The “Cold Test” in Pregnancy

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AMERICAN JOURNAI, OF OBSTETRICS AND GYNECOLOGY

(108) Sygm~Undin: Brandenburgische Wehmutter, Berlin, 1689; eited by Taruffi. (109) Simpson: Zentralbl. f. Gynak. 21: 680, 1897. (110) Tiedemam: Sieboldt's Lucina 111: 19, 1805. (111) Trautner: Ueber monoamniotische Zwillinge (Er· Ianger), Mii.nchen, 1915. (112) Underhill: Zentralbl. f. Gyniik., p. 24, 1877. (113) Vallois: Bull. et mem. Soc. d'anthrop. de Paris 4: 213 1 1913. (114) Weiss: Cited by Hink. (115) Wenczel, G.: Zentralbl. f. Gynak., No. 22, 1904. (116) Wenczel, Th.: Z'entralbl. f. Gynak., No. 32, 1905. ( 117) Wilder: Am. J. Anat. 3: 384, 1904. (118) Williams, T. J.: AM. J. OBST. & GYNEC. 21: 129, 1931. (119) Williams, Textbook on Obstetrics, New York, 1927, D. Appleton Company, p. J. W.: 406. (120) Winslow: Philadelphia Med. Times 47: July, 1872. Arch. f. Gynak. 7: 266, 187fi. (121) Winckel: Lchrbueh der Geburtshiilfe, I Auflage, p. 443, 1889; II Auflage, p. 417, 1893: (122) Wolf: Zwei neue Faile monoamniotischer Zwillinger, Leipzig, 1920. (123) Ygonin: Gaz. med. de Lyon, No. l:l, 1864. 26 SOUTH

GoODMAN

STREJ;;T

THE "COLD TEST" IN PREGNANCY* A

PRELIMINARY REPORT oF ITs UsE IN PRENATAL CARE

E. MURRAY, M.D., M.D., RocHESTER, lVIrNN.

I..;AWRENCE M. RANDALL, M.D., STEPHEN RoBERT

D.

MussEY,

AND

(From the Mayo Clinic)

AGENER has shown that changes in the retinal arterioles usually keep pace with increase in hypertension in cases of toxemia of the latter months of pregnancy. The first change is narrowing of the lumens of the arterioles, resulting from spasm or spastic constriction. As the toxemia and blood pressure increase, this constriction may become fixed, and in the retina occur other changes which are rooognized as characteristics of the retinitis of the toxemia of pregnancy. The initial retinal changes suggest that the normal balance of the autonomic nervous system has been disturbed, and that vasomotor imbalance of the entire arteriolar bed has occurred. Evidence indicates that an incipient rise in blood pressure is the earliest sign of beginning preeclamptic toxemia, and the severity of the toxemia is usually considered to be in direct relation to the degree of hypertension. Exceptions occur, however. It would be advantageous, if by some test it might be possible to determine the presence of vasomotor imbalance before onset of the usual symptoms of toxemia of pregnancy or at least to determine with what frequency this vasomotor imbalance occurs during pregnancy. Hines and Brown, in studying the subject of hypertension from the :,;tandpoint of the internist, devised a type of standard stimulus whereby the pattern of reaction of the vasomotor system could be determined. This is known as the "cold test," and the technic of it is as

W

*Read at the Forty-Seventh Annual Meeting of th"' American As!
follows: The subject remains recumbent for fifteen minutes, or until the blood pressure has attained or approximated the basal level. In cases of hypeliension as long as forty-five minutt>s may be requirf•(l. With the cuff of the sphygmomanometer plaeed on one arm, the hand on the opposite side is placed in water that iN a1 a tt>mperatut'(' of 4" to 5o ( ~. ; the blood pressure is taken at the end of thirty seeonds and again at the end of sixty secolllls. The hand is remoYed from thP water and readings are taken every two minuter,; until tlw blood pt·P,.;sure has returned to its previous basal ll. Thr highest reading· obtainrd is recorded as the nH:>asure of the responst•. The originator::; of the test reported that there is a respon~e of both systolic and diastolie pressure. but that thr re:.;ponse of the latter i-; somewhat less than that of the former, and is more variable. The~· ronl-lidered that the response tn (~old ha~ a pm·ely l'PilPx basi~, bPr:a11s1'

A

ldO <\1

~norCIJ

~ 16Dr t,

~

tt..150-

15

140

'l

130-

·8 .....,

12.or-

0 .....,

\)

"' 110 1-

~

Cl) 100

1\

A

J

Group 4

\

Gr>oup 3

Gt>oup 1 Gt"'oup 2,

l<'ig. 1.-Rf'spons" to cold test.

The groups are described in the text, and nated briefly in Table l.

al'l'

desig··

the reaction is so rapid that any known hormonai or chemical faetor could not be concerned. A tourniquet, producing stasis of the flow of blood in the arm that is immersed, fails to inhibit the reaction. Hines and Brown did not apply their test to pregnant women, but

we thought that it should be applied, in the prenatal period, to a sufficient number of patients to prove or di!:iprove its value in forecasting preeclamptic toxemia. MATERIAL AND RESULTS

Reactions to the cold test, numbering 130, were determined on 104 pregnant women who were divided into five groups. Results in four of the groups are given in Table I and Fig-. 1. Compo:;ition of the group:; was as follows: Group L-Among the sixty-five women in this group, no evidence o£ toxemia of pregnancy had appeared by the time of performance of the tests represented in

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AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY

Line 1 of Table I, nor had such signs appeared at the time of writing of this paper. These women gave normal responses to the tests. Hines and Brown found a mean rise of systolic pressure of 8.62 mm. of mercury and a mean rise of diastolic pressure of 8.14 mm. of mercury in studies of the nor· mal male and of the normal, nonpregnant female. They considered 15 mm. of mereury as the maximal rise for normal persons, for the range of their readings in this group was between 5 and 15 mm. of mercury. The range in our normal group was slightly higher, so that we accepted 20 mm. of mercury as the maximal reaction of the normal female in the prenatal period. TABLE I. RESPONSE OF PREGNANT WOMEN TO COLD TEST OF HINES AND BROWN GROUP 1

-2 3

4

Normal response to test; no toxemia to time of writing of paper Exaggerated response to test ; no toxemia to time of writing of paper Exaggerated response to test; t o x e m i a between time of performance of test and time of writing of paper* Toxemia at time of performance of test*

PATIENTS 65

·····

------·~

BLOOD PRESSURE, MM. OF MEAN BASAL MEAN RISE SYSTOLIC DIASTOLIC SYSTOLIC DIASTOLIC 112

~IO:a-1o:Y

67

110

65

26.0

120

77

10.0

155

94

14

30.0

22.5

7

35.2

8

21.0 -·---··

I

I

-

•Four of the patients mcluded m this group were also included in the other group indicated by an asterisk. Results with fourteen other patients are recorded in the text. Thus the total of patients was 104.

Group e.-None of the fourteen women in this group had given evidence of toxemia of pregnancy by the time of performance of the tests represented in Line 2 of Table I, nor had such signs appeared at the time of writing of this paper, even though one of the patients had been confined. The patients, however, did give exaggerated responses to the tests. Group 3.-.Among the seven women of this group, no evidence of toxemia of pregnancy had appeared by the time of performance of the tests represented in Line 3 of Table I, but all of the seven women had given signs of toxemia before the time of writing of this paper. These patients also gave exaggerated responses to the tests. Of three of these seven patients, reactions when first determined, were within normal limits, but they became exaggerated later in pregnancy, before onset of the signs of toxemia. Group 4.--The eight women in this group had given signs of toxemia of pregnancy before the time of performance of the tests represented in Line 4 of Table I. We are not prepared at present to try to evaluate the reaction to the cold test of patients, such as these in this group, who have toxemia of pregnancy at the time the test is performed. Groop 5.-.A group of fourteen patients who gave no symptoms of toxemia, reacted in a manner which does not correspond to any of the reactions obtained by Hines and Brown. This reaetion consisted in a persistent fall from the basal levels, of both systolic and diastolic prellsures, during the period of immersion of the hand in cold water. In some of these cases, the fall persisted after removal of the ha.nd, and in others the pressures rose to approximate the basal levels within two minutes. In two eases in which fall of the blood pressure was persistent, there was an asso-

RANDALL ET AL.:

"!'OIJD TEST" IN PREGNANCY

eiated sense of faintness, which disappeared as the blood pressure rose. This repn•· sen.ts essentially an inverted reaction for which we have no explanation at present. Swelling of the immersed hand, or other symptoms which might be associated with cold allergy, did not appear. The symptoms relate
In attempting to apply this standard test of measuring the variability of blood pressure in the prenatal period, the only values we have for comparison deal with the general problem of hypertension. Although the exact cause of elevation of the blood pressure is not yet determined, it is felt that the hypertension associated with toxemia of the latter months of pregnancy is related to a toxin which affects the whole maternal organism. We have evidence that preeclamptic toxemia is associated with spastic constriction or with contraction of the arteriolar system, through observations made on the arterioles of the retinas of patients suffering from this condition. This constriction or contraction may be related to a particularly reactive vasomotor system. It is possible that a pregnant woman who manifests an exaggeratedly reactive vasomotor system in response to the cold test is more likely to suffer from toxemia of the latter months of pregnancy. It is significant that in no case in which the response to the cold test has been persistently normal, has toxemia developed, and that in all cases in which toxemia has developed a hypertensive reaction has been demonstrated. Of the patients who have manifested a definitely exaggerated reaction (Groups 2 and 3, Table I), 33 per cent have presented the usual signs of toxemia in the latter months of pregnancy. This paper is presented as a preliminary report. More studies are to be made on the patients already under obsPrvation and the number of patientf.l is to be enlarged. REFERENCES

(1) Hines, E. A., Jr., and Brown, G. E.: Ann. Int. Med. 7: 209, 1933. Wagener, H. P.: J. A. M. A. 101: 1380, 1933.

Estes, Jr., a.nd Heitmeyer:

(2)

Pregnancy Following Ovarian Implantation, Am ..J.

Snrg. 24: 563, 1934. After bilateral salpingectomy an ovarian implantation had been done in which the cut surface of the ovary, still attached to its pedicle, was implanted upon the cut surface of the uterine horn. Of 50 patients operated upon in this manner, whose records are complete, four (8 per cent) became pregnant, two had abortions at about the third month and two hd full·term pregnancies. J.

THQRNWELL WITHERSPOON.