A further challenge to the validity of the weekly interval between oxytocin challenge tests

Communications in brief 849

Volume l:lt) Numher i

a wee k of a negative oxytocin challenge tes r (OCT). I- " The purpose of this communicatior~ is to add one further case and to present a case in which more frequent testing led to the discovery of obvio us intrauterine fetal compromise. In Case I . a 31-year-old Caucasian woman . J;:ravida 2, para I, with an expected date of confinement of January 15, 1977,

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imbedded in the bladder, forming a bladder stone. A previous case was described in 197 4, by Saranwala and associates, 2 of a similar perforation and calculus formation by a Lippes Loop. In the case we have described, the patient's symptomatology was easily explained by the organic pathology found at laparotomy and cystotomy. This case illustrates the importam:e of thorough evaluation of the "missing intrauterine contraceptive device," both clinically and radiologically . It also adds to the large, diversified, and growing list of complications associated with intrauterine contraceptive devices.

REFERENCES 1. Editorial: Risk of pelvic infection associated with intrauterine devices, Br. Med. J. 6038; 717, 1976. 2. Saranwala, K. C. , Ravinder, S., and Harcharan, D.: Lippes Loop perforation of the uterus and urinary bladder with stone formation, Obstet. Gynecol. 44: 424, 1974.

A further challenge to the validity of the weekly interval between oxytocin challenge tests NICHOLAS

J.

SALERNO , M. D.

THOMAS R. KAY. M.D.

Department of Obstetrics and Gynecology, Gardl!n State Community Hospitd, Marlton, New jersey

THERE HAVE BEEN recent papers published in which a total of four intrauterine fetal deaths occurred within Reprint requests: Dr. Nicholas J. Salerno, Department of Obstetrics and Gynecology, Garden State Community Hospital. Route 73 and Brick Rd .. Marlton, New Jersey 08053 . 0002-9378178/07130-0849$00.30/0

©

1978 The C. V. Mosby Co.

was first thought to have a small-for-date fetus at the end of Decem~r. There were no previous medical or obstetric problems . Determinations of plasma fn~e esuiol and human placental lactogen (HPL) levels performed on December 28. 1976. were reported as 3.0 ng. and 2.3 fJ-g per milliliter, respectively. Because of these low values. rhe patient was rescheduled for an outpatient OCT on Januarv 6, 1977 (Fig. 1) . A repeat estriol level at that time was 4.8 ng. per milliliter and the HPL was 2.6 tJ-g per milliliter. The cervix was unfavorable for induction of labor and the patient was rescheduled for a repeat OCT on January 13, 1977. On the morning of the test, no fetal heart tones were audible or detectable by Doppler ultrasound . The patient related that she last felt fetal movement two hours prior 10 arriving at the hospitaL On J anuary 25, 1977. she was spontaneously delivered of a 4 pound. II ounce macerated stillborn infant. There were no evident cord problems at the time of deliverv and necropsy did not rewa! :til\' con!{enital anomalies. In Case 2, a 26-year-old obese Negro woman, gravida 2, para I. with an expected date of confinement of February 23 , 1977, was admitted to Garden State Community Hospital on January 9, 1977, because of generalized edema, epigastric pain, and a blood pressure of 180/110. There was no previous history of hypertension. Her off1ce prenatal record disclosed a normal blood pressure two weeks prior to admission. Her first pregnancy had an uncomplicated prenatal course and cesarean section was performed because of feropelvic disproportion . She was placed at bed rest and phenobarbital, Y~ grain every four hours, and Lasix were administered. The blood pressure returned to 130/80 on the second day. Initial studies disclosed: 3.4 Gm. of protein per 24 hours; crearinine clearance, 4 7 mL per minute; plasma free estriol level. 6. 7 ng. per milliliter; HPL, 3.8 J.tg per milliliter; and lecithin .' sphingomyelin (LIS) ratio, 1.2 to I. Ultrasound B scan showed a biparietal diameter of 8.6 em ., consistent with a gestation of 35 weeks. OCT was read as negative. Over the next two weeks of hospitalization , the blood pressure remained cont rolled . Daily estriol and HPL levels remained stable and the ( reatinine clearance improved. OCT was read as negative •>n January 14 , 1977. and again on january 21, 1977 (Fig. 2) The estriol fell to 4.4 ng. per milliliter· on .January 22, 4.8 ng. per milliliter on January 23, and 3.0 ng. per milliliter on January 24 . A repeat LIS ratio on J an uary 24 (:l6 weeks by dates) was 1.4 to I. Because of the falling esrriol values, the OCT was repeated on January 25 (four days after the last negative test), and was read as positive (Fig. 3). A cesarean section was performed the same day despite the immature LIS ratio. An infant weight 4 pounds, 9 Y.i ounces was delivered: Apgar scores were 6 and 7, and meconium staining was present. The baby subsequently did well with no('\ idence of respiratory distress.

Case 1 demonstrates a negative OCT followed hy intra uterine fetal death in slightly less than seven days.

850 Communications in brief

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Fig. 1. OCT done on January 6 and interpreted as negative (Hewlett-Packard monitor, HewlettPackard Co., Palo Alto, California, at I em. per minute).

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Fig. 2. OCT done on January 21 and interpreted as negative (Hewlett-Packard monitor at 2 em. per minute). In the second case, the OCT was repeated because of continually falling estriol levels, and late decelerations were noted. The presence of meconium staining of the fluid and low Apgar scores at the time of cesarean section seemed indicative of fetal compromise. In reviewing the previous articles, in three of the cases reported, the mothers were diabetic. In the re-

port by McCranie and Niebyl, 1 the interval between the negative OCT and the intrauterine fetal death was marked by a deterioration of the patient's diabetic control. In the first of two patients reported by Baskett and Sandy, 2 there was no mention of the patient's condition following the OCT. In the third paper,:! the patient's Class B diabetes was apparently well controlled.

Communications in brief

Volume 1:1 0 Numbt>r 7

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Fig. 3. OCT done on January 25 and interpreted as positive (Hewlett-Packard monitor at I crr1. pet minute).

The other reported case by Baskett and Sandy 2 was that of a hypertensive patient who had received antihypertensive medication during the interval between the negative OCT and the fetal death in utero. The diastolic blood pressure dropped from II 0 to 80. The case reported here, in which the infant was stillborn, disclosed no change in status of an apparently healthy pregnant woman and no medication was given. Decreasing the in terval between OCT's might have saved this baby, as well as those in some of the cases previously reported. We believe there is good suggestive evidence that a decrease in interval between OCT's saved the fetus in the second case presented. Apparently, fetal death in utero after a negative OCT not only follows deterioration in maternal diabetes or change in blood pressure but also occurs in unsuspected cases where there is no identifiable change in maternal status. Thus, it would seem wise to test at more frequent intervals and/or more frequently use other tests of fetal well-being, even in the presence of a negative OCT. REFERENCES

J. R.: A false negative oxytocin challenge test, Obstet. Gynecol. 49: 241, 1977. 2. Baskett, T. F., and Sandy, E.: False negative oxytocin challenge test, AM.]. OBSTET. GYNECOL. 123: 106, 1975. 3. Parer, J. T., and Alfonso, J. F.: Validity of the weekly interval between oxytocin challenge tests, AM. J. 0BSTET. GYNECOL. 127: 204, 1977. l. McCranie. W. M., and Niebyl,

Verrucous carcinoma of the cervix: A problem in diagnosis and management EDWARDA RORAT. M.D . FRED BEN JAM I N . 'vi. D. RALPH M . RICHAR T. M.D. Thf' Drpartmmt.l of Pathology and Ob.,tetric.l and Gynecology, Qu.eem Hospital Center Affi!iatf' of the Lu11g l.llmul jewi:>h-Hilllide Mediwl Cmtn·, Jrmwica . Neu• York, the Stale Unit•enity of New York at Starn• Brook, Stony Rrook, Neu• Ym'k. and the Columhia-Preslrytel·imt A1ediral Cmta. New l'ork. Nt'lt' rork

carcinoma has been reported as arising in the oral cavity, vulva, glans penis. anus, larynx, scrotum, and vagina but rarely in the cervix, where only I~ documented cases have been reported. The diagnosis is often missed. and the lesion is commonly mistaken both clinically and histologically for condyloma acuminatum or pseudoepitheliomatous hype rplasia. VERRUCOUS SQCAMOUS CELL

A -18-year-old woman wit.h a normal-sized uterus and without adnexal masses was admitted for irregular \'aginal bleeding. The parametria were free. There was an exophytic tumor of the cervix extending to the vagina posteriorlv and the right lateral fornix . Vaginal and cervical Papanicolaou smears takeu Reprint requests: Dr. Edwarda Rorat. Department of Pathology, Beth lsrae l MediCJI Center. 10 ~ a t han D. Perlman Place , New York. New York I 000~. 0002-9~78 / 78 / 07130-0R51SOO ..~O/ O

©

197R Th ~ C. V . Mosby Co.