274 attempt to develop desirable.
an
a more
sensitive method of screening
Health Commission of New South
Wales, Oliver Latham
Laboratory,
Psychiatric Centre, Cox’s Road, North Ryde, New South Wales 2113.
H.P.L. values above the mean+1 1 S.D. may considerreduce the number of gravida requiring X-ray or, preferably, ultrasonic examination for detection of multiple pregnancies. H.P.L. screening by this method seems to be valid for gestations exceeding twenty weeks. The value of H.r.L. determinations for selecting a target group to be examined for multiple pregnancy is emphasised by the observation that no false-negative tests were found with the selected level of discrimination. Routine H.P.L. determination in mid-pregnancy as a preliminary to ultrasonic examination seems to offer great advantages for the early detection of multiple pregnancies. GERHARD GENNSER LARS GRENNERT Department of Obstetrics and Gynæcology, STIG KULLANDER General Hospital, PER-HÅKAN PERSSON University of Lund, LARS WINGERUP. S-214 01 Malmö, Sweden.
with
ably
seems
BRIDGET WILCKEN.
HUMAN PLACENTAL LACTOGEN IN SCREENING FOR MULTIPLE PREGNANCIES
Sip,—The finding by Josimovich and MacLaren1 that human placental lactogen (H.P.L.) is produced by the syncytiotrophoblast suggested that H.p.L. measurements could be used to assess placental function. However, opinions differ on the value of measuring H.P.L. to detect pre-eclamptic pregnancies in which the fetus is at risk.2-4 We have found that H.P.L. determinations are useful in at least one important field of antenatal care. The diagnosis of multiple pregnancy has been taken as an important sign predicting premature delivery-with its
HUMAN PLACENTAL LACTOGEN AND FETAL ABNORMALITY
SIR,-Judging by the correspondence our letter (Sept. 28, p. 775) about the pattern of persistently low serum human placental lactogen (H.P.L.) levels and fetal abnormality seems to have been misunderstood. We did not suggest that persistently low H.P.L. levels were always associated with fetal abnormalities, nor that fetal abnormalities were always associated with low H.P.L. levels. There can be no dispute that in the 4 cases we studied4 the pattern of serial
serum
H.P.L.
levels
was
persistently low and that in all 4 cases fetuses with severe congenital defects were subsequently delivered. In view of this it would seem extremely unwise to discount the possibility that this pattern of persistently low H.P.L. values could be associated with severe congenital abnormality. I believe it was Karl Popper who said just because there awful lot of white swans about it doesn’t prove there aren’t any black ones. Wycombe General Hospital, GILLIAN S. GAU. High Wycombe, Bucks. HP11 2TT. are an
H.P.L. in plasma from 19 women with twin pregnancies in relation to gestational age.
Normal range is shown with mean ±11 s.n.
hazards of increased fetal mortality and morbidity-and in our unit multiple pregnancy has occasioned the admission to hospital of pregnant women for the last half of their gestations. This action reduced the risk of multiple pregnancies ending in a pronounced premature birth-i.e., with birth-weight < 1.500 g.-from 12% to 2%.s The early diagnosis of multiple pregnancies is one of the benefits of the routine ultrasonic screening now performed during the twentieth-twenty-sixth gestational week in all s pregnant women in Malmo. Plasma-H.P.L. was determined by radioimmunoassay in 1516 women in the seventeenth-fortieth week of gestation as part of this antenatal screening programme. The values from all 19 twin pregnancies fell above the mean +1 S.D. level of the normal values (see accompanying figure). This finding does not imply that patients with singleton pregnancies do not have high H.P.L. values. However, although the distribution of the normal range of H.P.L. levels is skewed,7 the selection of a group 1.
2. 3. 4. 5. 6. 7.
Josimovich, J. B., MacLaren, J. A. Am. J. Obstet. Gynec. 1962, 71, 209. Spellacy, W. N., Teoh, E. S., Buhi, W. C., Birk, S. A., McCreary, S. A. ibid. 1971, 109, 588. Letchworth, A. T., Chard, T. J. Obstet. Gynœc. Br. Commonw. 1972, 79, 680. Spellacy, W. N., Buhi, W. C., Birk, S. A., McCreary, S. A. Am. J. Obstet. Gynec. 1974, 120, 214. Kullander, S. Unpublished. Grennert, L., Persson, P.-H., Gennser, G. Unpublished. Chard, T. Clins Obstet. Gynœc. 1974, 1, 97.
INTRAVENOUS CHOLANGIOGRAPHY IN
JAUNDICE SIR,—Recently it was brought to our attention that our experimental work was misquoted in your journal.5 The investigation referred to was at that time in progress and is now completed. 6-8 From our experimental work in the healthy dog 6,9 and the dog with either hepatocellular jaundice 7,8 or common bileduct obstruction 7,8 the following conclusions should be drawn. With a bolus injection over a few minutes or a 30-minute infusion, 06 ml. per kg. iodipamide 52% (’ Biligrafin "Chologrann’) seems to be the optimum dose for intravenous cholangiography. Delayed visualisation of the biliary system occurs in both hepatocellular and obstructive jaundice and, therefore, radiographs should be taken up to eight hours after the start of the examination, if the cholangiogram is not diagnostic earlier. When this method is non-diagnostic, prolongation of the iodipamide infusion time up to six hours neither improves the radioYlikorkala, O. Lancet, Nov. 9, 1974, p. 1141. Soler, N. G. ibid. Dec. 7, 1974, p. 1389. Spellacy, W. N. ibid. Jan. 11, 1975, p. 99. Gau, G., Cadle, G. Unpublished. Lancet, 1972, ii, 1406. Burgener, F. A., Fischer, H. W. Radiology (in the press). Burgener, F. A., Fischer, H. W., Adams, J. T. Invest. Radiol. (in the press). 8. Burgener, F. A., Fischer, H. W. Fortschr. Geb. Röntgenstrahl. (in the press). 9. Fischer, H. W. Radiology, 1965, 84, 483. 1. 2. 3. 4. 5. 6. 7.
an
a more
sensitive method of screening
Health Commission of New South
Wales, Oliver Latham
Laboratory,
Psychiatric Centre, Cox’s Road, North Ryde, New South Wales 2113.
H.P.L. values above the mean+1 1 S.D. may considerreduce the number of gravida requiring X-ray or, preferably, ultrasonic examination for detection of multiple pregnancies. H.P.L. screening by this method seems to be valid for gestations exceeding twenty weeks. The value of H.r.L. determinations for selecting a target group to be examined for multiple pregnancy is emphasised by the observation that no false-negative tests were found with the selected level of discrimination. Routine H.P.L. determination in mid-pregnancy as a preliminary to ultrasonic examination seems to offer great advantages for the early detection of multiple pregnancies. GERHARD GENNSER LARS GRENNERT Department of Obstetrics and Gynæcology, STIG KULLANDER General Hospital, PER-HÅKAN PERSSON University of Lund, LARS WINGERUP. S-214 01 Malmö, Sweden.
with
ably
seems
BRIDGET WILCKEN.
HUMAN PLACENTAL LACTOGEN IN SCREENING FOR MULTIPLE PREGNANCIES
Sip,—The finding by Josimovich and MacLaren1 that human placental lactogen (H.P.L.) is produced by the syncytiotrophoblast suggested that H.p.L. measurements could be used to assess placental function. However, opinions differ on the value of measuring H.P.L. to detect pre-eclamptic pregnancies in which the fetus is at risk.2-4 We have found that H.P.L. determinations are useful in at least one important field of antenatal care. The diagnosis of multiple pregnancy has been taken as an important sign predicting premature delivery-with its
HUMAN PLACENTAL LACTOGEN AND FETAL ABNORMALITY
SIR,-Judging by the correspondence our letter (Sept. 28, p. 775) about the pattern of persistently low serum human placental lactogen (H.P.L.) levels and fetal abnormality seems to have been misunderstood. We did not suggest that persistently low H.P.L. levels were always associated with fetal abnormalities, nor that fetal abnormalities were always associated with low H.P.L. levels. There can be no dispute that in the 4 cases we studied4 the pattern of serial
serum
H.P.L.
levels
was
persistently low and that in all 4 cases fetuses with severe congenital defects were subsequently delivered. In view of this it would seem extremely unwise to discount the possibility that this pattern of persistently low H.P.L. values could be associated with severe congenital abnormality. I believe it was Karl Popper who said just because there awful lot of white swans about it doesn’t prove there aren’t any black ones. Wycombe General Hospital, GILLIAN S. GAU. High Wycombe, Bucks. HP11 2TT. are an
H.P.L. in plasma from 19 women with twin pregnancies in relation to gestational age.
Normal range is shown with mean ±11 s.n.
hazards of increased fetal mortality and morbidity-and in our unit multiple pregnancy has occasioned the admission to hospital of pregnant women for the last half of their gestations. This action reduced the risk of multiple pregnancies ending in a pronounced premature birth-i.e., with birth-weight < 1.500 g.-from 12% to 2%.s The early diagnosis of multiple pregnancies is one of the benefits of the routine ultrasonic screening now performed during the twentieth-twenty-sixth gestational week in all s pregnant women in Malmo. Plasma-H.P.L. was determined by radioimmunoassay in 1516 women in the seventeenth-fortieth week of gestation as part of this antenatal screening programme. The values from all 19 twin pregnancies fell above the mean +1 S.D. level of the normal values (see accompanying figure). This finding does not imply that patients with singleton pregnancies do not have high H.P.L. values. However, although the distribution of the normal range of H.P.L. levels is skewed,7 the selection of a group 1.
2. 3. 4. 5. 6. 7.
Josimovich, J. B., MacLaren, J. A. Am. J. Obstet. Gynec. 1962, 71, 209. Spellacy, W. N., Teoh, E. S., Buhi, W. C., Birk, S. A., McCreary, S. A. ibid. 1971, 109, 588. Letchworth, A. T., Chard, T. J. Obstet. Gynœc. Br. Commonw. 1972, 79, 680. Spellacy, W. N., Buhi, W. C., Birk, S. A., McCreary, S. A. Am. J. Obstet. Gynec. 1974, 120, 214. Kullander, S. Unpublished. Grennert, L., Persson, P.-H., Gennser, G. Unpublished. Chard, T. Clins Obstet. Gynœc. 1974, 1, 97.
INTRAVENOUS CHOLANGIOGRAPHY IN
JAUNDICE SIR,—Recently it was brought to our attention that our experimental work was misquoted in your journal.5 The investigation referred to was at that time in progress and is now completed. 6-8 From our experimental work in the healthy dog 6,9 and the dog with either hepatocellular jaundice 7,8 or common bileduct obstruction 7,8 the following conclusions should be drawn. With a bolus injection over a few minutes or a 30-minute infusion, 06 ml. per kg. iodipamide 52% (’ Biligrafin "Chologrann’) seems to be the optimum dose for intravenous cholangiography. Delayed visualisation of the biliary system occurs in both hepatocellular and obstructive jaundice and, therefore, radiographs should be taken up to eight hours after the start of the examination, if the cholangiogram is not diagnostic earlier. When this method is non-diagnostic, prolongation of the iodipamide infusion time up to six hours neither improves the radioYlikorkala, O. Lancet, Nov. 9, 1974, p. 1141. Soler, N. G. ibid. Dec. 7, 1974, p. 1389. Spellacy, W. N. ibid. Jan. 11, 1975, p. 99. Gau, G., Cadle, G. Unpublished. Lancet, 1972, ii, 1406. Burgener, F. A., Fischer, H. W. Radiology (in the press). Burgener, F. A., Fischer, H. W., Adams, J. T. Invest. Radiol. (in the press). 8. Burgener, F. A., Fischer, H. W. Fortschr. Geb. Röntgenstrahl. (in the press). 9. Fischer, H. W. Radiology, 1965, 84, 483. 1. 2. 3. 4. 5. 6. 7.
