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Obstetric care of Southeast Asian refugees
472
October 15. 1YilO Am . .J. Ob•tel. Cynecol.
Correspondence
5,000 U of heparin. However, during surgery the plasma heparin levels decrease much more rapidly than in normal individuals. Therefore, coagulation studies in our report were done not during or immediately after surgery but at 24 and 72 hours postoperatively in· order to examine the maximum effect of heparin. The blood samples were drawn 3 to 5 hours after the previous heparin dose. The timing of the studies was carefully planned and tests were done at the optimum times to evaluate changes caused by heparin. They were not "improperly timed." We are well aware of the problem of thrombocytopenia induced occasionally in patients by both therapeutic intravenous doses of heparin and low-dose subcutaneous heparin. However, in this study the heparin was continued for only 5 days postoperatively and the chances of heparin-induced thrombocytopenia were reduced as compared to use of high-dose heparin for longer periods of time follo\ving surgery. As pointed out in our paper we saw none of the hyperresponsiveness to heparin as reported by Gurewich and colleagues. 2 In spite of increases of two times the control partial thromboplastin times in 10% to 15% of patients, only three (4.5%) of the patients of Gurewich and colleagues had excessive bleeding. One of these three had ingested aspirin. The incidence of bleeding complications during heparin therapy reported by some authors is indeed bothersome. Other authors have seen no significant differences in bleeding between control subjects and patients receiving low-dose heparin. Kakkar and associates:! in a multicenter study of 1,475 patients found no significant differences in number of patients requiring transfusion, in mean volume of blood transfused, or in mean drop of hematocrit between heparinized and control patients. Although our group of heparinized patients was only half as large as that of Pachter and Riles, 4 by their statistics we should have seen 7 or 8 patients with wound hematomas or hematuria. We had one patient with hematoma in the heparinized group and four patients with wound dehiscence or hematoma in the control group. In the group studied in our report where extensive pelvic surgery was performed, many for malignancies (exenterations, radical vulvectomies, or radical hysterectomies with bilateral salpingo-oophorectomy and pelvic node dissection), the risk of pelvic vein thrombosis and pulmonary embolism is high (not low as Dr. Clarke-Pearson states). Therefore, such bleeding complications as wound hematoma or hematuria (which is seldom caused by heparin), as reported by Pachter and Riles, may be minor as compared to the danger of deep vein thrombosis and thromboembolism. Our study of 7 5 patients showed that there were no significant changes caused by low-dose heparin in coagulation tests which would normally be used to monitor patients. The only exception to this is in the
levels of fibrin degradation products, which were much lower in the heparinized group. (There is an error in the abstract of our paper in line 5 which should have read, 'There was a statistically significant decrease noted in fibrin degradation products .... " The statements m the "Results" and "Comment" sections are correct.) This indicates that the amount of fibrin deposition is less in the heparinized patients 'tvhich is a distinct advantage. The bleeding seen in these elderly and often debilitated patients on subcutaneous low-dose heparin is much less than that in those given therapeutic doses of heparin starting 2 days after surgery with subsequent oral anticoagulation. Such anticoagulation has previously been routine treatment at this institution for radical pelvic surgery. The criteria for "excessive clinical bleeding attributable to low-dose heparin" was observation by one or both of two experienced pelvic surgeons (Drs. Dillon and Chung), estimated blood loss during surgery, and incidence of postoperative anemia. Louise Lang Phillips, Ph.D. 428 West 59th Street New York, New York 10019 REFERENCES I. Kakkar, V. V., Corrigan, T., Spindler,]., et al.: Efficacy of
low doses of heparin in prevention of deep-vein thrombosis after major surgery, Lancet 2:101 1972. 2. Gurewich, V., Nunn, T., Thazhathekudyil, T., et al.: Hemostatic effects of uniform low-dose subcutaneous heparin in surgical patients, Arch. Intern. Med. 138:41, 1978. 3. Kakkar, V. V., Corrigan, T. P. Fossaid, D.P., et al.: Prevention of fatal postoperative pulmonary embolism by low doses of heparin, Lancet 2:45, 1975. 4. Pachter, H. L., and Riles, T. S.: Low dose heparin: Bleeding and wound complication in the surgical patient, Ann. Surg. 186:669, 1977.
Obstetric care of Southeast Asian refugees To the Editors: The Center for Disease Control has recently published a clinician's guide to diseases of Indochinese refugees. Although these guidelines cover many of the disease states encountered in these refugees, notably absent, however, is an acknowledgement that the pregnant Southeast Asian refugee may represent an important public health hazard both to her unborn child and to obstetric and neonatal care personnel. Physicians and nurses involved in the obstetric care of Southeast Asian refugees should be alerted that these women may be acutely or chronically ill with such diseases as hepatitis B, tuberculosis, malaria, a variety of intestinal parasite infections, and a variety of hemoglobinopathies. Detection early in pregnancy of any such illness would seem advisable not only because obstetric management might be influenced by diag-
Volume 13H Numhn 4
Correspondence
noses such as chronic active hepatitis or a hemoglobinopathy but also so that, when infectious diseases are diagnosed, appropriate isolation precautions could be planned for the intrapartum hospitalization and. where indicated, arrangements for early prophylaxis of or surveiiiance for disease in the newborn infant could be made. In specific terins. pregnant Southeast Asian refugees should be screened in early pregnancy with at least a hemoglobin electrophoresis. a hepatitis B surface antigen determination, a stool analysis for ova and parasites, and a tuberculin skin test. The many women who have a positive tuberculin skin test should be evaluated further for active tuberculosis and an effort should be made to ensure that no other family member has active tuberculosis. Additional unusual diseases, such as malaria, should be considered in women with suggestive symptoms. Attention to these special concerns for the pregnant Southeast Asian refugee will, at the very least, improve the obstetric care of these ~;omen and may minimize the health risk which they can present both to their newborn infants and to the physicians and nurses involved in their care. David F. Wender, M.D. Department of Pediatrics Mainf Medical Center Portland, Maine 04102
4 73
Correlation between computed variability indexes and subjective evaluation To the Editors: In a recent article by Escarcena and associates, entitled "Fetal baseline heart rate variability estimation. I. Comparison of clinical and stochastic quantification techniques" (AM.j. 0BSTET. GYNECOL. 1:~5:615, 1979), the authors concluded that correlation benveen visual subjective and stochastic methods was low. According to the authors the study was started because there had been no attempt to correlate the computed variability indexes with the subjective evaluation of variability. Thev failed to cite a report 1 in this JocRKAL in which similar conclusions were reported. This studv also showed that the obstetric staff can be taught to evaluate the two components of variahilitv with greater precision. Veikko Karinifmi, AJ.D. 1st Departnzent of Obstetrics and Gynrcofogy Helsinki University Central Hospital Haartmanink. 2 00290 Helsinki 29, Finland
REFERENCE ! . Kariniemi. V.: Evaluation of fetal heart rate variability by a visual semiquantitative method and by a quantitative statistical method with the use of minicomputer, AM . .J. 0BSTET. GYNECOL. 130:588, 1978.
Erratum In the June 15, 1980, issue of the JouRNAL, in the article by Donowitz and Wenzel, entitled "Endometritis following cesarean section," on page 468, in Table II, the number corresponding to Hospital cost and Controls should have been $1,252.57.
October 15. 1YilO Am . .J. Ob•tel. Cynecol.
Correspondence
5,000 U of heparin. However, during surgery the plasma heparin levels decrease much more rapidly than in normal individuals. Therefore, coagulation studies in our report were done not during or immediately after surgery but at 24 and 72 hours postoperatively in· order to examine the maximum effect of heparin. The blood samples were drawn 3 to 5 hours after the previous heparin dose. The timing of the studies was carefully planned and tests were done at the optimum times to evaluate changes caused by heparin. They were not "improperly timed." We are well aware of the problem of thrombocytopenia induced occasionally in patients by both therapeutic intravenous doses of heparin and low-dose subcutaneous heparin. However, in this study the heparin was continued for only 5 days postoperatively and the chances of heparin-induced thrombocytopenia were reduced as compared to use of high-dose heparin for longer periods of time follo\ving surgery. As pointed out in our paper we saw none of the hyperresponsiveness to heparin as reported by Gurewich and colleagues. 2 In spite of increases of two times the control partial thromboplastin times in 10% to 15% of patients, only three (4.5%) of the patients of Gurewich and colleagues had excessive bleeding. One of these three had ingested aspirin. The incidence of bleeding complications during heparin therapy reported by some authors is indeed bothersome. Other authors have seen no significant differences in bleeding between control subjects and patients receiving low-dose heparin. Kakkar and associates:! in a multicenter study of 1,475 patients found no significant differences in number of patients requiring transfusion, in mean volume of blood transfused, or in mean drop of hematocrit between heparinized and control patients. Although our group of heparinized patients was only half as large as that of Pachter and Riles, 4 by their statistics we should have seen 7 or 8 patients with wound hematomas or hematuria. We had one patient with hematoma in the heparinized group and four patients with wound dehiscence or hematoma in the control group. In the group studied in our report where extensive pelvic surgery was performed, many for malignancies (exenterations, radical vulvectomies, or radical hysterectomies with bilateral salpingo-oophorectomy and pelvic node dissection), the risk of pelvic vein thrombosis and pulmonary embolism is high (not low as Dr. Clarke-Pearson states). Therefore, such bleeding complications as wound hematoma or hematuria (which is seldom caused by heparin), as reported by Pachter and Riles, may be minor as compared to the danger of deep vein thrombosis and thromboembolism. Our study of 7 5 patients showed that there were no significant changes caused by low-dose heparin in coagulation tests which would normally be used to monitor patients. The only exception to this is in the
levels of fibrin degradation products, which were much lower in the heparinized group. (There is an error in the abstract of our paper in line 5 which should have read, 'There was a statistically significant decrease noted in fibrin degradation products .... " The statements m the "Results" and "Comment" sections are correct.) This indicates that the amount of fibrin deposition is less in the heparinized patients 'tvhich is a distinct advantage. The bleeding seen in these elderly and often debilitated patients on subcutaneous low-dose heparin is much less than that in those given therapeutic doses of heparin starting 2 days after surgery with subsequent oral anticoagulation. Such anticoagulation has previously been routine treatment at this institution for radical pelvic surgery. The criteria for "excessive clinical bleeding attributable to low-dose heparin" was observation by one or both of two experienced pelvic surgeons (Drs. Dillon and Chung), estimated blood loss during surgery, and incidence of postoperative anemia. Louise Lang Phillips, Ph.D. 428 West 59th Street New York, New York 10019 REFERENCES I. Kakkar, V. V., Corrigan, T., Spindler,]., et al.: Efficacy of
low doses of heparin in prevention of deep-vein thrombosis after major surgery, Lancet 2:101 1972. 2. Gurewich, V., Nunn, T., Thazhathekudyil, T., et al.: Hemostatic effects of uniform low-dose subcutaneous heparin in surgical patients, Arch. Intern. Med. 138:41, 1978. 3. Kakkar, V. V., Corrigan, T. P. Fossaid, D.P., et al.: Prevention of fatal postoperative pulmonary embolism by low doses of heparin, Lancet 2:45, 1975. 4. Pachter, H. L., and Riles, T. S.: Low dose heparin: Bleeding and wound complication in the surgical patient, Ann. Surg. 186:669, 1977.
Obstetric care of Southeast Asian refugees To the Editors: The Center for Disease Control has recently published a clinician's guide to diseases of Indochinese refugees. Although these guidelines cover many of the disease states encountered in these refugees, notably absent, however, is an acknowledgement that the pregnant Southeast Asian refugee may represent an important public health hazard both to her unborn child and to obstetric and neonatal care personnel. Physicians and nurses involved in the obstetric care of Southeast Asian refugees should be alerted that these women may be acutely or chronically ill with such diseases as hepatitis B, tuberculosis, malaria, a variety of intestinal parasite infections, and a variety of hemoglobinopathies. Detection early in pregnancy of any such illness would seem advisable not only because obstetric management might be influenced by diag-
Volume 13H Numhn 4
Correspondence
noses such as chronic active hepatitis or a hemoglobinopathy but also so that, when infectious diseases are diagnosed, appropriate isolation precautions could be planned for the intrapartum hospitalization and. where indicated, arrangements for early prophylaxis of or surveiiiance for disease in the newborn infant could be made. In specific terins. pregnant Southeast Asian refugees should be screened in early pregnancy with at least a hemoglobin electrophoresis. a hepatitis B surface antigen determination, a stool analysis for ova and parasites, and a tuberculin skin test. The many women who have a positive tuberculin skin test should be evaluated further for active tuberculosis and an effort should be made to ensure that no other family member has active tuberculosis. Additional unusual diseases, such as malaria, should be considered in women with suggestive symptoms. Attention to these special concerns for the pregnant Southeast Asian refugee will, at the very least, improve the obstetric care of these ~;omen and may minimize the health risk which they can present both to their newborn infants and to the physicians and nurses involved in their care. David F. Wender, M.D. Department of Pediatrics Mainf Medical Center Portland, Maine 04102
4 73
Correlation between computed variability indexes and subjective evaluation To the Editors: In a recent article by Escarcena and associates, entitled "Fetal baseline heart rate variability estimation. I. Comparison of clinical and stochastic quantification techniques" (AM.j. 0BSTET. GYNECOL. 1:~5:615, 1979), the authors concluded that correlation benveen visual subjective and stochastic methods was low. According to the authors the study was started because there had been no attempt to correlate the computed variability indexes with the subjective evaluation of variability. Thev failed to cite a report 1 in this JocRKAL in which similar conclusions were reported. This studv also showed that the obstetric staff can be taught to evaluate the two components of variahilitv with greater precision. Veikko Karinifmi, AJ.D. 1st Departnzent of Obstetrics and Gynrcofogy Helsinki University Central Hospital Haartmanink. 2 00290 Helsinki 29, Finland
REFERENCE ! . Kariniemi. V.: Evaluation of fetal heart rate variability by a visual semiquantitative method and by a quantitative statistical method with the use of minicomputer, AM . .J. 0BSTET. GYNECOL. 130:588, 1978.
Erratum In the June 15, 1980, issue of the JouRNAL, in the article by Donowitz and Wenzel, entitled "Endometritis following cesarean section," on page 468, in Table II, the number corresponding to Hospital cost and Controls should have been $1,252.57.