De Villiers, J.N.

Slabber, C.F.

Van Heerden, P.D.R.

English

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22 ovember 1969 S.A. TVDSKRIF VIR OBSTETRIE E GI EKOlOGIE 29haematocrit values of the blood at regular interval.2. The patients complained of no symptoms referableto Ihe polycythaemia. Hypertension was not a constantfeature.3. As opposed to polycythaemia vera, there is no in-crea e in the leucocyte or platelet count and no spleno-megaly. This is important from the operative point ofview because if there was any evidence of thrombocytosis.the ever-present fear of postoperative thrombosis andconsequent pulmonary embolism would be present.4. Should the condition be recognized pre-operatively,it might be useful-as some authors have done-to bleedthe patient pre-operatively, store the blood and administerit again during or after the operation should bleedingbecome excessive. Menzies'· is of the opinion that to givewhole blood during or immediately after the operation isdangerous. If blood volume has to be restored, plasmatransfusion is the method of choice.SUMMARYA case of polycythaemia associated with uterine fibroids hasbeen presented. The condition is rare and to date only 14 caseshave been reported. The polycythaemia is usually secondary,and differs from polycythaemia vera in that a panmyelopathydoes not occur. Various theories regarding the pathogenesishave been put forward. After hysterectomy. the polycythaemiausually disappears.We wish to thank Or G. Elliot, Medical SuperintendeD! ofCoronation Hospital, for permission to publish.REFERE 'CEI. lllOmson. A. P. and Marson. F. G. W. (1953): Lancet, 2, 759.2. De Gruchy. G. C. (1964): Clinical HlU'marology in Medical Proclire.2nd ed. Oxford: Blackwell Scientific Publications.3. Damon, A. and Holub, D. A. (1958): Ann. Intern. Med .. 49. 43.4. Babuna. c.. Gardner, G. H. and Greene. R. R. (1959): Amcr. JObstet. Gynec.. 77. 424.5. Cohen, M. and Rothenberg. S. P. (1962): Obstet. and Gynec.. 19. ':16.6. Engel. H. W. and Singer. K. (1955): J. Amer. Med. Assoc.. 159. 190.7. Flemin~. A. R. and Markley. J. C. (1957): Amer. J. Obstet. Gyncc.74. 677.Horwitz. A. and McKelway, W. P. (1955): J. Amer. Med. Assoc ..158. 1360.9. Laurin. J. G.. Girard. Y., Gauthier, G. and Leduc. P. E. (1960):Canad. Med. Assoc. J .. 83, 318.10. Menzies. D. N. (1961): J. Obstet. Gynaec. Brit. Cwlth, 68, -0.11. Paranjothy. D. and Vaish. S. K. (1967): Ibid., 74, 603.12. Rothman, D. and Rennard, M. (1963): Obstet. and Gynec .. 21. 111213. SingmaSlcr. L. (1957): J. Amer. Med. Assoc., 163, 36.14. Zilliacus. H. (1959): Acta obstet. gynec. scand.. 38. 737.15. Van den Berg, A. R. and Vasu. C. M. (1963): J. Amer. Med. As",,: ..185. 249.16. Penington. D. G. (1965): Proc. Ro)". Soc. Med.. 58. 4PLACENTAL LOCALIZATION USING lNDIUM-113,,*c. F. SLABBER, M. MED. (STELL.), J. N. DE VILLlERS, M.O. & G. (CAPE TOWN), F.R.C.O.G. ADP. D. R. VAN HEER-DEN, M.D. (STELL.), Departments of Obstetrics and Gynaecology alld Medicine, University of Stel/enbosch andKar/ Bremer Hospital, Bel/vil/e, CP[n J950 Browne and Veall' reported the use of radioactivesodium to localize the placental blood pool. Because ofthe rapid diffusion and excretion of the radioactivesodium, it was substituted by radioactive iodinatedhuman serum albumin (RISA). The albumin was labelledwith various isotopes of iodine, ego mr'· and 1321.". Ery-throcytes labelled with "Cr were also used.'" With theuse of these radio-isotopes point-count localization of theplacenta is possible. In point-count localization the count-ing rates are recorded graphically on a strip of paper andonly a gross estimation of the size and position of theplacenta is provided. This method is not reliable in caseswhere the placenta is situated symmetrically on the pos-terior uterine wall.'·· Some difficulty is also experiencedin deciding whether the placenta is situated on theanterior or posterior wall.' Because amniocentesis is soimportant in the management of rhesus iso-immunizationwe are no longer merely interested in whether or notthe placenta encroaches on the lower segment; accuratelocalization is required to prevent further transplacentalimmunization.In 1964 McAfee and his colleagues'· introduced auto-matic scintillation scanning using ""technetium-labelledhuman serum albumin for the localization of the placen-tal blood pool. This method immediately became popular,and numerous papers produced evidence of the accuracyof the results."·'·In 1966 Stern et JJ.1.~' introduced -a new nucli<le -suitablefor localization of the placental blood pool-"nlindium.This nuclide has certain definite advantages, includingease of preparation and a long half-life of the parentnuclide.•Date received: 20 1arch 1969.MATERIALS A 0 METHODThe parent nuclide of "'''indium IS '''tin with a half-lifeof J 18 days.The preparation of "'''indium i essentially a simpleprocedure requiring 30 minutes. The l13>l indium is elutedfrom a "'Sn - "'MIn generator by the addition of 8 m!.dilute hydrochloric acid (pH 1'3). To this eluate one milli-litre of sodium chloride is added. By the further additionof dilute NaOH the mixture is then titrated to pH 3·4.This mixture is sterilized by autoclaving at IS Ib.jsq.in.(1'05 kg.jsq.cm.) for 20 minutes. Regular tests u ing rab-bits are undertaken to exclude pyrogenic contamination.We do not add gelatin to stabilize the U3>' indium as ad-vocated by Wagner,'· as we have not found that thisomission adversely affects the resulting photoscans.Scanning ProcedureScintillation scanning is done using a Picker Magna-scanner 2806 with a 3 x 2 in. thallium-activated sodiumiodide crystal and a 19-hole· focusing collimator. Thepulse-height analyser is set at 350 - 420 kev. Scanning isdone at 120 cm.jmin. with a line spacing of 0·5 cm.The time constant has been set at one-eighth of a secondand the background cut-off at 20o~ of the maximumcount rate. Scanning is started 1 cm. below the midpointof the symphysis pubis.RESULTSA·total of 98 placental localizations were done. The indi-cations were rhesus iso-immunization in 4 ca es and ante-partum haemorrhage in 94 cases.In the 4 cases of rhesus iso-immunization a total of 9amniocenteses were done. Tn not a ingle case was bloodobtained during the procedure, although the placenta wassituated on the anterior uterine wall in all cases.30 S.A. JOURNAL OF OBSTETRICS A D GYNAECOLOGY :n ovember 1969The group of patients where the photoscan was donebecause of antepartum haemorrhage comprised 94patients. The diagnosis of placenta praevia on the photo-scan was based on the radiological studies of Nelp andLarson." They found the external cervical os 3·5 ± 0·7cm. above the midpoint of the symphysis pubis when thepatient was in the recumbent scanning position. Althoughthe position of the internal os will vary with the degree ofeffacement of the lower uterine segment, the internal oswas usually I - 2 cm. higher than the external os. In thelateral scanning projection the external cervical os was anaverage of 2·4 cm. cephalad to a line drawn from thegreater trochanter to the pubic symphysis. For orienta-tion we place a mark on the scan image directly over themidpoint of the symphysis pubis, over the greater tro-chanter, over the umbilicus and over the upper marginof the uterus. In some of our cases the anterior superioriliac spines are also marked. In most cases a placentapraevia can be excluded without any doubt (Fig. I). Webelieve that in all doubtful cases or cases where theplacental position is not clearly seen a lateral scan is mostuseful in confirming placental position and size (Figs. 2and 3). This is particularly applicable to cases where theplacenta is situated posteriorly or laterally.So far 71 patients have been delivered. In 45 cases theplacental position was diagnosed antepartum as not beingplacenta praevia. In each of these cases the placentapraevia was also excluded by vaginal examination intheatre at the time of induction of labour. This indicatesthe value of this procedure in excluding placenta praevia.In the remaining 26 patients the diagnosis of placentapraevia was made on the photoscan.Fig. J. Anterior photoscan at the 34th week of pregnancy. Placenta situated ,in thefundus. Markings placed over the midpoint of the symphysis pubis and over theumbilicus.22 Tovember 1969 S.A. TYDSKRIF VIR OBSTETRIE E GI EKOLOGIE 31tages:(i) A certain amount of manipulation of the patient isrequired, disqualifying this procedure in an actively bleed-ing patient.(ii) The Seldinger method of catheterization'" of thefemoral artery is technicaliy more difficult than a simplevenepuncture.(iii) One mu t bear in mind the pos ibility of iodinesensitivity.(h) Although the patient are usually relatively young,with normal healthy arteries, arterial complications mustbe expected.(1-) Arteriography is critically time dependent. A visi-ble roentgenographic image can only be obtained whenthe initial bolu of injected dye is pas ing through theplacental blood pool....Fig. 2. Anterior photoscan showing placental blood pool to be low-lying. Markingsover the midpoint of the symphysis pubis and anterior superior iliac spines.DISCUSSIOAlthough Law and Hartley" cou~d demonstrate the pla-cental site in 90 - 95°~ of cases with soft-tissue placento-graphy, an analysis of cases at Karl Bremer Hospitalshowed an error in diagnosi of at least 20o~ with soft-tis-sue placentography. '" A more accurate method for demon-strating the placental site was sought and in 1961 thetechnique of retrograde aortic placentography was intro-duced and very promising results were obtained." In aseries of 87 aortic placentograms no case of placentapraevia subsequently proved at caesarean section or vagi-nal examination under anaesthesia was missed radio-logically. Thi method entail certain definite di advan-If we summarize all the results ofradio-isotope placental localization incases of antepartum haemorrhage wefind that of the 94 photoscans, 64were diagnosed as not being placentapraevia. There were 45 diagnoses con-firmed as not being placenta praeviaby vaginal examination and 19 byretrograde aortic placentography.Thirty cases were diagnosed asplacenta praevia and the diagnosewere confirmed at caesarean sectiono~ by vaginal examination in 14; and by retrograde aorticplacentography (cases not delivered) in 3. There were 13diagnoses of placenta praevia that were not confirmed.in 12 patients a caesarean section wasdone, and the diagnosis of placentapraevia was contirmed at operation.In an additional 2 patients the pla-centa was felt with vaginal examina-tion in theatre. These patientsdelivered vaginally, because the degreeof placenta praevia was a minor one.In the other 12 patients the diagnosisof placenta praevia on the photoscancould not be confirmed by vaginalexamination. However, minor degreesof placenta praevia are difficult tofeel on vaginal examination. In 9 ofthe 12 patients retrograde aorticplacentography had also been doneand in 6 of these cases this latter ex-amination also showed a placentapraevia.In all of the remammg 23 patientswith antepartum haemorrhage whohave not yet delivered, a photoscanand retrograde aortic placentographyhave been done. In 19 patients theplacenta was situated in the uppersegment of the uterus with bothtechniques. In 3 patients according toboth techniques the diagnosis ofplacenta praevia was made. The oneremaining patient was diagnosed asplacenta praevia on the photoscan,but this diagnosis could not be con-firmed by retrograde aortic placento-graphy.32 S.A. JOUR AL OF OBSTETRICS AND Gy AECOLOGY 22 oyember 1969""Technetium is available, but wedecided to use IIn'indium, because ithas certain definite advantages: The'''Sn - 1I31n generator has a half-life of118 days, whereas the ""Mo - "'''Tcgenerator has a half-life of 67 hours.Hecause of the long half-life the gene-rator can be replaced every 6 monthsinstead of the weekly replacement ofthe ""Mo - """Tc generator. Because ofthe geographical remoteness of theRepublic of South Africa from thecentres producing these isotopes thelonger half-life generator eliminatesmany of the problems and costs oftransportation.Urinary excretion of IIn'indium isminimal (0'08 - 0,( %)." This eliminatescontinuous bladder drainage which isadvised when using "J"technetium.The preparation of ""'indium is essen-tially a simple procedure requiring 30minutes. Preparation of 99>lTc-labelledhuman serum albumin is a laboriousprocedure requiring a full hour."Because of the simplicity of prepara-tion there is less danger of contamina-tion with pyrogenic substances whenusing 113>'ln.The preparation of choice musthave a short half-life to diminish theradiation dosage to the patient. 113>'ln_dium has a physical half-life of 1·7hours and emits a mono-energeticphoton with energy of 390 kev., whichis suitable for most of the availableapparatus."Placental transfer of "3>'ln is mini-mal, and the radiation received byboth mother and foetus is of an ex-tremely low order."A few incidental references to theuse of ""'indium for placental locali-zation have appeared in the litera-ture."''''''Fig. 3. Lateral photoscan of patient shown in Fig. 2. The placental blood pool islow-Iyjng and on the anterior uterine wall. Markings over the umbilicus, the mid-point of the symphysis pubis, the greater trochanter and the anterior superior iliacspine.SUMMARYWith the use of 1I3",indium exclusion of a placenta praevia isextremely reliable. However. in the positive diagnosis ofplacenta praevia there is probably an element of over-diagnosiswhen confirmation is sought by vaginal examination. Thesecases are essentially low-lying placentas as confirmed by simul-taneous retrograde aortic placentography.We wish to thank Dr R. L. M. Kotze, Superintendent ofKarl Bremer Hospital, for permission to publish this article.REFERE CESI. Browne. J. C. McC. and Yeall. (1950): J. Ohstet. Gynaec. Brit.Emp., 57. 566.2. Hibbard. B. M. (t961): J. Obstet. Gynaec. Brit. Cwlth. 68. 481.3. Te Groen. F. W .. Jansen. C. R.. Van der Merwe, C. J. and Gelden-huys, F. G. (1965): S. Afr. J. Obstet. Gynaec .. 3. 46.4. Weinberg, A., Rizzi. J .. McManus. R. and Rivera. J. (1957): Obstet.and Gynec., 9. 692.5. Hibbard. B. M. and Herbert. R. J. T. (1960): C1in. Sei .. 19. 337.6. Pool. K. R. S .. Leach, K. G. and Hawkins. L. A. (1965): J. Ohs,et.Gynaec. Brit. Cwlth, 72. 706.7. Paul. J. D.. Gahres. E. E.. Albert. S. .. Terrell, W. D. and Dodek,S. M. (1963): Ohstet. and Gynec.. 21. 33.8. Yrettos, A. S., Megapanos, E., Costamis, P. and Binopoulos, D.(1965): Amer. J. Ohstet. Gynec., 93, 957.9. Shanabrook, D. W. (1966): Ohio St. Med. J .. 62, 677.10. McAfee, J. G., Stern. H. A., Fueger. G. F., Boggish, M. S.. Holzman,G. B. and Zolle, I. (1964): J. Nucl. Med., 5. 936.11. Larson, S. M. and Nelp, W. B. (1965): Amer. J. Obstet. Gynec.,93. 950.12. Walker, R. H. S. and Kohorn, E. I. (1968): 1. Obstet. Gynaec. Brit.Cwlth, 75, 464.13. Pieterse, P. J., Lotter. M. G. and Den Hartog, L. J. (1966): S. Afr.J. Ohstet. Gynaec.. 4. 87.14. Sonnendecker, E. W. W .. Du Toit, D. and Jansen, C. R. (1967):Ibid., 5. 35.15. Stern. H. S., Goodwin, D. A .. Wagner, H. . and Kramer, H. H.(1966): ucleonics, 24. 57.16. Wagner, H. '. (1968): Prillciples of Nuclear Medidlle. Philadelphia:W. B. Saunders Co.17. elp, W. B. and Larson. S. M. (1967): J. Amer. Med. Assoc .. 200.148. .1 . Law. R. G. and Hartley, J. B. (1959): Proc. Roy. Soc. Med., 52. 557.19. Basson, J. M. M. and De Villiers. J. . (1963): Clin. Radiol.. 14, 230.20. Seldinger, S. I. (1953): Acta radial. (Stockh.), 39. 368.21. Van der Merwe. E. J .. Letter, M. G .. Van Heerden. P. D. R ..Slabber. C. F. and Bester, J. (1969): J. ucl. Med. (in the press).22. Potchen, E. J., Adatepe, M .. Welch. M .. Archer. E. and Studer. R.(196): J. Amer. Med. Assoc .. 205. 20 .23. Stern, H. S.. Goodwin, D. A., Sehelfel, U .. Wagner, H. andKramer, H. H. (1967): Nucleonics. 25. 62.

Placenta localization using Indium-113

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Placenta localization using Indium-113

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