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The fimbrial biopsy in Chlamydia trachomatis pelvic inflammatory disease
Correspondence
Volume 159 Number 6
Regardless of the immunoassay used, false-positive results for serum hCG remain a perplexing, albeit infrequent, clinical problem. Bock et al.2 reported falsepositive results for hCG of 32 to 55 IU IL caused IgM antibodies using an immunoenzymatic assay (Tandem E hCG assay, Hybritech Inc., San Diego, Calif.). The recent report of Check et al. 1 and our case describe false-positive results caused heterophile antibodies (IgG) using an immunoradiometric assay (hCG MAIAclone, Serono Laboratories, Norwell, Mass.). Such antibodies have been well characterized and their interference in immunoassays well described. 3 • 4 Various laboratory techniques have been used to reduce assay interference, including the addition of nonspecific immunoglobulins. 5 Given the sensitivity and specificity of most commercially available assay kits for hCG, false-positive results are indeed rare but should be considered in the differential diagnosis in those patients in whom consistently low levels of hCG are not in agreement with clinical presentation. The data of the present case suggest that in such clinical circumstances, serial sampling and testing for hCG with the use of alternate assay techniques may be warranted before intervention is considered. Timely consultation with appropriate laboratory personnel and the commercial distributor proved invaluable in our management and should be incorporated, when clinical conditions permit, in the evaluation of patients with persistently low levels of serum hCG. Major Gerard S. Letterie, MC, USA Captain Scott Rose, MC, USA Colonel Kunio Miyazawa, MC, USA Department of Obstetrics-Gynecology Tripler Army Medical Center Honolulu, HI 96859-5000 REFERENCES I. Check JH, Nowrooz K, Chase JS, Lauer C, Elkins B, Wu CH. False-positive human chorionic gonadotropin levels caused by a heterophile antibody with the immunoradiometric assay. AM J 0BSTET GYNECOL 1988;158:99-100. 2. BockJL, FurqiueleJ, Wenz B. False-positive immunometric assays caused by antiimmunoglobulin antibodies: a case report. Clin Chim Acta 1985;147:241-6. 3. Boscato LM, Stuart MC. Incidence and specificity of interference in two-site immunoassays. Clin Chem 1986;32: 1491-5. 4. Thompson RJ, Jackson AP, Langlois N. Circulating antibodies to mouse monoclonal immunoglobulin in normal subjects-incidence, specificity and effects on a two-site assay for creatine-kinase-MB isoenzyme. Clin Chem 1986; 32:476-81. 5. Boscato LM, Stuart MC. Heterophilic antibodies: a problem for all immunoassays. Clin Chem 1988;34:27-33.
Pediatric cardlology To The Editors: In the report of Yagel et al. (Yagel S, HochnerCelnikier D, Hurwitz A, Patti Z, Gotsman MS. AM J
1599
Table I. Serial hCG monitoring with immunoradiometric assay Date
{3-hCG (m!Ulml)
91 I /87 9/8/87 9115/87 9/28/87 10/15/87 10/16/87 10/26/87
17 18 17 19 16 14 16
OBSTET GYNECOL 1988; 158:272-7), some of the cardiac descriptions were not precise. In the discussion of the patient with "complete atrioventricular canal," the authors conclude by describing a "complete endocardial cushion defect." In pediatric cardiology there are several schools of anatomic nomenclature, and generally, one chooses a particular classification and uses one set of terms consistently. The lesion to which the authors refer may be described as a complete atrioventricular canal, endocardial cushion defect, or atrioventricular septal defect depending on the particular system of nomenclature. The authors described a mitral and tricuspid valve in this patient with common atrioventricular canal. In this lesion, there is a common atrioventricular valve without distinct mitral and tricuspid valves. In addition, the authors described a "perimembranous" ventricular septal defect. The ventricular communication in this lesion might be described as a "canal-type" or "inlet" ventricular septal defect. In another case, the authors state that the parallel great arteries are "indicative of transposition of the great vessels." Although this characteristic view is often seen with dextrotransposition, the identity of each great vessel (and all cardiac structures) is based on the detection of specific anatomic characteristics (for example, the aorta gives rise to the head and neck vessels, the main pulmonary artery gives rise to two branch pulmonary arteries) rather than their location. Angela E. Lin, MD Medical Genetics West Penn Hospital Pittsburgh, PA 15224
The fimbrial biopsy In Chlamydia trachomatls pelvlc inflammatory disease To the Editors: Endocervical samples are routinely used for diagnosis of gynecologic Chlamydia trachomatis infection by culture or direct immunoftuorescent staining. Fallopian tube swabs and small biopsies did not increase the detection of C. trachomatis in pelvic inflammatory disease.' During laparoscopy in severe pelvic inflammatory disease, 3 by 2 mm fimbrial biopsies were performed with a Frangenheim forceps (Storz). All bleeding
1600 Correspondence
stopped within 30 seconds; the blood was then removed. We used direct immunofluorescent staining for C. trachomatis. In a series of 10 patients with severe pelvic inflammatory disease, four had positive endocervical samples. Six patients, including those with positive endocervical specimens, had positive fimbrial biopsy specimens. All patients had second-look laparoscopy performed after 1 week. No extra fimbrial adhesions were noticed. Our preliminary data suggest that the fimbrial biopsy is useful to exclude false-negative endocervical results for C. trachomatis in severe pelvic inflammatory disease. Rudy L. De Wilde, MD Department of Obstetrics and Gynecology Bethesda Clinic University of Muenster D-5600 Wuppertal I, Federal Republic of Germany REFERENCE 1. Kiviat N. Localization of Chlamydia trachomatis infection by direct immunofluorescence and culture in pelvic inflammatory disease. AMJ 0BSTET GYNECOL 1986;154:865-73.
Catecholamine concentration In amniotic fluid: Possible role of dopamine in parturition To the Editors: The presence of catecholamines in amniotic fluid was described by Zuspan and Abbott' in 1970. We measured catecholamines and their metabolites in amniotic fluid of women in the first stage of spontaneous labor with cervical dilatation ranging from 3 to 4 cm. Amniotic fluid was obtained by vaginal amniocentesis from 63 primiparous women. The samples of fluid (10 ml) were collected in tubes containing antioxidant solution (0.5 ml 1% ethylenediaminetetraacetic acid and three crystals ascorbic acid). The tubes were stored at - 20° C until the assays were performed. The catecholamines (dopamine, norepinephrine, and epinephrine) and their metabolites were isolated on Bio-Rad columns, and levels were determined with a fluorometric technique on an Aminco spectrophotofluorometer. The results demonstrated high levels of dopamine (179.55 to 441.39 nmol 100 ml) and homovanillic acid (155.0 to 428.23 nmol/ 100 ml) and relatively stable concentrations of 3-methoxytyramine ( 11.10 to 31. 99 nmol /100 ml). These results can manifest the presence of a dopaminergic system in the fetoplacental unit. Dopamine was classified as a predominant catecholamine in amniotic fluid, and its concentrations in this compartment increased markedly before parturition. 2 However, the role and function of that amine in sympathetic neurotransmission in the fetus remain unknown. Moreover, relatively stable, low levels of 3-methoxytyramine in amniotic fluid may suggest that dopamine is only somewhat metabolized by the catechol-0methyltransferase enzyme. The rapid metabolism of norepinephrine manifested by its absence in amniotic fluid may be taken the important role of sympathetic
December 1988 Am J Obstet Gynecol
system in the fetus. At parturition the dopamine concentrations were found to be 10 to 20 times higher than those of norepinephrine and epinephrine.' The increasing catecholamine levels in amniotic fluid, especially those of dopamine, are a fetal signal of facilitated intrauterine prostaglandin production and the eventual onset of labor. Jerzy Godziejewski, MD jerzy E. Maruchin, PhD Department of Obstetrics and Gynecology Medical Center of Postg;raduate Education Warsaw, Poland REFERENCES 1. Zuspan FP, Abbott M. Identification of a pressor substance in amniotic fluid. I. Role of epinephrine and norepinephrine. AM J OBSTET GYNECOL 1970;107:664. 2. Phillippe M, Ryan KJ. Catecholamines in human amniotic fluid. AM j 0BSTET GYNECOL 1981;139:204. 3. Godziejewskij, MaruchinJE, Lipski S. Catecholamines and their metabolites in human amniotic fluid in the first stage of spontaneous labor. Ginekol Pol 1986;57:514.
Ovulation in relation to cervical canal diameter To the Editors: In the presentation by Hill et al. (Hill LM, Coulam CB, Kislak SL, Peterson CS, Runco CJ. Sonographic evaluation of the cervix during ovulation induction. AM J 0BSTET GYNECOL 1987;157:1170) it is stated that there is an increase in size of the external cervical os at the time of ovulation. I wish to cite that Asplund' and Youssef2 showed radiographically the presence of a functional sphincter at the junction of the isthmus uteri and the internal cervical os, influenced by estrogen and progesterone, the former causing its relaxation, the latter contraction. They found the diameters of the internal and external cervical os and the canal largest just before and during menstruation and smallest immediately thereafter, with an increase in size during the follicular phase. A second maximal diameter occurs at the time of ovulation, with regression of the diameters under the influence of progesterone. Under normal conditions, events are beautifully precise and perfectly synchronized under hormonal influence so as to afford an ample passage in the cervix at the time of menstruation and ovulation. The diameter of the cervical canal is being monitored, as is that of the developing dominant ovarian follicle via sonography, very successfully as an adjunct in assessing the time of ovulation. Landrum B. Shettles, MD Womens Hospital 2025 East Sahara Avenue Las Vegas, NV 89104-3898 REFERENCES 1. Asplund]. The uterine cervix and isthmus under normal and pathological conditions: clinical and roentgenological studies. Acta Radio! 1952;9l(suppl):3. 2. Youssef AF. The uterine isthmus and its sphincter mech-
Volume 159 Number 6
Regardless of the immunoassay used, false-positive results for serum hCG remain a perplexing, albeit infrequent, clinical problem. Bock et al.2 reported falsepositive results for hCG of 32 to 55 IU IL caused IgM antibodies using an immunoenzymatic assay (Tandem E hCG assay, Hybritech Inc., San Diego, Calif.). The recent report of Check et al. 1 and our case describe false-positive results caused heterophile antibodies (IgG) using an immunoradiometric assay (hCG MAIAclone, Serono Laboratories, Norwell, Mass.). Such antibodies have been well characterized and their interference in immunoassays well described. 3 • 4 Various laboratory techniques have been used to reduce assay interference, including the addition of nonspecific immunoglobulins. 5 Given the sensitivity and specificity of most commercially available assay kits for hCG, false-positive results are indeed rare but should be considered in the differential diagnosis in those patients in whom consistently low levels of hCG are not in agreement with clinical presentation. The data of the present case suggest that in such clinical circumstances, serial sampling and testing for hCG with the use of alternate assay techniques may be warranted before intervention is considered. Timely consultation with appropriate laboratory personnel and the commercial distributor proved invaluable in our management and should be incorporated, when clinical conditions permit, in the evaluation of patients with persistently low levels of serum hCG. Major Gerard S. Letterie, MC, USA Captain Scott Rose, MC, USA Colonel Kunio Miyazawa, MC, USA Department of Obstetrics-Gynecology Tripler Army Medical Center Honolulu, HI 96859-5000 REFERENCES I. Check JH, Nowrooz K, Chase JS, Lauer C, Elkins B, Wu CH. False-positive human chorionic gonadotropin levels caused by a heterophile antibody with the immunoradiometric assay. AM J 0BSTET GYNECOL 1988;158:99-100. 2. BockJL, FurqiueleJ, Wenz B. False-positive immunometric assays caused by antiimmunoglobulin antibodies: a case report. Clin Chim Acta 1985;147:241-6. 3. Boscato LM, Stuart MC. Incidence and specificity of interference in two-site immunoassays. Clin Chem 1986;32: 1491-5. 4. Thompson RJ, Jackson AP, Langlois N. Circulating antibodies to mouse monoclonal immunoglobulin in normal subjects-incidence, specificity and effects on a two-site assay for creatine-kinase-MB isoenzyme. Clin Chem 1986; 32:476-81. 5. Boscato LM, Stuart MC. Heterophilic antibodies: a problem for all immunoassays. Clin Chem 1988;34:27-33.
Pediatric cardlology To The Editors: In the report of Yagel et al. (Yagel S, HochnerCelnikier D, Hurwitz A, Patti Z, Gotsman MS. AM J
1599
Table I. Serial hCG monitoring with immunoradiometric assay Date
{3-hCG (m!Ulml)
91 I /87 9/8/87 9115/87 9/28/87 10/15/87 10/16/87 10/26/87
17 18 17 19 16 14 16
OBSTET GYNECOL 1988; 158:272-7), some of the cardiac descriptions were not precise. In the discussion of the patient with "complete atrioventricular canal," the authors conclude by describing a "complete endocardial cushion defect." In pediatric cardiology there are several schools of anatomic nomenclature, and generally, one chooses a particular classification and uses one set of terms consistently. The lesion to which the authors refer may be described as a complete atrioventricular canal, endocardial cushion defect, or atrioventricular septal defect depending on the particular system of nomenclature. The authors described a mitral and tricuspid valve in this patient with common atrioventricular canal. In this lesion, there is a common atrioventricular valve without distinct mitral and tricuspid valves. In addition, the authors described a "perimembranous" ventricular septal defect. The ventricular communication in this lesion might be described as a "canal-type" or "inlet" ventricular septal defect. In another case, the authors state that the parallel great arteries are "indicative of transposition of the great vessels." Although this characteristic view is often seen with dextrotransposition, the identity of each great vessel (and all cardiac structures) is based on the detection of specific anatomic characteristics (for example, the aorta gives rise to the head and neck vessels, the main pulmonary artery gives rise to two branch pulmonary arteries) rather than their location. Angela E. Lin, MD Medical Genetics West Penn Hospital Pittsburgh, PA 15224
The fimbrial biopsy In Chlamydia trachomatls pelvlc inflammatory disease To the Editors: Endocervical samples are routinely used for diagnosis of gynecologic Chlamydia trachomatis infection by culture or direct immunoftuorescent staining. Fallopian tube swabs and small biopsies did not increase the detection of C. trachomatis in pelvic inflammatory disease.' During laparoscopy in severe pelvic inflammatory disease, 3 by 2 mm fimbrial biopsies were performed with a Frangenheim forceps (Storz). All bleeding
1600 Correspondence
stopped within 30 seconds; the blood was then removed. We used direct immunofluorescent staining for C. trachomatis. In a series of 10 patients with severe pelvic inflammatory disease, four had positive endocervical samples. Six patients, including those with positive endocervical specimens, had positive fimbrial biopsy specimens. All patients had second-look laparoscopy performed after 1 week. No extra fimbrial adhesions were noticed. Our preliminary data suggest that the fimbrial biopsy is useful to exclude false-negative endocervical results for C. trachomatis in severe pelvic inflammatory disease. Rudy L. De Wilde, MD Department of Obstetrics and Gynecology Bethesda Clinic University of Muenster D-5600 Wuppertal I, Federal Republic of Germany REFERENCE 1. Kiviat N. Localization of Chlamydia trachomatis infection by direct immunofluorescence and culture in pelvic inflammatory disease. AMJ 0BSTET GYNECOL 1986;154:865-73.
Catecholamine concentration In amniotic fluid: Possible role of dopamine in parturition To the Editors: The presence of catecholamines in amniotic fluid was described by Zuspan and Abbott' in 1970. We measured catecholamines and their metabolites in amniotic fluid of women in the first stage of spontaneous labor with cervical dilatation ranging from 3 to 4 cm. Amniotic fluid was obtained by vaginal amniocentesis from 63 primiparous women. The samples of fluid (10 ml) were collected in tubes containing antioxidant solution (0.5 ml 1% ethylenediaminetetraacetic acid and three crystals ascorbic acid). The tubes were stored at - 20° C until the assays were performed. The catecholamines (dopamine, norepinephrine, and epinephrine) and their metabolites were isolated on Bio-Rad columns, and levels were determined with a fluorometric technique on an Aminco spectrophotofluorometer. The results demonstrated high levels of dopamine (179.55 to 441.39 nmol 100 ml) and homovanillic acid (155.0 to 428.23 nmol/ 100 ml) and relatively stable concentrations of 3-methoxytyramine ( 11.10 to 31. 99 nmol /100 ml). These results can manifest the presence of a dopaminergic system in the fetoplacental unit. Dopamine was classified as a predominant catecholamine in amniotic fluid, and its concentrations in this compartment increased markedly before parturition. 2 However, the role and function of that amine in sympathetic neurotransmission in the fetus remain unknown. Moreover, relatively stable, low levels of 3-methoxytyramine in amniotic fluid may suggest that dopamine is only somewhat metabolized by the catechol-0methyltransferase enzyme. The rapid metabolism of norepinephrine manifested by its absence in amniotic fluid may be taken the important role of sympathetic
December 1988 Am J Obstet Gynecol
system in the fetus. At parturition the dopamine concentrations were found to be 10 to 20 times higher than those of norepinephrine and epinephrine.' The increasing catecholamine levels in amniotic fluid, especially those of dopamine, are a fetal signal of facilitated intrauterine prostaglandin production and the eventual onset of labor. Jerzy Godziejewski, MD jerzy E. Maruchin, PhD Department of Obstetrics and Gynecology Medical Center of Postg;raduate Education Warsaw, Poland REFERENCES 1. Zuspan FP, Abbott M. Identification of a pressor substance in amniotic fluid. I. Role of epinephrine and norepinephrine. AM J OBSTET GYNECOL 1970;107:664. 2. Phillippe M, Ryan KJ. Catecholamines in human amniotic fluid. AM j 0BSTET GYNECOL 1981;139:204. 3. Godziejewskij, MaruchinJE, Lipski S. Catecholamines and their metabolites in human amniotic fluid in the first stage of spontaneous labor. Ginekol Pol 1986;57:514.
Ovulation in relation to cervical canal diameter To the Editors: In the presentation by Hill et al. (Hill LM, Coulam CB, Kislak SL, Peterson CS, Runco CJ. Sonographic evaluation of the cervix during ovulation induction. AM J 0BSTET GYNECOL 1987;157:1170) it is stated that there is an increase in size of the external cervical os at the time of ovulation. I wish to cite that Asplund' and Youssef2 showed radiographically the presence of a functional sphincter at the junction of the isthmus uteri and the internal cervical os, influenced by estrogen and progesterone, the former causing its relaxation, the latter contraction. They found the diameters of the internal and external cervical os and the canal largest just before and during menstruation and smallest immediately thereafter, with an increase in size during the follicular phase. A second maximal diameter occurs at the time of ovulation, with regression of the diameters under the influence of progesterone. Under normal conditions, events are beautifully precise and perfectly synchronized under hormonal influence so as to afford an ample passage in the cervix at the time of menstruation and ovulation. The diameter of the cervical canal is being monitored, as is that of the developing dominant ovarian follicle via sonography, very successfully as an adjunct in assessing the time of ovulation. Landrum B. Shettles, MD Womens Hospital 2025 East Sahara Avenue Las Vegas, NV 89104-3898 REFERENCES 1. Asplund]. The uterine cervix and isthmus under normal and pathological conditions: clinical and roentgenological studies. Acta Radio! 1952;9l(suppl):3. 2. Youssef AF. The uterine isthmus and its sphincter mech-