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One-dimensional versus two-dimensional phosphatidylglycerol
718
Communications
in brief
Emesis induced by 30 ml of syrup of ipecac contained pill fragments and bright red blood. An x-ray examination of the abdomen confirmed radiopaque iron pills remaining in the stomach, and the patient was begun on a program of inactivation consisting of 5% sodium bicarbonate via a nasogastric tube followed by gastric Iavage and ingestion of magnesium citrate to decrease transit time in the intestines. Intramuscular deferoxamine (Desferal), an iron chelating agent, was begun with a 1 gm loading dose 3 hours following the ingestion. Deferoxamine was then administered intramuscularly and orally (Table I) according to serum iron levels. The levels decreased sharply until a normal value was reached within 23 hours after admission. Spontaneous labor began 8 hours after the iron overdose and was followed by spontaneous rupture of the amniotic membranes. The g-hour labor ended with the vaginal delivery of a 1,980 gm, appropriately sized male infant with Apgar scores of 8 and 9. At delivery, the umbilical venous iron level was 1 I5 pg/dI (normal, 106 to 227 pg/dl), TIBC was 171 @g/d], and hemoglobin was 14 gmidl. The infant’s clinical course was unremarkable except for low serum iron levels which required iron supplementation. With the use of special iron stains, histologic examination of the grossly normalappearing placenta revealed minimal iron deposits, not considered to be excessive. The mother was discharged on the fifth postpartum day after being observed closely with no evidence of hypotension, gastrointestinal bleeding, or abnormal liver function. The infant was discharged on the twelfth hospital day to his mother’s care with ferrous sulfate being prescribed for anemia presumably from the iron deficiency. Rapid removal of the iron was critical in that we saved this mother’s life rather than worrying about any drug effect on the fetus. In addition to inducing vomiting and gastric lavage, deferoxamine was given even though the only available literature about this drug during pregnancy involved two animal species with skeletal anomalies during exposure in early gestation.’ We found deferoxamine to be a useful adjunct in promptly lowering the serum iron levels and in eliminating the iron complex in the urine of the mother. The rapid decrease in the serum iron level of the infant cannot be explained as simply a normal physiologic event. It is possible that the transplacental transfer of deferoxamine may have led to chelation of the iron, even though no assay for deferoxamine is currently available to test this hypothesis. Iron deficiency in the newborn infant should be considered when deferoxamine is administered to the mother.
W’e thank Frederick Lovejoy, Jr., M.D., for his helpful consultation in the management of the infant and Charles Sander, M.D., for his meticulous examination of the placenta.
REFERENCES
1. Strom, R. L., &huller, P., Seeds, A. E., and Bensel, R. T.: Fetal iron poisoning in a pregnant female: A case report, Minn. Med. 7:483, 1976. 2 Physicians’ Desk Reference, ed. 36, Oradell, N. J., 1982, Medical Economics Co., Inc., p. 32.
November Am. J. Obstet.
15, 1983 Gynecol.
One-dimensional versus two-dimensional phosphatidylglycerol H. Grundy,
M.D.,
and S. L. Wiltjer,
B.S.N.
Maternal-Fetal Medicine, Kansas City, Missouri The appearance of certain phospholipids in the amniotic fluid has been strongly correlated with fetal pulmonary maturity in both normal and complicated pregnancies.’ Evidence has accumulated that phosphatidylglycerol may appear before term in certain conditions, such as premature rupture of the membranes, chronic hypertension, and intrauterine growth retardation.’ Several methods have appeared for detecting the presence of phosphatidylglycerol in the amniotic fluid. The first method, described by Kulovich and associates” 2 consists of a phospholipid profile which correlates with gestational age. Phosphatidylglycerol is obtained with the use of two-dimensional thin-layer chromatography. A separate one-dimensional approach has been introduced in order to reduce the time involved with this laboratory procedure.’ Difficulty with this one-dimensional method has been reported. Anderson and associates4 described hyaline membrane disease in a neonate with phosphatidylglycerol present in the amniotic fluid analyzed by the one-dimensional technique. We compared the results of the one-dimensional and two-dimensional methods in both diabetic and nondiabetic pregnancies in order to determine if the methods do, in fact, agree. The group of patients in Table I are the first 20 patients (one set of twins) who had amniotic fluid analyzed by both methods. These specimens were all collected transabdominally and were sent to two separate laboratories on the same day. These analyses were performed in a blinded fashion, and the results were known only to the clinician. Clinical decisions were made on the basis of the two-dimensional result. Five patients with diabetic pregnancies were studied. In four of the five patients the two-dimensional method revealed phosphatidylglycerol in various quantities as high as 11%. No phosphatidylglycerol was found in these four patients with the use of the one-dimensional method. In the remaining diabetic patient phosphatidylglycerol was present with the use of both methods, although the laboratory reported it simply as “present” when the one-dimensional method was used. There were 15 nondiabetic patients. In six patients there was complete disagreement as to the presence of phosphatidylglycerol. In only one of these was phosphatidylglycerol present by the one-dimensional method and absent by the two-dimensional method. In
Reprint requests: Howard Grundy, M.D., Maternal-Fetal Medicine, 4400 Broadway Suite 101, Kansas City, Missouri 64111.
Volume Number
Communications
147 6
Table I. Comparison phosphatidylglycerol
of one-dimensional
and two-dimensional
techniques
Disagreement of techniques
for the determination
Agreement
Patient PUP
Diabetic
Nondiabetic
Patient NO.
1 17 19 20
2b 3 5 11 13 6
dimensional f%) 0 0 0 0
0 0 0 0 0 2
Twodimensional f%) 3.9 Trace 11.9 Trace 4.5 16.5 14.8 Trace 13.6 0
Patient No.
4 8 9 15 12
five patients there was a greater than 7% discrepancy between the two methods. In the remaining five patients there was less than 7% discrepancy. However, in all but one of these last five patients no phosphatidylglycerol was detected by either method. There were two neonates with respiratory distress. One was an anemic 32-week twin from a severely Rhsensitized pregnancy. The other was the infant of a diabetic mother delivered at 35 weeks’ gestation for maternal indications. X-ray films and clinical courses of these neonates were reviewed by a consulting neonatologist. In the infant of the diabetic mother, transient tachypnea was the definitive diagnosis. In the sensitized twin the diagnosis was possibly very mild hyaline membrane disease. In summary, there seems to be little correlation between the results obtained with the one-dimensional and two-dimensional methods for the detection of phosphatidylglycerol. Admittedly, the number of patients is not large enough to gather statistical significance concerning the presence or absence of hyaline membrane disease. However, with such an obvious lack of correlation between the two methods, it would seem logical to use the method with the greatest amount of accumulated data to support its reliability. The twodimensional method is well accepted with more data available to substantiate its use at this time. It would seem wise to use the two-dimensional method until further testing and correlation can be obtained with other techniques.
REFERENCES
1. Kulovich, M. V., Hallman, M. B., and Cluck, L.: The lung profile. I. Normal pregnancy, AM, 1. OBSTET. GYNECOL. i35:57, 1979. s , 2. Kulovich, M. V., and Gluck, L.: The lung profile. II.
Onedimensional (%)
9
719
of
of techniques
> 7% dzjjfferace
One-
in brief
< Twodimensional (W
19.3 9.7 12.5 21.3 1
7% dzfference
Patient No.
Onedimensional m
18
Present
2a 7 10 14 16
TWOdimensional (%) 11.9
0 6 0 0 0
0 9.4 0 0 0
Complicated pregnancy, AM. J. OBSTET. GYNECOL. 135:64, 1979. 3. Pappas, A. A., Mullins, R. E.. and Gadsden, R. H.: Improved one-dimensional thin-layer chromatography of phospholipids in amniotic fluid, Clin. Chem. 28:209, 1982. 4. Anderson, C. W., Conrad, L., and Cordero, L.: Neonatal respiratory distress in the presence of amniotic fluid phosphatidylglycerol, Ahi. J. OBSTET. GYNECOL. 143:233, 1982.
Adolescents’ preference of source to obtain contraceptive information Bea J. van den Berg, M.D., and Marian A. Parry, B.A. University of California at Berkeley, School of Public Health, Child Health and Development Studies, Berkeley, California
A recent study of almost 2,000 adolescents included an interview in which the adolescents were asked to respond to questions on social and family living. The adolescents’ responses to one particular question of this interview regarding the place or person to whom the adolescent would go for information on pregnancy prevention appears to be of particular pertinence in relation to the current issue regarding the “Parental Notification Regulations.“* Recently, the federal government adopted the regulation that agencies receiving funds under Title X of the Public Health Service Act
HL
Supported 19859.
by National
Institutes
of Health
Grant
RO
Reprint requests: Bea J. van den Berg, M.D., Child Health and Development Studies, School of Public Health, 140 Warren Hall, University of California (Berkeley), Berkeley, California 94720.
1
Communications
in brief
Emesis induced by 30 ml of syrup of ipecac contained pill fragments and bright red blood. An x-ray examination of the abdomen confirmed radiopaque iron pills remaining in the stomach, and the patient was begun on a program of inactivation consisting of 5% sodium bicarbonate via a nasogastric tube followed by gastric Iavage and ingestion of magnesium citrate to decrease transit time in the intestines. Intramuscular deferoxamine (Desferal), an iron chelating agent, was begun with a 1 gm loading dose 3 hours following the ingestion. Deferoxamine was then administered intramuscularly and orally (Table I) according to serum iron levels. The levels decreased sharply until a normal value was reached within 23 hours after admission. Spontaneous labor began 8 hours after the iron overdose and was followed by spontaneous rupture of the amniotic membranes. The g-hour labor ended with the vaginal delivery of a 1,980 gm, appropriately sized male infant with Apgar scores of 8 and 9. At delivery, the umbilical venous iron level was 1 I5 pg/dI (normal, 106 to 227 pg/dl), TIBC was 171 @g/d], and hemoglobin was 14 gmidl. The infant’s clinical course was unremarkable except for low serum iron levels which required iron supplementation. With the use of special iron stains, histologic examination of the grossly normalappearing placenta revealed minimal iron deposits, not considered to be excessive. The mother was discharged on the fifth postpartum day after being observed closely with no evidence of hypotension, gastrointestinal bleeding, or abnormal liver function. The infant was discharged on the twelfth hospital day to his mother’s care with ferrous sulfate being prescribed for anemia presumably from the iron deficiency. Rapid removal of the iron was critical in that we saved this mother’s life rather than worrying about any drug effect on the fetus. In addition to inducing vomiting and gastric lavage, deferoxamine was given even though the only available literature about this drug during pregnancy involved two animal species with skeletal anomalies during exposure in early gestation.’ We found deferoxamine to be a useful adjunct in promptly lowering the serum iron levels and in eliminating the iron complex in the urine of the mother. The rapid decrease in the serum iron level of the infant cannot be explained as simply a normal physiologic event. It is possible that the transplacental transfer of deferoxamine may have led to chelation of the iron, even though no assay for deferoxamine is currently available to test this hypothesis. Iron deficiency in the newborn infant should be considered when deferoxamine is administered to the mother.
W’e thank Frederick Lovejoy, Jr., M.D., for his helpful consultation in the management of the infant and Charles Sander, M.D., for his meticulous examination of the placenta.
REFERENCES
1. Strom, R. L., &huller, P., Seeds, A. E., and Bensel, R. T.: Fetal iron poisoning in a pregnant female: A case report, Minn. Med. 7:483, 1976. 2 Physicians’ Desk Reference, ed. 36, Oradell, N. J., 1982, Medical Economics Co., Inc., p. 32.
November Am. J. Obstet.
15, 1983 Gynecol.
One-dimensional versus two-dimensional phosphatidylglycerol H. Grundy,
M.D.,
and S. L. Wiltjer,
B.S.N.
Maternal-Fetal Medicine, Kansas City, Missouri The appearance of certain phospholipids in the amniotic fluid has been strongly correlated with fetal pulmonary maturity in both normal and complicated pregnancies.’ Evidence has accumulated that phosphatidylglycerol may appear before term in certain conditions, such as premature rupture of the membranes, chronic hypertension, and intrauterine growth retardation.’ Several methods have appeared for detecting the presence of phosphatidylglycerol in the amniotic fluid. The first method, described by Kulovich and associates” 2 consists of a phospholipid profile which correlates with gestational age. Phosphatidylglycerol is obtained with the use of two-dimensional thin-layer chromatography. A separate one-dimensional approach has been introduced in order to reduce the time involved with this laboratory procedure.’ Difficulty with this one-dimensional method has been reported. Anderson and associates4 described hyaline membrane disease in a neonate with phosphatidylglycerol present in the amniotic fluid analyzed by the one-dimensional technique. We compared the results of the one-dimensional and two-dimensional methods in both diabetic and nondiabetic pregnancies in order to determine if the methods do, in fact, agree. The group of patients in Table I are the first 20 patients (one set of twins) who had amniotic fluid analyzed by both methods. These specimens were all collected transabdominally and were sent to two separate laboratories on the same day. These analyses were performed in a blinded fashion, and the results were known only to the clinician. Clinical decisions were made on the basis of the two-dimensional result. Five patients with diabetic pregnancies were studied. In four of the five patients the two-dimensional method revealed phosphatidylglycerol in various quantities as high as 11%. No phosphatidylglycerol was found in these four patients with the use of the one-dimensional method. In the remaining diabetic patient phosphatidylglycerol was present with the use of both methods, although the laboratory reported it simply as “present” when the one-dimensional method was used. There were 15 nondiabetic patients. In six patients there was complete disagreement as to the presence of phosphatidylglycerol. In only one of these was phosphatidylglycerol present by the one-dimensional method and absent by the two-dimensional method. In
Reprint requests: Howard Grundy, M.D., Maternal-Fetal Medicine, 4400 Broadway Suite 101, Kansas City, Missouri 64111.
Volume Number
Communications
147 6
Table I. Comparison phosphatidylglycerol
of one-dimensional
and two-dimensional
techniques
Disagreement of techniques
for the determination
Agreement
Patient PUP
Diabetic
Nondiabetic
Patient NO.
1 17 19 20
2b 3 5 11 13 6
dimensional f%) 0 0 0 0
0 0 0 0 0 2
Twodimensional f%) 3.9 Trace 11.9 Trace 4.5 16.5 14.8 Trace 13.6 0
Patient No.
4 8 9 15 12
five patients there was a greater than 7% discrepancy between the two methods. In the remaining five patients there was less than 7% discrepancy. However, in all but one of these last five patients no phosphatidylglycerol was detected by either method. There were two neonates with respiratory distress. One was an anemic 32-week twin from a severely Rhsensitized pregnancy. The other was the infant of a diabetic mother delivered at 35 weeks’ gestation for maternal indications. X-ray films and clinical courses of these neonates were reviewed by a consulting neonatologist. In the infant of the diabetic mother, transient tachypnea was the definitive diagnosis. In the sensitized twin the diagnosis was possibly very mild hyaline membrane disease. In summary, there seems to be little correlation between the results obtained with the one-dimensional and two-dimensional methods for the detection of phosphatidylglycerol. Admittedly, the number of patients is not large enough to gather statistical significance concerning the presence or absence of hyaline membrane disease. However, with such an obvious lack of correlation between the two methods, it would seem logical to use the method with the greatest amount of accumulated data to support its reliability. The twodimensional method is well accepted with more data available to substantiate its use at this time. It would seem wise to use the two-dimensional method until further testing and correlation can be obtained with other techniques.
REFERENCES
1. Kulovich, M. V., Hallman, M. B., and Cluck, L.: The lung profile. I. Normal pregnancy, AM, 1. OBSTET. GYNECOL. i35:57, 1979. s , 2. Kulovich, M. V., and Gluck, L.: The lung profile. II.
Onedimensional (%)
9
719
of
of techniques
> 7% dzjjfferace
One-
in brief
< Twodimensional (W
19.3 9.7 12.5 21.3 1
7% dzfference
Patient No.
Onedimensional m
18
Present
2a 7 10 14 16
TWOdimensional (%) 11.9
0 6 0 0 0
0 9.4 0 0 0
Complicated pregnancy, AM. J. OBSTET. GYNECOL. 135:64, 1979. 3. Pappas, A. A., Mullins, R. E.. and Gadsden, R. H.: Improved one-dimensional thin-layer chromatography of phospholipids in amniotic fluid, Clin. Chem. 28:209, 1982. 4. Anderson, C. W., Conrad, L., and Cordero, L.: Neonatal respiratory distress in the presence of amniotic fluid phosphatidylglycerol, Ahi. J. OBSTET. GYNECOL. 143:233, 1982.
Adolescents’ preference of source to obtain contraceptive information Bea J. van den Berg, M.D., and Marian A. Parry, B.A. University of California at Berkeley, School of Public Health, Child Health and Development Studies, Berkeley, California
A recent study of almost 2,000 adolescents included an interview in which the adolescents were asked to respond to questions on social and family living. The adolescents’ responses to one particular question of this interview regarding the place or person to whom the adolescent would go for information on pregnancy prevention appears to be of particular pertinence in relation to the current issue regarding the “Parental Notification Regulations.“* Recently, the federal government adopted the regulation that agencies receiving funds under Title X of the Public Health Service Act
HL
Supported 19859.
by National
Institutes
of Health
Grant
RO
Reprint requests: Bea J. van den Berg, M.D., Child Health and Development Studies, School of Public Health, 140 Warren Hall, University of California (Berkeley), Berkeley, California 94720.
1