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Ligation of the inferior vena cava in early pregnancy
Ligation of the inferior vena cava in early pregnancy HAROLD W. RUBIN, 1-.I.D. Brookline, McH,achusctt.>
T H R 0 M B 0 E M B 0 L I S M rarely OCCurs in early pregnancy and its treatment presents special problems. The reports in the literature concerning the use of Dicumarol in the pregnant patient are in conflict. The bulk of animal experimentation supports the view that Dicumarol crosses the placental barrier and causes fatal hemorrhage in the fetus. Schofield 1 and Roderick 2 • 3 fed spoiled sweet clover to pregnant cows and the calves died of hemorrhage within 28 hours of birth. Quick 4 fed Dicumarol to a pregnant dog before parturition and of the litter of 7 pups, 4 died of hemorrhage and 3, treated with vitamin K, survived. Sachs and Labate 5 reported on a 23-year-old gravida iii, para ii, who developed phlebothrombosis and pulmonary embolism at 31 weeks of pregnancy; she was treated with heparin for the first 48 hours and then with Dicumarol. Intrauterine death occurred on the fifty-third day of treatment. Total amount of Dicumarol used was 3,150 mg. Fetal postmortem examination revealed hemorrhage into the thymus. pericardia! sac, and the pleural cavities. On the other l!and, Ullery 6 reported the cases of 2 patients, one treated with Dinunarol and one with heparin, and both pn~gnancies tenninated successfully. Collins and his associates;- 1" reported on tlw ligation of the inferior vrna cava and
both ovanan veins for suppurative pelvic thrombophlebitis. This operation was performed on 70 patients from 1942 to 1950. These patients were closely followed to determine the eHect of the operation on peripheral ederna, pelvic circulation, venous pressure, menstruation, and ovulation. In the course of the follow-up, 15 pregnancies were found in 11 patients. Six abortions occurred in 5 patients (one admittedly induced) and in the other 6 patients, 9 pregnancies were delivered at term. Other successful pregnancies following ligation of the inferior vena cava only were reported by Burke and Rosenfield 18 and Heath and Carpenter. 1 " A search of the American literature reveals only one case report of ligation of the inferior \ ena cava in early pregnancy. This case was cited by Young and Derbyshire. 1'' The patient. a 21-year-old primigravida, developed left iliofemoral thrombophlebitis on the twelfth postoperatiw day following an unevt•ntful appendectomy during the tenth week of pregnancy. Ligation of the ,·ena cava with regional sympathetic block was promptly done. The immediate postoperati\ e course and su bseq uen t pn·gnancy wnc uneventfttl. Spontaneotts labor occurred at 39 weeks and a normal infant was delivered after 8 hours of labor. I i is he('attst· of the rarity of inferior vena ~·a,·a ligation in t·arh pregnancy and sllh~r·tpwut SIH < v"ftd tt:nr~ilt
Ftom the Department of 0/Hll'lrir'.· JJeth l;rael Hospital, Buston, Massachusetts.
542
Volume 80 Number 3
Case history The patient was a 28-ycar-old housewife, para 3-2-0-2, whose last menstrual period had occurred on June 8, 1956. The first pregnancy terminated in the pelvic delivery of binovular twins at 33 weeks after an uneventful prenatal course. The first twin, a 1 pound, 14 ounce anatomically normal male, died in 36 hours. The second twin, a 4 pound, 11 ounce male, had multiple congenital anomalies and died in 24 hours. The second and third pregnancies tf'rminatcd in full-term normal deliveries and both children are living and well. The fourth pregnancy ended in the spontaneous delivery of a 4 pound, 12 ounce stillborn female at 40 weeks. Occult prolapse of the cord, a true knot in the cord, and a small, severely infarcted placenta accounted for this intrauterine death. The past history revealed pleurisy at the age of 15 and a "mild" attack of poliomyelitis at 16. The family history was noncontributory. On Aug. 28, 1956, the patient experienced a "grippe-like feeling" with fever to 101° F., abdominal cramps, muscular aches and pains, and one loose bowel movement. Three days later pain occurred in the right lower anterior quadrant of th<~ chest radiating to the right shoulder and accentuated by deep breathing. Almost simultaneously with the chest pain, she noted pain in the left groin. All symptoms abated temporarily, and on September 3 pain recurred in the left groin and thigh and the left calf also became painful. The patient made her symptoms known on September 5 and was immediately admitted to the hospital. The pertinent physical findings on admission were: temperature 101° F.; pulse 90; respirations 24; percussion and auscultation of lungs normal. There was tenderness in the left calf, the left thigh over Hunter's canal, and just above the medial portion of the left Poupart's ligament. The left thigh, measured 5 inches above the patella, was 1)h inches greater in circumference than the right measured at the same level; the left calf, measured 5 inches below the patella, was 1Y4 inches greater in circumference than the right measured at the same level; the entire left leg from groin to toes was cold and mottled. The following laboratory findings were recorded: hemoglobin level, 11.2 Gm.; hematocrit determination, 36; red blood count, 3.62 million; white blood count, 13,800 with a normal differential; x-ray of the lungs revealed no evidence of pulmonary infarct.
Ligation of inferior vena cava
543
It was decided to treat this patient with anti· coagulant therapy. Aqueous heparin was given every 4 hours through an indwelling catheter in the left cubital vein. The amount given was determined by the clotting time and varied between 35 and 50 mg. The clotting time was maintained between 16 and 22 minutes as determined by the Lee-White method. The daily dose of heparin ranged from 190 mg. to 360 mg. In addition, 600,000 units of procaine penicillin was administered intramuscularly each day. The left leg was elevated on a pillow and protected by a cradle. Pain was controlled with meperidine, codeine, secobarbital, and aspirin. By the sixth hospital day the measurements of the left leg became equal to those of the right leg, temperature and pulse became normal, and all pain disappeared. Beginning on the eleventh hospital day the dose of heparin was gradually reduced and finally omitted on the fourteenth day. At this point the patient was allowed out of bed with elastic bandages applied to both legs. J\o vaginal staining occurred during heparin therapy. On Sept. 18, 1956, the thirteenth hospital day, the patient complained of a sore throat that persisted on the following day and in addition she noticed aching of the right side of the face and neck. Physical examination was negative and temperature, pulse, and respirations were normal. On Sept. 20, she was noted to be tense and anxious; the temperature was elevated to 100° F., pulse to 95, and respiration to 24 to 28 a minute. At this time she complained of sharp pain in the right lower part of the chest that was aggravated by deep breathing and a cough that produced bloody sputum. Auscultation revealed diminished breath sounds and friction rub in the right lower side of the chest posteriorly. In spite of the fact that x-ray examination did not confirm the diagnosis of pulmonary infarct, it was decided that surgical intervention was indicated. On September 21, under general anesthesia, the vena cava was ligated just above the bifurcation. The immediate postoperative condition was excellent. No anticoagulant therapy was given. Pain in the right side of the chest gradually disappeared over the next 5 days. Moderate vaginal staining occurred on the third postoperative day and diethylstilbestrol following the Smith1 6 regime was instituted. The patient made an uneventful recovery and was discharged on the eighth postoperative day wearing full-length elastic hose.
544
Rubin
\u1
Subsequently, the pn·nalal coursr~ was uneventful. Occasionally, thr·re was mild aching of the right leg but there was never any demonstrable edema. Spontaneous labor began on Feb. 25, 195 7, and after fJ hours and 30 minntcs of labor, a normal, active ti pound, 14 ounce f emak infant was delivered by low forceps. The postpartum course was a febrile and uneventfuL Postpartum examination on April 18 and Aug. 15, 195 7, revealed no edC'nn or \·aricosities of the lower extremities and they were equal in size. The uterus was anterior, symmetrical, normal in size, and frerly movable. The vaults and sides were normal and the cr•tvix well epithelized. Menstruation was re-established in Jmw, 195 7, occurring with the usual r<'gularity every 25 days, but the duration of the flow was 7 day~ instead of the usual 4· to 5 days. There was no excessive bleeding, im:rcast•d pn·menstrual tension, or dysmenorrhea. Tlw patient was fn·,· from symptoms and ran her household with hn
usual vigor and vitality. The patient has been checkt•d yearly, the last visit being in April, 1959. She stated that slw felt perfectly well, the m<'Hstrual cycle had not changed, and her legs had caused her no discomfort. The infant's mental and physical growth has been normal.
Comment
It ,,.·as decided that heparin was the anticoagulant of choice in the treatment of the
J,
:--;eptetnJ,er, FH)O ()b-.t, & Gr11cc.
acute thrombophlebitis since, from the available evidence it was thought that Dicumarol probably crosses the placental barrier. After 2 weeks of therapy all c\·idence indicated that the patient was cured. However, with the clinical evidence of pulmonary embolism so shortly after heparin therapy was omitted, it was decided that ligation of the inferior vena cava would probably be the safest course to follow. The vaginal staining that occurred on the third postoperative day probably \vas a manifestation of the temporary congestion of the uterine circulation until the collatcral circ11lation was completely taken over by the portal, \ ertebral, and azy\!ous systt:ms. Summary
The literature on ligation of the inferior \Tna ca\"a in early pregnancy and in women during thcir childbearing era has been re\·iewcd. As far as can be determined, the case presented hen' is the second case of ligation of the inferior vena cava in early pregnancy with a successful outcome.
The advice and help of Dr. Leon Ryack of the medical ;,taff and Dr. John S<'ars of thf' surgical staii is gratefully acknowledged.
REFERENCES
I. Schofield, F. W.:
J.
Arn. Vet. M. A. 64: 553,
1924. 2. Roderick, L. M.: ]. Am. Vet. M. A. 74: 314, 1929. 3. Roderick, L. M., and Schalk, A. F.: North Dakota Agr. Exp. Sta. Bull. 250: 1, 1931.
4. Quick, A. J.: J. Bioi. Chem. 164: :~71, 1946. 5. Sachs, J. J., and Labate, J. S.: AM. J. OBsT. & GY!\iEC. 57: 965, 1949. 6. Ullery, J. C.: AM. J. 0BsT. & GYNEC. 68: 1243, 1954. 7. Collins, C. G., Jones, J. R., and Nelson, E. W.: New Orleans M. & S. J. 95: 324, 19+3. 8. Nelson. E. \V., Jones, ]. R., and Collins, C, G.: New Orleans M. & S . .J. 95: 375, 1943. 9. Collins, C. G., Nelson. E. W., Roy, C. T .. Weinstein, B. B., and Collins, J. H.: AM. ]. 0BS1'. & GYNEC. 58: 1155, 1949.
l !1. Collins, C. G., MacCallum, E. A., Nelson, E. W., Weinstein, B. B.. and Collins, ]. H.: Surgery 30: 298, 311. 195 I. 11. Collins, C. G., and Ayers. W. B.: Surgery 30: 319, 1951. 12. Collins, ]. H., and Batson. H. W. K.: AM . .J. 0BST. & GYNEC. 67: 1202. 1954. 13. Burke, L, and Rosenfield, H. H.: A~;r. J. 0BST. & CYNEC. 64: 694, 1952. I+. Heath, L. P., and Carpenter, W. S.: A~;L J. 0BST. & GYKEC. 64: 692, 1952. 15. Young, R. L., and Derbyshire, R. C.: Ann. Surg. 131: 252, 1950. 16. Smith, 0. W.: A11oL J. OnsT. & GYNEC. 56: 821, 19+8.
1093 Beacon St. Brookline. Massachuseti;-
T H R 0 M B 0 E M B 0 L I S M rarely OCCurs in early pregnancy and its treatment presents special problems. The reports in the literature concerning the use of Dicumarol in the pregnant patient are in conflict. The bulk of animal experimentation supports the view that Dicumarol crosses the placental barrier and causes fatal hemorrhage in the fetus. Schofield 1 and Roderick 2 • 3 fed spoiled sweet clover to pregnant cows and the calves died of hemorrhage within 28 hours of birth. Quick 4 fed Dicumarol to a pregnant dog before parturition and of the litter of 7 pups, 4 died of hemorrhage and 3, treated with vitamin K, survived. Sachs and Labate 5 reported on a 23-year-old gravida iii, para ii, who developed phlebothrombosis and pulmonary embolism at 31 weeks of pregnancy; she was treated with heparin for the first 48 hours and then with Dicumarol. Intrauterine death occurred on the fifty-third day of treatment. Total amount of Dicumarol used was 3,150 mg. Fetal postmortem examination revealed hemorrhage into the thymus. pericardia! sac, and the pleural cavities. On the other l!and, Ullery 6 reported the cases of 2 patients, one treated with Dinunarol and one with heparin, and both pn~gnancies tenninated successfully. Collins and his associates;- 1" reported on tlw ligation of the inferior vrna cava and
both ovanan veins for suppurative pelvic thrombophlebitis. This operation was performed on 70 patients from 1942 to 1950. These patients were closely followed to determine the eHect of the operation on peripheral ederna, pelvic circulation, venous pressure, menstruation, and ovulation. In the course of the follow-up, 15 pregnancies were found in 11 patients. Six abortions occurred in 5 patients (one admittedly induced) and in the other 6 patients, 9 pregnancies were delivered at term. Other successful pregnancies following ligation of the inferior vena cava only were reported by Burke and Rosenfield 18 and Heath and Carpenter. 1 " A search of the American literature reveals only one case report of ligation of the inferior \ ena cava in early pregnancy. This case was cited by Young and Derbyshire. 1'' The patient. a 21-year-old primigravida, developed left iliofemoral thrombophlebitis on the twelfth postoperatiw day following an unevt•ntful appendectomy during the tenth week of pregnancy. Ligation of the ,·ena cava with regional sympathetic block was promptly done. The immediate postoperati\ e course and su bseq uen t pn·gnancy wnc uneventfttl. Spontaneotts labor occurred at 39 weeks and a normal infant was delivered after 8 hours of labor. I i is he('attst· of the rarity of inferior vena ~·a,·a ligation in t·arh pregnancy and sllh~r·tpwut SIH < v"ftd tt:nr~ilt
Ftom the Department of 0/Hll'lrir'.· JJeth l;rael Hospital, Buston, Massachusetts.
542
Volume 80 Number 3
Case history The patient was a 28-ycar-old housewife, para 3-2-0-2, whose last menstrual period had occurred on June 8, 1956. The first pregnancy terminated in the pelvic delivery of binovular twins at 33 weeks after an uneventful prenatal course. The first twin, a 1 pound, 14 ounce anatomically normal male, died in 36 hours. The second twin, a 4 pound, 11 ounce male, had multiple congenital anomalies and died in 24 hours. The second and third pregnancies tf'rminatcd in full-term normal deliveries and both children are living and well. The fourth pregnancy ended in the spontaneous delivery of a 4 pound, 12 ounce stillborn female at 40 weeks. Occult prolapse of the cord, a true knot in the cord, and a small, severely infarcted placenta accounted for this intrauterine death. The past history revealed pleurisy at the age of 15 and a "mild" attack of poliomyelitis at 16. The family history was noncontributory. On Aug. 28, 1956, the patient experienced a "grippe-like feeling" with fever to 101° F., abdominal cramps, muscular aches and pains, and one loose bowel movement. Three days later pain occurred in the right lower anterior quadrant of th<~ chest radiating to the right shoulder and accentuated by deep breathing. Almost simultaneously with the chest pain, she noted pain in the left groin. All symptoms abated temporarily, and on September 3 pain recurred in the left groin and thigh and the left calf also became painful. The patient made her symptoms known on September 5 and was immediately admitted to the hospital. The pertinent physical findings on admission were: temperature 101° F.; pulse 90; respirations 24; percussion and auscultation of lungs normal. There was tenderness in the left calf, the left thigh over Hunter's canal, and just above the medial portion of the left Poupart's ligament. The left thigh, measured 5 inches above the patella, was 1)h inches greater in circumference than the right measured at the same level; the left calf, measured 5 inches below the patella, was 1Y4 inches greater in circumference than the right measured at the same level; the entire left leg from groin to toes was cold and mottled. The following laboratory findings were recorded: hemoglobin level, 11.2 Gm.; hematocrit determination, 36; red blood count, 3.62 million; white blood count, 13,800 with a normal differential; x-ray of the lungs revealed no evidence of pulmonary infarct.
Ligation of inferior vena cava
543
It was decided to treat this patient with anti· coagulant therapy. Aqueous heparin was given every 4 hours through an indwelling catheter in the left cubital vein. The amount given was determined by the clotting time and varied between 35 and 50 mg. The clotting time was maintained between 16 and 22 minutes as determined by the Lee-White method. The daily dose of heparin ranged from 190 mg. to 360 mg. In addition, 600,000 units of procaine penicillin was administered intramuscularly each day. The left leg was elevated on a pillow and protected by a cradle. Pain was controlled with meperidine, codeine, secobarbital, and aspirin. By the sixth hospital day the measurements of the left leg became equal to those of the right leg, temperature and pulse became normal, and all pain disappeared. Beginning on the eleventh hospital day the dose of heparin was gradually reduced and finally omitted on the fourteenth day. At this point the patient was allowed out of bed with elastic bandages applied to both legs. J\o vaginal staining occurred during heparin therapy. On Sept. 18, 1956, the thirteenth hospital day, the patient complained of a sore throat that persisted on the following day and in addition she noticed aching of the right side of the face and neck. Physical examination was negative and temperature, pulse, and respirations were normal. On Sept. 20, she was noted to be tense and anxious; the temperature was elevated to 100° F., pulse to 95, and respiration to 24 to 28 a minute. At this time she complained of sharp pain in the right lower part of the chest that was aggravated by deep breathing and a cough that produced bloody sputum. Auscultation revealed diminished breath sounds and friction rub in the right lower side of the chest posteriorly. In spite of the fact that x-ray examination did not confirm the diagnosis of pulmonary infarct, it was decided that surgical intervention was indicated. On September 21, under general anesthesia, the vena cava was ligated just above the bifurcation. The immediate postoperative condition was excellent. No anticoagulant therapy was given. Pain in the right side of the chest gradually disappeared over the next 5 days. Moderate vaginal staining occurred on the third postoperative day and diethylstilbestrol following the Smith1 6 regime was instituted. The patient made an uneventful recovery and was discharged on the eighth postoperative day wearing full-length elastic hose.
544
Rubin
\u1
Subsequently, the pn·nalal coursr~ was uneventful. Occasionally, thr·re was mild aching of the right leg but there was never any demonstrable edema. Spontaneous labor began on Feb. 25, 195 7, and after fJ hours and 30 minntcs of labor, a normal, active ti pound, 14 ounce f emak infant was delivered by low forceps. The postpartum course was a febrile and uneventfuL Postpartum examination on April 18 and Aug. 15, 195 7, revealed no edC'nn or \·aricosities of the lower extremities and they were equal in size. The uterus was anterior, symmetrical, normal in size, and frerly movable. The vaults and sides were normal and the cr•tvix well epithelized. Menstruation was re-established in Jmw, 195 7, occurring with the usual r<'gularity every 25 days, but the duration of the flow was 7 day~ instead of the usual 4· to 5 days. There was no excessive bleeding, im:rcast•d pn·menstrual tension, or dysmenorrhea. Tlw patient was fn·,· from symptoms and ran her household with hn
usual vigor and vitality. The patient has been checkt•d yearly, the last visit being in April, 1959. She stated that slw felt perfectly well, the m<'Hstrual cycle had not changed, and her legs had caused her no discomfort. The infant's mental and physical growth has been normal.
Comment
It ,,.·as decided that heparin was the anticoagulant of choice in the treatment of the
J,
:--;eptetnJ,er, FH)O ()b-.t, & Gr11cc.
acute thrombophlebitis since, from the available evidence it was thought that Dicumarol probably crosses the placental barrier. After 2 weeks of therapy all c\·idence indicated that the patient was cured. However, with the clinical evidence of pulmonary embolism so shortly after heparin therapy was omitted, it was decided that ligation of the inferior vena cava would probably be the safest course to follow. The vaginal staining that occurred on the third postoperative day probably \vas a manifestation of the temporary congestion of the uterine circulation until the collatcral circ11lation was completely taken over by the portal, \ ertebral, and azy\!ous systt:ms. Summary
The literature on ligation of the inferior \Tna ca\"a in early pregnancy and in women during thcir childbearing era has been re\·iewcd. As far as can be determined, the case presented hen' is the second case of ligation of the inferior vena cava in early pregnancy with a successful outcome.
The advice and help of Dr. Leon Ryack of the medical ;,taff and Dr. John S<'ars of thf' surgical staii is gratefully acknowledged.
REFERENCES
I. Schofield, F. W.:
J.
Arn. Vet. M. A. 64: 553,
1924. 2. Roderick, L. M.: ]. Am. Vet. M. A. 74: 314, 1929. 3. Roderick, L. M., and Schalk, A. F.: North Dakota Agr. Exp. Sta. Bull. 250: 1, 1931.
4. Quick, A. J.: J. Bioi. Chem. 164: :~71, 1946. 5. Sachs, J. J., and Labate, J. S.: AM. J. OBsT. & GY!\iEC. 57: 965, 1949. 6. Ullery, J. C.: AM. J. 0BsT. & GYNEC. 68: 1243, 1954. 7. Collins, C. G., Jones, J. R., and Nelson, E. W.: New Orleans M. & S. J. 95: 324, 19+3. 8. Nelson. E. \V., Jones, ]. R., and Collins, C, G.: New Orleans M. & S . .J. 95: 375, 1943. 9. Collins, C. G., Nelson. E. W., Roy, C. T .. Weinstein, B. B., and Collins, J. H.: AM. ]. 0BS1'. & GYNEC. 58: 1155, 1949.
l !1. Collins, C. G., MacCallum, E. A., Nelson, E. W., Weinstein, B. B.. and Collins, ]. H.: Surgery 30: 298, 311. 195 I. 11. Collins, C. G., and Ayers. W. B.: Surgery 30: 319, 1951. 12. Collins, ]. H., and Batson. H. W. K.: AM . .J. 0BST. & GYNEC. 67: 1202. 1954. 13. Burke, L, and Rosenfield, H. H.: A~;r. J. 0BST. & CYNEC. 64: 694, 1952. I+. Heath, L. P., and Carpenter, W. S.: A~;L J. 0BST. & GYKEC. 64: 692, 1952. 15. Young, R. L., and Derbyshire, R. C.: Ann. Surg. 131: 252, 1950. 16. Smith, 0. W.: A11oL J. OnsT. & GYNEC. 56: 821, 19+8.
1093 Beacon St. Brookline. Massachuseti;-