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Low-dose heparin for prevention of thromboembolic disease in pregnancy
588
Communications
Nowmber Am. J. Obstet.
in brief
Fig. 1. Patient posteriorly
B. H. Note
may extend to involve major proach carries the possibility with cervical prolapse of major In summary, prolapse of the trimester. Antepartun bed rest, ing, and strict hygiene are proceeds spontaneously but made for rapid intervention.
the anterior
wall of the uterus
blood vessels, this apsignificant morbidity proportions. uterus may occur in any a pessary, vaginal packsuggested. Labor often preparations should be of
REFERENCES
1. Keettel, 2. Gastane. 1956.
W. C.: AM. J. OBSTET. GYNECOL. J., and Lahriola, B. F.: Obstet.
A mesenteric ROBERT JAMES ANTHONY H.
STEPHEN
12 1, 1941.
8: 278,
cyst in pregnancy
G. G.
42:
Gynecol.
O’DRISCOLL.
SALERNO, C.
M.D. M.D.
QUARTRELL, FLETCHER,
M.D. M.D.
Departments of Obstetrics and Gynecology and Surgery, Barnabas Medical Center. Livingston, New Jersey
Saint
A CASE of a mesenteric cyst during pregnancy, representing the third such reported case, is presented. Preoperative ultrasonography documented the coexistent presence of an intrauterine pregnancy and a pelvic cystic mass. Reprint requests: Ave., West Orange,
Dr. Robert New Jersey
G. O’Driscoll. 07052.
95 Northfield
outside
the introitus
with the bleeding
I. 1977 Gynecol.
cervix
A 31-year-old Philippine woman, gravida 3, para 2, whose last menstrual period began on May 17, 1975, was admitted to Saint Barnabas Medical Center on July 11, 1975. with an enlarging abdominal mass. Two weeks prior to admission. a nontender, mobile. cystic mass, extending 2 cm. above the umbilicus and seeming to arise from the left lower quadrant, had been found on physical examination. A qualitative urine test for chorionic gonadotropin was positive at that time. An ultrasound scan demonstrated a seven-week intrauterine gestational sac with an anterior cystic mass measuring 16 by 20 cm. (Fig. 1). Laparotomy with the use of epidural anesthesia was performed on the second hospital day because of rapid growth of the mass. Upon opening of the peritoneal cavity, a large multiloculated cyst and an a-week-size uterus were found (Fig. 2). The cyst was attached to the small bowel mesentery by multiple thick pedicles. The cyst was removed by sharp and blunt dissection with skeletonization of the inferior mesenteric artery which coursed through the cyst. The patient received two units of packed cells during the operation. The postoperative course was essentially uncomplicated, and she was discharged on the tenth postoperative day. The pathologic diagnosis was mesenteric cyst, lymphangioma. The patient’s subsequent prenatal course was uneventful. On February 15, 1976, she went into spontaneous labor. Following an uncomplicated labor, a low,-forceps delivery of a healthy 7 pound, 8 ounce male infant was accomplished. Six hundred primary mesenteric neoplasms have been reported since the original recognition of the first mesenteric cyst, in 1507, by the Florentine anatomist Benivieni. The case presented here represents the third reported mesenteric cyst occuring during pregnancy.
Volume Number
Communications
129 5
Fig.
1. A longitudinal
Fig. 2. The multiloculated uterus is seen in the right
sonogram
of the cyst and the gestational
589
sac.
mesenteric cyst is demonstrated at the time of laparotomy. lower corner, adjacent to the retractor.
Primary mesenteric tumors originate in the tissue between the two layers of peritoneum. The principal anatomic feature of importance in the cyst is the clear demonstration during laparotomy that it does not arise from any organ in the abdominal cavity and, therefore, merits the designation “mesenteric.” The etiology of mesenteric cysts is thought to be the presence of aberrant islands of lymphatic tissue without access to proper drainage or, perhaps, congenital absence of drainage of properly positioned lymphoid tissue. The most common form of mesenteric cyst occurs
in brief
The
pregnant
in the small bowel mesentery and is usually multiloculated. Mesenteric cysts often become adherent to intraperitoneal structures and may cause attenuation of any segment of bowel to which they adhere. The complications are those to be expected from mechanical factors such as rupture, torsion, and compression. The cyst characteristically presents as a gradually enlarging, painless abdominal mass. The sex distribution is equal, with the peak incidence being in the 40 to 50 year age group.
590
Communications
in brief
Simple enucleation is the treatment of choice, with maintenance of the intestinal vasculature and, in the presence of an intrauterine pregnancy, minimal uterine manipulation. The prognosis of mesenteric cysts is excellent, with recurrence being rare. In this case, as in both previously reported cases,‘. * the patient was delivered of a healthy infant. REFERENCES
1. Dunn, nancy,
J. M.: A large mesenteric J. A. M. A. ZOO: 1129, 1967.
cyst complicating
preg-
2. Hill, V. L., and Woomer, D. F.: Retroperitoneal cyst complicating pregnancy, Obstet. Gynecol. 22: 174, 1965.
Low-dose heparin for prevention of thromboembolic disease in pregnancy HAROLD USAF,
F.
BASKlN.
M.D..
MAJOR,
MC
JAMES
M.
USAF,
MC
MURRAY,
ROBERT
E.
COLONEL,
USAF,
M.D..
HARRIS,
Department of Obstetrics StatPs Air Force Medical Tf%fI.r
M.D.,
MAJCIR.
PH.D.,
MC and Gynecology, Wilford Hall United Center, Lackland Air Force Base,
A PREGNANT woman with thromboembolic disease prior to or during pregnancy has an increased risk of recurrence during that pregnancy and for at least six weeks post partum. Prevention of recurrences of thrombotic episodes during pregnancy is essential in order to lower the maternal mortality rate, but prophylaxis with full anticoagulation is hazardous to both mother and fetus. Low-dose heparin, utilized successfully to prevent thromboembolic disease and deaths from pulmonary embolus in surgical patients,’ has been instituted by the Obstetrics Service of Wilford Hall United States Air Force Medical Center for pregnant patients with a past history of thromboembolic disease. Thr experience gained from these patients forms the basis of this report. From June 1, 1975. to May 3 1, 1976. at the initial obstetric clinic visit, 2,000 patients were screened for a history of previous thromboembolic disease. Seven patients (0.35 per cent) with this history were identified and selected to have low-dose heparin prophylaxis therapy during the gestation (Table I). Each patient was taught by the nurses on the obstetric unit (three as The opinions expressed in this manuscript are those of the authors and not necessarily those of the United States Air Force or the Department of Defense. Reprint requests: Dr. Harold F. Baskin, 2400 24th Loop, Kirtland AFB, New Mexico 87116.
inpatients and four as outpatients) to self-administer 0.25 ml. of heparin (20,000 U. per milliliters-i.e., 5,000 U. per dose) subcutaneously in the abdominal wall. Heparin was administered for the duration of pregnancy and for six to eight weeks post partum at 12 hour intervals. The patients were examined every one to two weeks in the high-risk obstetric clinic hv the same group of physicians. Prothrombin and partial thromboplastin time determinations, obtain4 ar eat-h visit, remained normal for all seven patiems. The pi*tients were instructed to report immediately anv blerding episodes from any site. No complication attributable to heparin occured during pregnant\‘, Iahor. 01 delivery, and there was no clinical evidence 01 recurrent thrombophlebitis or pulmonary embolism. Pulmonary embolism remains a common (roust’ of’ maternal death. The risk of recurrcncc’ of thromboembolism during pregnancy and the p
Communications
Nowmber Am. J. Obstet.
in brief
Fig. 1. Patient posteriorly
B. H. Note
may extend to involve major proach carries the possibility with cervical prolapse of major In summary, prolapse of the trimester. Antepartun bed rest, ing, and strict hygiene are proceeds spontaneously but made for rapid intervention.
the anterior
wall of the uterus
blood vessels, this apsignificant morbidity proportions. uterus may occur in any a pessary, vaginal packsuggested. Labor often preparations should be of
REFERENCES
1. Keettel, 2. Gastane. 1956.
W. C.: AM. J. OBSTET. GYNECOL. J., and Lahriola, B. F.: Obstet.
A mesenteric ROBERT JAMES ANTHONY H.
STEPHEN
12 1, 1941.
8: 278,
cyst in pregnancy
G. G.
42:
Gynecol.
O’DRISCOLL.
SALERNO, C.
M.D. M.D.
QUARTRELL, FLETCHER,
M.D. M.D.
Departments of Obstetrics and Gynecology and Surgery, Barnabas Medical Center. Livingston, New Jersey
Saint
A CASE of a mesenteric cyst during pregnancy, representing the third such reported case, is presented. Preoperative ultrasonography documented the coexistent presence of an intrauterine pregnancy and a pelvic cystic mass. Reprint requests: Ave., West Orange,
Dr. Robert New Jersey
G. O’Driscoll. 07052.
95 Northfield
outside
the introitus
with the bleeding
I. 1977 Gynecol.
cervix
A 31-year-old Philippine woman, gravida 3, para 2, whose last menstrual period began on May 17, 1975, was admitted to Saint Barnabas Medical Center on July 11, 1975. with an enlarging abdominal mass. Two weeks prior to admission. a nontender, mobile. cystic mass, extending 2 cm. above the umbilicus and seeming to arise from the left lower quadrant, had been found on physical examination. A qualitative urine test for chorionic gonadotropin was positive at that time. An ultrasound scan demonstrated a seven-week intrauterine gestational sac with an anterior cystic mass measuring 16 by 20 cm. (Fig. 1). Laparotomy with the use of epidural anesthesia was performed on the second hospital day because of rapid growth of the mass. Upon opening of the peritoneal cavity, a large multiloculated cyst and an a-week-size uterus were found (Fig. 2). The cyst was attached to the small bowel mesentery by multiple thick pedicles. The cyst was removed by sharp and blunt dissection with skeletonization of the inferior mesenteric artery which coursed through the cyst. The patient received two units of packed cells during the operation. The postoperative course was essentially uncomplicated, and she was discharged on the tenth postoperative day. The pathologic diagnosis was mesenteric cyst, lymphangioma. The patient’s subsequent prenatal course was uneventful. On February 15, 1976, she went into spontaneous labor. Following an uncomplicated labor, a low,-forceps delivery of a healthy 7 pound, 8 ounce male infant was accomplished. Six hundred primary mesenteric neoplasms have been reported since the original recognition of the first mesenteric cyst, in 1507, by the Florentine anatomist Benivieni. The case presented here represents the third reported mesenteric cyst occuring during pregnancy.
Volume Number
Communications
129 5
Fig.
1. A longitudinal
Fig. 2. The multiloculated uterus is seen in the right
sonogram
of the cyst and the gestational
589
sac.
mesenteric cyst is demonstrated at the time of laparotomy. lower corner, adjacent to the retractor.
Primary mesenteric tumors originate in the tissue between the two layers of peritoneum. The principal anatomic feature of importance in the cyst is the clear demonstration during laparotomy that it does not arise from any organ in the abdominal cavity and, therefore, merits the designation “mesenteric.” The etiology of mesenteric cysts is thought to be the presence of aberrant islands of lymphatic tissue without access to proper drainage or, perhaps, congenital absence of drainage of properly positioned lymphoid tissue. The most common form of mesenteric cyst occurs
in brief
The
pregnant
in the small bowel mesentery and is usually multiloculated. Mesenteric cysts often become adherent to intraperitoneal structures and may cause attenuation of any segment of bowel to which they adhere. The complications are those to be expected from mechanical factors such as rupture, torsion, and compression. The cyst characteristically presents as a gradually enlarging, painless abdominal mass. The sex distribution is equal, with the peak incidence being in the 40 to 50 year age group.
590
Communications
in brief
Simple enucleation is the treatment of choice, with maintenance of the intestinal vasculature and, in the presence of an intrauterine pregnancy, minimal uterine manipulation. The prognosis of mesenteric cysts is excellent, with recurrence being rare. In this case, as in both previously reported cases,‘. * the patient was delivered of a healthy infant. REFERENCES
1. Dunn, nancy,
J. M.: A large mesenteric J. A. M. A. ZOO: 1129, 1967.
cyst complicating
preg-
2. Hill, V. L., and Woomer, D. F.: Retroperitoneal cyst complicating pregnancy, Obstet. Gynecol. 22: 174, 1965.
Low-dose heparin for prevention of thromboembolic disease in pregnancy HAROLD USAF,
F.
BASKlN.
M.D..
MAJOR,
MC
JAMES
M.
USAF,
MC
MURRAY,
ROBERT
E.
COLONEL,
USAF,
M.D..
HARRIS,
Department of Obstetrics StatPs Air Force Medical Tf%fI.r
M.D.,
MAJCIR.
PH.D.,
MC and Gynecology, Wilford Hall United Center, Lackland Air Force Base,
A PREGNANT woman with thromboembolic disease prior to or during pregnancy has an increased risk of recurrence during that pregnancy and for at least six weeks post partum. Prevention of recurrences of thrombotic episodes during pregnancy is essential in order to lower the maternal mortality rate, but prophylaxis with full anticoagulation is hazardous to both mother and fetus. Low-dose heparin, utilized successfully to prevent thromboembolic disease and deaths from pulmonary embolus in surgical patients,’ has been instituted by the Obstetrics Service of Wilford Hall United States Air Force Medical Center for pregnant patients with a past history of thromboembolic disease. Thr experience gained from these patients forms the basis of this report. From June 1, 1975. to May 3 1, 1976. at the initial obstetric clinic visit, 2,000 patients were screened for a history of previous thromboembolic disease. Seven patients (0.35 per cent) with this history were identified and selected to have low-dose heparin prophylaxis therapy during the gestation (Table I). Each patient was taught by the nurses on the obstetric unit (three as The opinions expressed in this manuscript are those of the authors and not necessarily those of the United States Air Force or the Department of Defense. Reprint requests: Dr. Harold F. Baskin, 2400 24th Loop, Kirtland AFB, New Mexico 87116.
inpatients and four as outpatients) to self-administer 0.25 ml. of heparin (20,000 U. per milliliters-i.e., 5,000 U. per dose) subcutaneously in the abdominal wall. Heparin was administered for the duration of pregnancy and for six to eight weeks post partum at 12 hour intervals. The patients were examined every one to two weeks in the high-risk obstetric clinic hv the same group of physicians. Prothrombin and partial thromboplastin time determinations, obtain4 ar eat-h visit, remained normal for all seven patiems. The pi*tients were instructed to report immediately anv blerding episodes from any site. No complication attributable to heparin occured during pregnant\‘, Iahor. 01 delivery, and there was no clinical evidence 01 recurrent thrombophlebitis or pulmonary embolism. Pulmonary embolism remains a common (roust’ of’ maternal death. The risk of recurrcncc’ of thromboembolism during pregnancy and the p