Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy.

OBJECTIVE: To estimate the incidence, timing, and associated clinical characteristics of objectively diagnosed pregnancy-associated venous thromboembolism. METHODS: We retrospectively reviewed venous thromboembolism cases (deep venous thrombosis and pulmonary embolism) that occurred between 1978 and 1996. Study inclusion criteria required the objective diagnosis with either Doppler ultrasound, venography, impedance plethysmography, pulmonary angiography, ventilation-perfusion scanning, or computed tomography or magnetic resonance imaging. RESULTS: Among 268,525 deliveries there were 165 (0.06%) episodes of venous thromboembolism (one per 1627 births). There were 127 cases of deep venous thrombosis and 38 cases of pulmonary embolism. Only 14% (23 of 165 patients) had a history of venous thromboembolism. Most cases of deep venous thrombosis were in the left leg (104 of 127, 81.9%), with nearly three quarters of them (94 of 127, 74.8%) occurring during the antepartum period. Among cases of antepartum deep venous thrombosis, half were detected before 15 weeks' gestation (47 of 95, 49.5%), and only 28 cases occurred after 20 weeks (P < .001). Most of the pulmonary embolisms occurred in the postpartum period (23 of 38, 60.5%) and were strongly associated with cesarean delivery (19 of 36,470 compared with four of 232,032, P < .001). CONCLUSION: The incidence of venous thromboembolism during pregnancy is lower than has been previously described. Most cases occurred in the antepartum period, with the risk of deep venous thrombosis appearing to begin even before the second trimester.

A medical method of early pregnancy termination using tamoxifen and misoprostol.

A study was undertaken to determine whether ingestion of the selective estrogen receptor modulator tamoxifen followed by vaginal administration of the prostaglandin misoprostol would be an effective medical method of elective termination of early pregnancy. A clinical trial was conducted with a study group of 100 healthy women with pregnancies of 56 days gestational age or less who desired elective pregnancy termination. Each subject ingested 20 mg of tamoxifen once daily for 4 days followed 4 days later by intravaginal placement of four 200 micrograms tablets of misoprostol. If abortion did not occur within the next 24 h a second dose of 800 micrograms of misoprostol was given. The main outcome measures were incidence of complete abortion, hemoglobin levels, duration of vaginal bleeding, and incidence of side effects. Complete abortion occurred in 92 (92%, 95% CI 86.7, 97.3%) of 100 subjects. Of these 92 women, four aborted after ingesting tamoxifen without use of misoprostol, 84 within 24 h after receiving a single dose of misoprostol, one 21 days following a single dose of misoprostol, and three after a second dose of misoprostol was administered. There were six (6.0%) complete treatment failures and two (2%) incomplete abortions that required a dilatation and curettage. The mean duration of uterine bleeding was 8.1 days (range 1-34 days) and there was a median decrease in hemoglobin level of 0.50 g/dL (+2.2 to -4.7 g/dL). Vomiting occurred in 28% of subjects and diarrhea in 8%. These initial data suggest that ingestion of tamoxifen followed by intravaginal misoprostol may be an effective, easily administered, and inexpensive method to electively induce complete abortion in pregnancies of 56 days gestational age or less. Additional studies are necessary to determine whether the addition of tamoxifen increases the success rate compared with that obtained with the use of vaginally administered misoprostol by itself.

Idiopathic thrombocytopenic purpura in pregnancy treated with pulsed high-dose oral dexamethasone.

Idiopathic thrombocytopenic purpura in pregnancy is usually treated with prednisone or intravenous immune globulin. Because of the fetal risk, there are few good alternatives for women who do not respond. We report a case of refractory idiopathic thrombocytopenic purpura successfully treated with pulsed high-dose oral dexamethasone, which offered ease of administration, low cost, and low risk.

All-trans retinoic acid for the treatment of acute promyelocytic leukemia in pregnancy.

BACKGROUND: Acute promyelocytic leukemia, a subset of acute myelogenous leukemia, is commonly associated with disseminated intravascular coagulation (DIC). All-trans retinoic acid is effective in the treatment of acute promyelocytic leukemia and may prevent an exacerbation of DIC. There is limited information, however, regarding the use of this agent in pregnancy. CASE: A 29-year-old woman with acute promyelocytic leukemia and DIC at 24 weeks' gestation was treated successfully with all-trans retinoic acid during the pregnancy, delivering a viable, normal infant at 33 weeks. CONCLUSION: This case illustrates the successful use of all-trans retinoic acid in pregnancy for the treatment of acute promyelocytic leukemia. With the combined, intensive efforts of the perinatal, neonatal, and hematology-oncology services, a favorable outcome was achieved.

Association of asynchronous protodiastolic segmental wall motion with impaired left ventricular relaxation.

To determine if asynchronous segmental relaxation is associated with altered left ventricular (LV) diastolic function, we examined systolic and diastolic wall motion and function indexes in 16 patients without and 16 with asynchronous relaxation (groups 1 and 2, respectively). The segment with asynchronous relaxation was observed most frequently in the free anterior LV wall and was not consistently related geographically to coronary stenosis, nor to systolic asynergy in the same region, but was frequently accompanied by simultaneous segmental inward motion elsewhere in the ventricle. LV chamber volume stiffness during diastolic filling and at end-diastole was statistically similar in each group. Conversely, both T (58.3 +/- 2.3 msec vs 41.0 +/- 3.6 msec) and the isovolumic relaxation period (140.9 +/- 7.5 msec vs 116 +/- 6 msec) were significantly more prolonged, peak negative dP/dt was lower (1314 +/- 57 mm Hg/sec vs 1604 +/- 114 mm Hg/sec), and the y-axis intercept of the diastolic pressure-volume curve was higher in group 2 patients (7.96 +/- 0.98 mm Hg vs 4.88 +/- 0.93 mm Hg) (p less than 0.05 for each), indicating impaired relaxation and altered diastolic tone. With improved systolic function and relaxation properties after nitroglycerin, both the asynchronous outward relaxation and the inferior segment of simultaneous inward motion were ameliorated. Conversely, with increased ventricular preload and afterload induced by isometric exercise, both the asynchronous segmental outward motion anteriorly and the inward motion inferiorly with exaggerated. Asynchronous segmental relaxation may represent a compensatory mechanism in areas of normal contraction that offsets abnormal inward motion elsewhere, tending to maintain isovolumic status of the ventricle.

Influence of right ventricular hemodynamics on left ventricular diastolic pressure-volume relations in man.

To clarify the mechanism of displacement of the left ventricular diastolic pressure-volume function with alteration of loading conditions, the effects of nitroglycerin on pressure-volume relations in 13 patients were compared with those of amyl nitrite in 13 other patients during cardiac catheterization. After nitroglycerin, average systemic mean arterial pressure declined by 15.1 mm Hg (17%) and left ventricular end-diastolic pressure by 9.4 mm Hg (49%); right ventricular systolic and end-diastolic pressures fell 11.6 mm Hg (36%) and 5 mm Hg (41%), respectively. In all patients diastolic pressure-volume curves were significantly displaced downward and leftward. After amyl nitrite, average systemic mean arterial pressure fell 20.1 mm Hg (22%), but left ventricular end-diastolic pressure and right ventricular systolic and end-diastolic pressures were not significantly reduced. No significant displacement of diastolic pressure-volume curves occurred. Both the rate constant of the exponentially fit diastolic pressure-volume curve, and the rate of diastolic isovolumic relaxation (T) were unchanged after each drug. Thus downward displacement of diastolic pressure-volume functions after nitroglycerin appears to be dependent more upon reduction of right ventricular filling dynamics than coronary perfusion pressures. More favorable effects upon left ventricular function may be associated with reduction of both left ventricular filling pressures and systemic impedance (reflecting both "preload" and "afterload") than of systemic arterial pressures ("afterload") alone.

Influence of reduction of preload and afterload by nitroglycerin on left ventricular diastolic pressure-volume relations and relaxation in man.

To clarify the mechanisms of afterload reduction on left ventricular diastolic function, the influence of nitroglycerin upon ventricular diastolic pressure-volume relations was studied in 22 patients during catheterization. After nitroglycerin, average ventricular systolic pressure declined by 25 mm Hg (18%) and end-diastolic pressure by 7 mm Hg (28%) (P less than 0.005). End-systolic and diastolic ventricular volumes decreased by 37% and 23% respectively (P less than 0.005). Although peak negative dP/dt fell by 22% (P less than 0.0005), "T", an index of the time course of isovolumic diastolic ventricular relaxation, was insignificantly changed. Diastolic pressure-volume curves were significantly displaced downward and leftward without significant change in slope, suggesting that a family of pressure-volume curves for each ventricle with similar slope but positions depend upon immediate loading conditions. Absence of change in slope or of "T" suggests that this displacement may be mediated indirectly, perhaps by relaxation of extracardiac constraints to ventricular distensibility. Accordingly, improvement in ventricular function by vasodilators may be partly due to downward displacement of the pressure-volume relation, with associated reduction of wall tension and myocardial oxygen consumption.