A comparison of the Aschheim-Zondek and the Friedman tests in normal and abnormal pregnancy

A COMPARISON

OF THE

FRIEDMAN AN ANALYSIS BP HAROLD C. (From

the

TESTS

IN NORMAL PREGNANCY”

AND

AND

THE

ABNORMAL

THE LITERATURE AND A REPORT OF THE RESULTS OBTAXNED IN 1112 CASES

OF

M.D.,

&IACK,

Departmmt

ASCHHEIM-ZONDEK

of

AND

GEORGE H. AGNEW, M.D., DETROIT, MICH.

Obstetrics am3 Gynecology Harper Hospital)

and

the

ClinioaaE

Laboratory,

T

HE hormonal relationships which form the basis of the AschheimZondek test for pregnancy have received such adequate mention in the literature that further repetition is superfluous. The uniformly good results obtained with the original mouse method left little ta be desired from the standpoint of accuracy. Although the original technic has been modified, the Aschheim-Zondek reaction in principle remains to date the only undisputed practical contribution to clinical practice which has come from the wealth of scientific facts gained through recent studies of female sex physiology. What it lacked in simplicity of technic and speed of reaction has been provided by the rabbit ovulation test, a modification based upon ident,ical principles and first suggested by FriedmanI. 2 The development of the Friedman modification of the Aschheim-Zondek test as a diagnostic procedure in pregnancy is due to the eflorts of numerous investigators (Friedman and Lapham;c Reinhart and Scott;4 Wilson and Corner;5 Schneider;% 71 * et al.). Except for slight variations in technic proposed by each of these workers, the methods used are essentially the same and the results reported are strikingly Summaries of the methods advocated by various authors appear in the uniform. publications of Schneidcr;s and Ware and Main.9 White and Severance10 have compared the accuracy of the original Aschheim-Zondek method with the Friedman modification in a series of 231 cases (Aschheim-Zondek, 191 cases: Friedman method, 40 cases).

The literature to date reports more than 8685 tests performed according to the Aschheim-Zondek technic. Table I summarizes the results reported by various authors; it includes only those series consisting of 100 or more tests. Approximately 1900 tests have been Table II summarizes these reported with the Friedman method. results. The variations in the results reported by different investigators may be due to some extent to technical skill; the chief factor, however, appears to be the interpretation of the results obtained. It must be *Read

before

the

Detroit

Obstetrical

and

232

Gynecological

Society,

May

1. 1933.

IMACK-AGNEW

:

ASCHHEIM-ZONDEK

AND

FRIEDMAN

233

TESTS

kept clearly in mind that this test is lzot a test for pregnancy per se, but a test for the hormonal response to the presence within the body of living fetal tissue in connection with the maternal blood stream. TABLE

I.

RESULTS

WITH

ASCHIIEIM-ZONDM

TECHNIC

-

-

PREQNANT PATIENTS TOTAL 1WMBE PATIENTS

AUTHOR

-Aschheimlz Ehrhardtl3

Lassen Wiesnerl5 von Ammonls Parvevlr Frad, Goldberger, and Felshinls Mazer and Hoffman19 Jones and Mugragezo Do&&i21 Beckerzz Kugazs White and Severance10 Briihlzb Bland, First, and Roederza Davis and Walker26 Wahls7 Mackns Stewart29 Total

cases,

8685;

-

1007 3000 1198 415 324 370 350 314 255 208 250 179 191 180 200 143 129 100 101 lverage

PER CEWT !ORREC’ POSITIVES

NONPREGNANT PATIEKTS

PER CENT FALSE NEGATIVES

PER CENT :ORREC’ NEGATIVES

r --

PER CENT FALSE POSITIVES

AC(

--

98.2

1.7

99.3

0.75

97.0

3.0

96.1

3.9

lU0.0 90.0 96.0 98.5

0.0 10.0 4.0 1.2

100.0 93.0 95.0 93.0 100.0 100.0 97.2

0.0 7.0 5.0 7.0 0.0 0.0 2.8 7. -7 J

73.0 99.0 96.8

27.0

100.0 99.0 98.6 82.4 96.0 98.9 100.0

0.0 1.0 7.6 4.0 1.1 0.0

accuracy,

96.6

1.0

3.2

1.1

98.8

-

per

XJRAOY GROSS PER CENT

98.5 96.9 97.6 99.4 98.5 96.9 82.0 97.6 97.6 98.0 100.0 90.0 96.8 93.0 98.0 99.3 99.0 99.0

cent

The source of the hormone present in the urine is still disputed, there being good evidence in favor of the contention (Philipp,309 31 Fels3? Collip33) that it is produced by the products of gestation themselves, and not solely by the anterior lobe. Regardless of source, death of the ovum and its elements (trophoblast, placenta) soon leads to failure of hormone production and a negative Aschheim-Zondek reaction, as in cases of incomplete abortion, missed abortion, tuba1 abortion, etc. A positive test in these cases signifies a continuance of the biologic connection between living fetal elements and the maternal circulation. Since a positive reaction can be obtained only when the living chorionic elements (normal or pathologic) are in conta,ct with the maternal blood stream, negative tests in cases of interrupted pregnancy cannot properly be classed as false negatives as appears in the publications of certain workers. White and Severance,1o for example, report a gross error of 10 per cent ; excluding in their series the negative reaction obtained in cases of interrupted pregnancies (intraand extrauterine), this error is reduced to 3.7 per cent. Aschheimlz and Zondek in evaluating their results caIculated only the false reactions (1.2 per cent) obtained from the urine specimens of patients known definitely to have been normally pregnant or not pregnant.

234

AMERICAN

.JOURKAJ>

OF

OBSTETRIC’S

AXD

C:YNl!X:OI~OGY

Without deducting thestt “false negat,ives” the average aconrac>with the original met,hod in the 86% cases summarized above exceeds 96 per cent, even inclutling the unusually poor results (82 per WIII acouracy) reported by hlaxrr and Hoftman.‘!

I /I

AUTHOR

-.-

Friedman and Laphams Reinhart and Scott4 Schneider34 White and Severance10 Magath and RandalP Davis and Walker26 Parache Strieker37 Dorn, Morse, and Sugarmans8 Martin@ Bradford and Todd40 Ekasley41 Wilson and Corner; Ware and Mains Mazer and Ziserman42

_

PREGNANT F’ATII?NTS ‘ER CEN’I FALSE s EG ATIVES

‘ER CENT CORRECT ‘OSITIVER .._

luo.u

I-

SONPREGNANT PATIENTS

‘ER CENT OOKRECT NEG. ATIVES

1

PEB CENT FALSE POSITIVES

-,hC!CURACY GROSS PER GENT ’

0.U

98..i 82.1) 97.0 97.0 100.0 1 on.0

s.,‘j ‘14.0 3.0 3.0 0.0 0.0

I

98.5 92.0

i

il.0 0.0 0.0 1.5 YO

Total cases: 1899 ; nverago accuracy:

98.5 per cent

The results obtained with the rabbit ovulat.ion method of Friedman are strikingly uniform considering t,he fact that the technics employed vary considerably, differing not only as to the amount of urine injected in one or several doses: the types of rabbits utilized (adult. immature), and the time which elapsed between the injection and the reading of the test. The uniformly good results seem to indicate that these variations in technic are of litt.le significance in determining the accuracy of the method. Our experience with these hormone t.ests in the diagnosis of pregnancy covers a period of about three and one-half years. Since our firsf report? of the results obtained in 100 cases with the original method in 1930, me have performed these test,s in more than 1400 additional cases. Since May, 1931, we have discontinued the use of the The accuracy original technic in favor of the Friedman modification. of these tests is definitely known in the series of 1112 cases which form the basis of this report. Our material consists almost entirely of cases referred to us by a large group of physicians engaged in private and clinic practice, the urine

specimens

being

submitted

for

the

most

part

without

clinical

data. In order to determine the comparative accuracy of these two methods in our hands. it was necessary to ascertain by means of subse-

quent questionnaires the results obtainctl and tile calinical data know11 only to the physician who referred t,he urine for diagnosis. This series, consisting as it does almost entirely of unknown cases, demonstrates t,he practical value of the test uninfluenced by any subjective bias. In our series of 1112 tests in which the accuracy has been tlefinit.ely determined, t,he original Aschhrim-Zondeli technic was followed in 546 cases, and the Friedman method in 466 cases. These were divided into three groups according to clinical outcome: 1. Normal pregnanq 3. Not pregnant 3. Abnormal or interrnytcd

1’aBLE

111.

.541

530 pregnancy

NORW\I,

&EGNANCY ___-

AWHHEIM-ZONDEK

METHOD

CORRECTPOSITIVES

Fifth Sixth Seventh Eighth Ninth Tenth Eleventh Twelfth Twelfth Unknown

-

week week week week week week week week meek plus

-_

Ii1

26 26 21 24 s 20

13 8 13 87 246 (97.3%)

FRIEDMAN

FALSE NEGATIVES I

l

METHOD FALSE NEGATIVES

CORRECT POSITIVES 131 ;

I 58

31 29 2

2

: 1

8

I I

1

! 1

j

3

/ I

(Pi%)

,i

1 2

262 (97.8%)

(2.&

1. Novelly Pregnant Patients.-This group includes only those tests performed upon patients subsequently ascertained to have been normally pregnant. Urine specimens were submitted for examination from the early weeks of pregnancy (in 5 cases on the second day of gestational amenorrhea) to full term. In 48 casesthe urine was examined within one week following t,he expectSed date of the first missed period; one false negative reaction was obt,ained in this group (Aschheim-Zondek technic). The highest degree of accuracy appears to result’ during the early months of pregnancy, due possibly to the fact that greater amounts of hormone are excreted during this period (Zondek) .4R Table III shows the results obtained with both methods in cases of normal intrauterine pregnancy. There appears to be little difference in the accuracy of both methods. The slightly great,er accuracy of the Friedman method lies undoubtedly in simplicity of technic. Mortality and morbidity of mice is an important source of error in the original method. Frequently only one of the 5 mice originally injected at the beginning of the test survived the hundred-hour period, particularly when the urine was toxic and during the hot summer months. Other

236

AMERI(‘AN

JOITRNAI.

OF

OBSTETRi(!!:

AND

<:YNW’OI,OGV

workers have reported a mortality of i to 20 per cent, among t,he mice. In such cases the result was a.lwaps doubtful when no ovarian changes were noted, since not infrecluently several mice of a group failed to react to the hormone, whereas t.he remainder showed strongly positivch reactions. Zondek’s methotlC4 of treating toxic specimens by detoxifying wit,h et,her was useful in urine samples known t.o have a toxic” effect, although t,his property of the urine was never discovered until a trial test had resulted in the death of the anima.ls. Much valuable time was thereby lost unt.2 the test could finaNy be completed. Toxi&y of the urine rarely causes deat,h of rabbits. The ether method of detoxification has been found useful on several occasions in treating the urine of patients suffering from pyelitis.

~-

-__---

-.. ASCHHEIAI-ZONDEK

Y--

CORRECT NEQATIVES

Amenorrhea Menopause Myoma Ovarian cyst Salpingitis Pelvic malignancy Pituitary tumor Brain tumor and amenorrhea Normal male Normal female Pseudoeyesis

-~

METHOD

203 16

FALSE POSITIVES

4

_--.----_

= I

FRIEDMAN

-

CORRECT NEQATIVES

201 26

8

-7

FALSE POSITIVES

3

6 A 9 5 2

10 7 10 2

.-

METHOD

3 3

BOLi --

‘,-n

(98.5%)

I (1.&Q I

(s;f.&,

I ct.:%)

II. Nonpregnawt Patdeds.-This group was composed of patients not considered to have been pregnant by the physician to whom the report was made. In several instances, however, particularly in eases which are recorded as having given false positive reactions (functional amenorrhea), the possibility of early, unrecognized abortion could not be ruled out with certainty. This series includes numerous endocrine cases and pelvic malignancies, although the majority represent cases of delayed menstruation associated with pelvic disorders where early pregnancy was to be excluded. Reaction I (AschheimZondek method) was frequently obtained in cases of pelvic malignancy. These cases, for the most part, were receiving deep roentgen irradiation. Table IV again shows how nearly both methods approach each other in accuracy. The degree of accuracy obtained in nonpregnant patients is somewhat greater than that obtained in pregnant patients (i.e., fewer false positives than false negatives).

MACK-AGNEW

:

ASCHHEIM-ZONDEK

AND

FRIEDMAN

237

TESTS

111. Abnormal or Interrupted P?*egna,a~ies.--This group includes cases of threatened and incomplete abortion, missed abortion, fetal death (near term), tubal abortion, unruptured tubal pregnancy. hydatidiform mole, malignant chorionepithelioma, and urine specimens from patients less than one week postpartum. The reactions obtained in cases of interrupted pregnancy (intra- ant1 extrauterine) were variable and depended upon the length of time which had elapsed since the fetal elements lost their connection with the maternal blood stream. This explains the occurrence of both positive and negative reactions in cases of incomplete abortion, tubal ahortion, and fetal death. It is important that laboratories performing these tests in cases submitted for the diagnosis of extrauterine pregnancy, particularly, stress the fact that a negative reaction does not exclude the possibility of a dead tubal pregnancy. Similarly a positive reaction does not exclude the possibility of intrauterine fetal death, since elimination of the hormone may continue for a time. as evidenced by the postpartum posit.ive tests noted in Table V. When TABLE

V.

1

~BK~S~IAL ASCHHEIM-ZONDEK POSITIVE

Abortion Missed abortion Fetd death near term pregnancy Tubal Hydatid. mole Chorionedthelioma Postpa&m 2-7 days

2

I

OR INTERKU~TED

1 4 4 6 4 21

1

METHOD

PREONASCS 1

NEGATIVE

4 1

1

METHOD NEQATIVE I

1 6 7 12

1

6

l%IEDMAN POSITIVE

I

27

1 3 3

I

7 -

tubal pregnancy is suspected a positive test in the presence of a tubal mass is strong presumptive evidence of tubal pregnancy. A negative reaction signifies that even if an ovum is present it is no longer alive or capable of further invasion. The practitioner must understand the hormonal significance of the reaction and, in the last analysis, must depend upon his clinical judgment in evaluating the laboratory findings in abnormal cases. It must be emphasized again that this reaction is not a test for pregnancy per se but, a demonstration of the hormonal response within the body to the presence of living fetal elements. Hydatidifornz Mole.-Five cases of hydatidiform mole have been available for study. Positive tests were obtained with both methods at the time of expulsion and as long as six months following expulsion. The amount of hormone present in the urine was in most instances so great that positive tests could be elicited with urine quantities much smaller than those necessary to provoke a test in normal pregnancy. This titration effect, described by numerous investigators (Rossler,” Zondek,45 Mack and Catherwood, 47 et al.) serves to differentiate hyda-

a nonpregnant st)ate or an interrupted pregnancy, a positive test strongly indicates living fetal elements, hut tluti to H tc~niporary lwrsistence in eliminatiun of t,llth lloriuone, rwrtit intwrrlption or 1’vt;kl death cannot. be excludecl. In cases of hptlatidiform mole and mwlignaut cllo~iotlepitlltli(~~~~~. the amount of hormone exuetecl is many t,imes yrratrr than that pxcret.ecl during normal prq~nancy. The persistcwc+cA of positive tests after trcahnent of t,liese neoplasms strongly s11pqsts continued chorionic proliferation. I$EFElIEXC’ES

(1) P&&aan, ;zi. H. : Am. J. Phpsiol. 90: 617, 1920. (2) E’rierlmnl~, Al. If.: Am. J. Physiol. 89: 438, 1929. (3) Friedman, M. H., awd T,a~@mn, 34. E.: AN. J. OBST. & GYNEC. 21: 405, 1931. (4) Reinhart, .lf. L., and Scott, E.: J. A. 31. A. 96: 1565, 1931. (5) Nilson, E. M., n?jiE Corer, G. TV’.: Aar. J. OUST. & Grs~c. 22: 513, 1931. (6) S&nei~der, P. P.: Surg. Gynec. Oljst. 52: 56, 1931. (7) Schneider, P. F. : Sot. Exper. Biol. &; Med. 28: 117, 1930, (8) *Sclti~irEet, P. I’.: (9) Ware, B. TT., ctrrd &fW~Tf,, B. J.: .r. :c,n11. ,“y.J. yB$-. 1”,G;;;C;$ 174, 1932. (10) While, M., amd Srrercckcc, .I.: J. A. 11. A. 97: 1275, i931. ’ (1;) ‘A’s&e~m,, s.: Aar. J. OBST. s; GYN~C. 19: 335, 1930. (12) Aschheim, S. : Die Sehwangerschaftsdiagnose aus dem Harne, A. Karger, Berlin, 1930. (13) Ehrhardt, K.: Arch. Gyniik. 149: 188, 1932. (14) Lassen, II. C. A.: Ugesk. f. laeg. 94: 198, 1932. (15j Wiemer, B. P.: &it. M. J. 1: 860, 1931. (16) 00% Ammon, E. : Zentralbl. f. Gvn%k. 55: 1122, 1931. (17) Pwuy. B.: Endocrinology 16: 225, 1931”. (18) Fra&, R. %., Goldbergrr, M. A., and Feld~i.??., G. : J. Lab. & Clin. Med. 17: 61, 1931. (19) NUXW, C., cmd Hofmar~, 6. : J. A. M. A. 96: 23, 1931. (20) JOT&es, R. H., and Xu.grago, E. R.: $1x1. J. Clin. Path. 1: 379, 1931. (21) DoCads, E. C.: Anr. J. OBST. & GYKEC. 22: 520,1931. (22) Brckrr, M. R.: Ther. d. Gegenw. 71: 353, 1930. (23) &Y?qa, S.: J. Orient. Med. 14: 56, 1931. (94) BriiAZ, R.: Deutsehc med. Wchnschr. 55: 696, 19%. (25) BZa0u7, P. B., First, A., and Roeder, P.: AM. J. OBST. & G~NEC. 23: 83, 1932. ("6) Dnui.y, X., and JVaZker, E. m.: Nex England J. Med. 206: 173, 1.932. (37) JT~ah~. F. -4.: Zentralbl. f. Gyn%k. 54: 1258, 1930. (28) Ma&, H. C.: Burg. Gynec. Obst. 51: 476, 1930. (29) S~WJCW~,TV.: Lancet 1: 1X6, 1931. (‘30) Pkilipp, 13.: Z~entrallIl. f. Gyn%k. 54: 450, 1930. (31) Philipp, E.: Zantralbl. f. Gy&k. 54: 2754, 1930. (32) Fe&, E.: Zentrdbl. f. GynLk. 54: 2191, 1930. (33) Coll,ip, J. B.: Cnnad. M. A. J. 22: 312, 19:30. (3-l) S’olwzeitZer, P. F.: Trclns. Sect. on Ol)st., Gyneca. & (3.5) Xagn27(, 2’. R., and Ram,&7l. Abdom. Surgery, American Medical Assn., 1931. L. Y.: J. A. M. A. 96: 1933, 1931. (36) Para:che.‘E.: Zent,ralbl. f. GynLk. 56: 1353, 1932. (37) st?Wx?r, Kc.: Miinchen. med. Wchnschr. 79: 313, 1932. (38) Tjorzl., J. H., Morse, J. It., wncF rSugarman, &‘,‘. 1.: Calif. & West. Med. 35: 966, 1931. (39) Marttiw, Z’.: Compt. rend. Sot. de Biol. 107: 180, 1931. i&O) RrudforZ, IV.

z.,

amt

Toad, L. c.: south. M. 6; s. 93: 582, 1931.

(41) Bende?/, B. T.:

sout1,.

3f. .T. 24: 831, 1931. (42) Mazer, C., a.& Zisennun~, A. J.: Cited by Mazer and Goldstein in Clinical Endocrinology of the Female, Philadelphia, 1933, W. B. Saunders, p. 389. (43) ZondeL, K.: Die Hormone drs O~ariums und des 11~~~ physenvorderlappens, Berlin, 1931, Julius Springer, 13. 0111. (44) Zb,id.: 12. ‘311x. (45) Ibid.: p. 311. (46) Riissls~, B.: Ztsrhr. f. Geburtsh. n. Gytik. 96: 516, 1929. (47) Ma&, H. C., ad Cntlrewood, A. E.: Ax .T. ORST. S; (:PxE(‘. 20: 6711, l!l:30. !).S;i

FISHER

BUILDING;