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Sulfadiazine concentration in the blood and lochia
SULFADlAZlXE BRUCE P. ZUMMO, (From the Department
CXHWE~RATION Mll).,
AND
IN TEE BLOOD LOUIS
RUDOLPH,
M.D.,
AND CHICAGO,
LOORIA ILL.
of Obstetrics, Cook ‘County Hospital and Hektoen. Institude Research of the Cook County Hospital)
Of
T
HIS study was undert,aken to determine the amount of the sulfonamides excrctcd from the postpartum uterus and its relation to the blood concentration. The recent use of chemotherapy justifies t,his report. These patients were nfehrile and the use of the sulfonamide was academic. In this series of twenty-five pat,ients, all but t,hree were primiparas; Their prenatal and labor two were gravida ii and one was gravida iii. courses were uormal. Each primipara was delivered by outlet forceps under pudendal block with mediolateral episiotomy. Procedure
Sulfadiazine was st,arted within twelve hours after delivery. The routine consisted of 60 grains initially and 15 grains every four hours, with equal amounts of sodium bicarbonate. Lochia was collected after twenty-four and forty-eight hours, and after seven days, by means of a contraceptive vaginal diaphragm. This dia.phragm was inserted and removed with sterile technique. II was found tha.t the diaphragm has to be inserted four to five hours prior to the collection of the twenty-four and forty-eight specimens in order to obtain the necessary amount (8 to 10 cc.) of lochia. Upon the removal of the diaphragm and its contents, blood was drawn from the cubital vein. Both specimens were collected in oxalated bottles. The seven-day lochia was collected by a diaphragm placed ten to twelve hours before, since the output at this postpartum period was minimal. This seven-day specimen was of particular interest because the lochia contained little blood, with an abundance of shreds and debris from the uterus. All contents were kept refrigerated and taken to the Institute within i-welve hours. The sulfadiazine levels were determined by the same technician, using the Bratton-Marshall Photelometer technique. Patients were ambulatory after the first postpartum day, save during the pchrio(l of lochial collection. Only one tablet of Ergotrate. grain szo, was zircn lo each paCent post delivery. ‘Fhc sulfn caoncentrations in the blood were estremely variable for all ~l’ollps, remaining proportionately similar in each case. Thus patient, No. 2 JY’vtYIkd a. level of 5.8’i mg. per cent at the end of twenty-four hours, and 7.5 mg. per cent at the end of forty-eight hours. On the other hand, patient Nap. 14 had a blood level of 15.9 mg. per cent at the end of twenty-four 11011~ and 14.2 mg. per cent at t,he end of forty-eight hours. Lo&al con~tn~ri!tions behaved in a similar manner, though less in amount. Thus, it: ~)alicnt No. 2, the sulfonamide blood concentration at the end of twenty.ff~ur Iwurs was 5 07 nicj’ per cent, while the lochial concentration was 4.74 Iriz. alar At. ’ $ain. <ient No. 34 revealed a blood concentration of 18.9 mu. per cent al the end of twenty-four hours and a lochial concentration of 15.7 me. per cent. Thus. if the concentration of the sulfadiazine was 1168
Volume Number
56 6
SULFADIAZINE
IN
BLOOD
AND
1169
LOCHIA
high in the blood, we could expect high concentration in the lochia. This is true whether we study the twenty-four hour or the seven-day specimen (Table I). There are paradoxial levels noted in the 4%hour specimen for patients No. 2, No. 3, No. 13, and No. 14, as well as in the seven-day specimen of patients No. 19, No. 21, and No. 25. In these, the diaphragm had to be retained for longer periods than the time allotted for the medication, because the lochia collected for the previous four to five hours and ten to twelve hours, respectively, was not sufficient for analysis. It would seem to indicate that a fairly rapid loss of sulfadiazine occurs in the blood stream, and, despite their ambulatory state, some patients still discharge small amounts of lochia. The character of the lochia was no different than in the nonmedicated There were no complications patients, although the odor tended to be “sharper.” in any of these patients, and all were discharged on the eighth postpartum day. TABLE
PATIENT
1
(~~~~~Ho7zH&y?
1
12.19
2 3
5.97 15.0 12.64 7.38 9.7 11.4 6.31 7.3 11.38 8.37 10.3 5.7
4
5 6 7 II
9” 10 11 12 19
14 15 is
18.9
15.9
1 9.45
4.74 8.59 10.47 4.47 8.82 10.3 4.17 4.0 7.65 7.6 10.3 3.5 15.7 14.2
1
(;Y$HjYijy&?
Specimen 7.5* 16.23* Snecimen 8.27 8.37 10.39 7.2 7.6 7.95
15.5” 11.7
(
(+r!&fl:
was lost 2%3 lost 5.43 7.0 9.0 5.15 6.0 6.85 6.2 ::i 17.2 10.9 6.8 8.3
17 18 19 20
ET&
ii*: 6:0 6.7 -7.5
24 25 *See Discussion.
Summary 1. The sulfonamide concentration of the lochia paralleled the blood concentration in each instance. 2. The sulfadiazine routine of 60 grains initially and 15 grains every four hours results in extremely variable blood and lochial concentrations. 3. Ambulatory patients do not always reveal an increase in the amount of lochia. 4. The lochial odor of these patients tended to be “sharper”’ than that of those nonmedicated. 55 EAST
WASHINGTON
BOULEVARD
CXHWE~RATION Mll).,
AND
IN TEE BLOOD LOUIS
RUDOLPH,
M.D.,
AND CHICAGO,
LOORIA ILL.
of Obstetrics, Cook ‘County Hospital and Hektoen. Institude Research of the Cook County Hospital)
Of
T
HIS study was undert,aken to determine the amount of the sulfonamides excrctcd from the postpartum uterus and its relation to the blood concentration. The recent use of chemotherapy justifies t,his report. These patients were nfehrile and the use of the sulfonamide was academic. In this series of twenty-five pat,ients, all but t,hree were primiparas; Their prenatal and labor two were gravida ii and one was gravida iii. courses were uormal. Each primipara was delivered by outlet forceps under pudendal block with mediolateral episiotomy. Procedure
Sulfadiazine was st,arted within twelve hours after delivery. The routine consisted of 60 grains initially and 15 grains every four hours, with equal amounts of sodium bicarbonate. Lochia was collected after twenty-four and forty-eight hours, and after seven days, by means of a contraceptive vaginal diaphragm. This dia.phragm was inserted and removed with sterile technique. II was found tha.t the diaphragm has to be inserted four to five hours prior to the collection of the twenty-four and forty-eight specimens in order to obtain the necessary amount (8 to 10 cc.) of lochia. Upon the removal of the diaphragm and its contents, blood was drawn from the cubital vein. Both specimens were collected in oxalated bottles. The seven-day lochia was collected by a diaphragm placed ten to twelve hours before, since the output at this postpartum period was minimal. This seven-day specimen was of particular interest because the lochia contained little blood, with an abundance of shreds and debris from the uterus. All contents were kept refrigerated and taken to the Institute within i-welve hours. The sulfadiazine levels were determined by the same technician, using the Bratton-Marshall Photelometer technique. Patients were ambulatory after the first postpartum day, save during the pchrio(l of lochial collection. Only one tablet of Ergotrate. grain szo, was zircn lo each paCent post delivery. ‘Fhc sulfn caoncentrations in the blood were estremely variable for all ~l’ollps, remaining proportionately similar in each case. Thus patient, No. 2 JY’vtYIkd a. level of 5.8’i mg. per cent at the end of twenty-four hours, and 7.5 mg. per cent at the end of forty-eight hours. On the other hand, patient Nap. 14 had a blood level of 15.9 mg. per cent at the end of twenty-four 11011~ and 14.2 mg. per cent at t,he end of forty-eight hours. Lo&al con~tn~ri!tions behaved in a similar manner, though less in amount. Thus, it: ~)alicnt No. 2, the sulfonamide blood concentration at the end of twenty.ff~ur Iwurs was 5 07 nicj’ per cent, while the lochial concentration was 4.74 Iriz. alar At. ’ $ain. <ient No. 34 revealed a blood concentration of 18.9 mu. per cent al the end of twenty-four hours and a lochial concentration of 15.7 me. per cent. Thus. if the concentration of the sulfadiazine was 1168
Volume Number
56 6
SULFADIAZINE
IN
BLOOD
AND
1169
LOCHIA
high in the blood, we could expect high concentration in the lochia. This is true whether we study the twenty-four hour or the seven-day specimen (Table I). There are paradoxial levels noted in the 4%hour specimen for patients No. 2, No. 3, No. 13, and No. 14, as well as in the seven-day specimen of patients No. 19, No. 21, and No. 25. In these, the diaphragm had to be retained for longer periods than the time allotted for the medication, because the lochia collected for the previous four to five hours and ten to twelve hours, respectively, was not sufficient for analysis. It would seem to indicate that a fairly rapid loss of sulfadiazine occurs in the blood stream, and, despite their ambulatory state, some patients still discharge small amounts of lochia. The character of the lochia was no different than in the nonmedicated There were no complications patients, although the odor tended to be “sharper.” in any of these patients, and all were discharged on the eighth postpartum day. TABLE
PATIENT
1
(~~~~~Ho7zH&y?
1
12.19
2 3
5.97 15.0 12.64 7.38 9.7 11.4 6.31 7.3 11.38 8.37 10.3 5.7
4
5 6 7 II
9” 10 11 12 19
14 15 is
18.9
15.9
1 9.45
4.74 8.59 10.47 4.47 8.82 10.3 4.17 4.0 7.65 7.6 10.3 3.5 15.7 14.2
1
(;Y$HjYijy&?
Specimen 7.5* 16.23* Snecimen 8.27 8.37 10.39 7.2 7.6 7.95
15.5” 11.7
(
(+r!&fl:
was lost 2%3 lost 5.43 7.0 9.0 5.15 6.0 6.85 6.2 ::i 17.2 10.9 6.8 8.3
17 18 19 20
ET&
ii*: 6:0 6.7 -7.5
24 25 *See Discussion.
Summary 1. The sulfonamide concentration of the lochia paralleled the blood concentration in each instance. 2. The sulfadiazine routine of 60 grains initially and 15 grains every four hours results in extremely variable blood and lochial concentrations. 3. Ambulatory patients do not always reveal an increase in the amount of lochia. 4. The lochial odor of these patients tended to be “sharper”’ than that of those nonmedicated. 55 EAST
WASHINGTON
BOULEVARD