Volume 164 Number I, Part 1

Budd-Chiari syndrome, obstetric complications, and antiphospholipid antibodies To the Editors: Budd-Chiari syndrome l -3 has been as-

sociated with the presence of antiphospholipid antibodies (lupus anticoagulants or anticardiolipin antibodies), in addition to better-known obstetric complications. Diagnosis of antiphospholipid antibodies would be important in evaluation of a hypercoagulable state in the case reported by Ilan et al. (Ilan Y, Oren R, Shouval D. Postpartum Budd-Chiari syndrome with prolonged hypercoagulability state. AM 1 OBSTET GyNECOL 1990; 162: 1164-5) of a woman with both BuddChiari syndrome and preeclampsia. The diagnosis would have added to treatment options when anticoagulation alone failed to halt progressive thrombosis by suggesting the addition of immunosuppressive agents or intravenous immunoglobulin infusions! In addition to tests for antiphospholipid antibodies and the lack of evidence for protein C deficiency mentioned (presumably normal levels of protein C), other studies for hereditary and acquired thrombotic disorders would also be an important part of evaluation in such cases.' Perhaps the authors would share this information with us so we can learn from this woman's unfortunate outcome. F. Susan Cowchock, MD Jefferson Medical College, Division of Medical Genetics, Room 406, 1100 Walnut St., Philadelphia, PA 19107

REFERENCES 1. Pomerory C, Knodell RG, Swan WR, et al. Budd-Chiari

syndrome in a patient with the lUpus anticoagulant. Gastroenterology 1984;86: 158-61. 2. Hughs GRV, Mackworth-Young CG, Harris EN, et al. Veno-occlusive disease in SLE: possible association with anticardiolipin antibodies. Arthritis Rheum 1984;27:1071. ~. Asherson RA, Thompson RP, MacLachlan N, et al. BuddChiari syndrome, visceral arterial occlusions, recurrent fetal loss and the "lupus" anticoagulant in systemic lUpus erythematosus. J Rheumatol 1989; 16:219-24. 4. Wapner ~, Cowchock FS, Shapiro SS. Successful treatment in two women with antiphospholipid antibodies and refractory pregnancy losses with intravenous immunoglobulin infusions. AMJ OBSTET GYNECOL 1989;161:1271-2. 5. Salem HH, Mitchell CA, Firkin BG. Current views on the pathophysiology and investigations of thrombotic disorders. Am J Hematol 1987;25:46~-74. Reply To the Editors: We appreciate the comments by Dr. Cow-

chock with regard to our case report of postpartum Budd-Chiari syndrome with prolonged hypercoagulability state. Budd-Chiari syndrome is known to occur in association with many hypercoagulable states including polycythemia vera; paroxysmal nocturia; hemoglobinuria; tumors such as adrenal carcinoma, hypernephroma, and hepatomas; radiation; oral contraceptives; proteins S, C, and antithrombin deficiencies; and inferior vena cava webs. 1-3 During the past few years, cases of Budd-Chiari syndrome were described in patients with anticardiolipin syndrome! The association of Budd-Chiari syndrome with pregnancy was first described by Chiari almost 100 years ago' and since then other case reports have been

Letters 235

published. 6 These cases were all considered to be associated with the hypercoagulable state that occurs post partum. The patient described in our article was unusual in that her hypercoagulable state lasted for months after delivery. We tried to find a basic systemic disorder that would explain the prolonged hypercoagulable state. Despite extensive workups including negative anticardiolipin test results, normal protein C and S levels, and searches for other malignancies, no explanation for the hypercoagulable state could be found. We think the most likely reason for the prolonged and uneventful course was postpartum deep vein thrombosis that later initiated a cascade of prolonged hypercoagulable state with extension of pelvic vein thrombosis along the inferior vena cava. Y. /lan, MD, R. Oren, MD, and D. Shouval, MD Department ofMedicine A, Hadassah University Hospital,Jerusalem, Israel IL-91120

REFERENCES 1. Clain D. Clinical diagnosis of the Budd-Chiari syndrome.

Am J Med 1967;4~:544-7. 2. Hoyumpa AM. Budd-Chiari syndrome in women taking oral contraceptives. AmJ Med 1971;50:137-9. 3. Mitchell MC. Budd-Chiari syndrome: etiology, diagnosis and management. Medicine 1982;61:199-218. 4. Pomerory C, Knodell RG, Swann WR. Budd-Chiari syndrome in a patient with the lupus anticoagulant. Gastroenterology 1984;86:158-61. 5. Chiari H. Ueber die selbstandige Phlebitis obliterans der Haupstamme der Vanae hepaticae als Todesursache. Beitr Z Pathol Anat 1899;26: 1. 6. Khuroo Ms, Datta DV. Budd-Chiari syndrome following pregnancy. AmJ Med 1980;68:113-9.

Was there really a difference with amnloinfusion? To the Editors: Research data of Dr. Owens et al. (Owen

l,

Henson BV, Hauth lC. A propspective randomized study of saline solution amnioinfusion. AM 1 OBSTET GYNECOL 1990; 162: 1146-9) showing the apparent benefits of amnioinfusion is a different finding from our clinical experience.' The authors' rate of 19% postpartum endometritis in their control group is high. Perhaps it reflects the high rate of cesarean section in the controls. Given that the treated and control groups had the same mean cord pH, I question the authors' impression about the apparent differences in fetal distress between the two groups. In our hospital, amnioinfusion appears to be most effective for the fetal heart rate abnormalities that occur after artificial rupture of the membranes. I wonder whether the authors have also observed success in treating this iatrogenic fetal heart rate abnormality? Robert C. Goodlin, MD

Department of Health and Hospitals, City and County of Denver, 777 Bannock St., Denver, CO 80204-4507

REFERENCE 1. Goodlin RC, Ingram M. Ultrasonic study of amnioinfusion.

J Reprod Med

1990;35:4~9-40.