Hickman catheter use in a pregnantpatient requiring therapeutic heparinanticoagulation

D. Michael Nelson, M.D., Ph.D.,Laurence E. Stempel, M.D., Peter J. Fabri, M.D., andMadonna Talbert, M.D.

Department of Obstetrics and Gynecology and Department ofSurgery, The Ohio State University Hospital, School of Medicine,Columbus, Ohio

A pregnant patient with a Starr-Edwards mitral valveprosthesis who had surgical placement of a Hickman

catheter at 20 weeks' gestation will be described. Thisprocedure provided "permanent" venous access and

optimized the continuous administration of intrave­nous heparin for therapeutic anticoagulation.

A Ifi-year-old black adolescent (gravida 1, para 0) with anexpected date of confinement of August 1, 1982, presentedfor prenatal care at 16 weeks' gestation. Following an episodeof rheumatic fever, she had developed mitral valve diseaserequiring placement of a Starr-Edwards prosthesis at 6 yearsof age. At her initial prenatal visit, she was believed to be inFunctional Class 1 by New York State Heart Associationcriteria.' She had been treated with coumadin, 5 mg daily,digoxin, 0.125 mg twice daily, and penicillin Y, 500 mg daily.She was also given quinidine sulfate, 200 mg four times daily,for atrial fibrillation.

Physical examination revealed a 62 kg, 162 ern, mentallydeficient pregnant adolescent with a sporadically irregularpulse of approximately 82 bpm, a blood pressure of 112/52mm Hg, and a respiratory rate of 24/min. There was no jugu­lar venous distention, the lungs were clear, and the liver edgewas not palpable. Cardiac examination revealed a grade 3/6holosystolic murmur at the apex radiating to the axilla, agrade 2/6 crescendo diastolic murmur, and a loud mitralvalve-closing click. The size of the uterus indicated a preg­nancy of 16 weeks. After counseling of both the patient andher mother about the risks of pregnancy in patients with pros­thetic heart valves and the risks of coumadin exposure to thefetus, the patient decided to continue the pregnancy. She wasadmitted for therapeutic heparinization.

Admission studies revealed a digoxin level of 0.3 ng/ml, aquinidine level below the detectable range, and a normal pro­thrombin time. An electrocardiogram confirmed atrial fibril­lation, and a two-dimensional echocardiogram revealed aborderline enlargement of the left ventricle with excellent sys­tolic function and a normal aortic valve. To optimize her car­diac status, she was digitalized to therapeutic levels, given

Reprint requests: D. Michael Nelson, M.D., Ph.D., Depart­ment of Obstetrics and Gynecology, The Jewish Hospital ofSt. Louis, 216 S. Kingshighway, St. Louis, MO 63110.

COMMUNICATIONSIN BRIEF

penicillin daily, hospitalized with orders for bed rest, andstarted on a regimen of continuous intravenous heparin. Thepatient was careless about her intravenous sites, and daily re­insertion of an intravenous line was required. Use of courna­din for anticoagulation was discussed but rejected because ofthe fetal risk associated with second- and third-trimester ex­posure? Alternatively, the risks and benefits of a Hickmancatheter for long-term venous access for continuous heparininfusion were discussed with the patient and her family.

At 20 weeks' gestation, the patient underwent surgicalplacement of a Hickman catheter through the right cephalicvein, with intravenous sedation and local infiltration of theskin with 0.5% Xylocaine used for anesthesia. The surgicalprocedure has been described in detail elsewhere." The pro­cedure uses an oblique incision made in the axilla to allowexposure of a large vein in the deltopectoral groove, where avenotomy is performed for insertion of a Hickman catheter.Confirmation of appropriate right atrial placement is ob­tained by Hypaque injection and fluoroscopy with abdominalshielding. The catheter is secured with sutures, and the skinexit site is developed by creating a tunnel subcutaneously tothe xiphoid. The catheter is irrigated with heparin solution,with reinstitution of the continuous intravenous heparin in­fusion 3 hours postoperatively.

The patient remained in stable condition in the hospitalwith a partial thromboplastin time maintained in the thera­peutic range by continuous heparin infusion through theHickman catheter, which she tolerated well. At 36 weeks' ges­tation, she developed spontaneous labor, at which time hepa­rin was discontinued. She had a normal labor and sub­sequently underwent forceps-assisted vaginal delivery of a2470 gm female infant (Apgar scores of 9 and 10). Threedoses of gentamicin and ampicillin were given prophylacti­cally. Her postpartum course was uneventful. The catheterwas removed without difficulty 2 months after delivery whenbreast hypertrophy in this nonlactating female adolescenthad resolved. She was doing well at follow-up 15 months postpartum.

We believe that this is the first report of the use of aHickman catheter in a pregnant patient requiring pro­longed intravenous therapy. In nonpregnant patientssuch catheters have been used most frequently to pro­vide "permanent" vascular access in patients under­going chemotherapy or hyperalimentation.' Results in

these patients have been favorable, with a relatively lowrisk for infection despite the immunocompromisedstatus of many of these patients.

When therapeutic anticoagulation is indicated in a

pregnant patient, the choice for the obstetrician is be­tween heparin and coumadin.! The advantage of oral

administration of coumadin has in recent years beenoffset by the increasing awareness of problems associ­ated with second- and third-trimester exposure to this

agent, including optic atrophy, mental retardation, and

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462 Communications in brief

stillbirth.v 5 These complications can develop irrespec­tive of the well-known coumadin embryopathy some­times seen in patients given coumadin in the firsttrimester. Heparin has the advantage of not crossingthe placenta, thereby making risk of fetal injury small.Heparin has the disadvantage of a short half-life andrequires parenteral administration. In patients at highrisk for thromboembolism in pregnancy we have suc­cessfully used intermittent bolus injection via a heparinwell for outpatient management, whereas continuousintravenous infusion for in-hospital management hasbeen used in noncompliant patients. Patients with ar­tificial heart valves are at significant risk for throm­boembolism, a risk which is increased by the hyper­coagulable changes encountered in pregnancy.

The patient whom we have described was noncom­pliant and had a very poor understanding of the im­portance of heparinization. Continuation of coumadinafter her first prenatal visit was ruled out because of thecomplications associated with coumadin exposure inthe last half of pregnancy. The use of a Hickman cathe­ter permitted therapeutic anticoagulation with heparinand was tolerated very well by the patient. Althoughplacement required a surgical procedure, the riskswere minimized by the use of local anesthesia andproper shielding for radiologic procedures. The risk ofinfection from an indwelling catheter is always of con­cern in a patient with valvular disease. The risk of in­fection caused by Hickman catheters has been found tobe minimal even in the immunocompromised patientsin whom the catheter is most commonly used." Theinfection risk from a Hickman catheter was felt to beonly minimally greater in our patient when comparedto the infection risk associated with frequent insertionsfor maintenance of a peripheral intravenous line.

We do not recommend the routine placement of aHickman catheter for pregnant patients requiringtherapeutic heparinization. However, in selected pa­tients this technique can provide "permanent" venousaccess to optimize heparin administration, therebyavoiding the fetal risks of coumadin exposure in pa­tients requiring anticoagulation during pregnancy.This technique could also be used for outpatient man­agement in compliant patients who were taught propercatheter care.

REFERENCES

1. New York Heart Association Criteria Committee. Nomen­clature and criteria for diagnosis of the diseases of theheart and great vessels. 8th ed. Boston; Little, Brown,1979.

2. Stevenson RE, Burton OM, Feriauto Gj, and Taylor HA.Hazards of oral anticoagulants during pregnancy. JAMA1980;243:1549.

3. Fabri PJ. Permanent right atrial catheter insertion. Am jSurg 1982;143:394.

4. Wade jC, Newman KA, Schimpff SC, Van Echo DA,Gelber RA, Reed WP, Wiernik PH. Two methods for im­proved venous access in acute leukemia patients. JAMA1981;246:140.

5. Nageotte MP. When the pregnant patient needs anticoagu­lation. Contemp Ob/Gyn November, 1982;20:123.

June 15, 1984Am. J. Obstet. Gynecol.

"Hydatoxi lualba" identified

Earl G. Long, Ph.D., Tsang-yu Tsin, B.Sc., A.S.C.P.,

James A. Reinarz, M.D., Vicki J. Schnadig, M.D.,Eddye McLucas, B.Sc., A.S.C.P., andR. T. Kelly, M.D.

Department of Pathology, University of Texas Medical Branch,Galveston, Texas

A report by Lueck et al.' described a worm-like ob­ject seen in blood films stained with toluidine blue-O.Developmental stages were described, and the objectwas named Hydatoxi lualba and proposed as the etio­logic agent of gestational trophoblastic disease andpreeclampsia-eclampsia.

We repeated the authors' investigations with the useof blood flms prepared from samples drawn by veni­puncture into Venoject tubes containing liquid ethyl­enediaminetetraacetic acid anticoagulant from five fe­male and five male volunteers including one of theauthors (E. G. L.), from maternal venous blood, frominfant umbilical cord blood, and from placental surfacefluid from two patients with preeclampsia-eclampsia.Control specimens were obtained from four patientswho had normal deliveries. Additional films were madefrom blood samples drawn from a rat, a mouse, and aguinea pig. We made touch preparations from the epi­thelial surfaces of the trachea, dorsal aorta, and in­ferior vena cava and from the cut surfaces of the liver,lung, and abdominal fat of a rat that had been put todeath. Smears of bovine serum albumin were includedto detect possible staining artifacts. All smears wereprepared in a laminar-flow safety cabinet to reducecontamination by atmospheric dust. Glass microscopeslides to be used had been cleaned with absoluteethanol and polished with sterile cotton gauze pads.

Smears were made from one drop of each specimenand allowed to air dry. Slides were then processed forstaining exactly as described by Lueck et al.' The slideswere placed in sulfation reagent for 8 minutes, rinsedin tap water for 30 seconds, immersed in toluidineblue-O for 5 minutes, rinsed, counterstained withmetanil yellow for 2 minutes, and rinsed. The slideswere dehydrated for I minute in each of three changesof 95% isopropyl alcohol, cleared in xylene, andmounted under coverslips.

Five smears were made with serum passed through a0.45 /-Lm Millipore filter and mixed with clippings froma cotton wool plug, and five were from serum filteredthrough four layers of cotton gauze. Ten controlsmears were made from unmodified serum.

All patient and animal specimens examined con­tained one or more of the forms reported.' Weobserved spheres with dark inclusions-"eggs,"

Reprint requests: Earl G. Long, Ph.D., Department ofPathology, G-43, University of Texas Medical Branch, Galves­ton, TX 77550.