1064

FERRON AND BILODEAU:

TEST FOR RUPTURED MEMBRANES

Canad. Med. Ass. J.

Nov.28 1963, vol.89

Amniotic Fluid Crystallization Test for Ruptured Membranes

MARCEL FERRON, M.D.,. F.I.C.S., F.A.C.O.G.* and
ROLLAND BILODEAU, M.D.,t Montreal

ABSTRACT
A simple and inexpensive test is described
which permits positive identification of
amniotic fluid by its fern-type crystallization. It permits a rapid and certain differential diagnosis between leukorrhea, hydrorrhea, urinary incontinence and spontaneous
amniotomy. The crystallization te:st was
shown to be most reliable and the few
sources of error are easily avoided. The
test is inhibited by cellular debris or blood
when it is in a concentration greater than
1:10. Centrifugation permits the reappearance of fern-leaf crystallization. The typical
image resembles that of the crystallization
of cervical mucus. However, amniotic fluid
crystallizes on the entire smear, whereas
mucus crystallizes in a linear fashion.
Cervical mucus crystallization is normally
absent during pregnancy. It may occur in
cases of threatened abortion. The authors
have performed the test in combination with
a nitrazin paper test in a series of 192
patients. In their hands it has given nearly
perfect results.

RESUME
II arrive fr.quemment qu'on ait .i faire un
diagnostic pr6cis d'un Scoulement vaginal
subit durant la grossesse. L'histoire, Vexamen clinique, et le laboratoire peuvent
aider . faire le diagnostic diff&entiel entre
leucorrhee abondante, hydrorrh6e, incontinence urinaire ou rupture spontan6e des
membranes.
Un nouveau test de laboratoire est ici
d6crit qui permet un diagnostic s.r: le test
de cristallis.tion du liquide amniotique.
Les faux n6gatifs sont rares, ils peuvent
.tre d.s aux d6bris vaginaux et au sang. La
centrifugation permet Ia r6apparition du test
quand il y a trop de sang ou de cellules.
Les faux positifs peuvent .tre, dfts & l'albuminurie ou & la cristallisaton de Ia glaire
cervicale. Cette 6ventualit6 est Ia plus
plausible. Elle est habituellement la marque
du mucus de Ia phase pnSovulatoire ou
annonce la menace d'avortement.
Le test de cristallisation associ6 au test
au papier Nitrazine a donn6 des r.sultats
exacts .i 98% et grAce A sa simplicit6 ii peut
.tre utile aussi bien au bureau et A Ia
clinique qu'A Ia salle de travail.

Canad. Med. Ass. J.

Nov. 23, 1963, vol. 89

FEBRON AND BJLODEAU:

TEST FOR RUPTURED MEMBRANES

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1066

FERRON AND BILODEAU: TEST FOR RUPTURED MEMBRANES

Fig. 3.-Crystallization of amniotic fluid.

mucin, which is dependent upon the estrogenprogesterone hormonal relationship. This dependence explains the variation in cervical mucus during
the menstrual cycle and also its appearance during
pregnancy in cases of threatened abortion. There
seems to be a higher incidence of spontaneous abortion when the mucus shows an arborization emanating from a clear ground substance, little mucoid
matrix, few cells and a distinctive image of clear
nuclei.9-'1
Although cervical mucus is normally absent
during pregnancy, its crystallization in the cervical
film may lead to a false interpretation of amniotic
fluid crystallization. Experience in the interpretation of the test, however, permits easy differentiation of these substances. Crystallization of amniotic
liquid involves the entire smear (Fig. 3), whereas
that of cervical mucus occurs in linear bands (Fig.
4) secondary to its stringlike macroscopic nature
(Spinnbarkeit).
With knowledge of possible sources of error, we
combined the results of the aforementioned test
with that of nitrazin paper in a study of 192 female
patients seen on the obstetrical service of the
"H6pital Maisonneuve", Montreal (Table I). There
were 108 positive smears indicating amniotomy and
84 negative smears.
The nitrazin test consists of the introduction into
the vagina of a small piece of nitrazin paper. It is

Canad. Med. Ass. 3.

Nov. 23, 1963, vol. 89

(.i.0'.-C17stailization of cervical mucus in linear bands

based on the change occurring in vaginal pH due

to the alkalinity of amniotic fluid. Normally the
vaginal pH is acid during pregnancy, but after
rupture of the membranes it may change from a
pH of 6 to 8.1. It is an accurate test, but a falsepositive reaction may be obtained in the presence
of blood or significant vaginal infection. It was
performed in this study to check the accuracy of
the crystallization test which was being used for
the first time.
All of the patients described in Table I as primiparas and multiparas were pregnant at the time
they were included in the test. The only patients
who were not pregnant are three of those included
in the column headed "False Positives".
Four smears showed crystallization of cervical
mucus. In only one of these four was the specimen
obtained from a gravid patient. This woman was
three months' pregnant and was followed up
closely, in view of possible abortion; she went on
to term and delivered spontaneously. The other
smears were obtained during the course of routine
postpartum physical examinations.
The only false positive result occurred after an
apparently successfully induced amniotomy in a
patient with 3 cm. cervical dilatation. At complete
dilatation the amniotomy had to be repeated. It
is possible that following the first attempt at amni-

Canad. Med. Ass. J.

FI.au.oN AND BILODEAU:

Nov. 23, 1963, vol.89

TABLE 1.-AMNIOTIC FLUID CRYSTALLIZATION TEST IN 192

FEMALE PATIENTS
POSITIVES: 108

Primiparas 55
(ages 17 to 34 years)
Dilation
of cervix

Multiparas 53
(ages 20 to 41 years)

Site of collection
Site of collection
En4oEndoFornix cervix Glove Forrtix cervix Glove

0-2cm...
18
2-5cm... 15
5-8cm...
1
Total true
positives.52

7
0
0

1
0
10

7
15
0
51

7
0
0

0
13
9
= 103

FALSE POSITIvES

Mucus: during pregnancy.1

fourth day post-menstrual.1
seventh day post-menstrual.2
actual false positive.1

Total.5
%error.0.92
NEGATIVES: 84

True negatives.
Debris.
False negative.

Primiparas 28 Multiparas 56
27
55
.
0
1
.
1
0
%error.1.2

otomy, the fetal head sealed the aperture in the

membranes.
The only false negative test occurred at the beginning of this study when, because of unfainiliarity with the technique, the drop of amniotic
fluid was spread by means of a cover slip, as in
urinalysis. The smear was then too thin for crystallization to take place.
One other negative smear was obtained on a
specimen of brownish, foul-smelling amniotic fluid,
from a gestation of 22 weeks; in this case fetal
death had occurred at five weeks. Here excess
debris interfered with crystallization.

TEST FOR RuPruIu. MEMBRANES

1067

SUMMARY

Not infrequently during pregnancy, a diagnosis must

be made of the cause of vaginal discharge.
A detailed case history and physical and laboratory
examinations assist in the differential diagnosis of
abundant leukorrhea, hydrorrhea, urinary incontinence
and spontaneous amniotomy.
A new laboratory test to detect the occurrence of
rupture of the membranes by demonstrating the crystallization of amniotic fluid is herein described.
False negative results are rare. They are caused by
vaginal debris or blood. Centrifugation permits separation of these contaminants and the test performed on
the remaining liquid is reliable.
False positive results may be due to contamination
by albuminous urine and crystallization of cervical
mucus. The finding of such mucus is generally a sign
of the proliferative phase of the menstrual cycle and,
during pregnancy, forewarns of threatened abortion.
The test of crystallization used in association with
the nitrazin paper test has in our 'hands given correct
results in 98% of cases. Because of its simplicity it is
a useful diagnostic measure in the labour room, outpatient department and the office.
REFERENCES
1. KARDOS, F. AND TAMiSI, J.: Magl/. Noorv. Lap., 18: 286,
1955.
2. ZONDEK B.: cervical mucus arborization as an aid In
diagAosis. In: Progress in gynecology, by J. V. Meigs
and S. H. Sturgiss. Vol. 3, Grune & Stratton, Inc.,
New York, 1957, p. 86.
3. MACKAY, D. G. et aL: Amer. I. Obstet. Gynec., 69: 735.
1955.
4. VOLET, B. AND MORIER-GENOUD, J.: Gt.fflaecolOgsa (Basel),
149: 151, 1960.
5. KovAcs, D.: Amer. J. Ob8tet. Gynec., 83: 1257, 1962.
6. SMITH, R. W. AND CALLAGAN, D. A.: Obstet. (h/nec., 20:
655, 1962.
7. ULLERv, J. C. AND SHABANAH, E. H.: Ibid., 10: 233, 1957.
8. SALVATORE, C. A.: Ibid., 18: 598, 1961.
9. JACoBSON, B. D.: Ibid., 10: 40, 1957.
10. URDAN, B. E. AND KURZON, A. M.: Ibid., 5: 3, 1955.
11. PIERCE, J. R. AND COPE, H.: Ibid., 5: 815, 1955.
12. EASTMAN, N. J.: Williams obstetrics, 12th ed., AppletonCentury-Crotts, Inc., 1961, p. 107.

PAGES OUT OF THE PAST: FROM THE JOURNAL OF FIFTY YEARS AGO

MONThEAL MEDICO-CHIRURGICAL
SOCIETY
Pathological Specimens. Dr. A. M. Burgess exhibited
the following series
Two cases of tumour of the neck; one from Dr. Elder's
clinic and one from Dr. Hutchison's.
Both cases were of rapid development, having grown
in less than six weeks . . . The diagnosis of these cases,
to use the ordinary term, is lym.hosarcoma. I was asked in
both cases whether or not e disease was Hodgkin's
disease. The rapid growth and extension of these and the
number of mitotic figures present in the growth seem to
leave no doubt that here we are dealing with a true malignant tumour. You will see, however, from the sections,
that the typical histological picture, which has been
described as pseudo-leukaemia, or Hodgkin's disease (the
presence of marked fibrosis and eosinophile leucocytes and
large multinuclear cells, many of which are in mitosis),
is present in one of these entirely and in the other paitially.
Dr. J. M. Elder: Clinically speaking, I do not think
the differentiation of Hodgkin's disease from lymphosarcoma is of very great importance. Both conditions should

be left alone. This case of mine was a man, stout, finelooking, from the Townships, who said that he had noticed
within a few weeks two masses, one at the root of the
neck on the left side and a smaller mass growing in the
axilla of the same side. The question came up at once, is
this lymphosarcoma or Hodgkin's disease, or is there any
differentiation between them? They are both essentially
malignant. One thing, in diagnosing from a clinical standpoint, is the enlargement of the superficial veins. It is in
the neighbourhood of this tumour, over the front of the
chest, that they are enormously enlarged. This, to me,
nearly always spells sarcoma. I do not know why the
sarcoma definitely interferes with the deep circulation, but
there it is .. The case reported, upon whom I did operate,
is now going down hill rapidly.
Dr. A. M. Burgess: Mention has been made of the
prevalent view that Hodgkin's disease is an intoxication
and not a true tumour and it is with that in mind that I
brought up this case as evidence of the neoplastic nature
of the disease. The papers mentioned on this subject have
been further supplemented by a Congress of Pathologists
in Germany in which they practically all agreed that
Hodgkin's disease was an intoxication and not a neoplasm.-Canad. Med. Ase. J., 3: 824, 1913.