- Email: [email protected]
Reply to Dr. De Gezelle and colleagues
CORRESPONDENCE
Secretion of human prolactin
Table I. Mean hPRL serum concentration (first series = 25 subjects) before, during, and after labor
during parturition
To the Editors:
We read the report by Rigg and Yen (AM. J. OBSTET. 128: 215, 1977) on human prolactin (hPRL) secretion during parturition with great interest, particularly because we had just completed a similar study. Our paper, which was in press at that time (De Gezelle, H., Dhont, M., Parewyck, W., and Thiery, M.: Prolactin levels during labor and the early postpartum period, Int. Res. Commun. Syst. Med. Sci. 5: 475, 1977), confirmed the multiphasic serum hPRL pattern (characterized by a decrease during labor and an increase after delivery) reported by Rigg and Yen, but our results showed a different time sequence of the prolactin changes. This led us to collect additional data and to submit the present comments. Initially, we studied 25 patients (first series). This material was classified according to type of labor and analgesia, which gave the following, numerically equal groups (No. = 5): spontaneous onset of labor; surgical induction, surgical induction of labor followed by intravenous administration of oxytocin, surgical induction of labor followed by intravenous administration of prostaglandin Ez, and surgical induction of labor and continuous lumbar epidural anesthesia. Prolactin was determined in maternal blood samples obtained via a separate antecubital indwelling catheter 30 minutes before and after amniotomy, at 8 cm. of cervical dilatation, at the time of delivery, and at one and 24 hours after delivery. No significant intergroup differences in mean hPRL concentrations were found, and the data were pooled (Table I). Unlike the hPRL levels observed by Rigg and Yen, which reached a nadir about two hours before delivery and started to rise immediately afterward, our mean hPRL concentration continued to decline until one hour after delivery. To clarify this discrepancy, we performed a more detailed study of hPRL levels, with special attention to the immediate postpartum period. To take into account a possible effect of analgesia on hPRL secretion, two groups of patients were investigated: six women given continuous epidural blocks and nine women who did not receive any analgesic drug during either labor or delivery. Blood was sampled at 30 minute intervals for three hours after delivery. No statistically significant difference was found between the two groups. Consequently, the material (second series) was pooled (Table II). The results of this additional series confirm our initial finding, i.e., that the
Mean
GYNECOL.
Time of sampling
30 min. before surgical induction 30 min. after surgical induction At 8 cm. of dilatation At delivery 1 hr. after delivery 24 hr. after delivery
2 S. E. M. (ng. lml.)
96.1 90.5 70.2 70.0 58.5 78.0
Table II. Mean hPRL serum concentration series = 15 subject) at delivery and during postpartum period
t k * t ” k
3.9 3.5 4.4 4.5 5.2 4.5
(second early
Mean 2 S. E. M. Time
of sampling
(ng. lml.)
At delivery 30 min. after delivery 60 min. after delivery 90 min. after delivery 120 min. after delivery 150 min. after delivery 180 min. after delivery
90.5 74.2 61.1 77.3 88.9 87.8 100.3
k 8.3 t 10.5 2 8.2 + 9.4 ‘- 11.2 2 12.1 -+ 14.7
nadir of the mean hPRL secretion occurs one hour after delivery. However, closer inspection of the individual data of both series showed that in a few cases (six of 40) the hPRL concentration rose immediately after delivery. Because the pattern of hPRL secretion described by Rigg and Yen was based on frequent sampling in only four patients, the discrepancy between their data and ours might well be ascribed to the inconstancies inherent in the investigation of a very tiny population. H.
Departmeti University 9000 Gent,
M. of Obstetrics and Gynecology of Gent De Pintelaan 135, Belgium
De Gezelle, M. Dhont, W. Parewyck, Thiery, M.D.,
M.D. M.D. M.D. Ph.D.
Reply to Dr. De Gezelle and colleagues To the Editors:
The implication by Dr. De Gezelle and co-workers of a different time sequence of prolactin changes from 736
Correspondence
what we reported in the immediate periparturitional period is easily explained. They did not find a predeliverv nadir in prolactin levels because they did not sample at appropriate times, i.e., samples were obtained at X cm. of dilatation (complete dilatation would have been more objective) and not again until delivery. The largt, number of individuals in their study is admirable; however, when one is examining hormonal dynamics, a few well-studied patients (i.e., obtaining frequent samples) may provide more meaningful information than will a large number of subjects sampled at infrequent intervals. Ltze A4. Rigg, Ph.D.. M.D. Depnrtmcrrt c/ Obstrtric.5 rind Cynrcolofl kt’ashingtt~n Uniiw5ity School qf Medic;rw St. Louis. A4i.r.\ouri cj?I IO S. S. C. Yen, M.D.
737
chest compression allows for more t horctt.gl~ tt-xheal clearing as gasping efforts. which md\ tlr,t\. meconium further down the tracheobronchial tI W. ‘11e prevented from the moment of birth. Since \\e bep;~il tlsing tIli\ technique, only Iwo infants among ihe ~I(EI ,a 111,ln .5,.3K! infants born in our hospital over the ~I”,I ISVO vc“t1.s have had any clinical evidence of II~C~COI~~I~III ;tspiralion syndrome: one infant with a pneun~c~r~~r~li.~sr~nlt~t~ end small bilateral pneumothoraces \\,hcr hat1 :mnim.J distress, required no supplemental os\grll. ,!n(l made ;rn uneventful recover>- and a second cllilrl :,illi a pnc~ momediastinum \vho was other&c tsrr~i WOE ~iormal.
REFERENCES
1. Ting, P.. and Brady, J. P.: AM. ,J. 0w-rk.1. ( ;I UECOL. 122: 767, 1YS5. 2. Carson, B. S.. Lose?, R. W., Bowes. u’. A JI.. and Simmons,
M.
A.:
AN.
J. OBSTET.
GYNECOL.
126:“71?.
1976
Prevention of meconium aspiration syndrome To the Editon: In recent years, techniques to aid in the prevention of the meconium aspiration syndrome in infants born through meconium-stained liquor have been reported in your JOURNAL. Ting and Brady1 showed the efficacy of tracheal suctioning immediately after delivery in removing meconium from the trachea, and Carson and associat.e? reported on a combined obstetric and pediatric approach involving thorough pharyngeal suctioning with delivery of the head followed by visualization of the vocal cords and tracheal suctioning, when indicated, after deliver) of the body. During the past two years, we have followed the protocol suggested by Carson and associates. In addition, however. we have used a further procedure which we believe ma! aid in removing meconium from the trachea prior to the first breath--the technique of chest compression. As rhe baby‘s head appears at the perineum, the obstetrician thoroughly suctions the mouth, nasopharynx, and hppopharynx. in order to remove as much meconium as possible. Then, as the body is delivered, the obstetrician grasps the thorax, with the thumbs meeting anteriorly over the sternum. Gentle but firm pressure is applied evenly throughout to prevent chest expansion without further compression of the thorax. After an assistant doubly clamps the cord and severs it, the obsretrician, while maintaining chest compression, immediately carries the infant to a nearby sterile table where the pediatrician visualizes the vocal cords and applies direct gentle suction, when indicated. Then, with release of the chest, routine resuscitative measures are undertaken beneath a radiant heater. We believe that the simple additional procedure of
Effect of fetal blood contamination upon alpha fetoprotein levels To tlw Editors: The recent article entitled “False posiiibr amniotic fluid alpha fetoprotein levels resulting t’~om contarnination with fetal blood: Results of’ an csperiment” 1,) Dr. Doran and co-workers (AM. J. OHS 1 FT. ~~k.NECffI.. 127: 759. 1977) is of great importance in tiw prenatal diagnosis of fetal malformations. The authors emphasized the necessit) of obtaining a red blood cell count and performing a Bet kc4leihauer test in the case of a blood-stained sampie. We are in agreement with this statement. However, there is a change in not onI\, the volumr of the amniotic Huid and the conccntratmI1 of’ alpha fetoprotein (AFP) in fetal plasma 11ur all m the fetal red blood cell count (Fig. l).’ During earl>- pregnancv. a certain amount of red blood cells represents muc11 more fetal plasma than the same amoutrr would rept esent in late pregnancy. Assuming a IWI ma1 fetal hematocrit and mean cell volume for all ca\es will lead to false results in the estimation of fetal hlo(,~d present in a stained sample. There are four factors upon which calculation of contamination is based: (1) volume of the amniotic ravit), (2) fetal AFP concent.ration, (3) fetal red blood cell count, and (4) concentration of AF’I’ in the amniotic fluid. Normal values of all of these fat tort increase az gestation advances. -4ssuming a mean value of all factors and a c.ontanlination of‘ 10,000 red blood cells per cwbi(~ millimeter, .L contamination that will cause the c;~rllplc io ht.1 ome
Secretion of human prolactin
Table I. Mean hPRL serum concentration (first series = 25 subjects) before, during, and after labor
during parturition
To the Editors:
We read the report by Rigg and Yen (AM. J. OBSTET. 128: 215, 1977) on human prolactin (hPRL) secretion during parturition with great interest, particularly because we had just completed a similar study. Our paper, which was in press at that time (De Gezelle, H., Dhont, M., Parewyck, W., and Thiery, M.: Prolactin levels during labor and the early postpartum period, Int. Res. Commun. Syst. Med. Sci. 5: 475, 1977), confirmed the multiphasic serum hPRL pattern (characterized by a decrease during labor and an increase after delivery) reported by Rigg and Yen, but our results showed a different time sequence of the prolactin changes. This led us to collect additional data and to submit the present comments. Initially, we studied 25 patients (first series). This material was classified according to type of labor and analgesia, which gave the following, numerically equal groups (No. = 5): spontaneous onset of labor; surgical induction, surgical induction of labor followed by intravenous administration of oxytocin, surgical induction of labor followed by intravenous administration of prostaglandin Ez, and surgical induction of labor and continuous lumbar epidural anesthesia. Prolactin was determined in maternal blood samples obtained via a separate antecubital indwelling catheter 30 minutes before and after amniotomy, at 8 cm. of cervical dilatation, at the time of delivery, and at one and 24 hours after delivery. No significant intergroup differences in mean hPRL concentrations were found, and the data were pooled (Table I). Unlike the hPRL levels observed by Rigg and Yen, which reached a nadir about two hours before delivery and started to rise immediately afterward, our mean hPRL concentration continued to decline until one hour after delivery. To clarify this discrepancy, we performed a more detailed study of hPRL levels, with special attention to the immediate postpartum period. To take into account a possible effect of analgesia on hPRL secretion, two groups of patients were investigated: six women given continuous epidural blocks and nine women who did not receive any analgesic drug during either labor or delivery. Blood was sampled at 30 minute intervals for three hours after delivery. No statistically significant difference was found between the two groups. Consequently, the material (second series) was pooled (Table II). The results of this additional series confirm our initial finding, i.e., that the
Mean
GYNECOL.
Time of sampling
30 min. before surgical induction 30 min. after surgical induction At 8 cm. of dilatation At delivery 1 hr. after delivery 24 hr. after delivery
2 S. E. M. (ng. lml.)
96.1 90.5 70.2 70.0 58.5 78.0
Table II. Mean hPRL serum concentration series = 15 subject) at delivery and during postpartum period
t k * t ” k
3.9 3.5 4.4 4.5 5.2 4.5
(second early
Mean 2 S. E. M. Time
of sampling
(ng. lml.)
At delivery 30 min. after delivery 60 min. after delivery 90 min. after delivery 120 min. after delivery 150 min. after delivery 180 min. after delivery
90.5 74.2 61.1 77.3 88.9 87.8 100.3
k 8.3 t 10.5 2 8.2 + 9.4 ‘- 11.2 2 12.1 -+ 14.7
nadir of the mean hPRL secretion occurs one hour after delivery. However, closer inspection of the individual data of both series showed that in a few cases (six of 40) the hPRL concentration rose immediately after delivery. Because the pattern of hPRL secretion described by Rigg and Yen was based on frequent sampling in only four patients, the discrepancy between their data and ours might well be ascribed to the inconstancies inherent in the investigation of a very tiny population. H.
Departmeti University 9000 Gent,
M. of Obstetrics and Gynecology of Gent De Pintelaan 135, Belgium
De Gezelle, M. Dhont, W. Parewyck, Thiery, M.D.,
M.D. M.D. M.D. Ph.D.
Reply to Dr. De Gezelle and colleagues To the Editors:
The implication by Dr. De Gezelle and co-workers of a different time sequence of prolactin changes from 736
Correspondence
what we reported in the immediate periparturitional period is easily explained. They did not find a predeliverv nadir in prolactin levels because they did not sample at appropriate times, i.e., samples were obtained at X cm. of dilatation (complete dilatation would have been more objective) and not again until delivery. The largt, number of individuals in their study is admirable; however, when one is examining hormonal dynamics, a few well-studied patients (i.e., obtaining frequent samples) may provide more meaningful information than will a large number of subjects sampled at infrequent intervals. Ltze A4. Rigg, Ph.D.. M.D. Depnrtmcrrt c/ Obstrtric.5 rind Cynrcolofl kt’ashingtt~n Uniiw5ity School qf Medic;rw St. Louis. A4i.r.\ouri cj?I IO S. S. C. Yen, M.D.
737
chest compression allows for more t horctt.gl~ tt-xheal clearing as gasping efforts. which md\ tlr,t\. meconium further down the tracheobronchial tI W. ‘11e prevented from the moment of birth. Since \\e bep;~il tlsing tIli\ technique, only Iwo infants among ihe ~I(EI ,a 111,ln .5,.3K! infants born in our hospital over the ~I”,I ISVO vc“t1.s have had any clinical evidence of II~C~COI~~I~III ;tspiralion syndrome: one infant with a pneun~c~r~~r~li.~sr~nlt~t~ end small bilateral pneumothoraces \\,hcr hat1 :mnim.J distress, required no supplemental os\grll. ,!n(l made ;rn uneventful recover>- and a second cllilrl :,illi a pnc~ momediastinum \vho was other&c tsrr~i WOE ~iormal.
REFERENCES
1. Ting, P.. and Brady, J. P.: AM. ,J. 0w-rk.1. ( ;I UECOL. 122: 767, 1YS5. 2. Carson, B. S.. Lose?, R. W., Bowes. u’. A JI.. and Simmons,
M.
A.:
AN.
J. OBSTET.
GYNECOL.
126:“71?.
1976
Prevention of meconium aspiration syndrome To the Editon: In recent years, techniques to aid in the prevention of the meconium aspiration syndrome in infants born through meconium-stained liquor have been reported in your JOURNAL. Ting and Brady1 showed the efficacy of tracheal suctioning immediately after delivery in removing meconium from the trachea, and Carson and associat.e? reported on a combined obstetric and pediatric approach involving thorough pharyngeal suctioning with delivery of the head followed by visualization of the vocal cords and tracheal suctioning, when indicated, after deliver) of the body. During the past two years, we have followed the protocol suggested by Carson and associates. In addition, however. we have used a further procedure which we believe ma! aid in removing meconium from the trachea prior to the first breath--the technique of chest compression. As rhe baby‘s head appears at the perineum, the obstetrician thoroughly suctions the mouth, nasopharynx, and hppopharynx. in order to remove as much meconium as possible. Then, as the body is delivered, the obstetrician grasps the thorax, with the thumbs meeting anteriorly over the sternum. Gentle but firm pressure is applied evenly throughout to prevent chest expansion without further compression of the thorax. After an assistant doubly clamps the cord and severs it, the obsretrician, while maintaining chest compression, immediately carries the infant to a nearby sterile table where the pediatrician visualizes the vocal cords and applies direct gentle suction, when indicated. Then, with release of the chest, routine resuscitative measures are undertaken beneath a radiant heater. We believe that the simple additional procedure of
Effect of fetal blood contamination upon alpha fetoprotein levels To tlw Editors: The recent article entitled “False posiiibr amniotic fluid alpha fetoprotein levels resulting t’~om contarnination with fetal blood: Results of’ an csperiment” 1,) Dr. Doran and co-workers (AM. J. OHS 1 FT. ~~k.NECffI.. 127: 759. 1977) is of great importance in tiw prenatal diagnosis of fetal malformations. The authors emphasized the necessit) of obtaining a red blood cell count and performing a Bet kc4leihauer test in the case of a blood-stained sampie. We are in agreement with this statement. However, there is a change in not onI\, the volumr of the amniotic Huid and the conccntratmI1 of’ alpha fetoprotein (AFP) in fetal plasma 11ur all m the fetal red blood cell count (Fig. l).’ During earl>- pregnancv. a certain amount of red blood cells represents muc11 more fetal plasma than the same amoutrr would rept esent in late pregnancy. Assuming a IWI ma1 fetal hematocrit and mean cell volume for all ca\es will lead to false results in the estimation of fetal hlo(,~d present in a stained sample. There are four factors upon which calculation of contamination is based: (1) volume of the amniotic ravit), (2) fetal AFP concent.ration, (3) fetal red blood cell count, and (4) concentration of AF’I’ in the amniotic fluid. Normal values of all of these fat tort increase az gestation advances. -4ssuming a mean value of all factors and a c.ontanlination of‘ 10,000 red blood cells per cwbi(~ millimeter, .L contamination that will cause the c;~rllplc io ht.1 ome