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The cutaneous pregnancy test
X1x0
FERRERO, (From
M.II., the
PASADENA,
Womnn
(hrm.
‘s Hospiful)
T
HE search for a simple pregnancy teat not involving the use of animals has been going on for many years. This search has brought forth both chemical tests, wherein the patient’s urine specimen is used, and injectable skin tests. The recent development of a disposable plastic microdispenser so constructed as to hold a minute dose and embodying a prepositioned needle so disposed as to be parallel with the skin contacting surface of the instrument, thereby minimizing the possibility ot’ a subcutaneous injection, has again aroused interest in the colustrum cutireaction for pregnancy, described by Falls, Freda, and Co11en.l The microdispenser” simplifies the modalities of thr, illjertion lay- furnishing the physician with a ready-to-use constant optimum l/70 C.C. of sterile colostrum. The previous technical dif3icuities of collection, sterilization, aud preservation of the colostrum have been reduced to a minimom since the original n-ark in 1941. Our clinical evaluation of this new test, called the “Q-Test,” employed the use of the aforementioned inject,ion instrument. am~l i he followi~rg sets forth the procedures. ColZrction of t11e ro1astrurn.A. Information gathered from Dr. Falls disclosed that attempts tn identify the antigen in. colostrum responsible for the reactions of this skin test resulted in failure. Tests to determine the optimum for collection and classificatir)n of donor (primipara or multipara) employed pooled (colostrum specimens from live or m(fre donors) and unpooled (colostrum specimen from a single donor’1 colostrum from primiparaa and pooled and uw pooled colost.rum from multiparap. The onl> ~:olost IWI~ which produ~d a consistently high cotlecte~l and pooled from primiparas during the degree of reliable readings was that This c*olost I’UI)L was withdrn\r\.n 11,~ elr&ric breast pump twenty-eighth week of pregnanc,v. from volunteer primiparas. H. In order t,o reduce to minimum tilt! seemingly ur~:rvi~itial~le cuntaminatiori 0Y the colostrum during the withdrawal, the donor ‘R nipples and the area around them which came into contact with the sterile glass breast rnp were scrubbed with aseptic soap and E:arh withdrawal MBS then transfrrred io a sterile centrifuge then washed with ether. it
tulle.
Preparation of the c’oloslwrn Fomula:-A. Each individual primiparous colostrum specimen was r.ent ri fugeti at 6,000 r.p.m. for ten minutes and the fat component then ri3no\-ed with a stc~rilc swat). ;2 minimum of five such t,reated specimens were then pooled and an equal amount of physiological sterile To earh 10 C.V. of this mixture l/IO of 1 :lOO Xerthiolate was normal saline was added. added as a preservative. This formula W:LP then kept t-onstnntl?under refrigeration brlow 59O F. 13. F;ven with the precautions taken at thr time of withdrawai as explained heretofore the pure eolostrum when plated 011 agar (~onsistentiy gave a growth of mixed staphyloAll colostrum used in this series NM ~lilutetl and the i,resarvstive added within coccus. A period of I rS days ’ minimum exposure to the preservative an hour following withdrawal. was then necessary before the formula was sterile to bacterial or mycotir growth. *Ogle corporation,
Micro Los
Dispenser units Angeles, Calif.
fWniShcd
thlou@~ ,37 !?
the
courtesy
of
General
Pharmacal
CUTANEOUS
Volume 6 I
PREGNANCY
673
TEST
C. When the colostrum formula was sterile to culture it was transferred under Each dispenser held exactly l/50 C.C. and aseptic conditions to sterile microdispensers. One serentieth C.C. was determined to be the dispensed l/70 C.C. plus or minus 41’1,000. optimum dose. D. The dispensers were then stored under refrigeration as it was discovered that \vhen tile formula was exposed to Eden room tc?mperature for periods in excess of 36 hours its potent>fell sharply.
Fig. l.-The Micro Dispenser. 4 is the fin by which it is grasped between R is the flexible bulb containing the colostrum C! is the needle protector cap.
Fig.
Z-When
the
needle
has
entered between
the thumb formula.
and
the skin sufficiently, squeeze the thumb and foreflnger.
foreflnger.
the
bulb
marked
B in
Fig.
1
The clinical evaluation of this test covers 228 individual tests. One hundred fifty-five of these tests were performed on volunteer clinical patients of the Woman’s Hospital and 73 tests were performed by collaborating investigators in their private practice. The 155 tests performed at Woman’s Hospital were clinically proved correct or incorrect by a sufficient lapse of time. The 73 tests performed by the collaborating investigators in their private practice were proved clinically correct or incorrect by Aschheim-Zondek, Friedman, or frog tests, plus a sufficient lapse of time. The tests were performed on patients as early as 12 days and as late as 16 weeks past a first missed menstrual period. Other tests were performed in postpartum, nonpregnanr>(females and males), menopau%, and two special eases.
‘l’hr c~olostrunt should 1~ deposit~etl inir0 llrck sul)er(ici:rl layrrs 01 the skin, possibly just under the stratnm t~~rneum, and this i* easily ilone 1)~. inserting l.he fine needle of the dispenser parallel tcl the skin (the need1 6’ itself should I),: \ iGl,le through the ~traturn corneum ) . The needle &ould IW withdrawtt from the site of injec(ion without releasing the colosl rum chamber. otherwise the C*OIOS~ rum itself would trfl rPaspir:ktrxd into thf, lm111, giving doubtful or erroneous readings. S’l;i?t, Test Readinys.-Readings were made 13 minutes The pregnant patients at the l:i-minute reading somewhat increased in size and little or no rr~thema. At of the wheal and erpthema had disappeared.
jections.
and 60 minutes following iu‘ would exhibit a pearl?; wheal the 60 minute rh&ading all sipn~
The nonpregnant patient at, the 15 minute reading exhil)its a marked increase ill This wheal is still pearly at this time and is usually surrounded 1)~ irregular wheal size. At the @l-minute reading the erythema has disappeared erythema. 1 to 2 cm. in diameter. l)nt the tvheal has Ijecome inflamed aud still is easily visible and normally l)Orfiists fog several hours past this 60.minute reading. I found it to 1~ of great help in comparing the size of llle wheal at the diderent readings, to circle the primary wheal immediately after the injection with a dermographic This is art important detail, l)t:canse the size of t,he wheal and pencil or a rommon ink pen. the time element are prot)al)ly more imlmrtant than the peripheral erythema in thr interpretation
of
the
tt’st.
-
TYPE
*Exhibited
ti
0
1 1
0 I)
The
3” 85 5
I’ERCEKTAGK FALSE I’OSITIVE I’RBGNANCIES
_--.-. PERCENTAGE FALSE ! NEGATIVE NOSI’REGNAN C1E.S
0 ‘1.4 0
5.5 il 0
6
CASE
Il. (JOLLABORATING _..-..--.___--.-~----___.---____--__--
INVESTIGATORS IS . ._.~. --_ (!I,INICALLII I CLISICALT,V (‘OliF’IRMEI, C0NFIRMF.I) I SONPREGPREGNAXCY i SANCP ( SKIiX TEST NO. OF , SK1.X TE.ST CASES j POSITIVE) 1 NEGATIVE j -. -_ -.___---.-.--..f -._---------
Early pregnancy Nonpregnant controls __--_..-TF’
positive negative Results
.I_
-._- -~-___-I__. CLINICALI;L CONFIRMEI) NONPREGNANCY ( SKIh- TEST NEGATIVE)
dermatographia. TABLE
TYPE
CLINICALLY CONFIRMED PREGNANCY. (SKIN TEST POSITIVE) .-52 2 0
CASE
Early pregnancy Postpartum Nonpregnancy (males) Menopause Chronic P.I.D. IJntreated Grade 3 carcinoma of the cervix
-T
----
/
.__~_.
54 0
I .~ .!
3 .--. 16 ~.
~~KIVATE I’RA~~TI~F: __--_---___- -.- -...... ..- _.-_’ I’F:R~:ENTAGF. FALSE POSITIVE PREGNANCIES -.--.--___
0 0
_._..___ ___ -. __
!
j !
l’EKCENl~AGI; F’AI..SE NEGATIVE NONPREGNANCIES .____ __.._
i5.4 0
Wminute reading wa,s taken as the uptimunr for diagnosis. Tests were read as (pregnant) if no erythema or wheal was visible at. the 60 minut*: reading and (nonpregnant) if the wheal was visible arId persisted at the 60-minute reading. of the 228 tests are shown in the table.
Volume 6 I Number 3
CUTANEOUS
PREGNANCY
675
TEST
Summary 1. C(dostrum formula prepared following instructions as set forth in report of Falls, Freda, and Cohen1 has been given intraepidermically to a series of human volunteers. 2. Method of collection and preparation of the colostrum formula is presented. 3. Colostrum formula caused no immediate or late toxic or untoward reactions in 228 human subjects. 4. Each test was confirmed by further clinical observation or by other pregnancy i ests. 5. Intraepidermal injection is stressed. 6. Circling primary wheal recommended. 7. The accuracy of our series compares favorably to that experienced 1)y the original investigators (Falls, Freda, and Cohenl).
Conclusion In i.he present series the Q-Test was proved reliable (93 per cent) in 112 normal pregnant women and still more reliable (98 per cent) in 116 nonpregnant women (including a patient 6 weeks postpartum who delivered premature1.v at 28 weeks whose test was still indicative of pregnancy). I dcl not want to be overoptimistic and accept as definitive these results, as many more pregnant and nonpregnant patients should be tested before drawing such a conclusion. If these percentages might be lowered, it is equally true that the test itself may be further perfected, its limitations established, and a minimum of skill in performing it acquired. It appears that the total behavior of the reaction must be considered in the final interpretation. In addition to the reaction of the wheal, the erythema and the time element as described herein, it was noted in this series that within 5 minutes following injection several nonpregnant, patients reported a slight itching around the enlarging wheal, followed I)y a sensation of warmness as the erythema developed. The itching and erythema gradually subsided in approximately one hour. One of the reported cases on Sept. 14, 1950, had an early positive pregnancy reading, notwithstanding a negative clinical diagnosis and the statement: “It itches very badly.” On a control test on Sept. 21, 1950, the result was negative pregnancy, and the patient was None of the pregnant women have ever complained of later discharged as nonpregnant. itching or warmness. This additional signal might prove of diagnostic value in interpreting a questior able nonpregnancy reaction.
Reference 1. Falls,
Frederick 4:t: 431,
H., 1941.
Freda,
Vincent
C.? and
Cohen,
Harold
H.:
AM.
J. ORST.
SC GYNEC.
FERRERO, (From
M.II., the
PASADENA,
Womnn
(hrm.
‘s Hospiful)
T
HE search for a simple pregnancy teat not involving the use of animals has been going on for many years. This search has brought forth both chemical tests, wherein the patient’s urine specimen is used, and injectable skin tests. The recent development of a disposable plastic microdispenser so constructed as to hold a minute dose and embodying a prepositioned needle so disposed as to be parallel with the skin contacting surface of the instrument, thereby minimizing the possibility ot’ a subcutaneous injection, has again aroused interest in the colustrum cutireaction for pregnancy, described by Falls, Freda, and Co11en.l The microdispenser” simplifies the modalities of thr, illjertion lay- furnishing the physician with a ready-to-use constant optimum l/70 C.C. of sterile colostrum. The previous technical dif3icuities of collection, sterilization, aud preservation of the colostrum have been reduced to a minimom since the original n-ark in 1941. Our clinical evaluation of this new test, called the “Q-Test,” employed the use of the aforementioned inject,ion instrument. am~l i he followi~rg sets forth the procedures. ColZrction of t11e ro1astrurn.A. Information gathered from Dr. Falls disclosed that attempts tn identify the antigen in. colostrum responsible for the reactions of this skin test resulted in failure. Tests to determine the optimum for collection and classificatir)n of donor (primipara or multipara) employed pooled (colostrum specimens from live or m(fre donors) and unpooled (colostrum specimen from a single donor’1 colostrum from primiparaa and pooled and uw pooled colost.rum from multiparap. The onl> ~:olost IWI~ which produ~d a consistently high cotlecte~l and pooled from primiparas during the degree of reliable readings was that This c*olost I’UI)L was withdrn\r\.n 11,~ elr&ric breast pump twenty-eighth week of pregnanc,v. from volunteer primiparas. H. In order t,o reduce to minimum tilt! seemingly ur~:rvi~itial~le cuntaminatiori 0Y the colostrum during the withdrawal, the donor ‘R nipples and the area around them which came into contact with the sterile glass breast rnp were scrubbed with aseptic soap and E:arh withdrawal MBS then transfrrred io a sterile centrifuge then washed with ether. it
tulle.
Preparation of the c’oloslwrn Fomula:-A. Each individual primiparous colostrum specimen was r.ent ri fugeti at 6,000 r.p.m. for ten minutes and the fat component then ri3no\-ed with a stc~rilc swat). ;2 minimum of five such t,reated specimens were then pooled and an equal amount of physiological sterile To earh 10 C.V. of this mixture l/IO of 1 :lOO Xerthiolate was normal saline was added. added as a preservative. This formula W:LP then kept t-onstnntl?under refrigeration brlow 59O F. 13. F;ven with the precautions taken at thr time of withdrawai as explained heretofore the pure eolostrum when plated 011 agar (~onsistentiy gave a growth of mixed staphyloAll colostrum used in this series NM ~lilutetl and the i,resarvstive added within coccus. A period of I rS days ’ minimum exposure to the preservative an hour following withdrawal. was then necessary before the formula was sterile to bacterial or mycotir growth. *Ogle corporation,
Micro Los
Dispenser units Angeles, Calif.
fWniShcd
thlou@~ ,37 !?
the
courtesy
of
General
Pharmacal
CUTANEOUS
Volume 6 I
PREGNANCY
673
TEST
C. When the colostrum formula was sterile to culture it was transferred under Each dispenser held exactly l/50 C.C. and aseptic conditions to sterile microdispensers. One serentieth C.C. was determined to be the dispensed l/70 C.C. plus or minus 41’1,000. optimum dose. D. The dispensers were then stored under refrigeration as it was discovered that \vhen tile formula was exposed to Eden room tc?mperature for periods in excess of 36 hours its potent>fell sharply.
Fig. l.-The Micro Dispenser. 4 is the fin by which it is grasped between R is the flexible bulb containing the colostrum C! is the needle protector cap.
Fig.
Z-When
the
needle
has
entered between
the thumb formula.
and
the skin sufficiently, squeeze the thumb and foreflnger.
foreflnger.
the
bulb
marked
B in
Fig.
1
The clinical evaluation of this test covers 228 individual tests. One hundred fifty-five of these tests were performed on volunteer clinical patients of the Woman’s Hospital and 73 tests were performed by collaborating investigators in their private practice. The 155 tests performed at Woman’s Hospital were clinically proved correct or incorrect by a sufficient lapse of time. The 73 tests performed by the collaborating investigators in their private practice were proved clinically correct or incorrect by Aschheim-Zondek, Friedman, or frog tests, plus a sufficient lapse of time. The tests were performed on patients as early as 12 days and as late as 16 weeks past a first missed menstrual period. Other tests were performed in postpartum, nonpregnanr>(females and males), menopau%, and two special eases.
‘l’hr c~olostrunt should 1~ deposit~etl inir0 llrck sul)er(ici:rl layrrs 01 the skin, possibly just under the stratnm t~~rneum, and this i* easily ilone 1)~. inserting l.he fine needle of the dispenser parallel tcl the skin (the need1 6’ itself should I),: \ iGl,le through the ~traturn corneum ) . The needle &ould IW withdrawtt from the site of injec(ion without releasing the colosl rum chamber. otherwise the C*OIOS~ rum itself would trfl rPaspir:ktrxd into thf, lm111, giving doubtful or erroneous readings. S’l;i?t, Test Readinys.-Readings were made 13 minutes The pregnant patients at the l:i-minute reading somewhat increased in size and little or no rr~thema. At of the wheal and erpthema had disappeared.
jections.
and 60 minutes following iu‘ would exhibit a pearl?; wheal the 60 minute rh&ading all sipn~
The nonpregnant patient at, the 15 minute reading exhil)its a marked increase ill This wheal is still pearly at this time and is usually surrounded 1)~ irregular wheal size. At the @l-minute reading the erythema has disappeared erythema. 1 to 2 cm. in diameter. l)nt the tvheal has Ijecome inflamed aud still is easily visible and normally l)Orfiists fog several hours past this 60.minute reading. I found it to 1~ of great help in comparing the size of llle wheal at the diderent readings, to circle the primary wheal immediately after the injection with a dermographic This is art important detail, l)t:canse the size of t,he wheal and pencil or a rommon ink pen. the time element are prot)al)ly more imlmrtant than the peripheral erythema in thr interpretation
of
the
tt’st.
-
TYPE
*Exhibited
ti
0
1 1
0 I)
The
3” 85 5
I’ERCEKTAGK FALSE I’OSITIVE I’RBGNANCIES
_--.-. PERCENTAGE FALSE ! NEGATIVE NOSI’REGNAN C1E.S
0 ‘1.4 0
5.5 il 0
6
CASE
Il. (JOLLABORATING _..-..--.___--.-~----___.---____--__--
INVESTIGATORS IS . ._.~. --_ (!I,INICALLII I CLISICALT,V (‘OliF’IRMEI, C0NFIRMF.I) I SONPREGPREGNAXCY i SANCP ( SKIiX TEST NO. OF , SK1.X TE.ST CASES j POSITIVE) 1 NEGATIVE j -. -_ -.___---.-.--..f -._---------
Early pregnancy Nonpregnant controls __--_..-TF’
positive negative Results
.I_
-._- -~-___-I__. CLINICALI;L CONFIRMEI) NONPREGNANCY ( SKIh- TEST NEGATIVE)
dermatographia. TABLE
TYPE
CLINICALLY CONFIRMED PREGNANCY. (SKIN TEST POSITIVE) .-52 2 0
CASE
Early pregnancy Postpartum Nonpregnancy (males) Menopause Chronic P.I.D. IJntreated Grade 3 carcinoma of the cervix
-T
----
/
.__~_.
54 0
I .~ .!
3 .--. 16 ~.
~~KIVATE I’RA~~TI~F: __--_---___- -.- -...... ..- _.-_’ I’F:R~:ENTAGF. FALSE POSITIVE PREGNANCIES -.--.--___
0 0
_._..___ ___ -. __
!
j !
l’EKCENl~AGI; F’AI..SE NEGATIVE NONPREGNANCIES .____ __.._
i5.4 0
Wminute reading wa,s taken as the uptimunr for diagnosis. Tests were read as (pregnant) if no erythema or wheal was visible at. the 60 minut*: reading and (nonpregnant) if the wheal was visible arId persisted at the 60-minute reading. of the 228 tests are shown in the table.
Volume 6 I Number 3
CUTANEOUS
PREGNANCY
675
TEST
Summary 1. C(dostrum formula prepared following instructions as set forth in report of Falls, Freda, and Cohen1 has been given intraepidermically to a series of human volunteers. 2. Method of collection and preparation of the colostrum formula is presented. 3. Colostrum formula caused no immediate or late toxic or untoward reactions in 228 human subjects. 4. Each test was confirmed by further clinical observation or by other pregnancy i ests. 5. Intraepidermal injection is stressed. 6. Circling primary wheal recommended. 7. The accuracy of our series compares favorably to that experienced 1)y the original investigators (Falls, Freda, and Cohenl).
Conclusion In i.he present series the Q-Test was proved reliable (93 per cent) in 112 normal pregnant women and still more reliable (98 per cent) in 116 nonpregnant women (including a patient 6 weeks postpartum who delivered premature1.v at 28 weeks whose test was still indicative of pregnancy). I dcl not want to be overoptimistic and accept as definitive these results, as many more pregnant and nonpregnant patients should be tested before drawing such a conclusion. If these percentages might be lowered, it is equally true that the test itself may be further perfected, its limitations established, and a minimum of skill in performing it acquired. It appears that the total behavior of the reaction must be considered in the final interpretation. In addition to the reaction of the wheal, the erythema and the time element as described herein, it was noted in this series that within 5 minutes following injection several nonpregnant, patients reported a slight itching around the enlarging wheal, followed I)y a sensation of warmness as the erythema developed. The itching and erythema gradually subsided in approximately one hour. One of the reported cases on Sept. 14, 1950, had an early positive pregnancy reading, notwithstanding a negative clinical diagnosis and the statement: “It itches very badly.” On a control test on Sept. 21, 1950, the result was negative pregnancy, and the patient was None of the pregnant women have ever complained of later discharged as nonpregnant. itching or warmness. This additional signal might prove of diagnostic value in interpreting a questior able nonpregnancy reaction.
Reference 1. Falls,
Frederick 4:t: 431,
H., 1941.
Freda,
Vincent
C.? and
Cohen,
Harold
H.:
AM.
J. ORST.
SC GYNEC.