Originalarbeit Gynäkol Geburtsh Rundsch 1992;32:159-163
R. Klimek M. Klimek University Institute of Obstetrics and Gynecology (Chairman: Prof. R. Klimek), Cracow, Poland
Biological Gestational Age and Its Calendar Assessment with Ultrasound Part 2: Biological-Calendar Scales for Prediction of Birth-Date
Biologische Schwangerschaftsdauer Kalendarische Schwangerschaftsdauer Geburtstermin Ultraschall-Biometrie Oxytozinase
Biologische Schwangerschaftsdauer und ihre kalendarische Beurteilung. Teil 2: Vorhersage des Geburtstermins Die Beurteilung der enzymatischen und der sonographischen Bestimmung erfolgt hinsicht lich der Relativität der Schwangerschaftsdauer. Dieses Prinzip der Relativität zeigt, dass nicht die kalendarische Zeit, sondern vielmehr die biologische Zeit mit den Ergebnissen des diagnostischen und therapeutischen Vorgehens festgestellt werden kann. Die beschriebene biologische Kalenderskala kombiniert und berücksichtigt sowohl die enzymatischen als auch die sonographischen Ergebnisse. Die Anpassung der biologischen Skala und der Kalender skala ermöglicht die entsprechende Beurteilung sowohl der Reife des Kindes als auch der Schwangerschaftsdauer von der letzten Menstruation her; deshalb ist die sonographische Skala bisher nur für etwa 50% der Entbindungen geeignet (bei einer üblichen Dauer von 40 Wochen) und müsste daher verlängert werden.
Key Words
Summary
Biological-calendar scales True term prediction Oxytocinase
Evaluation of enzymatic and sonographic assessments has been done in terms of relativity of gestational length. The principle of relativity means that it is not the calendar time but the biological one that qualifies the results of both the diagnostic procedures and treatments. The described biological-calendar scale comprises and links both the enzymatic and ultra sonographic data. The shifting of the end of the biological scale to the end of the calendar scale enables the appropriate evaluation of both the child’s maturation for labor, as well as the pregnancy duration from the last menstrual period until the end of normal births range. It is why almost all ultrasound scales heretofore useful only for 50% of deliveries (as usually encompassing range of 40 weeks) have to be lengthened.
La durée de gestation biologique et son évaluation conforme au calendrier. 2e partie: Prédiction de la date d'accouchement Les résultats enzymatiques et échographiques sont évalués selon cette relativité de la durée de gestation. Ce principe de relativité démontre qu’il s’agit de la durée biologique et non pas de celle conforme au calendrier qui peut être calculée par les résultats du procédé diagnostique et thérapeutique. L’échelle biologique décrite combine et tient compte, non seulement des résul tats enzymatiques, mais aussi des résultats échographiques. L’adaptation du calendrier à l’échelle biologique permet l’évaluation non seulement de la maturité de l’enfant, mais aussi de la durée de la gestation comptée à partir de la dernière menstruation: c’est pourquoi, jusqu’à présent l’échelle échographique n’est appropriée que pour environ 50% des accouche ments (lors d’une durée usuelle de 40 semaines) et devrait par conséquent être prolongée.
Eingegangen: 30. November 1991 Angenommen: 4. Juni 1991
Prof. R. Klimek Sebastiana 10/3 31-049 Cracow (Poland)
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/16/2019 11:48:12 PM
Schlüsselwörter
the beginning of the natural birth time if those children are already mature [10, 12, 14],
The issue of the ultrasonographic evaluation of the development of pregnancy and determination of the de livery term gained a firm position in the obstetrics as well. Unfortunately, the possibilities it offers have been consid erably limited because of the sole use of the calendar scale of time [2, 4, 6, 8, 11], For example, the body weight of the unborn child, who matures by the 259th day of calendar pregnancy, is Vi higher than that of a child, who at the same calendar age will reach the biological maturity after 6 weeks, i.e. at the 303rd pregnancy day. That is the reason why the widely quoted average results of sonographic measurements in particular weeks of the calendar scale, e.g. in the 37th week, include children of different biological age begin ning with those actually born this week and finishing with those, whose physiological labor will occur within the time of next 3 or 6 weeks later. Consequently, beginning from the 37th week of the calendar scale, the previous linear increases of fetal mass and volume, estimated from the 28th week becomes curved and dispersed. Unfortu nately this fact has not been corrected even by the official WHO and FIGO subcommittees [5], What more, most recently according to ACOG Com mittee Opinion No 98 [1] fetal maturity may be assumed, if one of the following criteria is met: 1. fetal heart tones have been documented for 20 weeks by nonelectronic fetoscope or for 30 weeks by Doppler; 2. it has been 36 weeks since a positive pregnancy test was performed by a reliable laboratory; 3. an ultrasound measurement of the crown-rup length, obtained at 6-11 weeks, supports a ges tational age > 39 weeks, or 4. an ultrasound, obtained at 12-20 weeks, confirms the gestational age of > 39 weeks determined by clinical history and physical examination. Therefore, it is - according to the above opinion appropriate to schedule e.g. elective repeat cesarean deliv ery at > 39 weeks by menstrual dates (?!). Last sentence of the document correctly but not only from the medical point of view - stated ‘that awaiting the onset of sponta neous labor is another option’. But first of all, these crite ria refer to the average gestational age of > 3 9 weeks, because until 39th week at least one-third of all pregnant women has to have the onset of spontaneous delivery. Thus the timing of e.g. a cesarean section is an extremely individual problem as before 39th week while fortunately the spontaneous onset of labor takes place in most of such pregnants. Comparison of the accuracy of ultrasonographic and our enzymatic monitoring of pregnancy development and prediction of birth date has been made possible due to 30 years of application of the rule of non-intervention in cases of pregnancy only lasting more than 294 days and. on the other hand, i.e. the active labor induction, even at
160
Klimek/Klimek
Oxytocinase Monitoring of Pregnancy
While investigating the level of oxytocinase and its isoenzymes, the possibility of predicting the high risk pregnancy’s transition into the state of clinical threat seems most advantageous. The oxytocinase blood levels determined by means of the same method (R. Klimek's modification of Vienna biochemists H. Tuppy and H. Nesvadba) remain the same as the data obtained 30 years ago [12,13], When it was introduced, the obtained results were comparable with the scientific reports at that time [3. 7,15,17,19, 20], Enzymatic monitoring is based upon the very well ver ified principle which comprises the rule that the constant increase of the oxytocinase level until delivery proves the proper course of pregnancy, whereas the establishing of the increased isooxytocinase level signals the coming labor. All the earlier reductions of this particular increase of oxytocinase level, especially its stabilization or de crease testifies possible fetal distress. This regularity has been verified also in pregnancies complicated with dia betes or hypertension, the ones that are often combined with earlier termination of pregnancy [9, 13], It should be emphasized that in healthy women the con tinuous increment of blood oxytocinase level until labor is observed in 81 % of cases, its stoppage or decrease on sev eral days before labor - in 12%, and irregular, variable pro file - only in 7%. In patients suffering from diabetes or hypertension this percentage tends to behave in an oppo site way and they equal to 26.7%, 26.7%, 46.7% and 16%, 24%, 60%, respectively [9], This remains coherent with the statement that in pregnant women, threatened with mis carriages or premature deliveries, the enzyme values are still lower, though the ACTH-therapy in such cases enables the successful outcome of pregnancy. The substitutive ACTH-therapy, introduced in the 60s - led to the fact that instead of intrauterine fetal deaths observed in 80% of pregnancies in women with hypothalamic syndrome, now adays, the survival of such infants amounts to above 90% [12, 13, 15]. The clinical application of ACTH as the optional treaatment in hypothalamic insufficiency syn drome has appeared gradually very useful in preventing the premature labors or neonatal respiratory distress. Oxytocinase determination can provide an example, illustrating the proper interpretation of the obstetrical data. The average value of oxytocinase for mature fetuses, normally born after spontaneous onset of labor is 9.1 ± 2.0 pmol/l/min (I.U.) which comprises the results of the enzymatic determination from 37°/7 to 43 Vi weeks of the calendar scale of pregnancy duration.
Gestational Age and Assessment with Ultrasound
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/16/2019 11:48:12 PM
Introduction
Fig. 1. Mean values of oxytocinasemia and their standard devi ations throughout advanced gestation. Fig. 2. Oxytocinasemia average increase since 28th calendar week for calendar (28-43) gestational age.
Fig. 3. Mean oxytocinasemia increases for biological ( 15-0) and calendar (28-43) gestational ages. Fig. 4. Prediction of confinement using biological-calendar scale for oxytocinase measurements.
Figure 1 presents the calendar scale from 24% to 432/7 weeks of pregnancy and the relationship to the average values and the two standard deviations which signify bio logical maturity of the fetus or pregnancy. Week intervals are marked on the axis of abscissae, the axis of ordinates includes the analyzed values, and the range of biological norm comprising ± 2 standard deviations (SD) from the average characteristic for these measurements. The average values for the 24% week and their ± SD indicate the ranges of correct values that during the subse quent weeks become connected with the enzyme values concerning mature fetuses. The diagram shows that be ginning from the 28th week, the average oxytocinase increase is linear in character. Apart from the line that links the average value of the 28th week with the middle of the calendar norm, the lines connecting it with the beginning and end of the normal range are equally impor tant (Fig. 2). In order to facilitate the reading of this calendar-biolo gical scale (28% -43%) and especially the delivery term
prediction, a graduation regarding the pregnancy biologi cal age before labor (22-0 weeks) has been added (fig. 3). The average value for the labor day at the end of the deliveries norm, has been linked with the lines that deter mine the increase of the analyzed value for the children that reach the average at the beginning, in the middle and at the end of the calendar norm, separately. In case of oxy tocinase their regression equations are as follows: y = 0.4x -6.6; y = 0.5x -10.6; y = 0.6x -17.1. Making use of both scales (Fig. 3) we can apply the cho sen oxytocinase value, e.g. 5.0 I.U. either to the range of the 305/7-32% calendar weeks or to the biological age from 10th to 6th week before labor. After two weeks the subsequent measurement, e.g. 6.5 I.U. depicts the pro gress of pregnancy (33%-36% calendar weeks and 7-4 biological weeks) in a more precise way and predicts that the probable labor term will take place after the passing of 4 weeks, taken into account the speed of enzyme increase (Fig. 4).
161
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4
6
8
Fig. 5. Fetal growth for biological-calendar scale. Fig. 6. Prediction of confinement using biological-calendar scale
for HC measurements. Fig. 7. Prediction of confinement using biological calendar scale for FL measurements. Fig. 8. Prediction of confinement using biological-calendar scale for BPD measurements. Fig. 9. Prediction of confinement using biological-calendar scale for AC measurements.
162
Klimck/Klimek
9
ference, the biparietal diameter and the length of femur bone, benable the proper interpretation of the ultrasono graphic results.
Conclusions
The biological-calendar scale, introduced to evaluate the pregnancy development comprises and links both the enzymatic and ultrasonographic data. Assuming the 28th week of pregnancy duration to indicate the beginning of
Gestational Age and Assessment with Ultrasound
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/16/2019 11:48:12 PM
Biological Scales for Ultrasound Prediction o f Term The existence of high correlation between the oxytocinase level and the fetus weight is commonly known [3, 12, 14], Therefore, the diagram identical to the one presented in figure 3 have been related by M. Klimek [9] to the clas sical description of the linear increase of the body weight and length of the unborn children since 28 weeks of preg nancy duration (fig. 5). The following figures: 6-9, showing the biological and calendar scales which include or own experience and text book diagrams of the infant’s head and abdomen circum
Gestational age, weeks
the linear increase of the fetus’ body weight and volume, the lines of the quickest and slowest increase of the aver age values can be marked on the same diagram. The shifting of the end of the biological scale (0) to the end of the calendar scale (43rd week) enables the time evaluation of both the child's maturation for labor, as well as the pregnancy duration from the last menstrual period until the end of normal births range, i.e. 43 Vi weeks. Almost all ultrasound scales heretofore useful only for 50% of deliveries, as usually encompassing range of 40 weeks - have to be lengthened. On the other hand, being aware of the values of ultrasonographic measurements, it is possible to evaluate the independent enzymatic results in order to recognize or exclude the influence of the mother’s neurohormonal condition. The step of the in
crease in the values on the biological scale is the decisive one. The enzymatic and ultrasonographic monitoring of pregnancy and predicting the birth date and course of delivery constitutes one of the lasting achievements of contemporary obstetrics. Enzymes reflect the biological state of the mother, the child and the placenta - the three being inseparable until the labor components of pregnan cy, whose features are imaged and measured by ultraso nography. That is why neglecting of any basic clinical exa minations, starting at least from the 37th calendar week of pregnancy on the one hand and induction of labor solely on the basis of calendar gestational age, on the other hand - is unacceptable from the medical, statistical and ethical points of view!
References 9 Klimck M: Enzymatic and Ultrasonographic Determination of Delivery Term; doctor’s the sis, Cracow, 1991. 10 Klimek R: Relative duration of human preg nancy and oxytocin therapy. Part I and II. Enzyme block. Gynaecologia 1967;163:48-58. 11 Klimck R: Ultrasonography in terms of biolog ical and calendar gestational age. Report FIGO Study Group on ’Assessment of New Technol ogy’. Cracow, DWN DReAM, 1991. 12 Klimek R: Pregnancy and labor in terms of the oxytocin-oxytocinase system. Folia Med Cracoviensis 1964;6:471; and in Klimck R, Krol W (eds): Oxytocin and Its Analogous. PTE, Cracow 1964, pp 66-92. 13 Klimek R: Enzymatic and Ultrasonographic Monitoring of Pregnancy. Cracow, DWN DReAM. 1991. 14 Klimek R, Bieniasz A, Drewniak K: Further studies on the oxytocin-oxytocinase system. A m J Obstet Gynecol 1969:105:427.
15 Klimek R, Stanek J: Comparative prognostic value of serum placental and tissue oxytoci nase, alkaline phosphatase and its heat-stabile fraction in pregnancy at neuroendocrinological risk. J Perinat Med 1976;4:234-241. 16 Merz A: Ultasound in Gynecology' and Obstet rics: Text and Atlas. New York. Thieme. 1991. 17 Ryden G: Cystine aminopeptidase activity in pregnancy. Acta Obstet Gynecol Scand 1971; 50:253-257. 18 Sabbagha RE, Minogue J. Tamura RK, et al: Estimation of birth weight by use of ultrasono graphic formulas targeted to large-, appro priate-, and small-for-gestational-age fetuses. A m J Obstet Gynecol 1989; 160:854-859. 19 Semm K: Die klinische Bedeutung der Oxytocinasebestimmung. Klin Wochenschr 1955;33: 817-818. 20 Tuppy H: The influence of enzymes on neuro hypophysical hormones and similar peptides; in Berde B (ed): Neurohypophysical Hormones and Similar Polypeptides. Handbook of Ex perimental Pharmacology. Berlin. Springer, vol 23, pp 66-106.
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1 ACOG Committee Opinion: Fetal MaturityAssessment Prior to Elective Repeat Cesarean Delivery. No 98, September 1991. 2 ACOPG Technical Bulletin: Ultrasound in Pregnancy. No 116, May 1988. 3 Berde B (ed): Neurohypophysical Hormones and Similar Polypeptides. Handbook o f Exper imental Pharmacology'. Berlin. Springer. 1968, vol 23. 4 Creasy RK, Resnik R (eds): Maternal-Fetal Medicine: Principles and Practice. Philadel phia, Saunders. 1989. 5 Dunn PM (ed): Report of the FIGO Sub-Com mittee on Perinatal Epidemiology. Cairo, 1984. 6 Fleischer A (ed): The Principles and Practice of Ultrasonography in Obstetrics and Gynecolo gy. ed 4. New York. Appleton & Lange. 1990. 7 Fylling P: Serum and plasma oxytocinase activ ity during induction of labour. Acta Obstet Gynecol Scand 1963:42:227—239. 8 Geirsson RT: Ultrasound instead of last men strual period as the basis of gestational age assignment. Ultasound Obstet Gynecol 1991:1: 212-219.
R. Klimek M. Klimek University Institute of Obstetrics and Gynecology (Chairman: Prof. R. Klimek), Cracow, Poland
Biological Gestational Age and Its Calendar Assessment with Ultrasound Part 2: Biological-Calendar Scales for Prediction of Birth-Date
Biologische Schwangerschaftsdauer Kalendarische Schwangerschaftsdauer Geburtstermin Ultraschall-Biometrie Oxytozinase
Biologische Schwangerschaftsdauer und ihre kalendarische Beurteilung. Teil 2: Vorhersage des Geburtstermins Die Beurteilung der enzymatischen und der sonographischen Bestimmung erfolgt hinsicht lich der Relativität der Schwangerschaftsdauer. Dieses Prinzip der Relativität zeigt, dass nicht die kalendarische Zeit, sondern vielmehr die biologische Zeit mit den Ergebnissen des diagnostischen und therapeutischen Vorgehens festgestellt werden kann. Die beschriebene biologische Kalenderskala kombiniert und berücksichtigt sowohl die enzymatischen als auch die sonographischen Ergebnisse. Die Anpassung der biologischen Skala und der Kalender skala ermöglicht die entsprechende Beurteilung sowohl der Reife des Kindes als auch der Schwangerschaftsdauer von der letzten Menstruation her; deshalb ist die sonographische Skala bisher nur für etwa 50% der Entbindungen geeignet (bei einer üblichen Dauer von 40 Wochen) und müsste daher verlängert werden.
Key Words
Summary
Biological-calendar scales True term prediction Oxytocinase
Evaluation of enzymatic and sonographic assessments has been done in terms of relativity of gestational length. The principle of relativity means that it is not the calendar time but the biological one that qualifies the results of both the diagnostic procedures and treatments. The described biological-calendar scale comprises and links both the enzymatic and ultra sonographic data. The shifting of the end of the biological scale to the end of the calendar scale enables the appropriate evaluation of both the child’s maturation for labor, as well as the pregnancy duration from the last menstrual period until the end of normal births range. It is why almost all ultrasound scales heretofore useful only for 50% of deliveries (as usually encompassing range of 40 weeks) have to be lengthened.
La durée de gestation biologique et son évaluation conforme au calendrier. 2e partie: Prédiction de la date d'accouchement Les résultats enzymatiques et échographiques sont évalués selon cette relativité de la durée de gestation. Ce principe de relativité démontre qu’il s’agit de la durée biologique et non pas de celle conforme au calendrier qui peut être calculée par les résultats du procédé diagnostique et thérapeutique. L’échelle biologique décrite combine et tient compte, non seulement des résul tats enzymatiques, mais aussi des résultats échographiques. L’adaptation du calendrier à l’échelle biologique permet l’évaluation non seulement de la maturité de l’enfant, mais aussi de la durée de la gestation comptée à partir de la dernière menstruation: c’est pourquoi, jusqu’à présent l’échelle échographique n’est appropriée que pour environ 50% des accouche ments (lors d’une durée usuelle de 40 semaines) et devrait par conséquent être prolongée.
Eingegangen: 30. November 1991 Angenommen: 4. Juni 1991
Prof. R. Klimek Sebastiana 10/3 31-049 Cracow (Poland)
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/16/2019 11:48:12 PM
Schlüsselwörter
the beginning of the natural birth time if those children are already mature [10, 12, 14],
The issue of the ultrasonographic evaluation of the development of pregnancy and determination of the de livery term gained a firm position in the obstetrics as well. Unfortunately, the possibilities it offers have been consid erably limited because of the sole use of the calendar scale of time [2, 4, 6, 8, 11], For example, the body weight of the unborn child, who matures by the 259th day of calendar pregnancy, is Vi higher than that of a child, who at the same calendar age will reach the biological maturity after 6 weeks, i.e. at the 303rd pregnancy day. That is the reason why the widely quoted average results of sonographic measurements in particular weeks of the calendar scale, e.g. in the 37th week, include children of different biological age begin ning with those actually born this week and finishing with those, whose physiological labor will occur within the time of next 3 or 6 weeks later. Consequently, beginning from the 37th week of the calendar scale, the previous linear increases of fetal mass and volume, estimated from the 28th week becomes curved and dispersed. Unfortu nately this fact has not been corrected even by the official WHO and FIGO subcommittees [5], What more, most recently according to ACOG Com mittee Opinion No 98 [1] fetal maturity may be assumed, if one of the following criteria is met: 1. fetal heart tones have been documented for 20 weeks by nonelectronic fetoscope or for 30 weeks by Doppler; 2. it has been 36 weeks since a positive pregnancy test was performed by a reliable laboratory; 3. an ultrasound measurement of the crown-rup length, obtained at 6-11 weeks, supports a ges tational age > 39 weeks, or 4. an ultrasound, obtained at 12-20 weeks, confirms the gestational age of > 39 weeks determined by clinical history and physical examination. Therefore, it is - according to the above opinion appropriate to schedule e.g. elective repeat cesarean deliv ery at > 39 weeks by menstrual dates (?!). Last sentence of the document correctly but not only from the medical point of view - stated ‘that awaiting the onset of sponta neous labor is another option’. But first of all, these crite ria refer to the average gestational age of > 3 9 weeks, because until 39th week at least one-third of all pregnant women has to have the onset of spontaneous delivery. Thus the timing of e.g. a cesarean section is an extremely individual problem as before 39th week while fortunately the spontaneous onset of labor takes place in most of such pregnants. Comparison of the accuracy of ultrasonographic and our enzymatic monitoring of pregnancy development and prediction of birth date has been made possible due to 30 years of application of the rule of non-intervention in cases of pregnancy only lasting more than 294 days and. on the other hand, i.e. the active labor induction, even at
160
Klimek/Klimek
Oxytocinase Monitoring of Pregnancy
While investigating the level of oxytocinase and its isoenzymes, the possibility of predicting the high risk pregnancy’s transition into the state of clinical threat seems most advantageous. The oxytocinase blood levels determined by means of the same method (R. Klimek's modification of Vienna biochemists H. Tuppy and H. Nesvadba) remain the same as the data obtained 30 years ago [12,13], When it was introduced, the obtained results were comparable with the scientific reports at that time [3. 7,15,17,19, 20], Enzymatic monitoring is based upon the very well ver ified principle which comprises the rule that the constant increase of the oxytocinase level until delivery proves the proper course of pregnancy, whereas the establishing of the increased isooxytocinase level signals the coming labor. All the earlier reductions of this particular increase of oxytocinase level, especially its stabilization or de crease testifies possible fetal distress. This regularity has been verified also in pregnancies complicated with dia betes or hypertension, the ones that are often combined with earlier termination of pregnancy [9, 13], It should be emphasized that in healthy women the con tinuous increment of blood oxytocinase level until labor is observed in 81 % of cases, its stoppage or decrease on sev eral days before labor - in 12%, and irregular, variable pro file - only in 7%. In patients suffering from diabetes or hypertension this percentage tends to behave in an oppo site way and they equal to 26.7%, 26.7%, 46.7% and 16%, 24%, 60%, respectively [9], This remains coherent with the statement that in pregnant women, threatened with mis carriages or premature deliveries, the enzyme values are still lower, though the ACTH-therapy in such cases enables the successful outcome of pregnancy. The substitutive ACTH-therapy, introduced in the 60s - led to the fact that instead of intrauterine fetal deaths observed in 80% of pregnancies in women with hypothalamic syndrome, now adays, the survival of such infants amounts to above 90% [12, 13, 15]. The clinical application of ACTH as the optional treaatment in hypothalamic insufficiency syn drome has appeared gradually very useful in preventing the premature labors or neonatal respiratory distress. Oxytocinase determination can provide an example, illustrating the proper interpretation of the obstetrical data. The average value of oxytocinase for mature fetuses, normally born after spontaneous onset of labor is 9.1 ± 2.0 pmol/l/min (I.U.) which comprises the results of the enzymatic determination from 37°/7 to 43 Vi weeks of the calendar scale of pregnancy duration.
Gestational Age and Assessment with Ultrasound
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/16/2019 11:48:12 PM
Introduction
Fig. 1. Mean values of oxytocinasemia and their standard devi ations throughout advanced gestation. Fig. 2. Oxytocinasemia average increase since 28th calendar week for calendar (28-43) gestational age.
Fig. 3. Mean oxytocinasemia increases for biological ( 15-0) and calendar (28-43) gestational ages. Fig. 4. Prediction of confinement using biological-calendar scale for oxytocinase measurements.
Figure 1 presents the calendar scale from 24% to 432/7 weeks of pregnancy and the relationship to the average values and the two standard deviations which signify bio logical maturity of the fetus or pregnancy. Week intervals are marked on the axis of abscissae, the axis of ordinates includes the analyzed values, and the range of biological norm comprising ± 2 standard deviations (SD) from the average characteristic for these measurements. The average values for the 24% week and their ± SD indicate the ranges of correct values that during the subse quent weeks become connected with the enzyme values concerning mature fetuses. The diagram shows that be ginning from the 28th week, the average oxytocinase increase is linear in character. Apart from the line that links the average value of the 28th week with the middle of the calendar norm, the lines connecting it with the beginning and end of the normal range are equally impor tant (Fig. 2). In order to facilitate the reading of this calendar-biolo gical scale (28% -43%) and especially the delivery term
prediction, a graduation regarding the pregnancy biologi cal age before labor (22-0 weeks) has been added (fig. 3). The average value for the labor day at the end of the deliveries norm, has been linked with the lines that deter mine the increase of the analyzed value for the children that reach the average at the beginning, in the middle and at the end of the calendar norm, separately. In case of oxy tocinase their regression equations are as follows: y = 0.4x -6.6; y = 0.5x -10.6; y = 0.6x -17.1. Making use of both scales (Fig. 3) we can apply the cho sen oxytocinase value, e.g. 5.0 I.U. either to the range of the 305/7-32% calendar weeks or to the biological age from 10th to 6th week before labor. After two weeks the subsequent measurement, e.g. 6.5 I.U. depicts the pro gress of pregnancy (33%-36% calendar weeks and 7-4 biological weeks) in a more precise way and predicts that the probable labor term will take place after the passing of 4 weeks, taken into account the speed of enzyme increase (Fig. 4).
161
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/16/2019 11:48:12 PM
4
6
8
Fig. 5. Fetal growth for biological-calendar scale. Fig. 6. Prediction of confinement using biological-calendar scale
for HC measurements. Fig. 7. Prediction of confinement using biological calendar scale for FL measurements. Fig. 8. Prediction of confinement using biological-calendar scale for BPD measurements. Fig. 9. Prediction of confinement using biological-calendar scale for AC measurements.
162
Klimck/Klimek
9
ference, the biparietal diameter and the length of femur bone, benable the proper interpretation of the ultrasono graphic results.
Conclusions
The biological-calendar scale, introduced to evaluate the pregnancy development comprises and links both the enzymatic and ultrasonographic data. Assuming the 28th week of pregnancy duration to indicate the beginning of
Gestational Age and Assessment with Ultrasound
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 1/16/2019 11:48:12 PM
Biological Scales for Ultrasound Prediction o f Term The existence of high correlation between the oxytocinase level and the fetus weight is commonly known [3, 12, 14], Therefore, the diagram identical to the one presented in figure 3 have been related by M. Klimek [9] to the clas sical description of the linear increase of the body weight and length of the unborn children since 28 weeks of preg nancy duration (fig. 5). The following figures: 6-9, showing the biological and calendar scales which include or own experience and text book diagrams of the infant’s head and abdomen circum
Gestational age, weeks
the linear increase of the fetus’ body weight and volume, the lines of the quickest and slowest increase of the aver age values can be marked on the same diagram. The shifting of the end of the biological scale (0) to the end of the calendar scale (43rd week) enables the time evaluation of both the child's maturation for labor, as well as the pregnancy duration from the last menstrual period until the end of normal births range, i.e. 43 Vi weeks. Almost all ultrasound scales heretofore useful only for 50% of deliveries, as usually encompassing range of 40 weeks - have to be lengthened. On the other hand, being aware of the values of ultrasonographic measurements, it is possible to evaluate the independent enzymatic results in order to recognize or exclude the influence of the mother’s neurohormonal condition. The step of the in
crease in the values on the biological scale is the decisive one. The enzymatic and ultrasonographic monitoring of pregnancy and predicting the birth date and course of delivery constitutes one of the lasting achievements of contemporary obstetrics. Enzymes reflect the biological state of the mother, the child and the placenta - the three being inseparable until the labor components of pregnan cy, whose features are imaged and measured by ultraso nography. That is why neglecting of any basic clinical exa minations, starting at least from the 37th calendar week of pregnancy on the one hand and induction of labor solely on the basis of calendar gestational age, on the other hand - is unacceptable from the medical, statistical and ethical points of view!
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