The return to the Grand Slam stage by Serena Williams, who hasn't played in a tennis tournament since winning her fourth Wimbledon last July, will take much longer now after the 29-year-old star underwent emergency medical treatment in Los Angeles this week, less than 10 days after doctors had hospitalized her for a blood clot in her lungs.
It was not immediately known what triggered Monday's treatment of a hematoma -- an area of bleeding -- at Cedars-Sinai, something first reported Wednesday morning by People magazine. She is now recuperating at home.
Late Wednesday, however, it was learned that Williams also had been hospitalized 10 days ago for a pulmonary embolism, or blood clot.
"She was first hospitalized for two days, Feb. 19 and 20," Jill Smoller, Williams' longtime publicist, told The Times. "She'd just gotten to Los Angeles." Williams owns homes in Florida and Los Angeles.
That hospital stay coincided with a tweet by Williams on Feb. 19 in which she said, "My day could not get any worse."
Williams' career, which includes 13 Grand Slam titles, is now on hold indefinitely.
Last week, she told the New York Post that she expected to return to the game in time for the French Open in May. Now she has to hope she can be well enough in time for Wimbledon, which begins June 20.
A statement released Wednesday afternoon by a Williams spokesperson said, "Serena did indeed suffer from a pulmonary embolism last week, and the hematoma was another unexpected scare. Thankfully everything was caught in time. With continued doctor visits to monitor her situation, she is recuperating at home under strict medical supervision.
"Says Serena, 'Thank you everyone for all of your prayers, concerns, and support. This has been extremely hard, scary, and disappointing. I am doing better, I'm at home now and working with my doctors to keep everything under control. I know I will be OK, but am praying and hoping this will all be behind me soon. While I can't make any promises now on my return, I hope to be back by early summer. That said, my main goal is to make sure I get there safely.'"
Williams has been out of action since shortly after Wimbledon when she cut tendons in her right foot in an accident that she said was caused by stepping on broken glass at a restaurant. That required two foot surgeries and until last week she wore a walking boot to restrict movement.
In fact, it was only late last week that Williams was told she would no longer need the boot. On Sunday she wore high heels to Oscar parties.
It is possible that clotting around her foot injury contributed to the embolism, said Dr. Ralph Brindis, president of the American College of Cardiology.
A pulmonary embolism usually originates in a vein in the leg, breaks loose and travels to the lung. Typically, a person develops a pulmonary embolism when he or she has risk factors -- these can include pregnancy, use of oral contraceptives, smoking, clotting disorders or obesity -- and then remains sedentary for a period of time, allowing blood to stagnate in the leg and form a clot. People who take long airplane trips are at particular risk.
Typically, doctors administer anticoagulant drugs such as Coumadin to prevent additional clotting. Williams may be on such medications for several months, doctors said.
In some cases, large emboli are also initially treated with clot-dissolving agents. Brindis said that such agents can cause bleeding, which could explain the hematoma.
Dr. Mark Adelman, chief of vascular and endovascular surgery at New York University's Langone Medical Center, said that Williams' lungs should heal completely. He estimated that for anywhere from six to 12 weeks her doctors would not want her to play tennis at all. After that, Williams might be able to play at a high level, but because the anticoagulants will put her at additional risk of bruises and bleeding, she'll want to avoid getting hit hard during play.
Debbie Graham, once a top-50 player, knows coming back won't be easy. In 2005, Graham returned to San Francisco from Wimbledon and noticed after the long flight that her leg was swollen. As she walked off the plane, she collapsed. The diagnosis? Pulmonary embolism.
Graham, 25 at the time, left the WTA Tour for a year.
"At first I was told I'd never play tennis again," Graham said Wednesday. "The doctors said it wasn't advisable as long as I was taking the medication [Coumadin] to prevent another. I was told the problem is that as long as you're on blood thinners, it's not advisable because even if you twist an ankle or get hit hard by a ball, you can get bleeding in the joints."
Pam Shriver, a former player and now a tennis commentator for ESPN, said that despite this latest setback, there is precedent for a player of Williams' age to make a successful comeback.
"If the desire is there, she's still young enough and talented enough," Shriver said. "You only have to look at some of the other comebacks from long injuries, layoffs, retirements. Look at the quality of Lindsay Davenport's comeback after she had a child in her early 30s, Kim Clijsters' comeback after her baby, Jennifer Capriati, Monica Seles after her stabbing."
Davenport, a three-time Grand Slam winner, cautioned, though, that age makes comebacks more difficult.
"No doubt about it, once you hit 30 it gets more difficult," she said.
But when Williams returns, her chief competition might be only Clijsters, because no other woman has proved dominant in Grand Slam play.
"So you can't ever count Serena out," Davenport said.