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Spectrophotometric analysis of amniotic fluid in ABO incompatibility
860
Communications
in brief
growth and development to severe hepatic, renal, hematopoietic, and central nervous system involvement resulting in neonatal death.5 The disease rarely, if ever, affects the heart. McCracken dnd other.@ found 3 infants with congenitally acquired cytomegalovirus to have heart disease diagnosed between the ages of 4 to Sf/2 years of age, but could not attribute the lesions to the cytomegalovirus infection. The respiratory system involvement in the form of recurrent pneumonitis, as exhibited by the infant in this report, has previously been described.91 lop 11 Women who develop primary infection with cytomegalovirus will often have a subclinical hepatitis and/or mild upper respiratory tract infection.lOp 12 This is only detected later by serologic testing and rarely by isolation of the virus in maternal throat or urine collections.7J 8~I2 Other than by early abortion or death in utero, the infected fetus usually gives no clinical indication of its health until after the onset of labor.53 12 It is not the intent of this report to suggest a definite correlation between fetal tachycardia prior to onset of labor and intrauterine infection with cytomegalovirus. But with the recognition of the rather high incidence of viral infection in pregnancy and more sophisticated methods of detecting fetal distress, this correlation may become more significant in the future.
REFERENCES 1.
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Levkoff, A. H.: AM. J. OBSTET. GYNECOL. 104: 73, 1969. McCredie Smith, J. A., Tennison, R. F., and Langley, F. A.: Lancet 2: 903, 1956. Hildebrandt, R. J., et al.: AM. J. OBSTET. GYNECOL. 98: 1125. 1967. Sever, J. L., et al.:‘Am. Rev. Resp. Dis. 88: 342, 1963. Monif, G. R. G.: Viral Infections of the Human Fetus, Toronto, 1969, The Macmillan Company, pp. 73-88. Potter, E. L.: AM. J. OBSTET. GYNECOL. 74: 505, 1957. McCracken, G. H., and Shinefield, H. R.: Pediatrics 36: 933. 1965. McCracken, G. H.; et al.: Am. J. Dis. Child. 117: 522, 1969. Lombard, J. P., O’Leary, J. A.: Obstet. Gynecol. 22: 654, 1963. Stern, H.: Br. Med. J. 1: 665, 1968. Quan, A., and Strauss, L.: AM. J. OBSTET. GYNECOL. 83: 1240. 1962. Medearis, D. N.: &a. J. OBSTET. GYNECOL. 90: 1140, 1964. 4200 East Ninth Denver, Colorado
Avenue 80220
March Am. J. Obstet.
Spectrophotometric analysis amniotic fluid in ABO incompatibility GEORGE
H. NELSON,
DONALD
S. FREEDMAN,
15, 1972 Gynecol.
of
PH.D.,
M.D.
B.S.
Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta, Georgia
IN THE PAS T decade, spectrophotometric analysis of amniotic fluid with the calculation of A O.D. at 450 rnp has been widely used in the management of I&sensitized pregnancies. More recently, Mandelbaum, La Croix, and Robinson1 suggested that in the absence of Rh incompatibility the same measurement could be used in the estimation of gestational age. At the present time, this determination is being run in our laboratories as one of several measurements in the evaluation of fetal maturity. As a test for fetal maturity, it is recognized that the 450 rnp A O.D. decreases with increasing gestational age and usually reaches a value of 0.02 or less at 36 weeks or more.2 The question arose, “Will samples collected from ABO-incompatible pregnancies show falsely high values and will this condition interfere with the usefulness of the determination as a fetal maturity test?” The purpose of this brief communication is to report the results of 450 rnp A O.D. measurements from 13 ABO-incompatible pregnancies, 7 of which showed a positive direct Coombs test on the fetal blood. The amniotic fluid samples were collected at term at the time of rupture of the membranes. No samples were contaminated with blood or meconium. The 450 rnEL A O.D. was determined in the manner previously described.3 The results of the determinations along with pertinent data regarding the patients are shown in Table I. The fetal blood type and direct Coombs were done on cord blood. The hemoglobin, hematocrit, and reticulocyte counts were done by heel stick within 20 hours of age. None of the infants required an exchange transfusion. In reviewing our over-all results regarding 450 mp A O.D. determinations at term, we find that 78 per cent of the values are 0.01 or less. Since all of the values obtained in the ABO-incompatible pregnancies were of this magnitude, we can conclude that, as a rule, the presence of
in
in
iNumbers
several
SNurnbers
*When
6 7 8 9 10 11 12 13
.i
‘1 3 4
1
Patient No.
to age
to the
refer
parenthem lefer
parentheses
determinations
were
age
of the
of
the
infant
done, infant
in at
to
the the
time
A+ .4+ .4+ .4+ B+ A+ B+ .4+ .4A+ .4+
A+
CPe
time
serum
highest jaundice
bilirubin
value
Pos. Pos. Neg. Neg. Neg. Neg. Neg. Ne
POS. POS. POS. POS.
POS.
Direct coombs
in ARO-incompatible
at the
refers irr hours
hours
number
o+ o+ 0+ o+ o+ o+ o+ o+ o+ o+ O+
2,450 3,150 3,100 3,145 3,890 3,100 3,165 3,3 15 3,535 3,320 3,545 4>800
40 37 40 39 40 40 39 38 40 39 40 40
bilirubin
0+
3,470
Maternal blood type
determinations
40
Birth weight (grams)
fluid 450 rn,u A 0.D.
Gestational age (wk.)
Table I. Amniotic
was
was
obtained. noticed.
done.
17.2 17.4 16.2 “3.0 16.1 18.6 18.0 18.1) 18.5 18.0 16.4 16.0
18.3
Hemoglobin
Determinations
pregnancies
-
fetal
60 56 53 49 70 51 59 63 55 68 56 55 .i .,
Hematocrit
on
blood
10 3 8 10 5 10 9 4 3 8 7 2 3 _-~--
Reticulocyte count (%)
(72)f ‘(36) (5) (48) (12)
Yes Yes Yes Yes Yes
No No
Developed clinical jaundice
(72 (36 (18 (48 (18 No I 0 Y No No No Yes---(48).-.. __.14.8-- (114).~-- .-...-
9.8 6.8 2.8 8.4 6.4
Total bilirubin” (w. %) -
fluid A O.D.
Amniotic
862
Communications
in brief
ABO incompatibility does not result in falsely high 450 rnp A O.D. values and does not interfere with the use of this determination as a test for fetal maturity. However, 450 rn,,,. A O.D. determinations in severe cases of ABO incompatibility, i.e., those in whom fetal bilirubin levels reach 20 mg. per cent or more and/or exchange transfusion is required, have not yet been reported. REFERENCES
Mandelbaum, B., LaCroix, G. C., and Robinson, A. R.: Obstet. Gynecol. 29: 471, 1967. 2. Nelson, G. H., Goodrich, S. M., Martin, T. R., Talledo, 0. E., and Freedman, M. A.: South. Med. J. 64: 1, 1971. 3. Nelson, G. H., and Talledo, 0. E.: Am. J. Clin. Pathol. 52: 363, 1969. 1.
A new instrument for cul-de-sac puncture H.
CIMBER,
R.
MOSER,
University Obstetrics
M.D.,
F.A.C.S.
M.D.
Clinic Hospital, and Gynecology,
Department of Berne, Switzerland
C u LDOC E N TE SIS is the most frequently performed diagnostic procedure for ectopic pregnancies. Although colposcopy and peritoneoscopy have become more popular in recent years, they require special equipment and training. In suspected ectopic pregnancies there is a relatively high maternal death toll if the diagnosis is missed or delayed.1 Our new puncture device represents a convenient diagnostic tool. The advantage is
Fig. 1. a, Spring-loaded guide: e, loader.
handle;
b,
that the instrument is painless, safe, rapid, and gives more accurate results than the usual puncture technique. One hundred examinations were done with the new instrument both in a private oflice and in the Emergency Room of the University Clinic Hospital, Department of Obstetrics and Gynecology in Berne, in order to rule out suspected ectopic pregnancies. This Bard unit (Patent No. 3 580 255), (Fig. 1 j, consists of a spring-loaded handle with a 7 inch long tube containing a 19 gauge needle and a special catheter with a fine wire guide. The distal end of the catheter has multiple perforations. The needle is propelled one inch at high speed by a trigger mechanism in the handle. After puncture of the cul-de-sac the catheter can be advanced 3 inches with the wire guide. The wire guide is then removed and a . . syrmge IS connected to the catheter in order to withdraw the peritoneal content. The entire unit can be presterilized and prepacked ready for use. None of the patients experienced pain. This can be attributed to the high-speed action of the spring mechanism. In 90 per cent peritoneal fluid or blood was obtained in the first attempt. The high average yield of the peritoneal fluid (3 to 5 ml.) with this unit compared with an ordinary needle puncture is explained by the use of this special catheter with its multiple perforations. With a simple catheter or needle, the chances of blockage are increased. No bowel perforations occurred because the needle perforated only one inch and the pliable catheter presented no danger to the bowel. No tenaculum was necessary in either the retro- or anteverted uterus because the catheter needle unit is adaptable to the anatomic conditions which prevail. A new culdocentesis instrument proved to be painless, safe, and provided a higher yield of
tube; c, 19 gauge needle: d, special catheter with wire
Communications
in brief
growth and development to severe hepatic, renal, hematopoietic, and central nervous system involvement resulting in neonatal death.5 The disease rarely, if ever, affects the heart. McCracken dnd other.@ found 3 infants with congenitally acquired cytomegalovirus to have heart disease diagnosed between the ages of 4 to Sf/2 years of age, but could not attribute the lesions to the cytomegalovirus infection. The respiratory system involvement in the form of recurrent pneumonitis, as exhibited by the infant in this report, has previously been described.91 lop 11 Women who develop primary infection with cytomegalovirus will often have a subclinical hepatitis and/or mild upper respiratory tract infection.lOp 12 This is only detected later by serologic testing and rarely by isolation of the virus in maternal throat or urine collections.7J 8~I2 Other than by early abortion or death in utero, the infected fetus usually gives no clinical indication of its health until after the onset of labor.53 12 It is not the intent of this report to suggest a definite correlation between fetal tachycardia prior to onset of labor and intrauterine infection with cytomegalovirus. But with the recognition of the rather high incidence of viral infection in pregnancy and more sophisticated methods of detecting fetal distress, this correlation may become more significant in the future.
REFERENCES 1.
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Levkoff, A. H.: AM. J. OBSTET. GYNECOL. 104: 73, 1969. McCredie Smith, J. A., Tennison, R. F., and Langley, F. A.: Lancet 2: 903, 1956. Hildebrandt, R. J., et al.: AM. J. OBSTET. GYNECOL. 98: 1125. 1967. Sever, J. L., et al.:‘Am. Rev. Resp. Dis. 88: 342, 1963. Monif, G. R. G.: Viral Infections of the Human Fetus, Toronto, 1969, The Macmillan Company, pp. 73-88. Potter, E. L.: AM. J. OBSTET. GYNECOL. 74: 505, 1957. McCracken, G. H., and Shinefield, H. R.: Pediatrics 36: 933. 1965. McCracken, G. H.; et al.: Am. J. Dis. Child. 117: 522, 1969. Lombard, J. P., O’Leary, J. A.: Obstet. Gynecol. 22: 654, 1963. Stern, H.: Br. Med. J. 1: 665, 1968. Quan, A., and Strauss, L.: AM. J. OBSTET. GYNECOL. 83: 1240. 1962. Medearis, D. N.: &a. J. OBSTET. GYNECOL. 90: 1140, 1964. 4200 East Ninth Denver, Colorado
Avenue 80220
March Am. J. Obstet.
Spectrophotometric analysis amniotic fluid in ABO incompatibility GEORGE
H. NELSON,
DONALD
S. FREEDMAN,
15, 1972 Gynecol.
of
PH.D.,
M.D.
B.S.
Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta, Georgia
IN THE PAS T decade, spectrophotometric analysis of amniotic fluid with the calculation of A O.D. at 450 rnp has been widely used in the management of I&sensitized pregnancies. More recently, Mandelbaum, La Croix, and Robinson1 suggested that in the absence of Rh incompatibility the same measurement could be used in the estimation of gestational age. At the present time, this determination is being run in our laboratories as one of several measurements in the evaluation of fetal maturity. As a test for fetal maturity, it is recognized that the 450 rnp A O.D. decreases with increasing gestational age and usually reaches a value of 0.02 or less at 36 weeks or more.2 The question arose, “Will samples collected from ABO-incompatible pregnancies show falsely high values and will this condition interfere with the usefulness of the determination as a fetal maturity test?” The purpose of this brief communication is to report the results of 450 rnp A O.D. measurements from 13 ABO-incompatible pregnancies, 7 of which showed a positive direct Coombs test on the fetal blood. The amniotic fluid samples were collected at term at the time of rupture of the membranes. No samples were contaminated with blood or meconium. The 450 rnEL A O.D. was determined in the manner previously described.3 The results of the determinations along with pertinent data regarding the patients are shown in Table I. The fetal blood type and direct Coombs were done on cord blood. The hemoglobin, hematocrit, and reticulocyte counts were done by heel stick within 20 hours of age. None of the infants required an exchange transfusion. In reviewing our over-all results regarding 450 mp A O.D. determinations at term, we find that 78 per cent of the values are 0.01 or less. Since all of the values obtained in the ABO-incompatible pregnancies were of this magnitude, we can conclude that, as a rule, the presence of
in
in
iNumbers
several
SNurnbers
*When
6 7 8 9 10 11 12 13
.i
‘1 3 4
1
Patient No.
to age
to the
refer
parenthem lefer
parentheses
determinations
were
age
of the
of
the
infant
done, infant
in at
to
the the
time
A+ .4+ .4+ .4+ B+ A+ B+ .4+ .4A+ .4+
A+
CPe
time
serum
highest jaundice
bilirubin
value
Pos. Pos. Neg. Neg. Neg. Neg. Neg. Ne
POS. POS. POS. POS.
POS.
Direct coombs
in ARO-incompatible
at the
refers irr hours
hours
number
o+ o+ 0+ o+ o+ o+ o+ o+ o+ o+ O+
2,450 3,150 3,100 3,145 3,890 3,100 3,165 3,3 15 3,535 3,320 3,545 4>800
40 37 40 39 40 40 39 38 40 39 40 40
bilirubin
0+
3,470
Maternal blood type
determinations
40
Birth weight (grams)
fluid 450 rn,u A 0.D.
Gestational age (wk.)
Table I. Amniotic
was
was
obtained. noticed.
done.
17.2 17.4 16.2 “3.0 16.1 18.6 18.0 18.1) 18.5 18.0 16.4 16.0
18.3
Hemoglobin
Determinations
pregnancies
-
fetal
60 56 53 49 70 51 59 63 55 68 56 55 .i .,
Hematocrit
on
blood
10 3 8 10 5 10 9 4 3 8 7 2 3 _-~--
Reticulocyte count (%)
(72)f ‘(36) (5) (48) (12)
Yes Yes Yes Yes Yes
No No
Developed clinical jaundice
(72 (36 (18 (48 (18 No I 0 Y No No No Yes---(48).-.. __.14.8-- (114).~-- .-...-
9.8 6.8 2.8 8.4 6.4
Total bilirubin” (w. %) -
fluid A O.D.
Amniotic
862
Communications
in brief
ABO incompatibility does not result in falsely high 450 rnp A O.D. values and does not interfere with the use of this determination as a test for fetal maturity. However, 450 rn,,,. A O.D. determinations in severe cases of ABO incompatibility, i.e., those in whom fetal bilirubin levels reach 20 mg. per cent or more and/or exchange transfusion is required, have not yet been reported. REFERENCES
Mandelbaum, B., LaCroix, G. C., and Robinson, A. R.: Obstet. Gynecol. 29: 471, 1967. 2. Nelson, G. H., Goodrich, S. M., Martin, T. R., Talledo, 0. E., and Freedman, M. A.: South. Med. J. 64: 1, 1971. 3. Nelson, G. H., and Talledo, 0. E.: Am. J. Clin. Pathol. 52: 363, 1969. 1.
A new instrument for cul-de-sac puncture H.
CIMBER,
R.
MOSER,
University Obstetrics
M.D.,
F.A.C.S.
M.D.
Clinic Hospital, and Gynecology,
Department of Berne, Switzerland
C u LDOC E N TE SIS is the most frequently performed diagnostic procedure for ectopic pregnancies. Although colposcopy and peritoneoscopy have become more popular in recent years, they require special equipment and training. In suspected ectopic pregnancies there is a relatively high maternal death toll if the diagnosis is missed or delayed.1 Our new puncture device represents a convenient diagnostic tool. The advantage is
Fig. 1. a, Spring-loaded guide: e, loader.
handle;
b,
that the instrument is painless, safe, rapid, and gives more accurate results than the usual puncture technique. One hundred examinations were done with the new instrument both in a private oflice and in the Emergency Room of the University Clinic Hospital, Department of Obstetrics and Gynecology in Berne, in order to rule out suspected ectopic pregnancies. This Bard unit (Patent No. 3 580 255), (Fig. 1 j, consists of a spring-loaded handle with a 7 inch long tube containing a 19 gauge needle and a special catheter with a fine wire guide. The distal end of the catheter has multiple perforations. The needle is propelled one inch at high speed by a trigger mechanism in the handle. After puncture of the cul-de-sac the catheter can be advanced 3 inches with the wire guide. The wire guide is then removed and a . . syrmge IS connected to the catheter in order to withdraw the peritoneal content. The entire unit can be presterilized and prepacked ready for use. None of the patients experienced pain. This can be attributed to the high-speed action of the spring mechanism. In 90 per cent peritoneal fluid or blood was obtained in the first attempt. The high average yield of the peritoneal fluid (3 to 5 ml.) with this unit compared with an ordinary needle puncture is explained by the use of this special catheter with its multiple perforations. With a simple catheter or needle, the chances of blockage are increased. No bowel perforations occurred because the needle perforated only one inch and the pliable catheter presented no danger to the bowel. No tenaculum was necessary in either the retro- or anteverted uterus because the catheter needle unit is adaptable to the anatomic conditions which prevail. A new culdocentesis instrument proved to be painless, safe, and provided a higher yield of
tube; c, 19 gauge needle: d, special catheter with wire