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Tovey and Valaes: Prevention of Stillbirth in Rh Hemolytic Disease
1068 Selected abstracts
ings. It is not stated clearly enough that symptoms due to carcinoma in situ do not exist and that symptoms that are present are due to other factors incidentally coexistent. Similarly, in remarking on the general appearance of the cervix in these cases, it is stated that only 14.5 per cent of the patients had "normal" appearing cervices. This figure, in the absence of a control figure of incidence in a similar group without carcinoma in situ, with use of the same criteria, is of little bearing, and can be misinterpreted. The importance of the nonspecific Schiller test in picking out areas with carcinoma in situ is well demonstrated. Furthermore, the significance of cervical smears in selecting patients for biopsy is emphasized. The authors state that when smear and biopsy (in areas indicated by a posItive Schiller test) are used as complementary diagnostic methods, failure to estab-
Am .
May, 1961 & Gynec.
.T. Obst.
lish the diagnosis in carcinoma in situ of the cervix should not exceed 2 per cent. It is to be noted that the authors prefer multiple punch biopsies taken with a large, square-jawed punch and endocervical curettage as their method of establishing the diagnosis and excluding invasion. As to therapy, they apparently prefer total hysterectomy in most cases, and more conservative therapy (conization, amputation) in a small, well-selected (on the basis of age and desire for children) group of cases. There is due emphasis on the need in all cases for posttreatment follow-up at regular intervals. If all physicians responsible for the care of women familiarized themselves with the contents of this monograph, a great stride would be made toward the realization of the concept of "cancer of the cervix: a preventable disease."
Selected abstracts The Lancet Vol. 2, Oct. 10, 1959. *Tovey, Geoffrey H., and Valaes, T.: Prevention of Stillbirth in Rh Hemolytic Disease,
p. 521. Tovey and Valaes: Prevention of Stillbirth in Rh Hemolytic Disease, p. 521. Following the suggestion of Kelsall and Vos (M. J. Australia I: 349, 1952) that the severity of disease in the baby is closely related to the level of anti-Rh in the mother's serum determined by the indirect antiglobin technique, a series of 200 babies born to mothers who had not previously carried an affected child (1) and 62 babies whose mothers had already had Rh antibodies during a previous pregnancy (2) was studied. The antibody levels discussed are the maxirnum titers obtained between the thirtyfourth and thirty-sixth weeks of the pregnancy. In (1) there were no stillbirths and only 45 per cent of the babies needed transfusions if the mothers' antenatal antiglobin titer was less than 1: 10 (59 patients). Among the 84 babies whose mothers' antenatal antibody titers were I : 10 but less than 1: 40 there was one stillbirth *These articles have been abstracted.
and 71 per cent of the babies required transfusions. However, among the 57 babies whose . mothers had an antenatal antiglobin titer of 1:40 or higher there were 24.5 per cent sti1Ibirths and 98 per cent of the babies required transfusions. In (2), although there were no stillbirths and no transfusions were needed in the babies whose mothers had antenatal antibody titers of less than 1: 10, when the latter was 1: 10 but less than 1:40 the stillbirth rate was five times higher (6.25 per cent) than when the mother is carrying a first affected baby, and 80 per cent of these babies required transfusion. In (I) and (2) the results are much the same when the antiglobulin titer is 1:-to or higher. However, the percentage of stillbirths in (2) would certainly have been higher hut for the fact that most mothers who had previously had a severely affected or stillborn bahy were delivered prematurely. That there were more severely affected babies in (2) than in (I) when the mother's antibody titer was 1: 10 but less than 1:40 tends to confirm the opinion of Kelsall, Vos, and Kirk (Brit. M. J. 2: 468, 1958) that duration of exposure of the baby to these anti-
VolWlle 81
Number 5
bodies is important in determining the severity of disease in the baby. The cord blood was studied, and a close correlation between the hemoglobin level, serum bilirubin level, and maternal anti-Rh titer was found. In (1) when the maternal Rh titer is 1:40 or higher the risk of death found before 34 weeks of pregnancy was 3 per cent; it was 5 per cent at 34 weeks, 3 per cent between 35 and 36 weeks, but 20 per cent after 37 weeks of pregnancy. These figures suggested that two thirds of the stillbirths might be prevented if the baby Were delivered 21 days before term. Few additional deaths would be prevented unless the pregnancy were terminated at or before the thirty-fourth week, and this would introduce too many hazards for prematurity. Therefore, the practice has been adopted to recommend premature delivery 21 days before the expected date of delivery if the mother's anti-Rh titer has reached or exceeded 1: 40 by the thirty-sixth week of pregnancy. When the mothers have previously had an aff~cted baby (group 2) the smallness of the senes did not provide such clear indication and the antenatal antibody titer could be used as only one criterion. At present the authors believe that if the previously affected child did not require treatment and if the maternal anti. less than 1: 10 the pregnancy may body t'Iter IS be allowed to proceed to term. However, if the preceding baby required treatment or if the maternal antibody titer has risen from that observed in the preceding pregnancy ( 1: 10 or 1:20), pregnancy should be terminated 21 days before full term because the stillbirth risk in thO IS group approaches 10 per cent. If the maternal titer is 1:40 or greater and ~he father is homozygous the risk of a dead baby IS about 1 in 3 and the death generally occurs before the thirty-seventh week. Therefore, premature delivery is advised 35 days before full ~erm. If the father is heterozygous-positive and If no change in maternal titer occurs the delive ry IS . d elayed until 21 days before ' term. In all of these recommendations the size of the baby and the accuracy of the time of gestation are, of course, considered in determining the oPl'Imum time for delivery. . The technique employed in the antibody titrahons is described in an appendix. Close standard' . IzatlOn of end points between various laboratories is difficult so that the critical titer of
Selected abstracts
1069
1:40 used in this study may be somewhat different from that found in different laboratories. Inasmuch as the only hope of preventing some of the stillbirths from hemolytic disease of the newborn is premature delivery (when weighed against the risks of the latter) each laboratory should evaluate the results of the test as it is done in that laboratory until such a time as standardization of end points can be obtained. David M. Kydd
Oct. 15, 1960. *Hayward, M. D., and Bower, B. D.: Chromosomal Trisomy Associated With the Sturge-Weber Syndrome, p. 844. *Tough, I., Buckton, K., Baikie, A. G., and Court-Brown, W. M.: X-ray-Induced Chromosome Damage in Man, p. 849. Hayward and Bower: Chromosomal Trisomy Associated With the Sturge-Weber Syndrome, p. 844. Culture of the bone-marrow cells from a boy almost 4 years of age with Sturge-Weber syndrome (mental retardation, convulsions, portwine nevus, buphthalmos) disclosed that there were 47 chromosomes. After matching, it was concluded that the extra chromosome represented a trisomy of No. 22. Only further study wiIl prove that this represents a specific defect, particularly in view of the discovery of a normal male with a trisomy chromosome No. 19 by Fraccaro, Kaijser, and Lindsten (Lancet 1: 724, 1960). David M. Kydd Tough et al.: X-ray-Induced Chromosome Damage in Man, p. 849. In this preliminary communication 2 patients who received x-ray treatment for ankylosing spondylitis were studied. The first patient received a total skin dose of 1,500 r in 10 equal daily fractions over the entire spine and sacroiliac joints. Study of chromosome preparations made from blood cultures before and after this treatment showed evidence of considerable chromosome damage (significant changes in count distribution and increases in the number of cells carrying structural abnormalities). The second patient received one dose of 250 r to the skin overlying the spine only. Cell preparations were made before and serially for 10 days after the treatment. Within 24 hours the percentage of cells with 46 chromosomes had fallen from 93 to 72, due to a remarkable in-
ings. It is not stated clearly enough that symptoms due to carcinoma in situ do not exist and that symptoms that are present are due to other factors incidentally coexistent. Similarly, in remarking on the general appearance of the cervix in these cases, it is stated that only 14.5 per cent of the patients had "normal" appearing cervices. This figure, in the absence of a control figure of incidence in a similar group without carcinoma in situ, with use of the same criteria, is of little bearing, and can be misinterpreted. The importance of the nonspecific Schiller test in picking out areas with carcinoma in situ is well demonstrated. Furthermore, the significance of cervical smears in selecting patients for biopsy is emphasized. The authors state that when smear and biopsy (in areas indicated by a posItive Schiller test) are used as complementary diagnostic methods, failure to estab-
Am .
May, 1961 & Gynec.
.T. Obst.
lish the diagnosis in carcinoma in situ of the cervix should not exceed 2 per cent. It is to be noted that the authors prefer multiple punch biopsies taken with a large, square-jawed punch and endocervical curettage as their method of establishing the diagnosis and excluding invasion. As to therapy, they apparently prefer total hysterectomy in most cases, and more conservative therapy (conization, amputation) in a small, well-selected (on the basis of age and desire for children) group of cases. There is due emphasis on the need in all cases for posttreatment follow-up at regular intervals. If all physicians responsible for the care of women familiarized themselves with the contents of this monograph, a great stride would be made toward the realization of the concept of "cancer of the cervix: a preventable disease."
Selected abstracts The Lancet Vol. 2, Oct. 10, 1959. *Tovey, Geoffrey H., and Valaes, T.: Prevention of Stillbirth in Rh Hemolytic Disease,
p. 521. Tovey and Valaes: Prevention of Stillbirth in Rh Hemolytic Disease, p. 521. Following the suggestion of Kelsall and Vos (M. J. Australia I: 349, 1952) that the severity of disease in the baby is closely related to the level of anti-Rh in the mother's serum determined by the indirect antiglobin technique, a series of 200 babies born to mothers who had not previously carried an affected child (1) and 62 babies whose mothers had already had Rh antibodies during a previous pregnancy (2) was studied. The antibody levels discussed are the maxirnum titers obtained between the thirtyfourth and thirty-sixth weeks of the pregnancy. In (1) there were no stillbirths and only 45 per cent of the babies needed transfusions if the mothers' antenatal antiglobin titer was less than 1: 10 (59 patients). Among the 84 babies whose mothers' antenatal antibody titers were I : 10 but less than 1: 40 there was one stillbirth *These articles have been abstracted.
and 71 per cent of the babies required transfusions. However, among the 57 babies whose . mothers had an antenatal antiglobin titer of 1:40 or higher there were 24.5 per cent sti1Ibirths and 98 per cent of the babies required transfusions. In (2), although there were no stillbirths and no transfusions were needed in the babies whose mothers had antenatal antibody titers of less than 1: 10, when the latter was 1: 10 but less than 1:40 the stillbirth rate was five times higher (6.25 per cent) than when the mother is carrying a first affected baby, and 80 per cent of these babies required transfusion. In (I) and (2) the results are much the same when the antiglobulin titer is 1:-to or higher. However, the percentage of stillbirths in (2) would certainly have been higher hut for the fact that most mothers who had previously had a severely affected or stillborn bahy were delivered prematurely. That there were more severely affected babies in (2) than in (I) when the mother's antibody titer was 1: 10 but less than 1:40 tends to confirm the opinion of Kelsall, Vos, and Kirk (Brit. M. J. 2: 468, 1958) that duration of exposure of the baby to these anti-
VolWlle 81
Number 5
bodies is important in determining the severity of disease in the baby. The cord blood was studied, and a close correlation between the hemoglobin level, serum bilirubin level, and maternal anti-Rh titer was found. In (1) when the maternal Rh titer is 1:40 or higher the risk of death found before 34 weeks of pregnancy was 3 per cent; it was 5 per cent at 34 weeks, 3 per cent between 35 and 36 weeks, but 20 per cent after 37 weeks of pregnancy. These figures suggested that two thirds of the stillbirths might be prevented if the baby Were delivered 21 days before term. Few additional deaths would be prevented unless the pregnancy were terminated at or before the thirty-fourth week, and this would introduce too many hazards for prematurity. Therefore, the practice has been adopted to recommend premature delivery 21 days before the expected date of delivery if the mother's anti-Rh titer has reached or exceeded 1: 40 by the thirty-sixth week of pregnancy. When the mothers have previously had an aff~cted baby (group 2) the smallness of the senes did not provide such clear indication and the antenatal antibody titer could be used as only one criterion. At present the authors believe that if the previously affected child did not require treatment and if the maternal anti. less than 1: 10 the pregnancy may body t'Iter IS be allowed to proceed to term. However, if the preceding baby required treatment or if the maternal antibody titer has risen from that observed in the preceding pregnancy ( 1: 10 or 1:20), pregnancy should be terminated 21 days before full term because the stillbirth risk in thO IS group approaches 10 per cent. If the maternal titer is 1:40 or greater and ~he father is homozygous the risk of a dead baby IS about 1 in 3 and the death generally occurs before the thirty-seventh week. Therefore, premature delivery is advised 35 days before full ~erm. If the father is heterozygous-positive and If no change in maternal titer occurs the delive ry IS . d elayed until 21 days before ' term. In all of these recommendations the size of the baby and the accuracy of the time of gestation are, of course, considered in determining the oPl'Imum time for delivery. . The technique employed in the antibody titrahons is described in an appendix. Close standard' . IzatlOn of end points between various laboratories is difficult so that the critical titer of
Selected abstracts
1069
1:40 used in this study may be somewhat different from that found in different laboratories. Inasmuch as the only hope of preventing some of the stillbirths from hemolytic disease of the newborn is premature delivery (when weighed against the risks of the latter) each laboratory should evaluate the results of the test as it is done in that laboratory until such a time as standardization of end points can be obtained. David M. Kydd
Oct. 15, 1960. *Hayward, M. D., and Bower, B. D.: Chromosomal Trisomy Associated With the Sturge-Weber Syndrome, p. 844. *Tough, I., Buckton, K., Baikie, A. G., and Court-Brown, W. M.: X-ray-Induced Chromosome Damage in Man, p. 849. Hayward and Bower: Chromosomal Trisomy Associated With the Sturge-Weber Syndrome, p. 844. Culture of the bone-marrow cells from a boy almost 4 years of age with Sturge-Weber syndrome (mental retardation, convulsions, portwine nevus, buphthalmos) disclosed that there were 47 chromosomes. After matching, it was concluded that the extra chromosome represented a trisomy of No. 22. Only further study wiIl prove that this represents a specific defect, particularly in view of the discovery of a normal male with a trisomy chromosome No. 19 by Fraccaro, Kaijser, and Lindsten (Lancet 1: 724, 1960). David M. Kydd Tough et al.: X-ray-Induced Chromosome Damage in Man, p. 849. In this preliminary communication 2 patients who received x-ray treatment for ankylosing spondylitis were studied. The first patient received a total skin dose of 1,500 r in 10 equal daily fractions over the entire spine and sacroiliac joints. Study of chromosome preparations made from blood cultures before and after this treatment showed evidence of considerable chromosome damage (significant changes in count distribution and increases in the number of cells carrying structural abnormalities). The second patient received one dose of 250 r to the skin overlying the spine only. Cell preparations were made before and serially for 10 days after the treatment. Within 24 hours the percentage of cells with 46 chromosomes had fallen from 93 to 72, due to a remarkable in-