Thromboembolic disease in obstetrics and gynecology; the value of early diagnosis and adequate treatment.

Summary In addition to reducing the incidence of fatal pulmonary emboli and chronic venous insufficiency the early and adequate treatment of thromboembolic disease greatly diminishes the hospital stay of these patients. It also shortens the duration of the disease and the period of bed rest. The average increase in hospital stay of 2.6 days in those patients treated early and adequately is 7.8 days less than the hospital stay of the patients treated adequately but late. The cost of this additional hospitalization is much more than that of the usual course of anticoagulant therapy; hence the expense of the anticoagulants should not be a consideration in initiating treatment. Also, with inadequate treatment, the patient's chances are greatly increased oi poor functioning of the leg, which results in a lifelong disability with its consequent expense and diminished earning power. The major etiological factors were summarized and, as emphasized in other reports, it is important to recognize the role played by heart disease, obesity, anemia, varicosities, hemorrhage', and morbidity. Aside from cesarean section, the type of delivery had little influence on the incidence oi thromboembolic disease. A few of the diagnostic features are discussed in detail. (Contrary lo other reports, an unusual number of these patients had femoral or pelvic thrombophlebitis at the onset. An explanation for this is that the trauma ul both operation and delivery in gynecology and obstetrics is centered on the pelvic veins and an increased incidence of thrombophlebitis in these vessels should be expected. An elevation in temperature was not always present at the onset or during the course of the disease despite other signs of active thrombophl ebitis. Pelvic thrombophlebitis is usually associated with pelvic infection and is rather difficult to diagnose. The lack of response to the antibiotics alone and the marked improvement which occurs when the anticoagulants are added is often the most conclusive diagnostic finding, although by careful pelvic examination the involved veins may sometimes be palpated. The response to treatment in the cases of pelvic thrombophlebitis was satisfactory and vena cava ligation was not necessary. However, the two cases of chronic venous insufficiency treated by deep femoral vein ligation were improved. The fundamentals of treatment with the anticoagulants, antibiotics, and the Trendelenburg position are well known. The accessory procedures such as paravertebral block and intravenous procaine have a definite place in therapy in selected cases. The time of ambulation has been difficult to decide but if it is begun when the anticoagulant level is within therapeutic range, the signs and symptoms are absent, and the temperature, has been normal for a 24 hour period, a minimum of complications will arise. Prenatal patients should receive heparin alone unless prolonged therapy is necessary', in which even I Dicumarol may be used with caution. Both heparin and Dicumarol may he begun immediately following delivery and operation when indicated. The complications due to anticoagulants were few in number and may lie kept at a minimum by careful clinical supervision. In general heparin causes fewer hemorrhagic complications than Dicumarol and these can he rapidly reversed with protamine sulfate and blood transfusion. The potential dangers of anticoagulant therapy must be remembered and the anticoagulants should be used only under careful clinical observation and laboratory control.