5 Februarie 1977 SA MEDIESE TYDSKRIF 165

Treatment of Threatened and Habitual Abortion withHuman Chorionic Gonadotrophin

The Role of Serum Human Placental Lactogen Determination

C.Z. VORSTER; P.R.PANNALL, C.F.SLABBER

SUMMARYTreatment of habitual and threatened abortion with humanchorionic gonadotrophin (HCG) is discussed. Two pro­blems are encountered: the selection of patients for treat­ment; and the correct dosage of HCG.

Determination of human placental lactogen (HPL) inthe serum was used to select patients for treat­ment. The dosage of HCG was varied according to theresponse of the patient and as indicated by the levelsof HPL in her serum.

S. Afr. med. J., 51, 165 (1977).

The failure to carry a conceptus to term may be theresult of an unhealthy environment surrounding a healthyovum, or an unhealthy ovum in a healthy environment. Forthe latter there is no treatment, but it may be possible toimprove the unfavourable milieu of the fetus.

The recognition of hormonal insufficiency as a causeof reproductive failure led to the extensive use of progesto­gens for threatened and habitual abortion. There is noclear evidence that this treatment increases fetal salvage.'Tt may, in fact, merely increase the incidence of missedabortion.'

In the search for alternative methods of treatment at­tention has been focused on human chorionic gonado­trophin (HCG). Little is known of the factors that regulatethe release and production of HCG in the human and itsfunction remains uncertain. Known actions include pre­vention of regression of the corpus luteum,"· stimulationof progesterone synthesis by the corpus luteum in vitro'and stimulation of placental steroidal synthesis."

Because of its effects on the corpus luteum and theplacenta, it is rational to use HCG in women at high riskas a result of hormonal insufficiency. This argument issupported by the abnormally low HCG excretion in threat­ened abortion.' The present study was undertaken to esta­blish the value of HCG treatment in such cases.

PATIENTS AND METHODSIn 27 of 85 patients with a history of threatened or habi­tual abortion, the serum human placental lactogen (HPL)

Departments of Obstetrics and Gynaecology and ChemicalPathology, University of the Orange Free State, Bloemfon­tein

C. Z. VORSTER, M.B. CH.B.P. R. PAN TALL, F.F. PATH.(S.A.), M.R.C. PATH.

C. F. SLABBER, M.D., F.C.O.G.(S.A.)

Date received: 31 August 1976.

levels were more than 2 SO below the mean of the referencerange. Five patients each had an abnormal ultrasonogram.No treatment was given and they aborted in due course. Afurther 5 patients aborted before any treatment could beinitiated. Of the remaining 17 patients, 8 had histories ofhabitual abortion (of 31 pregnanices only 2 had reachedterm) and 9 presented with threatened abortion before thetwelfth week of pregnancy. Syphilis, toxoplasmosis, diabetesmellitus, renal disease and folate deficiency were excluded inthese patients. Ultrasonography was done prior to treat­ment to confirm a normal pregnancy.

All 17 patients received HCG (APL; Ayerst). 0 dosageregimen was adhered to. After an initial dose of 3 000 IU3 times weekly, the response was monitored by serial de­terminations of HPL in the serum. When the HPL levelsfailed to rise, the dosage was increased. Treatment wasdiscQntinued at 16 weeks unless falling HPL levels indica­ted the need for further treatment. The course of thepregnancy was also monitored by weekly or fortnightlyultrasonography.

RESULTSIn 13 patients the HPL values increased normally in re­sponse to HCG treatment. Of these, 12 progressed to termand normal delivery. Paediatric examination immediatelyafter birth and again 6 weeks later did not disclose any ab­normalities in the infants. The remaining patient, who hadhad 3 previous abortions in the first trimester, respondedwell to HCG treatment, but had a complete abortion at18 weeks. An incompetent cervical os has since been diag­nosed.

In 3 patients ultrasonography failed to demonstrate pro­gressive fetal development despite HCG treatment andthere was no rise in the serum HPL levels. Evacuation ofthe uterine contents confirmed the diagnosis of a blightedovum. The last patient presented with a threatened abor­tion at 12 weeks but aborted after only 1 injection ofHCG. This patient probably presented too late for treat­ment.

DISCUSSIONThe diagnosis of threatened abortion is often uncertain. Aminor menstrual upset is often regarded as presaging anabortion, whereas early abortions are often not recognisedas such.

Because HCG therapy is expensive, it is necessary forpregnancy to be positively diagnosed before patients aretreated; abnormal pregnancy should be excluded by ultra­sonography, and low serum HPL levels should be demon­strated. Repeated ultrasonographic examinations can de-

Boeke Ontvang : Books Received

SA MEDICAL JOUR AL166

tect abnormal growth of the fetus. The important signsare an absence of fetal echoes after 8 weeks. a loss ofdefinition of the gestational ac, including fragmentation,and a gestational sac implanted Iow in the uterus.s

"

A double sac and an ill-defined placenta are bad prog­nostic signs. Patients with an initial equivocal ultrasono­gram are treated, but the test is repeated weekly and treat­ment is discontinued if the ultrasonogram should be ab­normal. Three of our patients were in this category.Serial ultrasoruc examination confirmed normal progressionof the pregnancy in I3 patients. The serial use of ultra­sonography is considered essential. '0

Threatened abortion has a high spontaneous cure rateand 70% of patients deliver a live and healthy child."Hormonal deficiency must therefore be demonstrated be­fore treatment is instituted. Sev~ral methods are availableto demonstrate such deficiency. Vaginal cytology candemonstrate a progesterone deficiency." A karyopyknoticindex greater than IO~o was the most important criterionin selecting patients for HCa treatment in one series."Ferrung of the cervical mucus is also of great value in theselection of patients and for following the effect of treat­ment."

The best method for assessing these patients is by meansof hormone estimations." Serum HPL determination is ofprognostic value in cases of threatened abortion."-17 In thisseries an initially low serum HPL value was mandatorybefore treatment was instituted and the response to HCa

Screening Tests in Chemical Carcinogenesis. Proceedings of aWorkshop Organised by IARC and the Commission of theEuropean Communities and held in Brussels, Belgium,9 - 12 June 1975. Ed. by R. Montesano, H. Bartsch andL. Tomatis. Pp. xx + 666. Sw.fr. 120,-. Lyons: Inter­nati<Jnal Agency for Research on Cancer. 1976. Availablefrom Van Schaik's Bookstore (pty) Ltd, PO Box 724,Pretoria 0001.

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5 February 1977

was monitored by serial determinations of HPL in theserum. Unlike other workers, we do not use a fixed dosageregimen."'" HCa dosage is increa ed or decreased accord­ing to the HPL response.

Baillie et al." have clearly demonstrated ultrasonically,clinically and biologically that HCa has an effect on theviable trophoblast. The present series confirms this effectbiochemically.

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