Thrombopénie sévère chez un nouveau né de mère splénectomisé pour purpura thrombopénique idiopathique

Neonatal thrombopenia is the most common hemostatic abnormality in newborns. It is defined as a platelet count below 150.000/mm3. 40% of newborns to mothers with a history of autoimmune thrombopenia are at risk of developing neonatal thrombopenia while 10-15% of them are at risk of developing severe thrombopenia. We here report the case of a 20 days old newborn to mother splenectomized for idiopathic thrombopenic purpura in order to highlight the relationship between the severity of maternal disease and the severity of the neonatal thrombopenia and thereby to avoid the risk of intracranial hemorrhage resulting in death or neurological sequelae.

Sonographic findings in two cases of complicated pregnancy in women previously treated with endometrial ablation

When medical therapy fails for menorrhagia in a premenopausal woman, minimally invasive endometrial ablation can be used as a conservative management alternative to hysterectomy. Endometrial ablation alone is not considered effective contraception, and women of reproductive age can become pregnant after ablative therapy. We now present two cases of pregnancy after endometrial ablation and associated imaging where both cases required cesarean hysterectomy due to post-partum hemorrhage. Pregnancy after endometrial ablation incurs increased morbidity and diagnostic dilemmas.

[Haemostasis disorders and ways of its correction in HIV-positive pregnant women receiving chemopreventive antiretroviral therapy]

The analysis of 162 surgical deliveries cases in HIV-positive patients with antiretroviral therapy--induced haemostasis disturbances and thrombocytopenia was carried out. The article gives the perioperative management during surgical delivery.

Neuraxial anesthesia for a parturient with hypogammaglobulinemia: a case report

Hypogammaglobulinemia is characterized as a deficiency in humoral immunity. Humoral immunity deficiencies include the absence of B cells and/or serum immunoglobulins. Common clinical features include a predisposition toward infections naturally defended against through antibody-mediated responses. Clinical manifestations of this condition, in the parturient, may contraindicate neuraxial anesthesia. A 30-year-old parturient with hypogammaglobulinemia was admitted for repeated cesarean delivery and a bilateral tubal ligation. The pathophysiology and anesthetic management of the parturient with hypogammaglobulinemia is discussed.

Warfarin-induced fetal intracranial subdural hematoma

Antenatal intracranial hemorrhage is a rare cause of intrauterine fetal death, with an incidence of 4.6-5.1% in autopsy studies of stillborn fetuses. Warfarin-associated fetal bleeding is also a rare problem, with an incidence of 4.3% in the literature. We present a case of warfarin-induced subdural hematoma occurring in the second trimester.

Laparoscopic splenectomy for the treatment of refractory immune thrombocytopenia in pregnancy

BACKGROUND

Immune thrombocytopenic purpura (ITP) is a condition with potential hazard during pregnancy for both mother and fetus if platelet concentrations fall below a critical level. This report describes the use of laparoscopic splenectomy following unsuccessful medical management.

CASE

A 35-year-old primigravid woman with systemic lupus erythematosis (SLE) developed ITP several years before becoming pregnant. She was treated early in pregnancy with high-dose oral prednisone and weekly intravenous immunoglobulin (IVIG) alternating with anti-D immune globulin, but laparoscopic splenectomy was indicated at 20 weeks' gestation because of thrombocytopenia. Following surgery, she continued prednisone and intermittent IVIG therapy until spontaneous delivery at 34 weeks' gestation. A small accessory spleen was identified postpartum by nuclear medicine scan. Satisfactory platelet concentrations were maintained postpartum using danazol and prednisone.

CONCLUSION

Laparoscopic splenectomy is a therapeutic option for women with ITP during pregnancy that fails to respond to medical management.

Placement of a temporary vena cava filter during labor

Placement of a vena cava filter for the prevention of pulmonary thromboembolism in select patients is a well established procedure in critical care medicine. We describe a case of placement and removal of a new removable vena cava filter in a pregnant patient, in this case during early labor. Vaginal delivery was accomplished without incident.

Spontaneous cervical epidural haematoma during pregnancy

Spontaneous cervical epidural haematoma is very rare during pregnancy. We describe a woman who presented with tetraplegia at 41 weeks of pregnancy. She had no previous history of any relevant medical disorder. Her upper level of anaesthesia was at the second thoracic segment. The condition was diagnosed by magnetic resonance imaging, and both caesarean section and decompression were conducted 12 hours after the event. The neurological deficit showed little recovery. Histology was non-specific and follow-up magnetic resonance imaging showed spinal cord ischaemia. The prognosis in this condition depends on the interval of time between onset and decompression.

Obstetric haemorrhage

Few obstetric emergencies cause greater concern than haemorrhage in late pregnancy and the immediate postpartum period. Massive haemorrhage can occur without forewarning with few reliable clinical indicators available to predict those at greatest risk. Patients may remain haemodynamically stable until a sudden deterioration in condition takes place. In many cases the extent of the bleeding can be unclear as the haemorrhage may be concealed behind the placenta. This article reviews the common causes of ante and postpartum haemorrhage, their associated factors and the immediate and subsequent management of the conditions. A variety of uterotonic agents is available for the treatment of postpartum haemorrhage and a structured approach for their use is required.

[Cesarean section combined with splenectomy in severely resistant immune thrombocytopenia]

Immune thrombocytopenic purpura (ITP) associated with pregnancy often involves considerable risk both for mother and child, and usually worsens in the third trimester of gestation. Pregnancy and delivery are especially difficult in patients with severe ITP (platelet count below 20 x 10(9)/L), who are resistant to prednisone and high dose intravenous immunoglobulin (IVIgG). In those cases we applied cesarean section (CS), to prevent intracranial haemorrhage due to fetal/neonatal ITP, and splenectomy at the same time as an effective therapeutic strategy for ITP. We present 5 patients (4 with chronic ITP and 1 with ITP associated with HIV infection), aged 21-35 years, with severe ITP (platelet count 2-10 x 109/L), resistant to prednisone (1-2 mg/kg), and 2/3 were resistant to IVIgG (0.4 g/kg x 5 d). Four patients with severe resistant ITP were supported with 1-2 doses of platelets from cell separator before CS and 1-3 dose during splenectomy. One patient increased platelet count to 55 x 109/L after treatment with IVIgG and splenectomy following CS were done without platelet transfusion. Splenectomy was performed immediately after CS in all patients, and two of them were hysterectomised (one with HIV infection). After splenectomy, platelet count was normalised in all patients, and they had no haemorrhage, wound haematoma formation or any adverse events. But ITP relapsed in 2/5 patients after 1-2 months. Two newborns had severe thrombocytopenia, which solved spontaneously after 3 days in one or after treatment with IVIgG in other. We propose that splenectomy following cesarean section should be considered as approach for delivery and treatment option for mothers with severe resistant ITP.

[Spontaneous hematoma of the rectus sheath during pregnancy: a case report]

A case of spontaneous rectus sheath hematoma is reported in a 32-year-old multigravida transferred to our antepartum unit for premature labor and persistent cough related to Candida dubliniensis upper airway infection. In pregnant patients presenting sudden-onset severe abdominal pain and parietal tenderness, there are two main differential diagnoses: abruptio placentae and aseptic necrobiosis of a uterine leiomyoma. The correct diagnosis may be obtained by ultrasonography and sometimes by computed tomography. In the present case an emergency cesarean section was performed at 35 weeks gestation after a 40% decrease in maternal hemoglobin and onset of fetal heart rate anomalies.

[Anticoagulation in pregnant women after artificial heart valve replacement: is low-molecular-weight heparin an alternative?]

We report on the case of a 24-year-old pregnant woman with acute mechanical mitral valve thrombosis due to a treatment failure of low molecular weight heparin (LMWH) for permanent anticoagulation following mechanical valve replacement. Initially, our patient was put on oral warfarin for anticoagulation, but when her pregnancy was perceived the anticoagulation regimen was switched to daily subcutaneous administration of LMWH in order to minimize the risk of warfarin-induced embryopathy. During her 24th week of gestation she developed acute life-threatening pulmonary edema and hemodynamic instability, which was caused by an acute thrombosis of her artificial mitral valve. In an emergency operation the thrombozed valve was replaced by a porcine biological heart valve. The patient recovered uneventfully and gave birth to a healthy child in her 35th gestational week by cesarean section. In addition we discuss the rationale of different anticoagulation regimens with regard to maternal and fetal outcome with special consideration of LMWH as an alternative strategy to oral anticoagulation during pregnancy in women with mechanical heart valves.

Anticoagulation for prosthetic heart valves during pregnancy: is low-molecular-weight heparin an alternative?

We report on the treatment failure of low molecular weight heparin (LMWH) for anticoagulation in a pregnant woman that underwent artificial mitral valve replacement 10 years prior to her pregnancy. Until she became pregnant warfarin was administered for anticoagulation, but due to the often mentioned increased risk for warfarin-induced maternal and fetal complications, at gestational week 5 the anticoagulation regimen was switched to subcutaneous application of low molecular weight heparin. At gestational week 24 our patient developed acute life-threatening pulmonary edema and hemodynamic instability due to acute mitral valve thrombosis and underwent emergency valve re-replacement with a biological porcine valve. She recovered uneventfully and gave birth to a healthy child at gestational week 35. In addition to our case presentation we review the sparse evidence in the literature regarding anticoagulation in pregnant women with mechanical heart valves and discuss the rational of different anticoagulation regimens with regards to maternal and fetal outcome. Special consideration is directed towards LMWH administration as an alternative to oral anticoagulation during pregnancy in women with mechanical heart valves.

Delivery management in a woman with thrombocytopenia of the May-Hegglin anomaly type

Thrombocytopenia of the May-Hegglin anomaly type was diagnosed in a woman with no past history of bleeding diathesis, who had been followed during her three pregnancies. No abnormal bleeding occurred although no platelet transfusion was administered during the second and third cesarean sections. Routine platelets transfusion is unnecessary but platelets should be available for use if abnormal bleeding occurs.

Postpartum acquired haemophilia: clinical recognition and management

Postpartum acquired haemophilia is a rare but serious complication of an otherwise normal pregnancy. Patients usually present with postpartum haemorrhage (PPH) or uncontrolled bleeding following surgical interventions, which fail to respond to conservative treatment. A high index of clinical suspicion along with early laboratory diagnosis and prompt institution of appropriate therapy is essential for the management of acute bleeding episodes. Our patient, a 32-year-old female, presented with severe PPH and shock. She had undergone dilation and curettage three times, with subsequent total abdominal hysterectomy and internal iliac artery ligation, before she was diagnosed with acquired haemophilia (factor VIII autoantibodies) and an inhibitor level of 8 Bethesda units (BU). The patient underwent an abdominal laparotomy for removal of the abdominal packing used in the previous operation, and blood and blood clots, and was given FEIBA(R) therapy. The patient responded to these measure and the factor VIII inhibitor level decreased to 2 BU at the time of discharge 10 weeks later.

Tubal curettage: a new conservative treatment for haemorrhagic interstitial pregnancies

Haemorrhagic interstitial pregnancies are commonly treated by cornual resection. This invasive procedure may increase the risk of uterine rupture in subsequent pregnancies. We report here a case of a haemorrhagic interstitial pregnancy, associated with a viable intrauterine pregnancy in a salpingectomized woman, which was treated successfully by curettage of the uterine cornu.

Splenectomy combined with cesarean section in a patient with severe immunological thrombocytopenic purpura refractory to medical therapy

Splenectomy as a treatment for severe immunological thrombocytopenic purpura is rarely performed in the third trimester of pregnancy. We report a 28-year-old patient who presented at the 34th gestational week with severe immunological thrombocytopenic purpura resistant to both corticosteroid and intravenous immunoglobulin therapies. Splenectomy combined with delivery by cesarean section provided remission of the disease.

Hand-assisted laparoscopic splenectomy for idiopathic thrombocytopenic purpura during pregnancy

A successful case of a hand-assisted laparoscopic splenectomy with low-pressure pneumoperitoneum for autoimmune thrombocytopenic purpura in a patient at 23 weeks' gestation is reported. Preoperative splenic arterial embolization was performed on the same day as the operation using painless contour embolic material and super-absorbent polymer microspheres. The abdominal wall retraction method first was applied to avoid the effects of pneumoperitoneum on systemic hemodynamic alterations. However, a sufficient surgical view could not be obtained, as the intra-abdominal organs were elevated because of the enlarged uterus. A surgical view with 4 to 6-mm Hg pneumoperitoneum was available for the hand-assisted splenectomy. The postoperative course was uneventful, and the patient vaginally delivered a healthy infant. A hand-assisted laparoscopic splenectomy with low-pressure pneumoperitoneum after splenic arterial embolization would be feasible for patients with autoimmune thrombocytopenic purpura during a relatively advanced pregnancy.

Mechanical valve thrombosis during pregnancy

Mechanical valve thrombosis is a life-threatening event, and prevention with meticulous anticoagulation is crucial. Pregnancy is associated with a hypercoagulable state that further emphasizes the importance of adequate anticoagulation. A case of mechanical mitral valve thrombosis in a pregnant woman due to suboptimal anticoagulation is presented. Methods of anticoagulation, as well as thrombolytic and surgical therapies, are discussed.

Immune thrombocytopenic purpura during pregnancy: laparoscopic treatment

BACKGROUND AND OBJECTIVES

Laparoscopic surgical techniques in pregnancy have been accepted and pose minimal risks to the patient and fetus. We present the first reported case of a pregnant woman with immune thrombocytopenia purpura who underwent laparoscopic splenectomy during the second trimester.

METHODS AND RESULTS

The anesthesia, hematology, and obstetrics services closely followed the patient's preoperative and intraoperative courses. After receiving immunization, stress close steroids, and prophylactic antibiotics, she underwent a successful laparoscopic splenectomy. After a short hospital stay, the patient was discharged home.

CONCLUSION

Immune thrombocytopenia purpura can be an indication for splenectomy. As demonstrated in appendectomy, cholecystectomy, and our case presentation, laparoscopic splenectomy can be safely performed during pregnancy.

[Emergency splenectomy in pregnancy complicated with idiopathic thrombocytopenia]

Thrombocytopenia can be a pathophysiological feature of pregnancy and spontaneous splenic rupture in pregnancy is a rare and potentially catastrophic event. A case of splenic rupture after cesarean delivery, performed for increasing thrombocytopenia is reported. The diagnosis was not suspected until laparotomy. Low transverse cesarean birth required a vertical extension of the incision into the upper uterine segment. An emergency splenectomy was undertaken without complications. The operation was followed by a massive increase in the thrombocyte count. Both mother and baby are in good health 10 months later. The newborn had a normal thrombocyte count at delivery and thereafter. The importance of early diagnosis and management techniques are discussed.

A complication in anticoagulation using low-molecular weight heparin in a patient with a mechanical valve prosthesis. A case report

All mechanical heart valves are thrombogenic, and are associated with thromboembolic complications becomes ineffective. when anticoagulation Controversy exists with regard to the appropriate and safe anticoagulation regimen of gravid women with mechanical heart valve prostheses. While oral anticoagulants such as warfarin may be associated with fetal complications, the role of low-molecular weight heparin (LMWH) and heparinoids (and their respective appropriate dosage) have still to be determined. In developing countries such as Saudi Arabia, the prevalence of rheumatic fever is high, as is the percentage of female patients with mechanical heart valves and who are of child-bearing age. Thus, the issue of adequate anticoagulation on one hand, and avoidance of warfarin-induced embryopathy on the other hand, is crucial. To date, few reports are available of LMWH as sole anticoagulant in patients with mechanical heart valves. We report a case of massive valve thrombosis with subsequent pulmonary edema after warfarin anticoagulation was changed to LMWH during pregnancy, and administered at too low a dose.

Hemorrhagic moyamoya disease during pregnancy

BACKGROUND

Intracranial hemorrhage in pregnant patients with Moyamoya disease is rare. We review the case of one such patient who presented with pre-eclampsia and a catastrophic intracerebral hemorrhage in order to highlight the associated management difficulties.

METHODS

A case of a pregnant (31 weeks) female brought to the emergency department with hypertension and a progressive decrease in her level of consciousness is presented. She rapidly developed a dilated right pupil and left extensor posturing. A CT scan of her head showed a large putamenal intracerebral hemorrhage. She was intubated, ventilated and given intravenous mannitol and magnesium sulfate. She underwent a simultaneous craniotomy and Cesarean section. Post-operatively the patient's ICP and jugular venous saturation were monitored in the intensive care unit.

RESULTS

The patient delivered a 1185 g infant who did well. The patient's ICP was well controlled until the tenth post-operative day when she developed malignant brain edema and died.

CONCLUSION

This case highlights three important points. First, simultaneous craniotomy and Cesarean section can be performed. Second, intraoperative control of bleeding Moyamoya vessels is described. Third, the difficult post-operative management of these cases is highlighted. The literature regarding Moyamoya disease and pregnancy is reviewed and some recommendations for the management of this rare but potentially deadly condition are presented.

[Venous thrombectomy in pregnancy. A follow-up study]

Deep venous thrombosis is an uncommon but feared complication in pregnancy. The treatment of choice in most centers is heparin and compression stockings, which effectively prevents pulmonary embolism, but the incidence of chronic venous insufficiency with skin change and ulcers after such treatment is reported to be up to 65%. In the period 1985-93, thirty-nine pregnant women were treated for femoroiliacal venous thrombosis (FIVT) with operative thrombectomy, arteriovenous fistula and anticoagulant therapy. The aim of this study was to examine those of the women who subsequently had been pregnant again. The pregnancy and delivery were closely monitored and the frequency of clinically detected as well as objectively measured venous insufficiency was recorded. Nineteen of the women subsequently became pregnant again, resulting in 25 deliveries. They were investigated at the Coagulation Laboratory and treated with phenendione or low molecularweight heparin. All pregnancies proceeded successfully. None showed clinical signs of rethrombosis during the subsequent pregnancy. At follow up 11 patients had dilated or varicose veins, nine had a closed iliaca at ultrasound examination, none had skin changes or ulcers. We conclude that women treated for FIVT in pregnancy with thrombectomy followed by anticoagulant therapy may undergo a new pregnancy with low risk of obstetrical complications and with a low risk of developing rethrombosis or chronic venous insufficiency.

Laparoscopic splenectomy at caesarean section

The role of minimally invasive surgery continues to expand in all the specialties and subspecialties of surgery. At one time, obesity and pregnancy were considered a relative contraindication to laparoscopic surgery. With improved technology and skills, surgeons are able to operate on patients who were once considered to be at too high a risk for laparoscopic surgery. Herein, laparoscopic splenectomy performed at the time of Caesarean section is reported. This case demonstrates the safety and efficacy of laparoscopic splenectomy in a morbidly obese female in the immediate postpartum time.

Laparoscopic splenectomy in pregnancy

A laparoscopic splenectomy during pregnancy is described in this case report. The operation took place at 18 weeks' gestation for life-threatening thrombocytopaenia secondary to antiphospholipid syndrome that had failed to respond to medical therapy. The patient made a full and rapid recovery and was delivered of a healthy baby girl at term.

Outcome of twin pregnancies in patients with haemoglobinopathies--case reports

Pregnancy in patients with haemoglobinopathy is associated with increased risk of maternal and perinatal morbidities and mortalities. Multiple pregnancy is potentially more hazardous than singleton pregnancy. There is a dearth of information concerning multiple pregnancies in patients with haemoglobinopathy. Four of such patients seen in the obstetric service of the University College Hospital, Ibadan are presented here and discussed. Increased surveillance and elective caesarean delivery are suggested in the management of these patients.

Successful emergency splenectomy during pregnancy in a patient with life-threatening idiopathic thrombocytopenia. Case report

Thrombocytopenia can be a pathophysiological feature of pregnancy. In the case reported, the thrombocyte count was reduced to 1% of normal (1 x 10(9) thrombocytes/l) at 28 weeks of gestation. In chronological order, the patient showed epistaxis, macrohematuria and gingival, conjunctival, intracerebral and pulmonary bleeding. The latter was life-threatening. An emergency splenectomy was undertaken, without complications. The operation was followed by a massive increase in the thrombocyte count, reaching 200 x 10(9)/l four days later. Unfortunately, a premature rupture of the membranes, with signs of amnion infection, occurred on the seventh day. A Cesarean section was undertaken (30 weeks of gestation), without complications. Both mother and baby are in good health 10 months later. The newborn had a normal thrombocyte count at delivery and thereafter. The life-threatening hemorrhage of the mother, the delivery of an unaffected baby and the relatively quick remission after splenectomy suggest an upregulated destruction of thrombocytes by the maternal spleen. The increased level of Macrophage-Colony Stimulating Factor (M-CSF), a normal feature of pregnancy, has the potential to augment thrombocyte destruction by activating macrophages. The production of anti-thrombocyte antibodies, especially if localized in the spleen, could result in increased thrombocyte sequestration by macrophages with severe effects focused on the mother.

Pregnancy complicated by von Hippel-Lindau disease

BACKGROUND

Von Hippel-Lindau disease is an autosomal-dominant genetic disorder with variable penetrance characterized by multiorgan hemangioblastomas and a predisposition to carcinoma.

CASE

A 23-year-old pregnant woman at 35 weeks' gestation, with a family history of von Hippel-Lindau disease, presented with paraplegia caused by an acute intramedullary hemorrhage from a spinal hemangioma at the thoracic (T) 4-5 level. An unruptured hemangioblastoma was noted at the T7-8 level. A T3-6 laminectomy resulted in the improvement of symptoms. The postoperative period was complicated by autonomic dysreflexia and preterm labor. The woman was delivered by cesarean under epidural anesthesia.

CONCLUSION

Pregnant patients with von Hippel-Lindau disease present problems related to hemangioblastomas of the central nervous system. Imaging studies of the central nervous system are mandatory for prompt recognition and treatment of complications related to intramedullary hemorrhage. If spinal hemangioblastomas are identified, cesarean delivery may be the most sensible choice.

Cardiopulmonary bypass in the early puerperium: possible new role for aprotinin

A case of successful emergency reoperation for mitral valve replacement 2 hours after a cesarean section is reported. The use of aprotinin (Trasylol; Bayer AG, Leverkusen, Germany) greatly simplified the surgical procedure and was in our opinion the most important factor in an uncomplicated outcome.

Splenic vein thrombosis. Diagnosed with Doppler ultrasonography

The case of a 31-year-old pregnant woman with an isolated splenic vein thrombosis, diagnosed with Doppler ultrasonography is presented. Routine ultrasound examination in the fourth month of the pregnancy revealed massive splenomegaly of unknown origin. Doppler ultrasonography subsequently revealed splenic venous thrombosis with absence of blood flow. Noteworthy gastric varices were present at the endoscopic examination. On splenectomy, a spleen weighing 2,600 was removed, and numerous venous collaterals were found in the perigastric region. The postoperative course was satisfactory, pregnancy evolved normally, and a healthy female baby was delivered at term. The patient remained in excellent health with normal clinical and laboratory data.

Role of splenectomy as a salvage procedure in thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura is a rare but serious haematological disease for which first-line therapy is medical, but not always successful. The role of splenectomy in the management of such patients is unclear. This paper reports three patients with the condition who went into remission following splenectomy after other forms of therapy had failed. Because thrombotic thrombocytopenic purpura is nearly always fatal if a remission is not obtained, splenectomy should be considered in patients who prove to be resistant to medical therapy.

[Treatment of serious iso-immunization to Rhesus factor by plasmapheresis. Report of two cases]

Plasmapheresis was performed in order to clean the excess of antibodies in two patients in whom previous fetal loss had occurred, due to rhesus disease. A reduction in antibodies titles was obtained in both cases. Both patients were delivered by cesarean section after normal full term pregnancies. The babies were followed for two years and revealed no fetal abnormalities.

Spontaneous rupture of the spleen in pregnancy with splenic conservation

Spontaneous rupture of the spleen in pregnancy is rare. It presents with severe internal haemorrhage with a high perinatal and maternal mortality. Splenic preservation is now a well-known option in dealing with splenic damage, and is recommended where possible to avoid diminished immunological competence. This is the first reported case of splenic preservation following splenic damage in pregnancy.

Abrupt reversal of gestational autoimmune thrombocytopenia after delivery. A case report

Autoimmune thrombocytopenia purpura frequently is first noted during pregnancy. The severity of the disorder varies, but when the patient presents with active bleeding from any site, therapy is mandatory. Treatment generally consists of corticosteroids and/or splenectomy. A woman developed severe autoimmune thrombocytopenia purpura during pregnancy that proved refractory to corticosteroids and splenectomy. Six days after delivery her platelet count returned to normal. The etiology of autoimmune thrombocytopenia purpura remains unknown, but this experience suggests that in this patient the thrombocytopenia was related to her pregnancy.

Thrombectomy and temporary arterio-venous fistula for ilio-femoral venous thrombosis

Sixty patients operated for ilio-femoral venous thrombosis with thrombectomy and temporary arterio-venous fistula (AVF) were evaluated. Fifty-one thromboses occurred in women and 48 were left-sided. A triggering mechanism was found in most patients. Fifty per cent of the women were pregnant or in the immediate postpartum period, one third of all patients had a recent operation or trauma and in one third a hereditary disorder could be traced. Blood coagulation studies postoperatively revealed disorders in the coagulation or fibrinolytic systems in 34 of 47 investigated patients. At operation it was possible to open the iliac vein in 50 patients and 42 received a functioning AVF. The AVF was closed after 3 months. Forty-six patients have been followed from 6 months to 5 years with one or several of the following investigations: venous plethysmography, radionuclide venography or routine venography. At follow-up the iliac vein was judged to be patent in 29 patients, in 17 it was occluded and in 8 patients it was probably occluded. All patients over 50 years of age were among those with occluded veins as were 6 of 9 men. The best results were achieved in women operated during pregnancy or in the puerperium. Venous thrombectomy with temporary AVF is effective treatment for ilio-femoral venous thrombosis, particularly in younger females with an obvious precipitating cause e.g. pregnancy or delivery.

Use of the Greenfield filter for thromboembolic disease in pregnancy

Recent technical advances in surgical intervention for thromboembolic disease have made the Greenfield filter a safe and effective treatment when heparin is contraindicated or recurrent emboli develop. One successful use of Greenfield filter placement in pregnancy has been reported. We report six additional cases. Maternal morbidity was negligible, and fetal outcomes were good. The use of the Greenfield filter as an adjunctive therapy for treatment of severe thromboembolic disease in pregnancy appears to be safe and should be considered in appropriate candidates.