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The presence of estrogenic hormones in maternal and fetal circulation
SOULE: ESTROGENIC HORMONES IN MATERNAL AND FETAL CIRCULATIONS
309
different patients of each clinical group, as well as considerable differences in the response of the same patient at different times, would exclude any value for the test in differential diagnosis for any individual case. RF..FERENCES
(1) Hines, E. A., and B1·own, G. E.: Ann. Int. Med. 7: 209, 1933. (2) Randall, L. M., and Murray, S. E.: AM. J. 0BST. & GYNEC. 29: 362, 1935. (3) Dieckmann, W. ,J., and Michel, H. L.: Arch. Int. Med. 55: 420, 1935. ( 4) Pickering, G. W., an
THE PRESENCE OF ESTROGENIC HORMONES IN MATERNAL AND FETAL CIRCULATION S. D. SouLE, M.D., ST. Loms, Mo. (From the Department of Obstetrics and Gynecology, Washington University School of Medicine, the St. Lo1-tis Maternity Hospital and Barnes Hospital)
T
HE problem of passage of substances through the placenta has been subjected to extensive investigation since the demonstration of the absence of anastomoses between maternal and fetal circulations.
Ruppl and Schlossmann2 in authoritative monographs, discuss the permeability of the placenta to carbohydrates, proteins, lipoids, salts, hormones, vitamins, antibodies and antigens. Brandstrupa also notes that through the work of Slemons, Von Oettingen, Hellmuth, Runge and others, we now have quantitative data on various salts, glucose, urea, uric acid, creatine, creatinine, amino aeids, proteins, lipoids and lactic acid.
The phase of this problem which has interested us most is the question concerning the presence of hormones in the fetal circulation. In a previous paper 4 the bibliography concerning the permeability of the placenta to various hormones was presented. Snyder, Snyder and Hoskins, Schlossmann and others have discussed the problem of transmission of adrenalin, insulin, posterior lobe of the pituitary and parathyroid extract. Soule 4 discussed the transmission of anterior pituitary or anterior pituitary-like hormones (Prolan B). The literature concerning the presence of estrogenic hormone in the fetal circulation is meager. Schlossmann, quoting Courrier and von Loewe, concludes that female sex hormone (folliculin) is demonstrated in fetal blood. Skowron and Skarzynski,5 working with rabbits, conclude that the placenta permits follicular hormone to pass through. The most expedient method for the study of the interchange of substances between the mother and fetus is a comparative analysis of the maternal and fetal blood at the time of parturition. The approach to the problem in this laboratory is based on the simultaneous determinations of the presence of er.trogenic hormone in hnman maternal and fetal blood.
310
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
Estrogenic hormone was determined by the Fluhmann method. 6 This test is based on the stimulation of the atrophied vaginal mucosa of the trst animal (mouse). Whereas earlier tests utilized this principle by observing changes in the vaginal n1ucosa hy smears, Fluhmann's procedure is dependent on ''the histologic demonstration of certain changes in the vaginal mucosa of recently spayed mice which precede cornification, the most important of which is the formation of tall columnar cells secreting mucus (mucification)." Although this change was formerly thought to be a specific effect of a corpus luteum hormone, more recent investigation has demonstrated conclusively that mucification is an effect of estrin, and that the production of this change by corpus luteum extracts is due to the presence of small amounts of estrogenic hormone in these preparations. Thus mucification is reeognized now as an estrogenic hormone response. METHOD
'l'he animals used were young adult female mice, which had been spayed nine days prior to the onset of the test. For convenience to the operator the mice were spayed on Monday morning and were available for injection on the following \Vednesday morning. }'or this problem the test materials were blood samples taken from mother and child at the time of parturition. The mother's blood was obtained by venipuncture. 'l'he fetal blood was obtained by ''milking'' the cord before expression of the placenta. These blood samples were always obtained within the twenty-four hours immediately prior to the onset of the test. The samples were kept sterile; the elear serum separated by centrifugation and kept in the ice box. The time element is important in view of the possible variation of hormone content due to standing several days. The previously prepared mice were injected three times daily; 0.5 c.c. at 9:00 A.M., 1:00 P.M., and 5:00P.M., for three consecutive days. On the morning of the fourth day, the mice were killed and after abdominal incision and splitting the symphysis, the vagina was dissected free and fixed in formalin. The individual specimens were mounted in celloidin, sectioned at two or three levels and stained with hemotoxylin and eosin. Because of the biologic variation in response to any one dosage, three or four mice were used for each determination. Thus this technique adhered closely to that originally published by Fluhmann. 'l'he Fluhmann tests were performed using varying concentrations of maternal and fetal blood serums. In the earlier tests in the series, full strength serums were injected. The results revealed such a high concentration of estrogenic hormone, however, that subsequently both maternal and fetal serums were diluted with normal ~alt Rolution. Dilutions of 1:2,1:4,1:8, 1:Hl and 1:20 were used. The maternnl and fetal serums of any one Het o£ injections were always of the same dilution. RESULT
As the concentration of estrogenic hormone in the testea serums became less, due to dilution, the degree of response became progressively lessened also. Thus, with the more dilute serums the type response was such as to allow for fairly delicate discrimination.
PARSONS: VAIJUE OF CESAREAN SECTION IN PRESENCE OF INF'ECTION
311
The degree of mucification as determined by the Fluhmann test was always the same in corresponding maternal and fetal serums in all dilutions. The observation is most interesting when one recalls that most hormones are not found in similar concentrations on the two sides of the placental barrier. CONCLUSION 1. Estrogenic hormones are present in equal concentration 1n both maternal and fetal circulations. 2. The presence of estrogenic hormone in marked concentration in the fetal circulation is consistent with the clinical observance of enlarged breasts and bloody vaginal discharge in newborn infants. 3. Considering that there is no evidence that the fetus produces an excess of estrogenic hormone, we may assume that the placenta is permeable to estrogenic hormone. REFERENCES (1) Rupp, H.: Arch. f. Gynak. 143: 80, 1930. (2) Schlossmann, H.: Ergeb. J. Physiol. 34: 731, 1932. (3) Brandstmp, E.: Acta Gynec. Scandinav. 10: 252, 19:l0. (4) Soule, S. D.: AM . .J. 0BST. & GYNEC. 27: 723, 1934. (5) Skowron, S., and Skarzynslci, B.: Compt. rend. Soc. de bioi. 112: Hi04, 1933. (G) Fluhmann, F.: Endocrinology 18: 705, 1934.
THE VALUE OF CESAREAN SECTION WITH PORTES' TECHNIQUE IN THE PRESENCE OF INFECTION, WITH REPORT OF THREE CASES SusANNE R. PARSONS, M.D., F.A.C.S., SANTA BARBARA, CALIF. (From the Department of Obstetrics and Gynecology, Hunan-Yale Medical School., Changsha, China)
THE treatment of frankly infected patients in whom delivery from below is either
impossible or necessitates a destructive operation on a living child, has long been a matter of discussion. Classical section followed by supravaginal amputation of the uterus is usually considered the safest, but in a young woman, perhaps in her first pregnancy, it is far from ideal. Also the surgical risk to an exhausted patient is considerable, Transperitoneal or extraperitoneal sedion does not remove the source of infection, namely the uterus, and is not free from danger of subsequent peritonitis. Also almost the same surgical risk is encountered as with the amputation of the uterus. In 1908 Sellheim suggested using a uterine-abdominal fistula in these cases. 'l'his allowed free drainage of the uterus and the abdominal cavity was protected by suturing the edges of the open uterus into the abdominal incision. A second lap· arotomy was necessary to return the uterus into the abdominal eavity. This operation seems to have been widely used in Germany. In 1924 L. Fortes first suggested and used the '' exteriorisation'' of the uterus in cases of infection. rne tecnmque eonsists briefly in delivering the entire uterus and adnexa intact through an ah-
309
different patients of each clinical group, as well as considerable differences in the response of the same patient at different times, would exclude any value for the test in differential diagnosis for any individual case. RF..FERENCES
(1) Hines, E. A., and B1·own, G. E.: Ann. Int. Med. 7: 209, 1933. (2) Randall, L. M., and Murray, S. E.: AM. J. 0BST. & GYNEC. 29: 362, 1935. (3) Dieckmann, W. ,J., and Michel, H. L.: Arch. Int. Med. 55: 420, 1935. ( 4) Pickering, G. W., an
THE PRESENCE OF ESTROGENIC HORMONES IN MATERNAL AND FETAL CIRCULATION S. D. SouLE, M.D., ST. Loms, Mo. (From the Department of Obstetrics and Gynecology, Washington University School of Medicine, the St. Lo1-tis Maternity Hospital and Barnes Hospital)
T
HE problem of passage of substances through the placenta has been subjected to extensive investigation since the demonstration of the absence of anastomoses between maternal and fetal circulations.
Ruppl and Schlossmann2 in authoritative monographs, discuss the permeability of the placenta to carbohydrates, proteins, lipoids, salts, hormones, vitamins, antibodies and antigens. Brandstrupa also notes that through the work of Slemons, Von Oettingen, Hellmuth, Runge and others, we now have quantitative data on various salts, glucose, urea, uric acid, creatine, creatinine, amino aeids, proteins, lipoids and lactic acid.
The phase of this problem which has interested us most is the question concerning the presence of hormones in the fetal circulation. In a previous paper 4 the bibliography concerning the permeability of the placenta to various hormones was presented. Snyder, Snyder and Hoskins, Schlossmann and others have discussed the problem of transmission of adrenalin, insulin, posterior lobe of the pituitary and parathyroid extract. Soule 4 discussed the transmission of anterior pituitary or anterior pituitary-like hormones (Prolan B). The literature concerning the presence of estrogenic hormone in the fetal circulation is meager. Schlossmann, quoting Courrier and von Loewe, concludes that female sex hormone (folliculin) is demonstrated in fetal blood. Skowron and Skarzynski,5 working with rabbits, conclude that the placenta permits follicular hormone to pass through. The most expedient method for the study of the interchange of substances between the mother and fetus is a comparative analysis of the maternal and fetal blood at the time of parturition. The approach to the problem in this laboratory is based on the simultaneous determinations of the presence of er.trogenic hormone in hnman maternal and fetal blood.
310
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
Estrogenic hormone was determined by the Fluhmann method. 6 This test is based on the stimulation of the atrophied vaginal mucosa of the trst animal (mouse). Whereas earlier tests utilized this principle by observing changes in the vaginal n1ucosa hy smears, Fluhmann's procedure is dependent on ''the histologic demonstration of certain changes in the vaginal mucosa of recently spayed mice which precede cornification, the most important of which is the formation of tall columnar cells secreting mucus (mucification)." Although this change was formerly thought to be a specific effect of a corpus luteum hormone, more recent investigation has demonstrated conclusively that mucification is an effect of estrin, and that the production of this change by corpus luteum extracts is due to the presence of small amounts of estrogenic hormone in these preparations. Thus mucification is reeognized now as an estrogenic hormone response. METHOD
'l'he animals used were young adult female mice, which had been spayed nine days prior to the onset of the test. For convenience to the operator the mice were spayed on Monday morning and were available for injection on the following \Vednesday morning. }'or this problem the test materials were blood samples taken from mother and child at the time of parturition. The mother's blood was obtained by venipuncture. 'l'he fetal blood was obtained by ''milking'' the cord before expression of the placenta. These blood samples were always obtained within the twenty-four hours immediately prior to the onset of the test. The samples were kept sterile; the elear serum separated by centrifugation and kept in the ice box. The time element is important in view of the possible variation of hormone content due to standing several days. The previously prepared mice were injected three times daily; 0.5 c.c. at 9:00 A.M., 1:00 P.M., and 5:00P.M., for three consecutive days. On the morning of the fourth day, the mice were killed and after abdominal incision and splitting the symphysis, the vagina was dissected free and fixed in formalin. The individual specimens were mounted in celloidin, sectioned at two or three levels and stained with hemotoxylin and eosin. Because of the biologic variation in response to any one dosage, three or four mice were used for each determination. Thus this technique adhered closely to that originally published by Fluhmann. 'l'he Fluhmann tests were performed using varying concentrations of maternal and fetal blood serums. In the earlier tests in the series, full strength serums were injected. The results revealed such a high concentration of estrogenic hormone, however, that subsequently both maternal and fetal serums were diluted with normal ~alt Rolution. Dilutions of 1:2,1:4,1:8, 1:Hl and 1:20 were used. The maternnl and fetal serums of any one Het o£ injections were always of the same dilution. RESULT
As the concentration of estrogenic hormone in the testea serums became less, due to dilution, the degree of response became progressively lessened also. Thus, with the more dilute serums the type response was such as to allow for fairly delicate discrimination.
PARSONS: VAIJUE OF CESAREAN SECTION IN PRESENCE OF INF'ECTION
311
The degree of mucification as determined by the Fluhmann test was always the same in corresponding maternal and fetal serums in all dilutions. The observation is most interesting when one recalls that most hormones are not found in similar concentrations on the two sides of the placental barrier. CONCLUSION 1. Estrogenic hormones are present in equal concentration 1n both maternal and fetal circulations. 2. The presence of estrogenic hormone in marked concentration in the fetal circulation is consistent with the clinical observance of enlarged breasts and bloody vaginal discharge in newborn infants. 3. Considering that there is no evidence that the fetus produces an excess of estrogenic hormone, we may assume that the placenta is permeable to estrogenic hormone. REFERENCES (1) Rupp, H.: Arch. f. Gynak. 143: 80, 1930. (2) Schlossmann, H.: Ergeb. J. Physiol. 34: 731, 1932. (3) Brandstmp, E.: Acta Gynec. Scandinav. 10: 252, 19:l0. (4) Soule, S. D.: AM . .J. 0BST. & GYNEC. 27: 723, 1934. (5) Skowron, S., and Skarzynslci, B.: Compt. rend. Soc. de bioi. 112: Hi04, 1933. (G) Fluhmann, F.: Endocrinology 18: 705, 1934.
THE VALUE OF CESAREAN SECTION WITH PORTES' TECHNIQUE IN THE PRESENCE OF INFECTION, WITH REPORT OF THREE CASES SusANNE R. PARSONS, M.D., F.A.C.S., SANTA BARBARA, CALIF. (From the Department of Obstetrics and Gynecology, Hunan-Yale Medical School., Changsha, China)
THE treatment of frankly infected patients in whom delivery from below is either
impossible or necessitates a destructive operation on a living child, has long been a matter of discussion. Classical section followed by supravaginal amputation of the uterus is usually considered the safest, but in a young woman, perhaps in her first pregnancy, it is far from ideal. Also the surgical risk to an exhausted patient is considerable, Transperitoneal or extraperitoneal sedion does not remove the source of infection, namely the uterus, and is not free from danger of subsequent peritonitis. Also almost the same surgical risk is encountered as with the amputation of the uterus. In 1908 Sellheim suggested using a uterine-abdominal fistula in these cases. 'l'his allowed free drainage of the uterus and the abdominal cavity was protected by suturing the edges of the open uterus into the abdominal incision. A second lap· arotomy was necessary to return the uterus into the abdominal eavity. This operation seems to have been widely used in Germany. In 1924 L. Fortes first suggested and used the '' exteriorisation'' of the uterus in cases of infection. rne tecnmque eonsists briefly in delivering the entire uterus and adnexa intact through an ah-