Volume Number
Correspondence
125 4
If dexamethasone can lower the incidence of RDS in the premature infant from approximately 30 to 9 per cent, it will be a significant advance in the prevention of RDS. However, it is my opinion that the etiology of RDS is composed of multiple factors, and research into the importance of the aspiration aspect must not be neglected. Charles Newborn Nurseries Hotel Dieu and Cornwall General Cornwall, Ontario, Canada
B. Pender,
M.D.
Hospitals
REFERENCES
1. Caspi, I:., Schreyer, P., Weinraub, Z., Bukovsky, I. and Tamir, 1.: AM. J. OBSTET. GYNECOL. 122: 327, 1975. 2. L&gins, G. C., and Howie, R. N.: Pediatrics 50: 515, 1972. 3. Kaplan, S. D.: Lancet 1: 834, 1973. 4. p,ak:, C. B.: Resuscitation 2: 157, 1973.
Reply to Dr. Pewter To the Editors:
In response to Dr. Pender’s letter, we would like to point out that our study was concerned only with the changes of the amniotic fluid lecithin/sphingomyelin (L/S) ratio following maternal administration of dexamethasone and not with the incidence of the respiratory distress syndrome (RDS) in these small series of premature infants. We never stated that the development of RDS is solely dependent on a certain level of surfactant expressed by a mature value of the L/S ratio. We agree that RDS is a result of a multitude of factors, of which surfactant is certainly an important one. It happens that the 9 per cent incidence (calculated by Dr. Pender) of RDS in our small series is very similar to that found by Liggins and Howiei after betamethasone administration. In a recent study to be published,’ we found an incidence of 8.3 per cent of RDS in a dexamethasonetreated group compared to 35.2 per cent in a control group. It seems that pharmacologic doses of glucocorti,zoids reduced the incidence of RDS from approximately 30 to 9 per cent. This reduction is probably concomitant with an increase of the L/S ratio. That dexamethasone induces an increase of the L/S ratio is supported by the observation of Kling and Kotas3 made in the pregnant baboon, injected intra-amniotically with dexamethasone. This was followed by a significant rise in the amniotic L/S ratio. Eliahu Department of Obstetrics Asaf Harojh Government
Zer$n,
and
Caspi,
M.D.
Gynecology
Hospital
Israrl
REFERENCES
1. Liggins, C. C., and Howie, R. H.: Pediatrics 50: 515, 1972. 2. Caspi, E., Schreyer, P., Weinraub, Z., Reif, R., Levi, I., and Mundel. G.: J. Obstet. Gynaecol. Br. Commonw. In press.
575
3. Kling, 0. R., and Kotas, R. V.: AM. J. OBSTET. GYNECOL. 121: 664, 1975.
Unforeseen fetal death in a monitored labor To the Editors:
This concerns a “Communication in brief” entitled “Unforeseen sudden intrapartum fetal death in a monitored labor,” by Drs. R. H. Hayashi and M. E. Fox, published in the July 15, 1975, issue of theJouRNAL, on p. 786. The case reported by these authors is an interesting one and may be an exceptional one too. I want to express some criticism about some conclusions drawn from the monitoring charts represented. First, about half of the adequate “fetal” heart rate (FHR) registration is lacking following the onset of the sudden drop of the FHR from 150 to 86 beats per minute. Moreover, it is also important to remember the technical limits of the fetal monitoring procedure used. Most of the monitoring apparatuses indeed are not provided with a continuous visual, e.g., oscilloscope, or graphic control of the fetal scalp electrode input signal. Furthermore, the electronic brain of the monitor only “accepts” standardized FHR patterns, triggers “automatically” but with some delay on the amplitude of the input signal and eliminates “noise.” In this way, irregular and weak or slow-but still existing-fetal heart activity cannot be registered with this type of cardiotocograph. Therefore, what exactly happened to this fetus before death cannot be ascertained from the registration chart; it may well be different from what is suggested by the monitor. Dr. Department of Gynecolog?r St. Maria Kliniek 1500 Halle, Belgium
and
Stefaan
Vroman
Obstetrics
Routine pregnancy test on admission to hospital To the Editors:
I was disappointed when I finished reading “Routine pregnancy test on admission to hospital, by Drs. Laubach and Wilchins (AM. J. OBSTET. GYNECOL. 123: 69 1, 1975) because the authors did not demonstrate in their paper that by doing a pregnancy test their patient’s embryos were going to be protected and they did not demonstrate why the 97 per cent of other hospitals should start doing routine pregnancy testing. Although most hospitals with which I am familiar require routine pregnancy tests for gynecologic admissions, this is not always enforced practice for all women of reproductive age. My personal experience, and that of many of my colleagues in this area, is that with the present availability of abortions at low cost in the city of and with newspaper advertisements, we Chicago, rarely see a woman trying to con us into performing an abortion. However, I agree that there is still a large group of women who have so-called “luteal pregnan-
576
Correspondence
June .4m. J. Obstet.
ties” who are unaware of their condition and there are others who deny, for many other reasons, their pregnant condition. In reviewing many hospital charts from departments other than those of obstetrics and gynecology during the last few years, it has been obvious that even very interested physicians who wrote beautifully detailed histories failed to record the date of last menstruation, medications (including contraceptives), and information about pregnancies and sexuality; of course, the line for pelvic and rectal examinations is usually deferred to (when?). Many radiologic request forms do not include the date of last menstrual period, or ask if the patient is pregnant. I think in our daily contact with patients we should encourage such things as behavior modification in relation to the habit of taking medication at the reflex level, encouraged by television advertisements since childhood. We should avoid any elective radiologic evaluation during the luteal phase of the patient’s cycle, and, when prescribing medications, we should consider the possibility of pregnancy. The available commercial pregnancy tests are negative in about 32 per cent of normal pregnancies before the sixth week when the patient has missed a period for two weeks.’ Accuracy improves with the passing of time. However, a competent gynecologist should be able to make a diagnosis by manual examination at that time. If we are going to rely on pregnancy tests, we should use sensitive tests such as those described by Saxena and associates’ which are positive six days following ovulation,3 even before the pregnant woman has missed a menstrual period. How do Drs. Laubach and Wilchins advise us to manage a false positive test? Pedro
‘4. Poma,
M.D.
Departmmt of Obstetrics and Gynecology Mount Sinai Hospital Medical Center California Avenue af 15th Street Chicago, Illinois 60608 REFERENCES
1. Brenner, W., Edelman, D. A., Davis, G. L. R., and Kessel, E.: Suction curettage for “menstrual regulation,” Presented to the American Association of Planned Parenthood Physicians, Houston, Texas, April 1 I-13, 1973, p. 1. 2. Saxena. B. B., Hasan, S. H., Haour, I., and Gallwitzer, M. S.: Radioreceptor assay of human chorionic gonadotropin: Early detection of pregnancy, Science 184: 793, 1974. 3. Saxena, B. B., and Landesman, R.: The use of radioreception assay of human chorionic gonadotropin for diagnosis
and management 397, 1975.
of ectopic
pregnancy,
Fertil.
15. 1976 Cynecol.
Steril.
26:
Reply to Dr. Poma To the Editors:
The following are our answers to the questions raised by Dr. Poma. 1. We never maintained that the patient’s embryo will be protected by pregnancy tests. What we do believe is that the patient and physician should know of a possible pregnancy before ordering medication or certain diagnostic procedures-since many women do not know they are pregnant or do not tell their physicians of a pregnancy. We believe that all hospitals should routinely screen for pregnancy all women of childbearing age to provide this information. When a pregnancy test is positive, the benefit-to-risk ratio of drug and/or therapy can then be made. 2. Pregnancy tests should not be the complete measure of whether a woman is pregnant or not. However, they are the best available indication of pregnancy at early stages. Our information about the accuracy of available tests differs from Dr. Poma’s. We have seen studies which show better than 95 per cent reliability at 41 days from last normal menstrual period. 3. The test described by Saxena is not now available commercially. 4. False positive tests do occur but not often. Yet, they can be important diagnostic aids since the test indicates not pregnancy but total human chorionic gonadotropin in the sample. Positive tests occur not only with pregnancy but also with various types of choriocarcinoma and hydatidiform mole. We follow up on positive and negative tests whenever our clinical judgment dictates. There is usually no harm in asking a patient to return for another test and a physical examination in a few days, if and when the test results seem questionable. George Sidney
14 East Westjield Avow Roselle Park, New Jersey
E. Laubach, A. W&him.
M.D. M.D.
07204
REFERENCES
1. Horwitz, C. A., et al.: A comparative study of five immunologic pregnancy tests: An analysis of 1,863 cases, AM. J. Clin. Pathol. 58: 305, 1972. 2. Porres, J. M., et al.: Comparison of eight kits for the diagnosis of pregnancy. 64: 452, 1975.
Correspondence
125 4
If dexamethasone can lower the incidence of RDS in the premature infant from approximately 30 to 9 per cent, it will be a significant advance in the prevention of RDS. However, it is my opinion that the etiology of RDS is composed of multiple factors, and research into the importance of the aspiration aspect must not be neglected. Charles Newborn Nurseries Hotel Dieu and Cornwall General Cornwall, Ontario, Canada
B. Pender,
M.D.
Hospitals
REFERENCES
1. Caspi, I:., Schreyer, P., Weinraub, Z., Bukovsky, I. and Tamir, 1.: AM. J. OBSTET. GYNECOL. 122: 327, 1975. 2. L&gins, G. C., and Howie, R. N.: Pediatrics 50: 515, 1972. 3. Kaplan, S. D.: Lancet 1: 834, 1973. 4. p,ak:, C. B.: Resuscitation 2: 157, 1973.
Reply to Dr. Pewter To the Editors:
In response to Dr. Pender’s letter, we would like to point out that our study was concerned only with the changes of the amniotic fluid lecithin/sphingomyelin (L/S) ratio following maternal administration of dexamethasone and not with the incidence of the respiratory distress syndrome (RDS) in these small series of premature infants. We never stated that the development of RDS is solely dependent on a certain level of surfactant expressed by a mature value of the L/S ratio. We agree that RDS is a result of a multitude of factors, of which surfactant is certainly an important one. It happens that the 9 per cent incidence (calculated by Dr. Pender) of RDS in our small series is very similar to that found by Liggins and Howiei after betamethasone administration. In a recent study to be published,’ we found an incidence of 8.3 per cent of RDS in a dexamethasonetreated group compared to 35.2 per cent in a control group. It seems that pharmacologic doses of glucocorti,zoids reduced the incidence of RDS from approximately 30 to 9 per cent. This reduction is probably concomitant with an increase of the L/S ratio. That dexamethasone induces an increase of the L/S ratio is supported by the observation of Kling and Kotas3 made in the pregnant baboon, injected intra-amniotically with dexamethasone. This was followed by a significant rise in the amniotic L/S ratio. Eliahu Department of Obstetrics Asaf Harojh Government
Zer$n,
and
Caspi,
M.D.
Gynecology
Hospital
Israrl
REFERENCES
1. Liggins, C. C., and Howie, R. H.: Pediatrics 50: 515, 1972. 2. Caspi, E., Schreyer, P., Weinraub, Z., Reif, R., Levi, I., and Mundel. G.: J. Obstet. Gynaecol. Br. Commonw. In press.
575
3. Kling, 0. R., and Kotas, R. V.: AM. J. OBSTET. GYNECOL. 121: 664, 1975.
Unforeseen fetal death in a monitored labor To the Editors:
This concerns a “Communication in brief” entitled “Unforeseen sudden intrapartum fetal death in a monitored labor,” by Drs. R. H. Hayashi and M. E. Fox, published in the July 15, 1975, issue of theJouRNAL, on p. 786. The case reported by these authors is an interesting one and may be an exceptional one too. I want to express some criticism about some conclusions drawn from the monitoring charts represented. First, about half of the adequate “fetal” heart rate (FHR) registration is lacking following the onset of the sudden drop of the FHR from 150 to 86 beats per minute. Moreover, it is also important to remember the technical limits of the fetal monitoring procedure used. Most of the monitoring apparatuses indeed are not provided with a continuous visual, e.g., oscilloscope, or graphic control of the fetal scalp electrode input signal. Furthermore, the electronic brain of the monitor only “accepts” standardized FHR patterns, triggers “automatically” but with some delay on the amplitude of the input signal and eliminates “noise.” In this way, irregular and weak or slow-but still existing-fetal heart activity cannot be registered with this type of cardiotocograph. Therefore, what exactly happened to this fetus before death cannot be ascertained from the registration chart; it may well be different from what is suggested by the monitor. Dr. Department of Gynecolog?r St. Maria Kliniek 1500 Halle, Belgium
and
Stefaan
Vroman
Obstetrics
Routine pregnancy test on admission to hospital To the Editors:
I was disappointed when I finished reading “Routine pregnancy test on admission to hospital, by Drs. Laubach and Wilchins (AM. J. OBSTET. GYNECOL. 123: 69 1, 1975) because the authors did not demonstrate in their paper that by doing a pregnancy test their patient’s embryos were going to be protected and they did not demonstrate why the 97 per cent of other hospitals should start doing routine pregnancy testing. Although most hospitals with which I am familiar require routine pregnancy tests for gynecologic admissions, this is not always enforced practice for all women of reproductive age. My personal experience, and that of many of my colleagues in this area, is that with the present availability of abortions at low cost in the city of and with newspaper advertisements, we Chicago, rarely see a woman trying to con us into performing an abortion. However, I agree that there is still a large group of women who have so-called “luteal pregnan-
576
Correspondence
June .4m. J. Obstet.
ties” who are unaware of their condition and there are others who deny, for many other reasons, their pregnant condition. In reviewing many hospital charts from departments other than those of obstetrics and gynecology during the last few years, it has been obvious that even very interested physicians who wrote beautifully detailed histories failed to record the date of last menstruation, medications (including contraceptives), and information about pregnancies and sexuality; of course, the line for pelvic and rectal examinations is usually deferred to (when?). Many radiologic request forms do not include the date of last menstrual period, or ask if the patient is pregnant. I think in our daily contact with patients we should encourage such things as behavior modification in relation to the habit of taking medication at the reflex level, encouraged by television advertisements since childhood. We should avoid any elective radiologic evaluation during the luteal phase of the patient’s cycle, and, when prescribing medications, we should consider the possibility of pregnancy. The available commercial pregnancy tests are negative in about 32 per cent of normal pregnancies before the sixth week when the patient has missed a period for two weeks.’ Accuracy improves with the passing of time. However, a competent gynecologist should be able to make a diagnosis by manual examination at that time. If we are going to rely on pregnancy tests, we should use sensitive tests such as those described by Saxena and associates’ which are positive six days following ovulation,3 even before the pregnant woman has missed a menstrual period. How do Drs. Laubach and Wilchins advise us to manage a false positive test? Pedro
‘4. Poma,
M.D.
Departmmt of Obstetrics and Gynecology Mount Sinai Hospital Medical Center California Avenue af 15th Street Chicago, Illinois 60608 REFERENCES
1. Brenner, W., Edelman, D. A., Davis, G. L. R., and Kessel, E.: Suction curettage for “menstrual regulation,” Presented to the American Association of Planned Parenthood Physicians, Houston, Texas, April 1 I-13, 1973, p. 1. 2. Saxena. B. B., Hasan, S. H., Haour, I., and Gallwitzer, M. S.: Radioreceptor assay of human chorionic gonadotropin: Early detection of pregnancy, Science 184: 793, 1974. 3. Saxena, B. B., and Landesman, R.: The use of radioreception assay of human chorionic gonadotropin for diagnosis
and management 397, 1975.
of ectopic
pregnancy,
Fertil.
15. 1976 Cynecol.
Steril.
26:
Reply to Dr. Poma To the Editors:
The following are our answers to the questions raised by Dr. Poma. 1. We never maintained that the patient’s embryo will be protected by pregnancy tests. What we do believe is that the patient and physician should know of a possible pregnancy before ordering medication or certain diagnostic procedures-since many women do not know they are pregnant or do not tell their physicians of a pregnancy. We believe that all hospitals should routinely screen for pregnancy all women of childbearing age to provide this information. When a pregnancy test is positive, the benefit-to-risk ratio of drug and/or therapy can then be made. 2. Pregnancy tests should not be the complete measure of whether a woman is pregnant or not. However, they are the best available indication of pregnancy at early stages. Our information about the accuracy of available tests differs from Dr. Poma’s. We have seen studies which show better than 95 per cent reliability at 41 days from last normal menstrual period. 3. The test described by Saxena is not now available commercially. 4. False positive tests do occur but not often. Yet, they can be important diagnostic aids since the test indicates not pregnancy but total human chorionic gonadotropin in the sample. Positive tests occur not only with pregnancy but also with various types of choriocarcinoma and hydatidiform mole. We follow up on positive and negative tests whenever our clinical judgment dictates. There is usually no harm in asking a patient to return for another test and a physical examination in a few days, if and when the test results seem questionable. George Sidney
14 East Westjield Avow Roselle Park, New Jersey
E. Laubach, A. W&him.
M.D. M.D.
07204
REFERENCES
1. Horwitz, C. A., et al.: A comparative study of five immunologic pregnancy tests: An analysis of 1,863 cases, AM. J. Clin. Pathol. 58: 305, 1972. 2. Porres, J. M., et al.: Comparison of eight kits for the diagnosis of pregnancy. 64: 452, 1975.
