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Reply to Pearson
108 Correspondence Am.
J.
May 1, 1984 Obstet. Gynecol.
Outpatient intravenous heparin
Fig. 1. RNG-R230-S needle guide attached to an ADR 3.5 mHz sector transducer.
Fig. 2. A 23-gauge amniocentesis needle placed under direct visualization. 1 = Fetal foot; 2 = needle tip; 3 = fetal extremity; 4 = shaft of the needle in the placenta. The needle tip's width is secondary to an air bubble. others for placement of intrauterine fetal catheters.* There has been only one blood-contaminated tap in the last 900 patients who have undergone genetic amniocentesis at the University of Iowa with this guide. Roger A. Williamson, M.D. Michael W. Varner, M.D. Carl P. Weiner, M.D. Department of Obstetrics and Gynecology The University of Iowa Hospitals and Clinics Iowa City, Iowa 52242 *Personal communication, R. E. Sabbagha, M.D., Northwestern University.
To the Editors: The case report of Cohen, Gabbe, and Mennuti, entitled "Adjusted-dose heparin therapy by continuous intravenous infusion for recurrent pulmonary embolism during pregnancy" (AM. J. OBSTET. GYNECOL. 146:463, 1983), serves to remind us of the value of outpatient intravenous heparin in the management of antepartum deep vein thrombophlebitis and/or embolization. l - a To date, as noted in the references, we have had no recurrences or significant complications when the patient has maintained a self-administered intravenous program with a heparin lock. Our combined experience in two centers now numbers well over 25 cases since 1964. The comment regarding the use of therapeutic subcutaneous heparin requires further amplification. The preponderance of current literature points out the lack of predictability and, in fact, the minimal measurable anticoagulant effect with the subcutaneous regimen and emphasizes it as a prophylactic rather than a therapeutic measure. I would like to ask the authors whether the intravenous line required replacement during the 18Y2 weeks of heparin administration. Also, I must admit to a concern regarding the possible mechanical failure of the pump with resulting undertreatment or overtreatment and all of the hazards involved in either event. J. W. Pearson, M.D. Department of Obstetrics and Gynecology Arizona Health Sciences Center 150 1 North Campbell Avenue Tucson, Arizona 85724 REFERENCES 1. Hill, W. C., and Pearson, J. W.: Outpatient intravenous heparin therapy for thrombophlebitis in pregnancy, Obstet. Gynecol. 37:785, 1971. 2. Pearson, J. W.: Preferable management of complications of the venous system in pregnancy and the puerperium, in Reid, D. E., and Christian, C. D., editors: Controversy in Obstetrics and Gynecology, ed. 2, Philadelphia, 1974, W. B. Saunders Co. 3. Pearson, J. W., Padilla, L. M.: Preferable management of complications of the venous system in pregnancy, in Christian, C. D., and Zuspan, F. P., editors: Controversy in Obstetrics and Gynecology, ed. 3, Philadelphia, 1983, W. B. Saunders Co.
Reply to Pearson To the Editors: Pearson emphasizes the efficacy and safety of outpatient intravenous heparin therapy in the management of antepartum deep vein thrombophlebitis. We concur with his conclusions and offer the continuous intravenous infusion via pump as an alternative method to intermittent bolus therapy with a heparin lock. The patient in the case presented was initially maintained in the hospital on a regimen of 7,000 U of heparin admin-
Volume 149 Number I
istered subcutaneously every 6 hours. This dose maintained the partial thromboplastin time in a therapeutic range of two to two and a half times the control value. After the patient was discharged from the hospital, subcutaneous heparin was continued and partial thromboplastin time determinations were done twice a week. The heparin dose was adjusted so that the therapeutic range was maintained on an outpatient basis without difficulty. Despite this therapy, the patient had a recurrence and was then placed on the continuous intravenous infusion pump. The intravenous line was a 21-gauge butterfly inserted in the forearm. It was changed every 3 to 5 days. The patient did not develop any evidence of thrombophlebitis or other complications from the intravenous line. There was no difficulty in maintaining the pump's infusion rate. The battery was changed on a daily basis and the pump (AS6C [Auto Syringe]) functioned flawlessly. We would share Pearson's concerns regarding the
Correspondence
109
possible mechanical failure of the pump but have had a large experience with this pump in diabetic patients and have found it to be reliable. The pump is maintained on a basal dosage rate. Adjustments can be made by the patient. The pump used in this fashion proved to be flawless and allowed maintenance of the anticoagulant state without the need for intermittent administration of medication. The patient tolerated this physically, as well as psychologically, very well. We would, therefore, propose that this form of therapy be considered in the future for pregnant patients who require anticoagulation with heparin for prolonged periods of time. Arnold W. Cohen, M.D. Division of Perinatology Albert Einstein Medical Center Northern Division York and Tabor Roads Philadelphia, Pennsylvania 19141
J.
May 1, 1984 Obstet. Gynecol.
Outpatient intravenous heparin
Fig. 1. RNG-R230-S needle guide attached to an ADR 3.5 mHz sector transducer.
Fig. 2. A 23-gauge amniocentesis needle placed under direct visualization. 1 = Fetal foot; 2 = needle tip; 3 = fetal extremity; 4 = shaft of the needle in the placenta. The needle tip's width is secondary to an air bubble. others for placement of intrauterine fetal catheters.* There has been only one blood-contaminated tap in the last 900 patients who have undergone genetic amniocentesis at the University of Iowa with this guide. Roger A. Williamson, M.D. Michael W. Varner, M.D. Carl P. Weiner, M.D. Department of Obstetrics and Gynecology The University of Iowa Hospitals and Clinics Iowa City, Iowa 52242 *Personal communication, R. E. Sabbagha, M.D., Northwestern University.
To the Editors: The case report of Cohen, Gabbe, and Mennuti, entitled "Adjusted-dose heparin therapy by continuous intravenous infusion for recurrent pulmonary embolism during pregnancy" (AM. J. OBSTET. GYNECOL. 146:463, 1983), serves to remind us of the value of outpatient intravenous heparin in the management of antepartum deep vein thrombophlebitis and/or embolization. l - a To date, as noted in the references, we have had no recurrences or significant complications when the patient has maintained a self-administered intravenous program with a heparin lock. Our combined experience in two centers now numbers well over 25 cases since 1964. The comment regarding the use of therapeutic subcutaneous heparin requires further amplification. The preponderance of current literature points out the lack of predictability and, in fact, the minimal measurable anticoagulant effect with the subcutaneous regimen and emphasizes it as a prophylactic rather than a therapeutic measure. I would like to ask the authors whether the intravenous line required replacement during the 18Y2 weeks of heparin administration. Also, I must admit to a concern regarding the possible mechanical failure of the pump with resulting undertreatment or overtreatment and all of the hazards involved in either event. J. W. Pearson, M.D. Department of Obstetrics and Gynecology Arizona Health Sciences Center 150 1 North Campbell Avenue Tucson, Arizona 85724 REFERENCES 1. Hill, W. C., and Pearson, J. W.: Outpatient intravenous heparin therapy for thrombophlebitis in pregnancy, Obstet. Gynecol. 37:785, 1971. 2. Pearson, J. W.: Preferable management of complications of the venous system in pregnancy and the puerperium, in Reid, D. E., and Christian, C. D., editors: Controversy in Obstetrics and Gynecology, ed. 2, Philadelphia, 1974, W. B. Saunders Co. 3. Pearson, J. W., Padilla, L. M.: Preferable management of complications of the venous system in pregnancy, in Christian, C. D., and Zuspan, F. P., editors: Controversy in Obstetrics and Gynecology, ed. 3, Philadelphia, 1983, W. B. Saunders Co.
Reply to Pearson To the Editors: Pearson emphasizes the efficacy and safety of outpatient intravenous heparin therapy in the management of antepartum deep vein thrombophlebitis. We concur with his conclusions and offer the continuous intravenous infusion via pump as an alternative method to intermittent bolus therapy with a heparin lock. The patient in the case presented was initially maintained in the hospital on a regimen of 7,000 U of heparin admin-
Volume 149 Number I
istered subcutaneously every 6 hours. This dose maintained the partial thromboplastin time in a therapeutic range of two to two and a half times the control value. After the patient was discharged from the hospital, subcutaneous heparin was continued and partial thromboplastin time determinations were done twice a week. The heparin dose was adjusted so that the therapeutic range was maintained on an outpatient basis without difficulty. Despite this therapy, the patient had a recurrence and was then placed on the continuous intravenous infusion pump. The intravenous line was a 21-gauge butterfly inserted in the forearm. It was changed every 3 to 5 days. The patient did not develop any evidence of thrombophlebitis or other complications from the intravenous line. There was no difficulty in maintaining the pump's infusion rate. The battery was changed on a daily basis and the pump (AS6C [Auto Syringe]) functioned flawlessly. We would share Pearson's concerns regarding the
Correspondence
109
possible mechanical failure of the pump but have had a large experience with this pump in diabetic patients and have found it to be reliable. The pump is maintained on a basal dosage rate. Adjustments can be made by the patient. The pump used in this fashion proved to be flawless and allowed maintenance of the anticoagulant state without the need for intermittent administration of medication. The patient tolerated this physically, as well as psychologically, very well. We would, therefore, propose that this form of therapy be considered in the future for pregnant patients who require anticoagulation with heparin for prolonged periods of time. Arnold W. Cohen, M.D. Division of Perinatology Albert Einstein Medical Center Northern Division York and Tabor Roads Philadelphia, Pennsylvania 19141