54
bined ventilation/perfusion lung scans after abdominal surgery suggests that up to 18% of patients with calf-vein thrombosis have small emboli.26 Although the T.R.c.H.i.i. levels were above 40 µg. per ml. in all patients with emboli, the increase was transient, and in only two would there have been any prior warning of the episode. Thus, the relatively prolonged rise in FgE levels would be much superior to the rise indicated by T.R.c.H.i.i. as a guide to the need for other investigations. It would be of great interest to know whether the value of FgE determination in the prediction of pulmonary embolus after major hip surgery extends to other surgical procedures. There is evidence that the " background F.D.P. noise " varies with the amount of local fibrinolysis at the site of operation, and is relatively low after less traumatic procedures such as abdominal surgery.’,- Under these circumstances, it may be anticipated that distinction between " normal " postoperative subjects and those at specific risk of embolus would be considerably greater than that reported here, although the frequency of thromboembolism would be less. It seems that the routine performance of FgE determination in the postoperative period might provide a valuable screening test for the prediction of serious thromboembolic episodes. The procedure is simple, cheap, and offers little inconvenience to either patient or staff. Although false-positive results are likely, this is not an important problem because a raised FgE is an indication for further investigations rather than for immediate and potentially hazardous
therapy. Y. B. G. is in receipt of a Blair-Bell memorial fellowship from the Royal College of Obstetricians and Gynaecologists. This project was supported by the British Heart Foundation
(award no. 532). Requests for reprints should be addressed to E. D. C., Postgraduate Institute, Hackney Hospital, London E9 6BY. REFERENCES 1. 2. 3.
4.
5. 6. 7.
8. 9. 10. 11. 12. 13. 14.
15. 16. 17.
18. 19.
J., Hillman, F., Charnley, J. Centre for Hip Surgery, Crawford, Wrightington Hospital, Internal Publications no. 14, 1968. Evarts, C. M., Feil, A. J. J. Bone Jt Surg. 1971, 53, 1271. Hampson, W. G. J., Harris, F. C., Lucas, H. K., Roberts, P. H., McCall, I. W., Jackson, P. C., Powell, N. L., Staddon, G. E. Lancet, 1974, ii, 795. Coventry, M. B., Declan, R. N., Beckinbaugh, R. D. J. Bone Jt Surg. 1973, 55, 1487. Sevitt, S. Am. J. Med. 1962, 33, 703. Morrell, M. T., Dunnill, M. S. Br. J. Surg. 1968, 55, 347. Ruckley, C. V., Das, P. C., Leitch, A. G., Donaldson, A. A., Copland, W. A., Redpath, A. T., Scott, P., Cash, J. D. Br. med. J. 1970, iv, 395. Wilson, J. E., Frankel, E. P., Pierce, A. K., Johnson, R. L., Winga, E. A., Curry, G. C., Mierzewiak, D. S.J. clin. Invest. 1971, 50, 474. Sonnabend, D., Cooper, D., Fiddes Penny, E. Pathology, 1972, 4, 47. Wood, E. H., Prentice, C. R. N., McNicol, G. P. Lancet, 1971, i, 166. Rickman, F. D., Handin, R., Howe, J. P., Alpert, J. S., Dexter, L., Dalen, J. E. Ann. intern. Med. 1973, 79, 664. Todd, A. S. J. Path. Bact. 1959, 78, 281. Ratky, Susan M., Martin, Marion J., Gordon, Y. B., Baker, L. R.I., Leslie, J., Chard, T. Br. J. Hœmat. 1975, 30, 147. Cooke, E. D., Pilcher, M. F. Br. med. J. 1973, ii, 523. Cooke, E. D., Pilcher, M. F. Br. J. Surg. 1974, 61, 971. Merskey, C., Kleiner, G. J., Johnson, A. J. Am. J. clin. Path. 1966, 55, 452. Gordon, Y. B., Martin, M. J., Landon, J., Chard, T. Br. J. Hœmat. 1975, 29, 87. Thomas, M. Lea, McAllister, V., Tonge, K. Clin. Radiol. 1971, 22, 490. Williams, W. J. Circulation, 1973, 47, 220. W.
SERIAL DETERMINATIONS OF HUMAN PLACENTAL LACTOGEN IN THE MANAGEMENT OF DIABETIC PREGNANCY N. G. SOLER
J. M. General
H. O. NICHOLSON MALINS
Hospital, Birmingham, and Birmingham Maternity Hospital
Serial human placental lactogen (H.P.L.) determinations were carried out in 98 diabetic women during the third trimester of pregnancy. H.P.L. levels were consistently higher than those in normal pregnant women. When were classified to the according patients severity of their diabetes (White classification), no significant differences in H.P.L. were detected between groups. Changes in blood-sugar during the day did not affect H.P.L. readings, and insulin requirements during pregnancy could not be related to H.P.L. levels. 10 pregnancies ended in fetal death, and in 4 of them H.P.L. levels were persistently below 4 µg. per ml. Of these 4 infants only 1, whose intrauterine death remains unexplained, could have been saved, 2 having fatal malformations and another infant having died during an episode of maternal ketoacidosis. Among the 6 unsuccessful pregnancies in which H.P.L. levels were >4 µg. per ml., congenital malformations accounted for 5 losses and hyaline-membrane disease for a single neonatal death. These results indicate that H.P.L. determinations probably have a very limited role in the successful management of diabetic pregnancy.
Summary
Introduction SEVERAL diabetic centres have reported an improvein the outcome of diabetic pregnancy, but even so perinatal mortality remains at least four times higher among infants of diabetic mothers than among infants born to normal women.’ Any technique which promises to identify the fetus at risk and to reduce perinatal mortality should therefore be investigated. The main aim of the present study was to value of serial human investigate the placental lactogen (H.P.L.) determinations in the management of diabetic pregnancy and to find out whether these measurements could be used to reduce perinatal ment
predictive
mortality. Patients and Methods This study was carried out between 1971 and 1974 and includes 98 pregnant women with diabetes of all Serial H.P.L. determinations were degrees of severity.
Suprenant, E. L., Webber, M. N., Bennett, L. R. J. appl. Radiat. Isotopes, 1969, 20, 77. 21. Ratnoff, O. D. Pulmonary Thromboembolism (edited by K. M. Moser and M. Stein); p. 3. Chicago, 1973. 22. Negus, D., Pinto, P. J., Le Quesne, L. P., Brown, M., Chapman, M. Br. J. Surg. 1968, 55, 835. 23. Miller, W. T., Smith, J. F. B. Lancet, 1974, ii, 695. 24. Kempi, V., van der Linden, W., von Scheele, C. Br. med. J. 1974, iv, 748. 25. Butler, M. J., Gordon, Y. B., Irving, M. H., Sola, C. M., Chard, T. Unpublished. 26. Browse, N. L., Clemenson, G., Croft, D. N. Br. med. J. 1974, i, 603. 20.
55
weekly or fortnightly intervals in the third At clinic attendances a venous blood-sample was withdrawn from patients between 9 and 10 A.M. for blood-glucose and also for H.P.L. determinations. When patients were admitted to hospital the same procedure was followed up to the time of delivery. To assess the influence of variations in blood-sugar on the H.P.L. level, women in the third trimester of pregnancy who had been admitted to hospital for the final phase before delivery had venous blood sampled at 9 A.M., 11.30 A.M., and 5.30 P.M. Each sample was analysed for blood-glucose and H.P.L. H.P.L. was determined using the Amersham radioimmunoassay kit. Each sample was analysed in duplicate and specimens giving high and low H.P.L. readings were
performed
at
trimester.
II-H.P.L. LEVELS IN DIABETIC WOMEN IN RELATION TO INCREASE IN INSULIN REQUIREMENTS DURING PREGNANCY
TABLE
TABLE III—H.P.L. VARIATION IN RELATION TO CHANGING BLOODSUGAR LEVELS
analysed separately. Blood-glucose was determined using the Hoffman ferricyanide method2 on an ’‘ AutoAnalyzer’. Results Five hundred and two H.P.L. determinations were in 98 diabetic pregnant women (table i).
performed
could be TABLE I-H.P.L. IN DIABETIC WOMEN IN DIFFERENT WHITE CLASSES
determined, despite careful examination
at
necropsy. Toxaemia did not feature in the list of 3 of the stillbirths and 1 of the causes of death. neonatal deaths were associated with H.P.L. levels
bined ventilation/perfusion lung scans after abdominal surgery suggests that up to 18% of patients with calf-vein thrombosis have small emboli.26 Although the T.R.c.H.i.i. levels were above 40 µg. per ml. in all patients with emboli, the increase was transient, and in only two would there have been any prior warning of the episode. Thus, the relatively prolonged rise in FgE levels would be much superior to the rise indicated by T.R.c.H.i.i. as a guide to the need for other investigations. It would be of great interest to know whether the value of FgE determination in the prediction of pulmonary embolus after major hip surgery extends to other surgical procedures. There is evidence that the " background F.D.P. noise " varies with the amount of local fibrinolysis at the site of operation, and is relatively low after less traumatic procedures such as abdominal surgery.’,- Under these circumstances, it may be anticipated that distinction between " normal " postoperative subjects and those at specific risk of embolus would be considerably greater than that reported here, although the frequency of thromboembolism would be less. It seems that the routine performance of FgE determination in the postoperative period might provide a valuable screening test for the prediction of serious thromboembolic episodes. The procedure is simple, cheap, and offers little inconvenience to either patient or staff. Although false-positive results are likely, this is not an important problem because a raised FgE is an indication for further investigations rather than for immediate and potentially hazardous
therapy. Y. B. G. is in receipt of a Blair-Bell memorial fellowship from the Royal College of Obstetricians and Gynaecologists. This project was supported by the British Heart Foundation
(award no. 532). Requests for reprints should be addressed to E. D. C., Postgraduate Institute, Hackney Hospital, London E9 6BY. REFERENCES 1. 2. 3.
4.
5. 6. 7.
8. 9. 10. 11. 12. 13. 14.
15. 16. 17.
18. 19.
J., Hillman, F., Charnley, J. Centre for Hip Surgery, Crawford, Wrightington Hospital, Internal Publications no. 14, 1968. Evarts, C. M., Feil, A. J. J. Bone Jt Surg. 1971, 53, 1271. Hampson, W. G. J., Harris, F. C., Lucas, H. K., Roberts, P. H., McCall, I. W., Jackson, P. C., Powell, N. L., Staddon, G. E. Lancet, 1974, ii, 795. Coventry, M. B., Declan, R. N., Beckinbaugh, R. D. J. Bone Jt Surg. 1973, 55, 1487. Sevitt, S. Am. J. Med. 1962, 33, 703. Morrell, M. T., Dunnill, M. S. Br. J. Surg. 1968, 55, 347. Ruckley, C. V., Das, P. C., Leitch, A. G., Donaldson, A. A., Copland, W. A., Redpath, A. T., Scott, P., Cash, J. D. Br. med. J. 1970, iv, 395. Wilson, J. E., Frankel, E. P., Pierce, A. K., Johnson, R. L., Winga, E. A., Curry, G. C., Mierzewiak, D. S.J. clin. Invest. 1971, 50, 474. Sonnabend, D., Cooper, D., Fiddes Penny, E. Pathology, 1972, 4, 47. Wood, E. H., Prentice, C. R. N., McNicol, G. P. Lancet, 1971, i, 166. Rickman, F. D., Handin, R., Howe, J. P., Alpert, J. S., Dexter, L., Dalen, J. E. Ann. intern. Med. 1973, 79, 664. Todd, A. S. J. Path. Bact. 1959, 78, 281. Ratky, Susan M., Martin, Marion J., Gordon, Y. B., Baker, L. R.I., Leslie, J., Chard, T. Br. J. Hœmat. 1975, 30, 147. Cooke, E. D., Pilcher, M. F. Br. med. J. 1973, ii, 523. Cooke, E. D., Pilcher, M. F. Br. J. Surg. 1974, 61, 971. Merskey, C., Kleiner, G. J., Johnson, A. J. Am. J. clin. Path. 1966, 55, 452. Gordon, Y. B., Martin, M. J., Landon, J., Chard, T. Br. J. Hœmat. 1975, 29, 87. Thomas, M. Lea, McAllister, V., Tonge, K. Clin. Radiol. 1971, 22, 490. Williams, W. J. Circulation, 1973, 47, 220. W.
SERIAL DETERMINATIONS OF HUMAN PLACENTAL LACTOGEN IN THE MANAGEMENT OF DIABETIC PREGNANCY N. G. SOLER
J. M. General
H. O. NICHOLSON MALINS
Hospital, Birmingham, and Birmingham Maternity Hospital
Serial human placental lactogen (H.P.L.) determinations were carried out in 98 diabetic women during the third trimester of pregnancy. H.P.L. levels were consistently higher than those in normal pregnant women. When were classified to the according patients severity of their diabetes (White classification), no significant differences in H.P.L. were detected between groups. Changes in blood-sugar during the day did not affect H.P.L. readings, and insulin requirements during pregnancy could not be related to H.P.L. levels. 10 pregnancies ended in fetal death, and in 4 of them H.P.L. levels were persistently below 4 µg. per ml. Of these 4 infants only 1, whose intrauterine death remains unexplained, could have been saved, 2 having fatal malformations and another infant having died during an episode of maternal ketoacidosis. Among the 6 unsuccessful pregnancies in which H.P.L. levels were >4 µg. per ml., congenital malformations accounted for 5 losses and hyaline-membrane disease for a single neonatal death. These results indicate that H.P.L. determinations probably have a very limited role in the successful management of diabetic pregnancy.
Summary
Introduction SEVERAL diabetic centres have reported an improvein the outcome of diabetic pregnancy, but even so perinatal mortality remains at least four times higher among infants of diabetic mothers than among infants born to normal women.’ Any technique which promises to identify the fetus at risk and to reduce perinatal mortality should therefore be investigated. The main aim of the present study was to value of serial human investigate the placental lactogen (H.P.L.) determinations in the management of diabetic pregnancy and to find out whether these measurements could be used to reduce perinatal ment
predictive
mortality. Patients and Methods This study was carried out between 1971 and 1974 and includes 98 pregnant women with diabetes of all Serial H.P.L. determinations were degrees of severity.
Suprenant, E. L., Webber, M. N., Bennett, L. R. J. appl. Radiat. Isotopes, 1969, 20, 77. 21. Ratnoff, O. D. Pulmonary Thromboembolism (edited by K. M. Moser and M. Stein); p. 3. Chicago, 1973. 22. Negus, D., Pinto, P. J., Le Quesne, L. P., Brown, M., Chapman, M. Br. J. Surg. 1968, 55, 835. 23. Miller, W. T., Smith, J. F. B. Lancet, 1974, ii, 695. 24. Kempi, V., van der Linden, W., von Scheele, C. Br. med. J. 1974, iv, 748. 25. Butler, M. J., Gordon, Y. B., Irving, M. H., Sola, C. M., Chard, T. Unpublished. 26. Browse, N. L., Clemenson, G., Croft, D. N. Br. med. J. 1974, i, 603. 20.
55
weekly or fortnightly intervals in the third At clinic attendances a venous blood-sample was withdrawn from patients between 9 and 10 A.M. for blood-glucose and also for H.P.L. determinations. When patients were admitted to hospital the same procedure was followed up to the time of delivery. To assess the influence of variations in blood-sugar on the H.P.L. level, women in the third trimester of pregnancy who had been admitted to hospital for the final phase before delivery had venous blood sampled at 9 A.M., 11.30 A.M., and 5.30 P.M. Each sample was analysed for blood-glucose and H.P.L. H.P.L. was determined using the Amersham radioimmunoassay kit. Each sample was analysed in duplicate and specimens giving high and low H.P.L. readings were
performed
at
trimester.
II-H.P.L. LEVELS IN DIABETIC WOMEN IN RELATION TO INCREASE IN INSULIN REQUIREMENTS DURING PREGNANCY
TABLE
TABLE III—H.P.L. VARIATION IN RELATION TO CHANGING BLOODSUGAR LEVELS
analysed separately. Blood-glucose was determined using the Hoffman ferricyanide method2 on an ’‘ AutoAnalyzer’. Results Five hundred and two H.P.L. determinations were in 98 diabetic pregnant women (table i).
performed
could be TABLE I-H.P.L. IN DIABETIC WOMEN IN DIFFERENT WHITE CLASSES
determined, despite careful examination
at
necropsy. Toxaemia did not feature in the list of 3 of the stillbirths and 1 of the causes of death. neonatal deaths were associated with H.P.L. levels
