226
.J anuarv 15. 1979 Am . J. Obstet. Gvnecol.
Communications in brief
Fig. I. Vascular invasion by cytotrophoblast. Intraluminal cytotrophoblast is present in a vein in the wall of the salpinx . In the adjacent interstitial tissues are infiltrates of inflammatory cells. ( Hematoxylin and eosin. x 150.)
vage procedures has not been described in the English literature of the past 20 years. Ploman and WickseiP and Rosenblum, Dowling, and Barnes, 2 whose combined experience is 149 conservative operations, advised ligation of vessels in the mesosalpinx adjacent to the implantation in order to secure hemostasis. The source of the delayed hemorrhage in this case was demonstrated to be associated with vascular invasion by persistent trophoblast in the implantation site in the salpinx. The operative management of this patient did not include a prophylactic suture in the mesosalpinx to interrupt the vascular supply to the implantation site. Such a maneuver would probably have prevented the delayed hemorrhage. We therefore recommend this precautionary measure in conservative surgical procedures in cases of ectopic gestation.
REFERENCES I. Ploman, L., and Wicksell, F.: Fertility after conservative surgery in tubal pregnancy, Acta Obstet. Gynecol. Scand . 39:143, 1960. 2. Rosenblum, J. M., Dowling, R. W., and Barnes , A. C.: Treatment of tubal pregnancy, AM . J. 0BSTET. GYNECOL. 80:274 , 1960.
External pneumatic compression for prevention of deep venous thrombosis and pulmonary emboli ANN B . BARNES , M . D.
Vincent Memorial Hospital (Gynecological Service of the Massachusetts General Hospital) , Boston, Massachusetts
RECENT EXPERIENCE has Jed to the recognition of a need for control trials in obstetrics and gynecology to evaluate external pneumatic compression (EPC) for the prevention of deep-vein thrombosis and pulmonary emboli. A 21-yea r-old patient with mesangial-type glomerulonephritis, in her fourth pregnancy, was admitted in the twentieth week of pregnancy for hypertension , vaginal staining, abdominal cramping, edema, and a rising serum creatinine despite H ydrodiuril and Aldomet thera py . Her blood pressure ra nged from 140/90 mm. Hg despite increasing Hydrodiuril and Aldomet. At 20 weeks, with vaginal staining and crampy pains, she was placed on bed rest. Ultrasound Reprint requests: Ann B. Barnes, M.D., Vincent Memorial Hospital , 32 Fruit St. , Boston, Massachusetts 02114. 0002-9378/79/ 020226+02$00.20/0
©
1979 The C. V. Mosby Co.
Volume 133 Number 2
confirmed an intrauterine pregnancy of 19 weeks with a biparietal diameter of 4.2 em. and diminished anmiotic fluid. During hospitalization, an EPC boot was applied to both legs to prevent the possibility of deep-vein thrombosis due to the bed rest, pregnancy, and underlying disease. The boots diminished the edema in her legs; however, ultrasound studies suggested a possible early thrombus formation. Fetal growth to a biparietal diameter of 5.3 em. occurred in the subsequent 5 weeks, followed by spontaneous abortion of a 496 gram fetus at 26 weeks' gestation. A 56-year-old patient seen for consultation for a pelvic mass had had a left radical mastectomy 10 years prior to her visit and developed extensive edema of the left arm. In the past 2 years, she had used an EPC on her arm. She found that this reduced the edema sufficiently each morning to enable her to don an elastic sleeve. She offered her compression boot for her gynecologic surgery.
Cotton and Roberts in England have been pioneers in the development of external pressure compression of the calves during surgical procedures to prevent deep-vein thrombosis by preventing pooling in the soleal sinus, femoral, and popliteal veins. 1 There is extensive variation in equipment presently available for EPC. The total pressure attained varies from 35 to 60 mm. Hg and the time to attainment varies from 10 to 48 seconds. The interval between compressions varies from 1 minute to more. There is a wide range of materials and designs used for the boot. Saltzman and associates have recently demonstrated the use of intraoperative EPC in urologic and neurologic patients. In these situations, EPC proved superior to low-dose heparin in the urologic patients and no deep-vein thrombosis occurred in the neurologic patients. In neurologic patients, the boot, to be effective, had to be worn for the duration of their bed rest. In urologic patients, EPC was used initially intraoperatively as well as postoperatively until the patient was fully ambulatory. However, subsequent experience has shown that intraoperative use was equally effective as the more prolonged use. Both trials were controlled and used 12 '~1 fibrinogen uptake for identifying deepvein thrombosis. Two urologic patients suffered pulmonary emboli without evidence of deep-vein thrombosis in the extremities. Presumably these emboli originated in the pelvic veins. Earlier studies have shown that elastic stockings and elevation of legs are not effective in preventing deep-vein thrombosis. In patients undergoing total hip replacement who have had a history of prior venous disease, EPC was not as effective as anticoagulation. In some situation, low-dose heparin and anti platelet agents have been shown to prevent venous thrombosis and pulmonary emboli. Yet, as in our patient with hypertension or patients undergoing extensive surgery for malignancy, hemorrhagic complications of anticoagulants led to undesirable-even fatal-complications. At present, heparin in the most common cause of inhospital drug-related deaths in recently healthy patients. 2 In gynecologic patients undergoing surgery for malignancy or benign pelvic pathology, control trials
Communications in brief
227
including EPC, low-dose heparin, and no anticoagulation, can easily be envisaged, with the use of isotopic techniques to identify the presence or absence of deep-vein thrombosis. Additionally, the incidence of pelvic thrombi and emboli might be more dearly enumerated. Prior venous disease, birth control usage, present and past, renal disease-all could be concurrently evaluated for their contributions to risk. Costs in both dollars and patient parameters could be compiled simultaneously. In obstetric patients, 12"1-fibrinogen is a hazard even in the puerperium, as it will pass into the milk. Ultrasound or phlebograms might be adequate to define the presence of pelvic vs. lower limb thrombosis. Although each category of patients must be considered, cesarean section patients, those receiving estrogens to suppress lactation, and those in the puerperium are known at present to be at greatest risk. On the other hand, the risk of pulmonary emboli in young previously healthy people is not established and may be perceived at a higher rate than is accurate because earlier estimates were based on autopsy findings. 2 A prospective control trial is required to clarify such issues in pregnant women so as to justify prophylactic therapy of any type. Prior institution of therapy without such trials has led to such well-known disasters as the DES story. As with surgical patients, certain gynecologic and obstetric patients have long been recognized to have two of Virchow's triad: stasis and coagulation defects. Vessel wall lesions are an enigma. Because this information is missing, variation in effectiveness of methods to prevent deep-vein thrombosis and pulmonary emboli has occurred. Thus trials specific to obstetric and gynecologic problems are needed.
REFERENCES 1. Saltzman, E. W.: Physical methods for prevention of ve-
nous thrombosis, Surgery 81:123, 1977. 2. Rubin, E. D.: Over-diagnosis and over-treatment of pulmonary embolism: The emperor may have no clothes. Ann. Intern. Med. 87:775, 1977.
Benign obstructive myxometra: Report of a case LOUIS H. HONORE, F.R.C.P.(C.) Department of Laboratories, Grace General Hospital, arui Di:uision of Pathology, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
HEMATOMETRA, pyometra, and hydrometra are wellknown complications of cervical obstruction resulting Reprint requests: Dr. Louis H. Honore, Department of Laboratories, Grace General Hospital, 241 LeMarchant Rd., St. John's, Newfoundland, Canada AlE I P9. 0002-9378/79/020227+03$00.30/0
© 1979 The
C. V Mosby Co.
.J anuarv 15. 1979 Am . J. Obstet. Gvnecol.
Communications in brief
Fig. I. Vascular invasion by cytotrophoblast. Intraluminal cytotrophoblast is present in a vein in the wall of the salpinx . In the adjacent interstitial tissues are infiltrates of inflammatory cells. ( Hematoxylin and eosin. x 150.)
vage procedures has not been described in the English literature of the past 20 years. Ploman and WickseiP and Rosenblum, Dowling, and Barnes, 2 whose combined experience is 149 conservative operations, advised ligation of vessels in the mesosalpinx adjacent to the implantation in order to secure hemostasis. The source of the delayed hemorrhage in this case was demonstrated to be associated with vascular invasion by persistent trophoblast in the implantation site in the salpinx. The operative management of this patient did not include a prophylactic suture in the mesosalpinx to interrupt the vascular supply to the implantation site. Such a maneuver would probably have prevented the delayed hemorrhage. We therefore recommend this precautionary measure in conservative surgical procedures in cases of ectopic gestation.
REFERENCES I. Ploman, L., and Wicksell, F.: Fertility after conservative surgery in tubal pregnancy, Acta Obstet. Gynecol. Scand . 39:143, 1960. 2. Rosenblum, J. M., Dowling, R. W., and Barnes , A. C.: Treatment of tubal pregnancy, AM . J. 0BSTET. GYNECOL. 80:274 , 1960.
External pneumatic compression for prevention of deep venous thrombosis and pulmonary emboli ANN B . BARNES , M . D.
Vincent Memorial Hospital (Gynecological Service of the Massachusetts General Hospital) , Boston, Massachusetts
RECENT EXPERIENCE has Jed to the recognition of a need for control trials in obstetrics and gynecology to evaluate external pneumatic compression (EPC) for the prevention of deep-vein thrombosis and pulmonary emboli. A 21-yea r-old patient with mesangial-type glomerulonephritis, in her fourth pregnancy, was admitted in the twentieth week of pregnancy for hypertension , vaginal staining, abdominal cramping, edema, and a rising serum creatinine despite H ydrodiuril and Aldomet thera py . Her blood pressure ra nged from 140/90 mm. Hg despite increasing Hydrodiuril and Aldomet. At 20 weeks, with vaginal staining and crampy pains, she was placed on bed rest. Ultrasound Reprint requests: Ann B. Barnes, M.D., Vincent Memorial Hospital , 32 Fruit St. , Boston, Massachusetts 02114. 0002-9378/79/ 020226+02$00.20/0
©
1979 The C. V. Mosby Co.
Volume 133 Number 2
confirmed an intrauterine pregnancy of 19 weeks with a biparietal diameter of 4.2 em. and diminished anmiotic fluid. During hospitalization, an EPC boot was applied to both legs to prevent the possibility of deep-vein thrombosis due to the bed rest, pregnancy, and underlying disease. The boots diminished the edema in her legs; however, ultrasound studies suggested a possible early thrombus formation. Fetal growth to a biparietal diameter of 5.3 em. occurred in the subsequent 5 weeks, followed by spontaneous abortion of a 496 gram fetus at 26 weeks' gestation. A 56-year-old patient seen for consultation for a pelvic mass had had a left radical mastectomy 10 years prior to her visit and developed extensive edema of the left arm. In the past 2 years, she had used an EPC on her arm. She found that this reduced the edema sufficiently each morning to enable her to don an elastic sleeve. She offered her compression boot for her gynecologic surgery.
Cotton and Roberts in England have been pioneers in the development of external pressure compression of the calves during surgical procedures to prevent deep-vein thrombosis by preventing pooling in the soleal sinus, femoral, and popliteal veins. 1 There is extensive variation in equipment presently available for EPC. The total pressure attained varies from 35 to 60 mm. Hg and the time to attainment varies from 10 to 48 seconds. The interval between compressions varies from 1 minute to more. There is a wide range of materials and designs used for the boot. Saltzman and associates have recently demonstrated the use of intraoperative EPC in urologic and neurologic patients. In these situations, EPC proved superior to low-dose heparin in the urologic patients and no deep-vein thrombosis occurred in the neurologic patients. In neurologic patients, the boot, to be effective, had to be worn for the duration of their bed rest. In urologic patients, EPC was used initially intraoperatively as well as postoperatively until the patient was fully ambulatory. However, subsequent experience has shown that intraoperative use was equally effective as the more prolonged use. Both trials were controlled and used 12 '~1 fibrinogen uptake for identifying deepvein thrombosis. Two urologic patients suffered pulmonary emboli without evidence of deep-vein thrombosis in the extremities. Presumably these emboli originated in the pelvic veins. Earlier studies have shown that elastic stockings and elevation of legs are not effective in preventing deep-vein thrombosis. In patients undergoing total hip replacement who have had a history of prior venous disease, EPC was not as effective as anticoagulation. In some situation, low-dose heparin and anti platelet agents have been shown to prevent venous thrombosis and pulmonary emboli. Yet, as in our patient with hypertension or patients undergoing extensive surgery for malignancy, hemorrhagic complications of anticoagulants led to undesirable-even fatal-complications. At present, heparin in the most common cause of inhospital drug-related deaths in recently healthy patients. 2 In gynecologic patients undergoing surgery for malignancy or benign pelvic pathology, control trials
Communications in brief
227
including EPC, low-dose heparin, and no anticoagulation, can easily be envisaged, with the use of isotopic techniques to identify the presence or absence of deep-vein thrombosis. Additionally, the incidence of pelvic thrombi and emboli might be more dearly enumerated. Prior venous disease, birth control usage, present and past, renal disease-all could be concurrently evaluated for their contributions to risk. Costs in both dollars and patient parameters could be compiled simultaneously. In obstetric patients, 12"1-fibrinogen is a hazard even in the puerperium, as it will pass into the milk. Ultrasound or phlebograms might be adequate to define the presence of pelvic vs. lower limb thrombosis. Although each category of patients must be considered, cesarean section patients, those receiving estrogens to suppress lactation, and those in the puerperium are known at present to be at greatest risk. On the other hand, the risk of pulmonary emboli in young previously healthy people is not established and may be perceived at a higher rate than is accurate because earlier estimates were based on autopsy findings. 2 A prospective control trial is required to clarify such issues in pregnant women so as to justify prophylactic therapy of any type. Prior institution of therapy without such trials has led to such well-known disasters as the DES story. As with surgical patients, certain gynecologic and obstetric patients have long been recognized to have two of Virchow's triad: stasis and coagulation defects. Vessel wall lesions are an enigma. Because this information is missing, variation in effectiveness of methods to prevent deep-vein thrombosis and pulmonary emboli has occurred. Thus trials specific to obstetric and gynecologic problems are needed.
REFERENCES 1. Saltzman, E. W.: Physical methods for prevention of ve-
nous thrombosis, Surgery 81:123, 1977. 2. Rubin, E. D.: Over-diagnosis and over-treatment of pulmonary embolism: The emperor may have no clothes. Ann. Intern. Med. 87:775, 1977.
Benign obstructive myxometra: Report of a case LOUIS H. HONORE, F.R.C.P.(C.) Department of Laboratories, Grace General Hospital, arui Di:uision of Pathology, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
HEMATOMETRA, pyometra, and hydrometra are wellknown complications of cervical obstruction resulting Reprint requests: Dr. Louis H. Honore, Department of Laboratories, Grace General Hospital, 241 LeMarchant Rd., St. John's, Newfoundland, Canada AlE I P9. 0002-9378/79/020227+03$00.30/0
© 1979 The
C. V Mosby Co.
