Canad. Med. A s s . J .

1064 FERRON A ND BILODEA U: TEST FOR RUPTURED MEMBRA NES Nov.28 19 63 , vol .89
A m ni ot i c Fl u i d Cr y s t al l i z at i on Tes t f or Ru p t u r ed Mem b r anes
MA RCEL FERRON, M.D., . F.I.C.S., F.A .C.O.G .* and
ROLLA ND BILODEA U, M.D., t Mont r eal
A BSTRA CT
A s i m p l e and i nex p ens i ve t es t i s des c r i b ed
w h i c h p er m i t s p os i t i ve i dent i f i c at i on of
am ni ot i c f l u i d b y i t s f er n- t y p e c r y s t al l i z a-
t i on. It p er m i t s a r ap i d and c er t ai n di f f er -
ent i al di ag nos i s b et w een l eu k or r h ea, h y dr or -
r h ea, u r i nar y i nc ont i nenc e and s p ont aneou s
am ni ot om y . Th e c r y s t al l i z at i on t e:s t w as
s h ow n t o b e m os t r el i ab l e and t h e f ew
s ou r c es of er r or ar e eas i l y avoi ded. Th e
t es t i s i nh i b i t ed b y c el l u l ar deb r i s or b l ood
w h en i t i s i n a c onc ent r at i on g r eat er t h an
1:10. Cent r i f u g at i on p er m i t s t h e r eap p ear -
anc e of f er n- l eaf c r y s t al l i z at i on. Th e t y p i c al
i m ag e r es em b l es t h at of t h e c r y s t al l i z at i on
of c er vi c al m u c u s . H ow ever , am ni ot i c f l u i d
c r y s t al l i z es on t h e ent i r e s m ear , w h er eas
m u c u s c r y s t al l i z es i n a l i near f as h i on.
Cer vi c al m u c u s c r y s t al l i z at i on i s nor m al l y
ab s ent du r i ng p r eg nanc y . It m ay oc c u r i n
c as es of t h r eat ened ab or t i on. Th e au t h or s
h ave p er f or m ed t h e t es t i n c om b i nat i on w i t h
a ni t r az i n p ap er t es t i n a s er i es of 19 2
p at i ent s . In t h ei r h ands i t h as g i ven near l y
p er f ec t r es u l t s .
RESUME
II ar r i ve f r .q u em m ent q u ' on ai t .i f ai r e u n
di ag nos t i c p r 6c i s d' u n Sc ou l em ent vag i nal
s u b i t du r ant l a g r os s es s e. L' h i s t oi r e, V ex -
am en c l i ni q u e, et l e l ab or at oi r e p eu vent
ai der . f ai r e l e di ag nos t i c di f f & ent i el ent r e
l eu c or r h ee ab ondant e, h y dr or r h 6e, i nc ont i -
nenc e u r i nai r e ou r u p t u r e s p ont an6e des
m em b r anes .
Un nou veau t es t de l ab or at oi r e es t i c i
d6c r i t q u i p er m et u n di ag nos t i c s .r : l e t es t
de c r i s t al l i s .t i on du l i q u i de am ni ot i q u e.
Les f au x n6g at i f s s ont r ar es , i l s p eu vent
.t r e d.s au x d6b r i s vag i nau x et au s ang . La
c ent r i f u g at i on p er m et Ia r 6ap p ar i t i on du t es t
q u and i l y a t r op de s ang ou de c el l u l es .
Les f au x p os i t i f s p eu vent .t r e, df t s & l ' al -
b u m i nu r i e ou & l a c r i s t al l i s at on de Ia g l ai r e
c er vi c al e. Cet t e 6vent u al i t 6 es t Ia p l u s
p l au s i b l e. El l e es t h ab i t u el l em ent l a m ar q u e
du m u c u s de Ia p h as e p nSovu l at oi r e ou
annonc e l a m enac e d' avor t em ent .
Le t es t de c r i s t al l i s at i on as s oc i 6 au t es t
au p ap i er Ni t r az i ne a donn6 des r .s u l t at s
ex ac t s .i 9 8% et g r A c e A s a s i m p l i c i t 6 i i p eu t
.t r e u t i l e au s s i b i en au b u r eau et A Ia
c l i ni q u e q u ' A Ia s al l e de t r avai l .
FEBRON A ND BJ LODEA U: TEST FOR RUPTURED MEMBRA NES
1065 Canad. Med. A s s . J .
Nov. 23 , 19 63 , vol . 89
1066 FERRON A ND BILODEA U: TEST FOR RUPTURED MEMBRA NES
Fi g . 3 .- Cr y s t al l i z at i on of am ni ot i c f l u i d.
m u c i n, w h i c h i s dep endent u p on t h e es t r og en-
p r og es t er one h or m onal r el at i ons h i p . Th i s dep end-
enc e ex p l ai ns t h e var i at i on i n c er vi c al m u c u s du r i ng
t h e m ens t r u al c y c l e and al s o i t s ap p ear anc e du r i ng
p r eg nanc y i n c as es of t h r eat ened ab or t i on. Th er e
s eem s t o b e a h i g h er i nc i denc e of s p ont aneou s ab or -
t i on w h en t h e m u c u s s h ow s an ar b or i z at i on em anat -
i ng f r om a c l ear g r ou nd s u b s t anc e, l i t t l e m u c oi d
m at r i x , f ew c el l s and a di s t i nc t i ve i m ag e of c l ear
nu c l ei .9 - ' 1
A l t h ou g h c er vi c al m u c u s i s nor m al l y ab s ent
du r i ng p r eg nanc y , i t s c r y s t al l i z at i on i n t h e c er vi c al
f i l m m ay l ead t o a f al s e i nt er p r et at i on of am ni ot i c
f l u i d c r y s t al l i z at i on. Ex p er i enc e i n t h e i nt er p r et a-
t i on of t h e t es t , h ow ever , p er m i t s eas y di f f er ent i a-
t i on of t h es e s u b s t anc es . Cr y s t al l i z at i on of am ni ot i c
l i q u i d i nvol ves t h e ent i r e s m ear ( Fi g . 3 ) , w h er eas
t h at of c er vi c al m u c u s oc c u r s i n l i near b ands ( Fi g .
4) s ec ondar y t o i t s s t r i ng l i k e m ac r os c op i c nat u r e
( Sp i nnb ar k ei t ) .
W i t h k now l edg e of p os s i b l e s ou r c es of er r or , w e
c om b i ned t h e r es u l t s of t h e af or em ent i oned t es t
w i t h t h at of ni t r az i n p ap er i n a s t u dy of 19 2 f em al e
p at i ent s s een on t h e ob s t et r i c al s er vi c e of t h e
" H 6p i t al Mai s onneu ve" , Mont r eal ( Tab l e I) . Th er e
w er e 108 p os i t i ve s m ear s i ndi c at i ng am ni ot om y and
84 neg at i ve s m ear s .
Th e ni t r az i n t es t c ons i s t s of t h e i nt r odu c t i on i nt o
t h e vag i na of a s m al l p i ec e of ni t r az i n p ap er . It i s
Canad. Med. A s s . 3 .
Nov. 23 , 19 63 , vol . 89
( .i .0' .- C17s t ai l i z at i on of c er vi c al m u c u s i n l i near b ands
b as ed on t h e c h ang e oc c u r r i ng i n vag i nal p H du e
t o t h e al k al i ni t y of am ni ot i c f l u i d. Nor m al l y t h e
vag i nal p H i s ac i d du r i ng p r eg nanc y , b u t af t er
r u p t u r e of t h e m em b r anes i t m ay c h ang e f r om a
p H of 6 t o 8.1. It i s an ac c u r at e t es t , b u t a f al s e-
p os i t i ve r eac t i on m ay b e ob t ai ned i n t h e p r es enc e
of b l ood or s i g ni f i c ant vag i nal i nf ec t i on. It w as
p er f or m ed i n t h i s s t u dy t o c h ec k t h e ac c u r ac y of
t h e c r y s t al l i z at i on t es t w h i c h w as b ei ng u s ed f or
t h e f i r s t t i m e.
A l l of t h e p at i ent s des c r i b ed i n Tab l e I as p r i m i -
p ar as and m u l t i p ar as w er e p r eg nant at t h e t i m e
t h ey w er e i nc l u ded i n t h e t es t . Th e onl y p at i ent s
w h o w er e not p r eg nant ar e t h r ee of t h os e i nc l u ded
i n t h e c ol u m n h eaded " Fal s e Pos i t i ves " .
Fou r s m ear s s h ow ed c r y s t al l i z at i on of c er vi c al
m u c u s . In onl y one of t h es e f ou r w as t h e s p ec i m en
ob t ai ned f r om a g r avi d p at i ent . Th i s w om an w as
t h r ee m ont h s ' p r eg nant and w as f ol l ow ed u p
c l os el y , i n vi ew of p os s i b l e ab or t i on; s h e w ent on
t o t er m and del i ver ed s p ont aneou s l y . Th e ot h er
s m ear s w er e ob t ai ned du r i ng t h e c ou r s e of r ou t i ne
p os t p ar t u m p h y s i c al ex am i nat i ons .
Th e onl y f al s e p os i t i ve r es u l t oc c u r r ed af t er an
ap p ar ent l y s u c c es s f u l l y i ndu c ed am ni ot om y i n a
p at i ent w i t h 3 c m . c er vi c al di l at at i on. A t c om p l et e
di l at at i on t h e am ni ot om y h ad t o b e r ep eat ed. It
i s p os s i b l e t h at f ol l ow i ng t h e f i r s t at t em p t at am ni -
Canad. Med. A s s . J .
Nov. 23 , 19 63 , vol .89 FI.au .oN A ND BILODEA U: TEST FOR Ru Pr u Iu . MEMBRA NES 1067
TA BLE 1.- A MNIOTIC FLUID CRYSTA LLIZA TION TEST IN 19 2
FEMA LE PA TIENTS
POSITIV ES: 108
Pr i m i p ar as 55 Mu l t i p ar as 53
( ag es 17 t o 3 4 y ear s ) ( ag es 20 t o 41 y ear s )
Si t e of c ol l ec t i on Si t e of c ol l ec t i on
Di l at i on En4o- Endo-
of c er vi x For ni x c er vi x G l ove For r t i x c er vi x G l ove
0- 2c m ... 18 7 1 7 7 0
2- 5c m ... 15 0 0 15 0 13
5- 8c m ... 1 0 10 0 0 9
Tot al t r u e
p os i t i ves .52 51 = 103
FA LSE POSITIvES
Mu c u s : du r i ng p r eg nanc y .1
f ou r t h day p os t - m ens t r u al .1
s event h day p os t - m ens t r u al .2
ac t u al f al s e p os i t i ve.1
Tot al .5
%er r or .0.9 2
NEG A TIV ES: 84
Pr i m i p ar as 28 Mu l t i p ar as 56
Tr u e neg at i ves . . 27 55
Deb r i s . . 0 1
Fal s e neg at i ve. . 1 0
%er r or .1.2
ot om y , t h e f et al h ead s eal ed t h e ap er t u r e i n t h e
m em b r anes .
Th e onl y f al s e neg at i ve t es t oc c u r r ed at t h e b e-
g i nni ng of t h i s s t u dy w h en, b ec au s e of u nf ai ni l i -
ar i t y w i t h t h e t ec h ni q u e, t h e dr op of am ni ot i c
f l u i d w as s p r ead b y m eans of a c over s l i p , as i n
u r i nal y s i s . Th e s m ear w as t h en t oo t h i n f or c r y s t al -
l i z at i on t o t ak e p l ac e.
One ot h er neg at i ve s m ear w as ob t ai ned on a
s p ec i m en of b r ow ni s h , f ou l - s m el l i ng am ni ot i c f l u i d,
f r om a g es t at i on of 22 w eek s ; i n t h i s c as e f et al
deat h h ad oc c u r r ed at f i ve w eek s . H er e ex c es s
deb r i s i nt er f er ed w i t h c r y s t al l i z at i on.
SUMMA RY
Not i nf r eq u ent l y du r i ng p r eg nanc y , a di ag nos i s m u s t
b e m ade of t h e c au s e of vag i nal di s c h ar g e.
A det ai l ed c as e h i s t or y and p h y s i c al and l ab or at or y
ex am i nat i ons as s i s t i n t h e di f f er ent i al di ag nos i s of
ab u ndant l eu k or r h ea, h y dr or r h ea, u r i nar y i nc ont i nenc e
and s p ont aneou s am ni ot om y .
A new l ab or at or y t es t t o det ec t t h e oc c u r r enc e of
r u p t u r e of t h e m em b r anes b y dem ons t r at i ng t h e c r y s t al -
l i z at i on of am ni ot i c f l u i d i s h er ei n des c r i b ed.
Fal s e neg at i ve r es u l t s ar e r ar e. Th ey ar e c au s ed b y
vag i nal deb r i s or b l ood. Cent r i f u g at i on p er m i t s s ep ar a-
t i on of t h es e c ont am i nant s and t h e t es t p er f or m ed on
t h e r em ai ni ng l i q u i d i s r el i ab l e.
Fal s e p os i t i ve r es u l t s m ay b e du e t o c ont am i nat i on
b y al b u m i nou s u r i ne and c r y s t al l i z at i on of c er vi c al
m u c u s . Th e f i ndi ng of s u c h m u c u s i s g ener al l y a s i g n
of t h e p r ol i f er at i ve p h as e of t h e m ens t r u al c y c l e and,
du r i ng p r eg nanc y , f or ew ar ns of t h r eat ened ab or t i on.
Th e t es t of c r y s t al l i z at i on u s ed i n as s oc i at i on w i t h
t h e ni t r az i n p ap er t es t h as i n ou r ' h ands g i ven c or r ec t
r es u l t s i n 9 8% of c as es . Bec au s e of i t s s i m p l i c i t y i t i s
a u s ef u l di ag nos t i c m eas u r e i n t h e l ab ou r r oom , ou t -
p at i ent dep ar t m ent and t h e of f i c e.
REFERENCES
1. KA RDOS, F. A ND TA Mi SI, J .: Mag l / . Noor v. Lap ., 18: 286,
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2. ZONDEK B.: c er vi c al m u c u s ar b or i z at i on as an ai d In
di ag A os i s . In: Pr og r es s i n g y nec ol og y , b y J . V . Mei g s
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4. V OLET, B. A ND MORIER- G ENOUD, J .: G t .f f l aec ol Og s a ( Bas el ) ,
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12. EA STMA N, N. J .: W i l l i am s ob s t et r i c s , 12t h ed., A p p l et on-
Cent u r y - Cr ot t s , Inc ., 19 61, p . 107.
PA G ES OUT OF TH E PA ST: FROM TH E J OURNA L OF FIFTY YEA RS A G O
MONTh EA L MEDICO- CH IRURG ICA L
SOCIETY
Pat h ol og i c al Sp ec i m ens . Dr . A . M. Bu r g es s ex h i b i t ed
t h e f ol l ow i ng s er i es
Tw o c as es of t u m ou r of t h e nec k ; one f r om Dr . El der ' s
c l i ni c and one f r om Dr . H u t c h i s on' s .
Bot h c as es w er e of r ap i d devel op m ent , h avi ng g r ow n
i n l es s t h an s i x w eek s . . . Th e di ag nos i s of t h es e c as es ,
t o u s e t h e or di nar y t er m , i s l y m .h os ar c om a. I w as as k ed i n
b ot h c as es w h et h er or not e di s eas e w as H odg k i n' s
di s eas e. Th e r ap i d g r ow t h and ex t ens i on of t h es e and t h e
nu m b er of m i t ot i c f i g u r es p r es ent i n t h e g r ow t h s eem t o
l eave no dou b t t h at h er e w e ar e deal i ng w i t h a t r u e m al i g -
nant t u m ou r . You w i l l s ee, h ow ever , f r om t h e s ec t i ons ,
t h at t h e t y p i c al h i s t ol og i c al p i c t u r e, w h i c h h as b een
des c r i b ed as p s eu do- l eu k aem i a, or H odg k i n' s di s eas e ( t h e
p r es enc e of m ar k ed f i b r os i s and eos i nop h i l e l eu c oc y t es and
l ar g e m u l t i nu c l ear c el l s , m any of w h i c h ar e i n m i t os i s ) ,
i s p r es ent i n one of t h es e ent i r el y and i n t h e ot h er p ai t i al l y .
Dr . J . M. El der : Cl i ni c al l y s p eak i ng , I do not t h i nk
t h e di f f er ent i at i on of H odg k i n' s di s eas e f r om l y m p h o-
s ar c om a i s of ver y g r eat i m p or t anc e. Bot h c ondi t i ons s h ou l d
b e l ef t al one. Th i s c as e of m i ne w as a m an, s t ou t , f i ne-
l ook i ng , f r om t h e Tow ns h i p s , w h o s ai d t h at h e h ad not i c ed
w i t h i n a f ew w eek s t w o m as s es , one at t h e r oot of t h e
nec k on t h e l ef t s i de and a s m al l er m as s g r ow i ng i n t h e
ax i l l a of t h e s am e s i de. Th e q u es t i on c am e u p at onc e, i s
t h i s l y m p h os ar c om a or H odg k i n' s di s eas e, or i s t h er e any
di f f er ent i at i on b et w een t h em ? Th ey ar e b ot h es s ent i al l y
m al i g nant . One t h i ng , i n di ag nos i ng f r om a c l i ni c al s t and-
p oi nt , i s t h e enl ar g em ent of t h e s u p er f i c i al vei ns . It i s i n
t h e nei g h b ou r h ood of t h i s t u m ou r , over t h e f r ont of t h e
c h es t , t h at t h ey ar e enor m ou s l y enl ar g ed. Th i s , t o m e,
near l y al w ay s s p el l s s ar c om a. I do not k now w h y t h e
s ar c om a def i ni t el y i nt er f er es w i t h t h e deep c i r c u l at i on, b u t
t h er e i t i s .. Th e c as e r ep or t ed, u p on w h om I di d op er at e,
i s now g oi ng dow n h i l l r ap i dl y .
Dr . A . M. Bu r g es s : Ment i on h as b een m ade of t h e
p r eval ent vi ew t h at H odg k i n' s di s eas e i s an i nt ox i c at i on
and not a t r u e t u m ou r and i t i s w i t h t h at i n m i nd t h at I
b r ou g h t u p t h i s c as e as evi denc e of t h e neop l as t i c nat u r e
of t h e di s eas e. Th e p ap er s m ent i oned on t h i s s u b j ec t h ave
b een f u r t h er s u p p l em ent ed b y a Cong r es s of Pat h ol og i s t s
i n G er m any i n w h i c h t h ey p r ac t i c al l y al l ag r eed t h at
H odg k i n' s di s eas e w as an i nt ox i c at i on and not a neo-
p l as m .- Canad. Med. A s e. J ., 3 : 824, 19 13 .