abnormally high urinary E,/E, ratio.14 An abnormally high P/E, ratio found in 4 of the 5 perinatal deaths may also indicate a diminished supply of E, precursors. A hypertrophic placenta producing large amounts of P may be associated with an increased conversion rate of E, precursors*3and may lead to higher than normal plasma E, levels. The confirmation that an abnormally high P/E, ratio is indeed indicative of diminished availability of E, precursors must await direct measurement of E, precursors in fetal circulation. The facts that the E,/E, ratio alone did not detect 2 of the 5 perinatal deaths and, likewise, P/E, remained normal in 1 of the 5 patients call for further explanation and investigation. It may well be that in the first two casesE, production was more influenced by the diminished availability of its fetal precursors than by the increase in the placental conversion rate, resulting in normal E2/E3 ratio. The P/E, ratio may have remained normal in 1 of the 5 casesbecauseof selective impairment of P production. Simultaneous utilization of these 2 hormone ratios seems, however, to overcome these difficulties since it predicted accurately fetal prognosis in this group of patients with Rh-isoimmunization disease.
REFERENCES
1. Tulchinsky, D., Hobel, C. J., Yeager, E., and Marshall, J. R.: Ana. J. OBSTET. GYNECOL. 112: 1095, 1972. 2. Diczfalusy, E., In Pecile A., and Finzi, C., editors: The Foeto-Placental Unit, Amsterdam, 1969, Excerpta Medica Foundation, p. 65. Siiteri, P. K., and MacDonald, P. C.: J. Clin. Endocrinol. 26: 751, 1966. Liley, A. W.: AM. J. OBSTET. GYNECOL. 82: 1359. 1961. Tulchinsky, D., and Abraham, G. E.: J. Clin. Endocrinol. 33: 775. 1971. Abraham, G. E., SwerdiofI, R. S., TulchinW. D.: J. Clin. Endosky, D., and Odell, crinol. 33: 42, 1971. 7. Tulchinsky, D., and Korenman, S. G.: J. Clin. Invest. 50: 1490, 1971.
8.
Klopper, A.: 813, 1968.
9.
Schindler, A. E., Lee, T. Y., Herrmann, W. L.: AM. J. OBSTET. GYNECOL. 99: 295, 1967. Tulchinsky, D., Hobel, C. J., and Korenman, S. G.: AM. J. OBSTET. GYNECOL. 111: 311, 1971. Hellman, L. M., and Hertig, A. T.: Am. J. Pathol. 14: 111, 1938. Samaan, N. A., Bradbury, J. T., and Coplerud, C. P.: AM. J. OBSTET. GYNECOL. 104: 781, 1969. MacDonald, P. Cl., and Siiteri, P. K.: J. Clin. Invest. 44: 465. 1965. Coyle, M. G.: J. Endocrinol. 25: 8, 1962.
Ratanasopa,V.,
and
10.
11. 12.
13. 14.
Obstet.
Gynecol.
Survey
23:
Plasma estradiol, estriol, and progesterone in human pregnancy II. Clinical
DAN
applications
TULCHINSKY,
CALVIN
J.
ELIZABETH
HOBEL,
in Rh-isoimmunization
M.D. M.D.
YEAGER,
JOHN
R.
MARSHALL,
Torrance,
California
disease
B.S. M.D.
The plasma concentrations of unconjugated estradiol (El), estriol (EJ), and progesterone (P) were measured by radioligand and radioimmunoassay in 8 patients with severe and 4 patients with mild Rh-isoimmunization disease. An abnormal ratio of either EJE, or P/ES was found to precede each of 5 perinatal deaths attributed to hemolytic disease. Normal ratios of both EJES and P/E, were found in 6 of 12 patients and were associated with good fetal prognosis. A normal ratio of only one of either Et/E, or P/Es was associated with 2 and I, respectively, of the 5 perinatal deaths attributed to the hemolytic disease. Determining both Es/Es and P/E, ratios is necessary for predicting fetal well-being in patients with Rh-isoimmunization disease. The method may be helpful in the follow-up of patients who undergo intrauterine fetal transfusion and may provide a more thorough assessment of fetoplacental function.
From the Department of Obstetrics Gynecology, University of California Los Angeles School of Medicine, and the Division of Reproductive Biology, Department of Obstetrics and Gynecology, Harbor General Hospital.
IN A PaEvro u s communication,1 we described the plasma estrogen/progesterone relationships of normal pregnancy. Becausein late pregnancy progesterone (P) is mainly derived from maternal cholesterol2 while estradiol (E2) is derived from both fetal and maternal precursors and estriol (ES) is mostly from fetal precursoq3 we suggested that the relationships existing between these 3 hormones may provide additional means for assessing the over-all function of the fetoplacental unit. The purpose of this study is to describe the relationships between Es, E,, and P in Rh-
and
Supported in part by Grant No. 404 from the California State Department of Health and by Harbor General Hospital Research Support Grant RR 0551 from the National Institutes of Health. ;9e$ved for publication January 12, Accepted for publication March 20, 1972. Reprint re uests: Dr. D. Tulchinsky, Dept. Ob. 7 Gyn., Harbor General Hospital, 1000 W. Carson St., Torrance, California 90509.
766
Volume Number
113 6
Estradiol,
estriol, and progesterone
in pregnancy.
II
767
Table I. The plasma E,, E,, and P concentrations of 8 patients with severe Rh-isoimmunization disease* --______--Patient No.
Weeks of
No. of
gestation
: 3 4 5 6 7 8
Fetal outcome
IUFly
1
35 36 34 35 28 30 32 30
(lo
Good
! 1 1
Neonatal Stillborn Stillborn
These values tIntrauterine 8ince the mean
are fetal
the last ones transfusions.
obtained
the plasma L, Ea. and P levels no&d value’- i at ;he corresponding
8A value l[Borderline
above normal
the
95 per
167 2 34.0 > 0.05 < 0.10
75 + 14.1 > 0.10
death
Stillborn
Value whencomparedto normalmean
cent
confidence
prior
to intrauterine
chame with the stage week of gestation. interval
fetal
EJS of normal)
100 ‘q 5511 65 50 65 50
Neonataldeath :
(%
135 ‘:,“I/ 160 300s 17011 3053 55
Premature-died
Mean k S.E. p
Ed of normal)
death
of gestation,
(q0
PS of normal)
2558 140
115 150 375s
100 1955 3508 210 k 42.0 < 0.05
or delivery. values
have
been
expressed
as the
per
cent
of
limit.
value.
isoimmunization diseasewhere the combination of an abnormally large placenta and an affected fetus may result in abnormal hormonal relationships, Measurement of these hormones and calculation of the E,/E, and E,/P ratios appear to offer important information which may be useful clinically in the management of patients with Rh disease. Material and methods Twelve patients with Rh-isoimmunization diseaseand anti-Rh titers of l/16 or greater provided serial plasma specimens for this study. The severity of the hemolytic disease was determined by spectrophotometric analysis of amniotic fluid according to the method of Liley.4 Four patients had mild diseasewith amniotic fluid optical densities at 450 rnp which fell within Zone A. E,ight had severe diseasewith amniotic fluid optical densities at 450 rnp which fell either in the upper portion of Zone B or within Zone C. All 8 patients underwent intrauterine fetal transfusion. Plasma P and unconjugated E, were measured by radioimmunoassay.5*e Plasma unconjugated E, was measuredby a radioligand assay with the use of uterine cytosol as a specific binder.’ The coefficient of variation of the 3 methods is lessthan 10 per cent for
values above 5 ng. per milliliter. Normal valueswere determined from 150 to 300 patients at various stagesof gestati0n.l Results The plasma concentrations of P and unconjugated E, and E, in 8 patients severely affected with Rh-isoimmunization diseaseare shown in Table I. Since the plasma E,, ES, and P levels change with the stage of gestation, values have been expressed as a percentage of the mean normal value at the corresponding week of gestation, The mean plasma P level in this severely affected group averaged 210 per cent of the mean normal and was significantly elevated (p < 0.05). Plasma E, levels were less consistent, with only 2 of the patients having values significantly above the mean, whereas the mean E, value, 160 per cent, was not significantly elevated (p < 0.05). The mean E, concentration averaged 75 per cent of normal but was not significantly low. In no case did the plasma E, levels fall below the 95 per cent confidence limit for normal pregnancies. Four patients with mild Rh-isoimmunization disease were studied for comparison (Table II). Their plasma E,, Es, and P concentrations did not differ sigrmicantly from the mean normal values. The relationship between E,/E, ratios and
768
Tulchinsky
July 15, 1972 Am. J. Obstet. Gyned.
et al.
........................ ........................ ........................ ........................ :::::::::::::::::::::::: ........................ ........................ ........................ ........................ ......................... ......................... ......................... ......................... ......................... .........................
........................ .................... .... .... .................... ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ................................................ ........................ ........................ ........................
L 20
I 22
I I 24 26 WEEKS
I, 20 30
I 32
I, 34
36
I 30
, 40
, 42
OF PREGNANCY
Fig. 1. E2/E3 ratios in Rh-isoimmunization disease. The shaded area represents the 95 per cent confidence interval for normal patients.1 The individual patients are numbered 1 to 12. T represents intrauterine fetal transfusion. The black squares indicate the time of fetal death and do not indicate actual E,/E, values.
gestational age for the 12 patients with Rhisoimmunization disease is presented in Fig. 1. The shaded area represents the 95 per cent confidence interval for normal patients. Of the 12 patients, three demonstrated EJE, ratios outside the 95 per cent confidence interval, and all three ended in either intrauterine fetal death (Nos. 5 and 6) or neonatal death (No. 7) which was attributed to the hemolytic disease and not to prematurity. Of the 9 patients with normal &/ES ratios, three sustained perinatal deaths and six were delivered of babies who survived. The 3 perinatal deaths included an intrauterine fetal death (No. 8) and a neonatal death, both attributed to hemolytic disease (No. 4), as well as a neonatal death attributed to prematurity (No. 3). The P/E, relationships for all 12 patients with Rh-isoimmunization disease is presented in Fig. 2. Six of the 12 patients showed rising P/E, values reaching ranges
I 20
I, 22
24
I 26
I 26
I 30
I 32
I 34
I 36
I 30
I 40
I 42
WEEKS OF PREGNANCY
Fig. 2. P/ES ratios in Rh-immunization disease. The shaded area represents the 95 per cent confidence interval for normal P/E2 values, and the upper dashed line indicates the 99 per cent confidence limit for high values. T represents intrauterine fetal transfusion. The black squares indicate fetal death and do not indicate actual P/E8 values. outside the 95 per cent confidence interval. Four of the six resulted in either stillbirths (Nos. 5 and 8) or neonatal deaths (Nos. 4 and 7) which were directly attributed to the hemolytic disease. One of the two others (No. 1) was delivered of a vigorous baby who survived, and the other (No. 3) was delivered of a premature baby who died of hyaline membrane disease. The observations made in Figs. 1 and 2 of the predictive value of determining P/E, and E,/E, ratios have been expressed in percentages and contrasted with infant survival and perinatal death, respectively (Table III). As can be seen, it is quite likely that the fetus may die if both the E,/E, and the P/E, ratios are abnormal, and the fetus appears to be safe as long as both ratios remain normal.
Volume Number
113 6
Estradiol,
estriol, and progesterone
in pregnancy.
II
769
Table II. The plasma E,, E, and P concentrations of 4 patients with mild Rh-isoimmunization disease* Patient No. 9 10 11 12 Means
No. of
Weeks of gestation
Fetal outcome
IUFTt
37 38 37 38
0 0 0 0
Good Good Good Good
2 S.E.
*These values +Intrauterine SSince the mean
are the last ones fetal transfusions.
obtained
the plasma E?, E3, and P levels ~OCUXAI VAL+ I at the corresponding
Ed of normal)
(70
prior
to intrauterine
fetal
change with the stage week of gestation.
Ed (TO of normal)
PS of normal)
(%
135 160 85 70
70 65 95 85
100 85 80 100
112 + 21.0
79 f 6.9
91 k 5.6
death
or delivery.
of gestation,
values
have
been
expressed
m the
per
cent
of
Table III. The usefulnessof determining the E,/E, and P/E, ratios in assessing fetal prognosisin Rh-isoimmunization disease Perinatal deaths erythroblastosis
Es/ES
and P/ES
ratios Both abnormal P/ES abnormal EJEs abnormal Either abnormal Either normal P/E, EJE, Both
normal normal normal
Total
Deaths in the tested group
(96)
No. of patients
100 67 100 83 30
2 4 3 5 3
17 22 0
12 0
due to fetalis
Alive
% of 5 deaths associated with an abnormal test
5
Comment
Plasma P/E, and E,/E, ratios appear to be useful in evaluating the fetal prognosis in patients with Rh-isoimmunization disease.In not 1 of the 6 caseswhere both the EJE, and the P/E, ratios were normal did a fetus or infant die from erythroblastosis fetalis (Table III). Each of the 5 perinatal deaths attributed to Rh-isoimmunization diseasewas preceded by a rise of at least one of the two ratios, in each case reaching values above the 95 per cent confidence limit. The 2 ratios should both be examined in each case, since in 3 of the 5 perinatal deaths attributed to hemolytic diseaseabnormality of only 1 of the 2 ratios was found (Table III) . Spectroscopic analysis of amniotic fluid is a simple and accurate procedure for assessing the severity of hemolytic disease.Once intrauterine fetal transfusion has been performed,
40 80
or died of cause other erythroblastosis fetalis
Alive of the tested group (%) 0 33 0 17 70 ;i 100
No. of
patients
than
70 of 7 survivals associated with normal test
0
Total No.
i 1 7
100
2 6 3 6 10
; 6
71 100 86
: 6
-
7
12
however, spectroanalysisof the amniotic fluid is difficult to interpret. Determination of the E,/E, and P/E, ratios may well be more helpful in assessing fetal well-being. With the use of presently available techniques, results of the 3 hormone determinations can be obtained by 2 technicians in one working day. Previous tests with the use of serial determinations of individual hormones, including urinary Es* and total conjugated plasma E,,g have not been found generally useful in the assessmentof fetal well-being in Rh-isoimmunization disease.In our previous study with the use of serial determinations of unconjugated estriol in plasma, we have shown that the E, levels did not fall or increase significantly until the fetuses died.10 In contrast, plasma progesterone (Table I) and plasma unconjugated estradioY kept increasing as pregnancy progressed, in several in-
770
Tulchinsky
July 15, 1972 Am. J. Obstet. Gynecol.
et al.
stances reaching values outside the 95 per cent confidence limit (Table I). These resulted in abnormal P/E, or E,/E, ratios. Perhaps one of the reasonsthat individual hormone determinations have not been very reliable in predicting fetal well-being in Rhisoimmunization diseaseis that no consideration has been given to the two- to three-fold increase in placental masswhich is so often observed.‘l This may account for the increased plasma human chorionic gonadotropin’* and progesterone (Table I) as well as an increased conversion rate of estrogen precursors.13This, in turn, could result in normal plasma E, concentration in the presence of a diminished supply of E, precursors. It may well be that for predicting fetal wellbeing in Rh-isoimmunization diseasedetermination of the actual plasma levels of E, precursors would be more helpful than measuring plasma E, itself. It is possible that abnormally high E,/E, ratios could be indicative of diminished availability of E, precursors. E, is partially (50 per cent) derived from maternal adrenal precursors whereas E3 is primarily of fetal origin3 If one assumesthat the conversion rate of E, and E, precursors would both be affected similarly in Rh-isoimmunization disease, then an abnormal E,/E, ratio could indicate a diminished supply of fetal precursors to the placenta. This could result from a diminished fetal adrenal production of E, precursors, impaired fetal circulation,
or impaired 16cr-hydroxylation by the fetal liver. The latter is substantiated by a report of intrauterine fetal cirrhosis which was associated with an abnormally high urinary E,/E, ratio.14 An abnormally high P/E, ratio found in 4 of the 5 perinatal deaths may also indicate a diminished supply of E, precursors. A hypertrophic placenta producing large amounts of P may be associated with an increased conversion rate of E, precursors*3and may lead to higher than normal plasma E, levels. The confirmation that an abnormally high P/E, ratio is indeed indicative of diminished availability of E, precursors must await direct measurement of E, precursors in fetal circulation. The facts that the E,/E, ratio alone did not detect 2 of the 5 perinatal deaths and, likewise, P/E, remained normal in 1 of the 5 patients call for further explanation and investigation. It may well be that in the first two casesE, production was more influenced by the diminished availability of its fetal precursors than by the increase in the placental conversion rate, resulting in normal E2/E3 ratio. The P/E, ratio may have remained normal in 1 of the 5 casesbecauseof selective impairment of P production. Simultaneous utilization of these 2 hormone ratios seems, however, to overcome these difficulties since it predicted accurately fetal prognosis in this group of patients with Rh-isoimmunization disease.
REFERENCES
1. Tulchinsky, D., Hobel, C. J., Yeager, E., and Marshall, J. R.: Ana. J. OBSTET. GYNECOL. 112: 1095, 1972. 2. Diczfalusy, E., In Pecile A., and Finzi, C., editors: The Foeto-Placental Unit, Amsterdam, 1969, Excerpta Medica Foundation, p. 65. Siiteri, P. K., and MacDonald, P. C.: J. Clin. Endocrinol. 26: 751, 1966. Liley, A. W.: AM. J. OBSTET. GYNECOL. 82: 1359. 1961. Tulchinsky, D., and Abraham, G. E.: J. Clin. Endocrinol. 33: 775. 1971. Abraham, G. E., SwerdiofI, R. S., TulchinW. D.: J. Clin. Endosky, D., and Odell, crinol. 33: 42, 1971. 7. Tulchinsky, D., and Korenman, S. G.: J. Clin. Invest. 50: 1490, 1971.
8.
Klopper, A.: 813, 1968.
9.
Schindler, A. E., Lee, T. Y., Herrmann, W. L.: AM. J. OBSTET. GYNECOL. 99: 295, 1967. Tulchinsky, D., Hobel, C. J., and Korenman, S. G.: AM. J. OBSTET. GYNECOL. 111: 311, 1971. Hellman, L. M., and Hertig, A. T.: Am. J. Pathol. 14: 111, 1938. Samaan, N. A., Bradbury, J. T., and Coplerud, C. P.: AM. J. OBSTET. GYNECOL. 104: 781, 1969. MacDonald, P. Cl., and Siiteri, P. K.: J. Clin. Invest. 44: 465. 1965. Coyle, M. G.: J. Endocrinol. 25: 8, 1962.
Ratanasopa,V.,
and
10.
11. 12.
13. 14.
Obstet.
Gynecol.
Survey
23: