European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 177183

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Lecithin/sphingomyelin ratio and lamellar body count for fetal lung maturity:
a meta-analysis
Anouk E. Besnard a, Soetinah A.M. Wirjosoekarto b,*, Kimiko A. Broeze c, Brent C. Opmeer d,
Ben Willem J. Mol c
a
Faculty of Medicine, University of Amsterdam, Amsterdam, The Netherlands
b
Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
c
Centre for Reproductive Medicine, Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
d
Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To determine and compare the diagnostic accuracy of the lecithin/sphingomyelin (L/S) ratio
Received 14 September 2012 and lamellar body count (LBC) in the prediction of neonatal respiratory distress syndrome (RDS).
Received in revised form 23 January 2013 Study design: A systematic review was performed to identify studies comparing either the L/S ratio or the
Accepted 9 February 2013
LBC with the occurrence of RDS published between January 1999 and February 2009. Two independent
reviewers performed study selection and data extraction. For each study sensitivity and specicity were
Keywords: calculated. Summary receiver-operating characteristics (ROC) curves, assessing the diagnostic
Fetal lung maturity
performance of both tests, were constructed. A subgroup analysis was performed to estimate the
Lamellar body count
Lecithin/sphingomyelin ratio
sensitivity and specicity of the various cut-off values.
Neonatal respiratory distress syndrome Results: 13 studies were included. The ROC curves of the collected data illustrate that the LBC and L/S
ratio perform equally well in the prediction of RDS. Comparison of the two summary ROC curves of each
test indicates that the diagnostic performance of LBC might even have a slight advantage over L/S ratio.
Due to the wide cut-off range it was not possible to dene specic cut-off values with the best accuracy.
Conclusion: We recommend replacing the L/S ratio as gold standard with the lamellar body count since
the LBC is easy to perform, rapid, inexpensive, and available to all hospitals 24 h per day.
2013 Elsevier Ireland Ltd. All rights reserved.

1. Introduction strategy in favor of fetal lung maturation is still considered safe,

Respiratory distress syndrome (RDS) is a major cause of
neonatal morbidity and mortality, affecting approximately 1% of
all live births and 10% of all preterm infants [1]. It is caused by
insufcient production of surfactant by type II pneumocytes, along
with structural immaturity of the lung. The risk and severity rise
with increasing prematurity, and infants born before 29 weeks of
gestation have a 60% chance of developing RDS [2].
RDS may be prevented with antenatal steroid therapy and
prophylactic (early) administration of exogenous surfactant [3]. In
management strategies to limit the risk of RDS, the assessment of
fetal lung maturity (FLM) in amniotic uid can assist in
determining the timing of delivery, particularly in pregnancies
with maternal and/or fetal complications for which a temporizing
* Corresponding author at: Department of Obstetrics and Gynecology, Maastricht
University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
E-mail address: s.wirjosoekarto@gmail.com (Soetinah A.M. Wirjosoekarto).
but which may eventually require preterm delivery [4].
Measurement of the lecithin/sphingomyelin (L/S) ratio in
amniotic uid by thin-layer chromatography for the prenatal
prediction of FLM was rst introduced in 1971 by Gluck et al. From
30 weeks of gestation onwards, the concentration of lecithin
begins to increase signicantly, while the sphingomyelin concen-
tration remains approximately the same. The L/S ratio has
remained the gold standard of FLM testing in the neonate, with
2.0 as a commonly accepted cut-off value, above which the risk for
RDS is low, and which will normally be reached at a gestational age
of 35 weeks [5].
The L/S ratio is a technically difcult test that requires trained
personal to interpret. It is time-consuming, costly, prone to
subjective interpretation, not universally available nor available
around the clock, and it cannot be determined in uids
contaminated by blood or meconium.
The lamellar body count (LBC) has been proposed as a potential
replacement of the L/S ratio. Lamellar bodies represent a storage
form of pulmonary surfactant within type II pneumocytes,

0301-2115/$ see front matter 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejogrb.2013.02.013
178 A.E. Besnard et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 177183
secretion of which increases with advancing gestational age, thus
enabling prediction of the degree of FLM. The size of lamellar
bodies is similar to platelets, which permits the use of widely
available cell counters to quantify the lamellar bodies in amniotic
uid, as described by Dubin [6]. This makes the LBC an easy-to-
perform, rapid, inexpensive FLM test which is available to all
hospitals 24 h per day.
Previous studies have suggested using the LBC as an initial
assessment prior to the use of L/S ratio [713]. The hypothesis that
LBC is an equal or possibly better predictor for the occurrence of
RDS than the gold standard, namely the L/S ratio, was tested in the
meta-analysis of Wijnberger et al. [14], but data from the most
recent studies were not included, and management of antenatal
and neonatal care keeps developing. In the last decade there have
been changes in clinical management to optimize care, such as
neonatal treatment of infants at low gestational age, treatment
with antenatal corticosteroids, e.g. single dose versus multiple
courses, and changes in the diagnostic criteria for RDS. Since these
could possibly inuence the outcome of the performance of the LBC
and L/S ratio, we performed an updated meta-analysis, comparing
the accuracy of the LBC and the L/S ratio in the prediction of RDS.
2. Methods
2.1. Literature search and study selection
A systematic literature search was performed in Medline and
Embase to identify articles published between January 1999 and
February 2009. Keywords used were lecithin/sphingomyelin ratio or
L/S ratio or lamellar body count or LBC and respiratory distress
syndrome or RDS or hyaline membrane disease or HMD. Duplicate
citations were detected and removed. Cross-references were
checked for additional eligible articles. Two reviewers (KAB and
AEB) independently screened all identied studies by reading the
title and abstract. When in doubt, the whole article was read. The
nal selection was made by using pre-dened inclusion and
exclusion criteria. Studies were included if they reported on
pregnant women at risk for preterm delivery in whom the FLM was
tested by either the LBC or the L/S ratio. The outcome had to be RDS
in the neonate. If the reported data were sufcient to construct a
two-by-two table of the test result (LBC and L/S ratio) the study
was included. Articles published in a language other than English
were excluded.
2.2. Data extraction
We extracted the following data: year of publication, rst
author, country of investigation, language of publication, total
number of included patients and patients with analyzable data.
Subsequently, each of the included studies was scored on the
following design characteristics concurrent to the previous meta-
analysis [14]: (1) sampling, (2) data collection, (3) study design, (4)
blinding for the test results when RDS was diagnosed and (5)
verication bias [15].
In addition, information was gathered on the following patient
characteristics; minimal and maximal gestational age, inclusion of
multiple pregnancies, inclusion of diabetic pregnancies, inclusion
of women with ruptured membranes and use of corticosteroids.
Moreover, the way amniotic uid was collected (abdominal,
vaginal or both), the time interval between amniocentesis and
delivery, whether samples contaminated with blood or meconium
were excluded, and how RDS was dened (clinical criteria,
radiological criteria and/or criteria for oxygen therapy) were
scored. Finally, the laboratory methods used to determine the L/S
ratio and LBC as well as the used cut-off values were reported.
2.3. Study quality
We assessed the methodological quality of the included studies
using the QUADAS checklist, a tool for quality assessment of
diagnostic accuracy studies [16]. Included studies were assessed
on 15 items on selection, verication, description of tests and study
population.
2.4. Statistical analysis
For each individual study, the prevalence of RDS was
calculated, as well as the sensitivity and specicity of both the
L/S ratio and LBC in the prediction of RDS. Sensitivity was dened
as the proportion newborns with RDS in which the test predicted
immaturity of the fetal lungs, whereas specicity was dened as
the proportion newborns without RDS in which the test predicted
mature fetal lungs. Secondly, heterogeneity in sensitivity and
specicity between studies was explored using scatter plots.
Variation or heterogeneity of the results of the studies included in
the meta-analysis can be the result of differences in cut-off values,
bias due to awed design, different clinical subgroups, or chance.
The random-effects approach estimates and incorporates the
amount of between-study variability in both sensitivity and
specicity. All accuracy estimates from different studies in terms
of sensitivity and specicity were plotted in receiver-operating
characteristics (ROC) space. A pooled estimate for sensitivity and
specicity was estimated with bivariate regression analysis, and
the corresponding summary ROC (sROC) curve was constructed
[17]. The bivariate regression model simultaneously estimates
sensitivity and specicity within a single model, which also
accommodates the inverse association between sensitivity and
specicity due to threshold effects.
At present, the statistical procedure to estimate the bivariate
model cannot accommodate multiple data points from the same
study, e.g. when a study reports sensitivity and specicity for
different cut-off values. In order to evaluate accuracy measures
over the whole range of reported cut-off values including all
studies, we did not limit our analysis to a single cut-off value. We
estimated accuracy measures for all reported cut-off values by
assuming that the shift in accuracy (higher sensitivity and lower
specicity) due to different cut-off values is accounted for by the
correlation term, as specied in the bivariate model.
Consequently, the sROC point reects the average operating
point on the curve, but as it does not reect the accuracy for a
particular cut-off, this point itself is clinically not very informative.
The sROC curve corresponding with the estimated model, however,
reects the change in accuracy (sensitivity and specicity)
associated with a shift in positivity threshold.
In order to avoid the results being biased toward studies
reporting data for multiple cut-offs, results are based on averaged
model estimates from stratied bootstrap samples.
3. Results
3.1. Literature search and study selection
The literature search in Medline and Embase yielded 144
articles, of which 46 were read in full text. Thirteen articles were
eligible. Of these articles, one reported solely on the predictive
capacity of the L/S ratio [18], nine reported solely on the predictive
capacity of the LBC [1927], and three articles reported on the
predictive capacity of both tests [2830].
3.2. Data extraction
The characteristics of the included studies are listed in Table 1.
All studies were designed as cohort studies, except one which was
 A.E. Besnard et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 177183 179

a prospective clinical trial. The presence of verication bias could

Radiological and therapy

Diagnosed by standard
not be excluded in any of the studies. The number of patients

Clinical, radiological
Clinical, radiological

Clinical, radiological
Clinical, radiological

Clinical, radiological

Clinical, radiological

Clinical, radiological

Clinical, radiological

Clinical, radiological
included in each study varied between 73 and 833. Most studies
included a diverse group of pregnant women at risk for preterm
Denition RDS

and therapy

and therapy

and therapy

and therapy

and therapy

and therapy

and therapy
delivery. However, one study explicitly excluded women with
diabetic pregnancies [23], one explicitly excluded women with

Therapy

Therapy
criteria
premature rupture of the membranes [19], and two studies
explicitly excluded women with multiple pregnancies [24,30]. The
minimum gestational age varied between 22 and 33 weeks,
sampling

Unknown
Unknown

Unknown
whereas the maximum gestational age varied between 37 and 42
<7 days
delivery
Interval

<72 h

<72 h

<72 h
<48 h

<24 h

<72 h

<72 h
<48 h

<72 h
weeks. In four studies women were treated with corticosteroids
[18,22,25,29].
For all studies, thin layer chromatography was used to
meconium stained
Exclusion blood/

determinetheL/Sratiointheamnioticuid,whichwascentrifuged
priortothedeterminationintwostudies[28,30].Fortheremaining
two studies, it was unclear whether the specimen was centrifuged
samples

[18,29]. To assess the LBC, resistive-pulse counting of lamellar

Yes

Yes

Yes
Yes

Yes

Yes
Yes

Yes
Yes
No

No

No

No

bodies with the platelet channel of a standard hematology cell

counter was used in all studies. Four studies assessed the LBC in
Abdominal/vaginal/cesarean
Abdominal/vaginal/cesarean

Abdominal/vaginal/cesarean

Abdominal/vaginal/cesarean
uncentrifugedamnioticuidspecimen[20,22,24,27],whereasthe
Amniotic uid sampling

other eight studies used centrifuged amniotic uid samples

[19,21,23,25,26,2830]. Seven studies described more than one
Abdominal/vaginal
Abdominal/vaginal

Abdominal/vaginal

cut-off value to indicate pulmonary maturity [18

20,22,24,27,29].FortheL/Sratio,thecut-offvaluesvariedbetween
Abdominal

Abdominal

Abdominal

Abdominal
Unknown

Adominal

2.0 and 2.5, and for the LBC between 6000 and 79,000 lamellar
bodies per micro liter.

3.3. Study quality

Unknown

Unknown

Unknown

Unknown

Unknown
Excluded

Included

Included

Included

Included

Included

Included
Included
PPROM

Table 2 shows the quality assessment with the adjusted

QUADAS tool. LBC and L/S ratio were both considered as index
tests, and the clinical diagnosis of RDS as the reference test. None of
pregnancies

Unknown
Unknown

Unknown

Unknown

Unknown

Unknown

Unknown
Excluded

Excluded

the studies met all criteria.

Included

Included

Included

Included
Multiple

3.4. Statistical analysis

pregnancies

Unknown

Unknown

Unknown

Unknown

Unknown

The prevalence of RDS varied between 6% and 32%. For the L/

Excluded
Included

Included

Included

Included

Included

Included
Included
Diabetic

S ratio, the sensitivity varied between 62% and 100%, whereas

the specicity varied between 64% and 89%. For the LBC, the
sensitivity varied between 73% and 99%, whereas the specici-
Consecutive

ty varied between 60% and 100%. For both tests, the prevalence
of RDS and sensitivity and specicity for each individual study
series

are summarized in Tables 3 and 4, respectively. Fig. 1

Yes
No
No

No

No

No
No
No

No

No

No
No

No

illustrates all reported cut-off values for the L/S ratio and
Blinding

LBC with their corresponding sensitivity and specicity in a

scatter plot.
No
No

No

No

No
No
No

No

No

No
No

No

No

To provide further information on the different cut-off

values, a subgroup analysis was performed to evaluate the
Verication

sensitivity and specicity within a specic range of cut-off

values. For the LBC, at a range of cut-off values from
bias

Yes
Yes

Yes

Yes

Yes
Yes
Yes

Yes

Yes

Yes
Yes

Yes

Yes

15,000/ mL to 25,000/mL, the sensitivity is 76% (95% CI 57

PPROM = preterm premature rupture of membranes.

88%) with a specicity of 90% (95% CI 7097%). The

Prospective

sensitivity is 94% (95% CI 18100%) and the specicity is

Key characteristics of the included studies.

75% (95% CI 1399%) when exploiting a range of cut-off

Yes
No

No

No

No
No
No

No

No

No
No

No

No

values from 45,000/mL to 57,000/mL.

Due to the small number of studies reporting on the L/S ratio in
Cohort

Partly
study

this meta-analysis, data were found insufcient to execute a

Yes

Yes

Yes

Yes
Yes
Yes

Yes

Yes

Yes
Yes

Yes

Yes

subgroup analysis and directly compare the two most frequently

Winn MacMillan (2005)

used cut-off values of 2.0 and 2.5. Therefore, we combined the

Roiz Hernandez (2002)

studies reporting on both LBC and L/S ratio in the same population
Khazardoost (2005)
Abd El Aal (2005)

with the studies in Wijnbergers meta-analysis [712,2830]. The

Bahasadri (2005)

Haymond (2006)
Chapman (2004)

Piazze 1 (1999)
Piazze 2 (2005)
Beinlich (1999)

Neerhof (2001)
Karcher (2005)
Ghidini (2005)

results are shown in Table 5.

Study (year)

Figs. 2 and 3 show all the cut-off values with their

corresponding sensitivity and specicity as well as summary
Table 1

ROC curves for the L/S ratio and LBC respectively of this subgroup
analysis.
 180
Table 2
Study quality per study of the 13 included studies assessed with the QUADAS checklist.

A.E. Besnard et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 177183
Abd Bahasadri Beinlich Chapman Ghidini Haymond Karcher Khazardoost Neerhof Piazze 1 Piazze 2 Roiz Hernandez Winn
El Aal (2005) (1999) (2004) (2005) (2006) (2005) (2005) (2001) (1999) (2005) (2002) MacMillan
(2005) (2005)

Patients representative Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
of practice
Clear description Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes
selection criteria
Reference standard Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Unclear Yes Unclear
likely to detect RDS
Time between test and Yes Unclear Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
reference standard
short enough
Complete verication Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Consistent reference Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
standard
Index test and reference Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
standard performed
independently
Clear description of Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
index test
Clear description of Yes Yes Yes Yes Yes Unclear Yes Yes Yes Yes Unclear Yes Unclear
reference standard
Results index tests Yes Yes Yes No No Yes Unclear No Yes Unclear Unclear Yes Yes
interpreted independent
of results reference
standard
Results reference standard Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Yes Unclear
interpreted independent
of results index tests
Clinical data same as Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
practice
Uninterpretable data No No No No No Yes No No No No No No No
reported
Withdrawals explained Yes Yes Yes Yes Yes Yes No Yes Yes No Yes No Yes
Intervention between No Unclear Unclear Yes Unclear No Unclear Yes Yes Unclear Unclear Unclear Unclear
index test and
<!!>reference
standard
 A.E. Besnard et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 177183 181

Table 3
Performance of the L/S ratio in the prediction of RDS. If a study reported on multiple cut-off values, only one is shown.

Study (year) Number of patients Number of cut-off values Cut-off value RDS No RDS Prevalence of RDS Prediction
of RDS

TP FN FP TN Sens Spec

Karcher (2005) 201 1 2.5 8 5 20 168 0.06 0.62 0.89

Neerhof (2001) 833 1 N/A 82 18 174 559 0.12 0.82 0.76
Piazze (1999) 92 1 2.5 14 5 26 47 0.18 0.74 0.64
Winn-McMillan I (2005) 109 2 2.0 9 0 20 80 0.08 1.00 0.80
Winn-McMillan II (2005) 96 1 2.0 8 0 14 74 0.08 1.00 0.84

TP = true positive; FN = false negative; FP = false positive; TN = true negative; sens = sensitivity; spec = specicity.

Table 4
Performance of the LBC ratio in the prediction of RDS. If a study reported on multiple cut-off values, only one is shown.

Study (year) Number Number of Cut-off value RDS No RDS Prevalence of RDS Prediction of
of patients cut-off values RDS

TP FN FP TN Sens Spec

Abd El Aal (2005) 73 4 18,000 18 5 0 50 0.32 0.78 1.00

Bahasadri (2005) 104 2 45,000 22.7 0.3 1.3 79.7 0.22 0.99 0.98
Beinlich (1999) 21 1 30,000 5 1 5 10 0.29 0.83 0.67
Chapman (2004) 88 6 25,000 13 1 9 65 0.16 0.93 0.88
Ghidini (2005) 102 1 37,000 16 1 31 54 0.17 0.94 0.64
Haymond (2006) 184 2 50,000 11 1 69 103 0.07 0.92 0.60
Karcher (2005) 219 1 30,000 11 2 51 155 0.06 0.85 0.75
Khazardoost (2005) 80 1 50,000 17 3 18 42 0.25 0.85 0.70
Neerhof (2001) 833 2 N/A 89 11 266 467 0.12 0.89 0.64
Piazze I (1999) 92 1 20,000 18 1 20 53 0.21 0.95 0.73
Piazze II (2005) 178 1 22,000 44 17 21 96 0.34 0.73 0.82
Roiz-Hernandez (2002) 264 3 57,000 36 3 65 160 0.15 0.92 0.71

TP = true positive; FN = false negative; FP = false positive; TN = true negative; sens = sensitivity; spec = specicity.

4. Discussion
This meta-analysis demonstrates that the LBC is a good
diagnostic test, having an accuracy similar to the L/S ratio, and
by comparing the ROC curves it perhaps performs slightly better.
Fig. 1. Receiver-operating characteristics (ROC) of studies comparing lamellar body
count and L/S ratio in their capacity to predict the occurrence of respiratory distress
syndrome. Summary ROC curves are also given.
The overall results of this meta-analysis are concurrent with the
meta-analysis in 2001 [14]. Wijnberger et al. analyzed six studies
[712], comparing the L/S ratio and the LBC, and similarly
concluded that the LBC performs slightly better than the L/S ratio
(p = 0.13).
One of the advantages of the current meta-analysis is that it
provides information on the different cut-off values. The sROC
curves of Fig. 1 give a general outline on the overall accuracy
combining the sensitivity and specicity points of different cut-off
values, whereas the subgroup analysis calculates the accuracy of a
certain cut-off value. The subgroup analysis for the LBC showed
that a high cut-off value, range 45,00057,000, correlates with a
higher sensitivity, whereas a low cut-off value, range 15,000
25,000, correlates with a high specicity.
As a result of the wide range of cut-off values described in the
different studies, we were unable to determine the cut-off value
with the best accuracy, which can subsequently be recommended
for the clinical practice. By obtaining more data around several
specic cut-off values with a small range, the best cut-off for
clinical application can eventually be derived.
A limitation of this meta-analysis is the clinical heterogeneity,
i.e. study population, clinical characteristics and cut-off values, as
well as the statistical heterogeneity, i.e. variation in results, of the
included studies. Since a small number of articles were found
between 1999 and 2009, this analysis could not be limited to
studies directly comparing the LBC and L/S ratio in the same
population. Therefore, this meta-analysis was obliged to compare
both tests in studies with different study designs, clinical
characteristics and differences in reported cut-off values.
By solely analyzing studies with identical cut-off values, the
heterogeneity concerning the cut-off values might be reduced, but
this analysis would cause loss of data points or may even exclude
complete studies if they did not report for that cut-off value. The
statistical heterogeneity is taken into account by using a random
182 A.E. Besnard et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 177183

Table 5
Sensitivity and specicity of the different cut-off values in studies comparing LBC and L/S ratio in the same population [712,2830].

Cut-off value Sensitivity 95% CI Specicity 95% CI

LBC 500010,000 0.59 0.370.78 0.97 0.930.99

20,000 0.82 0.650.92 0.88 0.730.95
30,000 0.95 0.750.99 0.82 0.660.91
50,00055,000 0.99 0.921.00 0.65 0.600.70

L/S ratio 1.82.0 0.73 0.600.83 0.92 0.820.97

2.22.6 0.86 0.650.95 0.80 0.680.89
2.73.0 0.96 0.790.99 0.84 0.770.89

Fig. 3. Receiver-operating characteristics (ROC) of studies comparing lamellar body

Fig. 2. Receiver-operating characteristics (ROC) of studies comparing lamellar body
count and L/S ratio in the same population per cut-off value of LBC in their capacity
count and L/S ratio in the same population per cut-off value of L/S ratio in their
to predict the occurrence of respiratory distress syndrome [712,2830].
capacity to predict the occurrence of respiratory distress syndrome [712,2830].

effects model that estimates the amount of between-study
variability in both sensitivity and specicity. Nevertheless, the
heterogeneity could have inuenced the results comparing both
tests on accuracy. To reduce the heterogeneity of the included
studies, an individual patient data meta-analysis should be used in
which the data of all the individual patients, the detailed patient
characteristics and the associated results are explored. This way
the possible interactions between patient factors and accuracy can
be evaluated.
Another problem in this meta-analysis is that 12 of the detected
articles reported on the performance of the LBC versus four that
reported on the L/S ratio. As stated before, the L/S ratio is currently
the gold standard, but it has limitations. In the search for an
alternative, the LBC is a promising option. Publication of only those
papers that report positive or topical results leads to publication
bias. If publication bias is present, the accuracy of the LBC reported
in this meta-analysis was most likely overestimated.
In all the mentioned studies, a random cut-off value was chosen
irrespective of clinical parameters, such as gestational age. It is
therefore possible that a certain value of LBC or L/S ratio indicates
FLM at one gestational age, but immaturity at another. A solution
to this problem lies in adjusting the cut-off value according to
gestational age. Previous studies show that increased gestational
age has a positive effect on the performance of both L/S ratio and
LBC, but fewer studies have reported on this effect on LBC. It is also
possible that the test performance is inuenced by clinical factors,
such as fetal growth, the total amount of amniotic uid, the
presence of blood, meconium or infection or diabetic status of the
mother. Future research should focus on these clinical factors and
determine their effect on the performance of both tests, especially
the effect of the amount of amniotic uid on LBC performance [31
33].
In clinical practice, it is important to predict the presence of
RDS accurately in order to prevent infants being born with
immature lungs and the associated complications. Consequent-
ly, the ideal diagnostic test for FLM should have a high
sensitivity and a high negative (mature) predictive value. This
also implies a high number of false positives. Delaying the
delivery incorrectly, i.e. in the presence of FLM, can have
negative consequences for child and mother, e.g. in cases of
pre-eclampsia, but in the majority of cases the consequences of
RDS are probably limited.
In conclusion, this meta-analysis illustrates that the LBC is a
good measure to predict the occurrence of RDS, with an equal, if
not slightly better, performance compared to the L/S ratio. Since
the LBC is easy to perform, rapid, inexpensive, and available to all
hospitals 24 h per day, we suggest that it should replace the L/S
ratio in the assessment of FLM.
Conict of interest
The authors declare that they have no conict of interest.
 A.E. Besnard et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 177183
References
[1] Breathing in America: diseases, progress, and hope. Schraufnagel DE, editor.
Respiratory distress syndrome of the newborn. The American Thoracic Society;
2010.
[2] Grenache DG, Gronowski AM. Fetal lung maturity. Clinical Biochemistry
2006;39:110.
[3] Sweet D, Bevilacqua G, Carnielli V, et al. European consensus guidelines on the
management of neonatal respiratory distress syndrome. Journal of Perinatal
Medicine 2007;35:17586.
[4] American College of Obstetricians and Gynecologists. ACOG Practice Bulletin
No. 97: fetal lung maturity. Obstetrics and Gynecology 2008;112:71726.
[5] Gluck L, Kulovich MV, Borer Jr RC, Brenner PH, Anderson GG, Spellacy WN.
Diagnosis of the respiratory distress syndrome by amniocentesis. American
Journal of Obstetrics and Gynecology 1971;109:4405.
[6] Dubin SB. Characterization of amniotic uid lamellar bodies by resistive-pulse
counting: relationship to measures of fetal lung maturity. Clinical Chemistry
1989;35:6126.
[7] Ashwood ER, Palmer SE, Taylor JS, Pingree SS. Lamellar body counts for rapid
fetal lung maturity testing. Obstetrics and Gynecology 1993;81:61924.
[8] Bowie LJ, Shammo J, Dohnal JC, Farrell E, Vye MV. Lamellar body number
density and the prediction of respiratory distress. Clinical Chemistry
1991;95:7816.
[9] Dalence CR, Bowie LJ, Dohnal JC, Farrell EE, Neerhof MG. Amniotic uid
lamellar body count: a rapid and reliable fetal maturity test. Obstetrics and
Gynecology 1995;86:2359.
[10] Fakhoury G, Daikoku NH, Benser J, Dubin NH. Lamellar body concentrations
and the prediction of fetal pulmonary maturity. American Journal of Obstetrics
and Gynecology 1994;170:726.
[11] Greenspoon JS, Rosen DJD, Roll K, Dubin SB. Evaluation of lamellar body
number density as the initial assessment in a fetal lung maturity test cascade.
Journal of Reproductive Medicine 1995;40:2606.
[12] Lee IS, Cho YK, Kim A, Min WK, Kim KS, Mok JE. Lamellar body count in
amniotic uid as a rapid screening test for fetal lung maturity. Journal of
Perinatology 1996;16:17680.
[13] Lewis PS, Lauria MR, Dzieczkowski J, Utter GO, Dombrowski MP. Amniotic uid
lamellar body count: cost-effective screening for fetal lung maturity. Obstet-
rics and Gynecology 1999;93:38791.
[14] Wijnberger LD, Huisjes AJ, Voorbij HA, Franx A, Bruinse HW, Mol BW. The
accuracy of lamellar body count and lecithin/sphingomyelin ratio in the
prediction of neonatal respiratory distress syndrome: a meta-analysis. BJOG
An International Journal of Obstetrics and Gynaecology 2001;108:5838.
[15] Lijmer GJ, Mol BW, Heisterkamp S, et al. Empirical evidence of design-related
bias in studies of diagnostic tests. JAMA Journal of the American Medical
Association 1999;282:10616.
[16] Whiting P, Rutjes AW, Reitsma JB, et al. The development of QUADAS: a tool for
the quality assessment of studies of diagnostic accuracy included in system-
atic reviews. BMC Medical Research Methodology 2003;10:25.
[17] Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH. Bivariate
analysis of sensitivity and specicity produces informative summary measures in
diagnostic reviews. Journal of Clinical Epidemiology 2005;58:98290.
183
[18] Winn-McMillan T, Karon BS. Comparison of the TDx-FLM II and lecithin to
sphingomyelin ratio assays in predicting fetal lung maturity. American Journal
of Obstetrics and Gynecology 2005;193:77882.
[19] Abd El Aal DE, Elkhirshy AA, Atwa S, El-Kabsh MY. Lamellar body count as a
predictor of neonatal lung maturity in high-risk pregnancies. International
Journal of Gynaecology and Obstetrics 2005;89:1925.
[20] Bahasadri S, Changizi N. Association between lamellar body count and respi-
ratory distress in neonates. Saudi Medical Journal 2005;26:14146.
[21] Beinlich A, Fischass C, Kaufmann M, Schlosser R, Dericks-Tan JS. Lamellar body
counts in amniotic uid for prediction of fetal lung maturity. Archives of
Gynecology and Obstetrics 1999;262:17380.
[22] Chapman JF, Ashwood ER, Feld R, Wu AH. Evaluation of two-dimensional
cytometric lamellar body counts on the ADVIA 120 hematology system for
estimation of fetal lung maturation. Clinica Chimica Acta 2004;340:8592.
[23] Ghidini A, Poggi SH, Spong CY, Goodwin KM, Vink J, Pezzullo JC. Role of
lamellar body count for the prediction of neonatal respiratory distress syn-
drome in non-diabetic pregnant women. Archives of Gynecology and Obstet-
rics 2005;271:3258.
[24] Haymond S, Luzzi VI, Parvin CA, Gronowski AM. A direct comparison between
lamellar body counts and uorescent polarization methods for predicting
respiratory distress syndrome. American Journal of Clinical Pathology
2006;126:8949.
[25] Khazardoost S, Yahyazadeh H, Borna S, Sohrabvand F, Yahyazadeh N, Amini E.
Amniotic uid lamellar body count and its sensitivity and specicity in
evaluating of fetal lung maturity. Journal of Obstetrics and Gynaecology
2005;25:2579.
[26] Piazze JJ, Maranghi L, Cerekja A, et al. Amniotic uid lamellar body counts for
the determination of fetal lung maturity: an update. Journal of Perinatal
Medicine 2005;33:15660.
[27] Roiz-Hernandez J, Navarro-Solis E, Carreon-Valdez E. Lamellar bodies as a
diagnostic test of fetal lung maturity. International Journal of Gynaecology and
Obstetrics 2002;77:21721.
[28] Karcher R, Sykes E, Batton D, et al. Gestational age-specic predicted risk of
neonatal respiratory distress syndrome using lamellar body count and surfac-
tant-to-albumin ratio in amniotic uid. American Journal of Obstetrics and
Gynecology 2005;193:16804.
[29] Neerhof MG, Haney EI, Silver RK, Ashwood ER, Lee IS, Piazze JJ. Lamellar body
counts compared with traditional phospholipid analysis as an assay for
evaluating fetal lung maturity. Obstetrics and Gynecology 2001;97:3059.
[30] Piazze JJ, Anceschi MM, Maranghi L, Porpora MG, Cosmi EV. The biophysical/
biochemical test. A new marker of fetal lung maturity in borderline cases.
Journal of Reproductive Medicine 1999;44:6115.
[31] Wijnberger LD, de KM, Voorbij HA, et al. The effect of clinical characteristics on
the lecithin/sphingomyelin ratio and lamellar body count: a cross-sectional
study. Journal of Maternal-Fetal and Neonatal Medicine 2003;14:37382.
[32] Hunink MGM, Richardson DK, Doubilet PM, Begg CB. Testing for fetal pulmo-
nary maturity: ROC analysis involving covariates, verication bias, and com-
bination testing. Medical Decision Making 1990;10:20111.
[33] St Clair, Norwitz ER, Woensdregt K, et al. The probability of neonatal respira-
tory distress syndrome as a function of gestational age and lecithin/sphingo-
myelin ratio. American Journal of Perinatology 2008;25:47380.