Thromboembolic disorders in obstetrics

Pain Scores after Open Fetal Spina Bifida Repair and Caesarean Section: A Longitudinal Cohort Study

INTRODUCTION

In fetal surgery, successful pain management is crucial for postoperative mobilization, prophylaxis of contractions, and fast recovery. This study analyzed patient's pain experience after open fetal spina bifida (fSB) repair in comparison to pain scores after the subsequent Caesarean section (C-section).

MATERIALS AND METHODS

Data were collected with a questionnaire given to 91 women, who had fSB repair and then C-section at our center between 2019 and 2022. It comprised 12 questions covering different aspects of pain experience and satisfaction with pain therapy and was answered by 67 women after fSB repair and 53 after C-section. Postoperative pain was rated on a Likert scale from 0 (slight/rarely) to 100 (strongest/always). Outcomes after fSB repair were compared to those after C-section. Additionally, subgroup analysis compared outcomes of women with different pain levels (group 1-5) after fSB repair.

RESULTS

Compared to women after C-section women after fSB repair reported significantly higher maximum pain scores (MPS) (p = 0.03), higher sleep disturbance due to pain (p = 0.03), and sedation rates (p = 0.001) as side effect from pain therapy. No differences were found regarding feelings of insecurity (p = 0.20) or helplessness (p = 0.40), as well as involvement in (p = 0.3) and satisfaction with pain therapy (p = 0.5). Subgroup analysis revealed that women with higher MPS after fSB repair were significantly more often non-Caucasians (p = 0.003) and more often affected by pain while lying in bed (p = 0.007) and during mobilization (p = 0.005). Additionally, they reported higher rates of dizziness (p = 0.02) and lower satisfaction rates with pain therapy (p = 0.03). Postoperative complication rate did not differ among groups.

CONCLUSION

Although women after fSB repair reported higher MPS compared to after C-section, the current pain management was generally perceived as satisfactory.

Enhanced Recovery after Surgery in Open Fetal Spina Bifida Repair

INTRODUCTION

For open fetal spina bifida (fSB) repair, a maternal laparotomy is required. Hence, enhanced maternal recovery after surgery (ERAS) is paramount. A revision of our ERAS protocol was made, including changes in operative techniques and postoperative pain management. This study investigates eventual benefits.

METHODS

Our study included 111 women with open fSB repair at our center. The old protocol group (group 1) either received a transverse incision of the fascia with transection of the rectus abdominis muscle (RAM) or a longitudinal incision of the fascia without RAM transection, depending on placental location. The new protocol required longitudinal incisions in all patients (group 2). Postoperative pain management was changed from tramadol to oxycodone/naloxone. Outcomes of the two different protocol groups were analyzed and compared regarding the primary endpoint, the length of hospital stay (LOS) after fetal surgery, as well as regarding the following secondary endpoints: postoperative pain scores, day of first mobilization, removal of urinary catheter, bowel movement, and the occurrence of maternal and fetal complications.

RESULTS

Out of 111 women, 82 (73.9%) were in group 1 and 29 (26.1%) were in group 2. Women in group 2 showed a significantly shorter LOS (18 [14-23] days vs. 27 [18-39] days, p = 0.002), duration until mobilization (3 [2-3] days vs. 3 [3-4] days, p = 0.03), and removal of urinary catheter (day 3 [3-3] vs. day 4 [3-4], p = 0.004). Group 2 less often received morphine subcutaneously (0% vs. 35.4%, p < 0.001) or intravenously (0% vs. 17.1%, p = 0.02) but more often oxycodone (69.0% vs. 18.3%, p < 0.001). No significant differences were seen regarding pain scores, bowel movement, and maternal and/or fetal complications.

CONCLUSION

The new ERAS protocol that combined changes in surgical technique and pain medication led to better outcomes while reducing LOS. Continuous revisions of current ERAS protocols are essential to improve patient care continuously.

Risk of retinopathy in women with pregnancy-induced hypertension: a nationwide population-based cohort study of 9-year follow-up after delivery

BACKGROUND

The retina is potentially associated with several physiological, hormonal, and metabolic changes during pregnancy. The few available epidemiologic studies of ocular changes in pregnancy have mainly concerned retinopathies. Pregnancy-induced hypertension, which leads to ocular manifestations including blurred vision, photopsia, scotoma, and diplopia, might induce reactive changes in the retinal vessels. Although several studies have suggested the existence of pregnancy-induced hypertension-related retinal ocular disease, there are few large cohort studies on this topic.

OBJECTIVE

This study aimed to investigate the risk of major retinal diseases including central serous chorioretinopathy, diabetic retinopathy, retinal vein occlusion, retinal artery occlusion, and hypertensive retinopathy in the long-term postpartum stage according to the presence of previous pregnancy-induced hypertension in a large cohort based on the Korean National Health Insurance Database.

STUDY DESIGN

On the basis of Korean health data, 909,520 patients who delivered from 2012 to 2013 were analyzed. Among them, patients who had previous ocular diseases or hypertension and multiple births were excluded. Finally, 858,057 mothers were assessed for central serous chorioretinopathy (ICD-10: H35.70), diabetic retinopathy (ICD-10: H36.0, E10.31, E10.32, E11.31, E11.32, E12.31, E13.31, E13.32, E14.31, E14.32), retinal vein occlusion (ICD-10: H34.8), retinal artery occlusion (ICD-10: H34.2), and hypertensive retinopathy (ICD-10: H35.02) for 9 years after delivery. Enrolled patients were divided into 2 groups: 10,808 patients with and 847,249 without pregnancy-induced hypertension. The primary outcomes were the incidence of central serous chorioretinopathy, diabetic retinopathy, retinal vein occlusion, retinal artery occlusion, and hypertensive retinopathy 9 years after delivery. Clinical variables were age, parity, cesarean delivery, gestational diabetes mellitus, and postpartum hemorrhage. In addition, pregestational diabetes mellitus, kidney diseases, cerebrovascular diseases, and cardiovascular diseases were adjusted.

RESULTS

Postpartum retinal disease during the 9 years after delivery and total retinal diseases showed higher rates in patients with pregnancy-induced hypertension. In detail, the rates of central serous chorioretinopathy (0.3% vs 0.1%), diabetic retinopathy (1.79% vs 0.5%), retinal vein occlusion (0.19% vs 0.1%), and hypertensive retinopathy (0.62% vs 0.05%) were higher than those found in patients without pregnancy-induced hypertension. After adjusting for confounding factors, pregnancy-induced hypertension was associated with development of postpartum retinopathy, with a >2-fold increase (hazard ratio, 2.845; 95% confidence interval, 2.54-3.188). Furthermore, pregnancy-induced hypertension affected the development of central serous chorioretinopathy (hazard ratio, 3.681; 95% confidence interval, 2.667-5.082), diabetic retinopathy (hazard ratio, 2.326; 95% confidence interval, 2.013-2.688), retinal vein occlusion (hazard ratio, 2.241; 95% confidence interval, 1.491-3.368), and hypertensive retinopathy (hazard ratio, 11.392; 95% confidence interval, 8.771-14.796) after delivery.

CONCLUSION

A history of pregnancy-induced hypertension increases the risk of central serous chorioretinopathy, diabetic retinopathy, retinal vein occlusion, and hypertensive retinopathy according to 9-year long-term ophthalmologic follow-up.

Pregnancy and thrombosis risk for women without a history of thrombotic events: a retrospective study of the real risks

Background

During pregnancy and puerperium women are at high VTE risk. Current guidelines recommend dynamic VTE-risk assessment during pregnancy. Based on related RCOG-guidelines we constructed a digital VTE-risk assessment tool: PATrisks (www.PATrisks.com). Using this tool, we retrospectively evaluated the thrombotic risk in 742 women from our previous work, women who received thromboprophylaxis based on clinical experience for A) pregnancy complications, B) IVF treatment and C) prothrombotic tendency, in order to investigate whether that practice was justified according to the PATrisks scoring system for VTE prevention.

Methods

Women with pregnancy complications [Group-A: 445], women who had undergone IVF [Group-B:132] and women with a prothrombotic tendency (thrombophilia, family history of VTE, other) [Group-C:165] were assessed using the PATrisks scoring system for thrombotic risk. The women were assigned into one of the following risk categories: low (score ≤ 2), intermediate (score = 3) and high (score ≥ 4). Further analysis per risk factor type (pre-existing or obstetric) and for various combinations of them, was also performed. We evaluated thrombotic risk early in pregnancy, and in the peripartum period.

Results

The mean risk score antepartum was higher for women in Group B (3.3 in comparison with 1.9 and 2.0 in Group A and Group C respectively). Moreover, the risk score increased significantly postpartum for all Groups. The chi-square test also proved that there was a higher percentage of women at high or intermediate risk in group B compared to C before birth (55.3% vs.26.1% respectively, p < 0.0001, OR: 3.5, 95% CI: 2.2 – 5.7) and similarly after birth (85.6% vs. 56.4%, OR: 4.6, 95%CI: 2.6–8.2, p < 0.0001). In total 12 (1.6%) out of 742 women experienced thrombotic events, whether pre- or post-partum.

Conclusions

LMWHs are widely prescribed during pregnancy for a number of indications, even when a proven scientific basis for such a practice is lacking. However, a considerable percentage of women were already at VTE-risk according to PATrisks and might have derived an additional benefit from LMWH in the form of VTE prevention. The rational use of these drugs should be optimized by establishing and implementing routine risk assessment for all pregnant women and by providing the necessary education to healthcare professionals.

Agreement between two scales used for assessing risk classification for thromboembolic events and the requirement of postpartum pharmacological prophylaxis

OBJECTIVES

To determine agreement in assessing the need for postpartum pharmacological prophylaxis between the scale of the Royal College of Obstetricians and Gynaecologists and the Colombian guideline scale in a Level IV institution in Bogota, Colombia.

MATERIAL AND METHODS

Diagnostic agreement study assembled on a cross-sectional study. The included population consisted of pregnant women with 24 or more weeks of pregnancy admitted between March 1 and April 30 of 2021 to a high complexity private institution in Bogotá, Colombia, for labor induction, in active labor, for elective cesarean section, or who required urgent cesarean section. Convenience sampling was used. Measured variables included demographics, risk factors, risk classification and pharmacological prophylaxis according to the two scales. The prevalence of risk factors for each scale was estimated and agreement regarding prophylaxis indication between the two scales was measured using the weighted kappa value.

RESULTS

Overall, 320 patients were included. According to the scale of the Royal College Obstetricians and Gynaecologists, 54.7 % patients were classified as low risk, 42.5 % as intermediate risk and 2.8 % as high risk. The Colombian scale classified 80 % of patients as low risk, 17.2 % as intermediate risk, 2.2 % as high risk, and 0.6 % as very high risk. The weighted kappa value for agreement regarding the indication was 0.47 (95 % CI: 0.38-0.56).

CONCLUSIONS

Agreement between the two scales to determine the need for postpartum pharmacological prophylaxis is moderate. Risk classification criteria for the Colombian scale should be validated in a second cohort. Moreover, the predictive ability of the Colombian guideline tool should be assessed at different cut-off points in terms of the consequences of false positive and false negative results.

Pregnancy-Associated Liver Diseases

The liver disorders unique to pregnancy include hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, and preeclampsia-associated hepatic impairment, specifically hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP). Their importance lies in the significant maternal and fetal/neonatal morbidity and mortality. Expeditious diagnosis and clinical evaluation is critical to ensure timely, appropriate care and minimize risks to the pregnant woman and her fetus/baby. A multidisciplinary approach is essential, including midwives, maternal-fetal-medicine specialists, anesthetists, neonatologists, and hepatologists.

Idiopathic combined retinal vessels occlusion in a pregnant woman: a case report

Background

Ocular vascular occlusion is an extremely rare event, especially in the young population. This diagnosis is always associated with active systemic diseases in young adults and needs thrombophilia workup. Nevertheless, we present the case of a pregnant woman suffering from idiopathic combined central retinal vein and cilioretinal artery occlusion.

Case presentation

A 36-year-old pregnant Iranian woman at the 36th week of her second pregnancy complained of subacute unilateral painless decreased vision of her left eye. She had experienced a transient vision loss that lasted several minutes, but attacks gradually became more frequent and finally persistent over a several-day period. Finally combined central retinal vein and cilioretinal artery occlusion was established. Her visual acuity improved to 4/10 in a month without any ocular intervention except for a short duration of prophylactic dose enoxaparin, and the acuity reached 8/10 without any complications in the third month follow-up visit. At 1 year follow-up, the visual acuity had not changed and no macular edema was seen.

Conclusions

Ocular vascular occlusion is extremely rare among young adults, and even rarer among pregnant women. According to this, any suspected retinal vascular event in this population should raise suspicion for underlying diseases such as hypertension, diabetes, autoimmune diseases, migraine, preeclampsia syndrome, and thrombophilia. However, as seen in this presented case, idiopathic ocular vascular occlusion events can occur also.

Hormone therapy for postmenopausal osteoporosis management

Menopausal hormone therapy (MHT) has been used for prevention and treatment of postmenopausal osteoporosis for several decades. However, public concerns were raised over the safety of MHT after the initial report was published in 2002 by the Women's Health Initiative. We conducted a historical review on this subject, primarily focusing on level I evidence from randomized controlled trials, systematic reviews and meta-analyses, and summarized high-quality evidence on the efficacy and safety of MHT in management of postmenopausal osteoporosis. Clinical issues were also discussed on MHT initiation, identification of treatment candidates and treatment duration, as well as discontinuation of MHT.

The Increasing Possibility of Pregnancy Postbariatric Surgery: a Comprehensive National Cohort Study in Asian Population

PURPOSE

The present study aimed to investigate bariatric surgery's effects on pregnancy in obese women.

MATERIALS AND METHODS

The source of the data was the Taiwan National Health Insurance Research Database. We extracted female patients aged 18 to 45 years who had been diagnosed with obesity from 2005 to 2010. Two groups were formed based on bariatric surgery, according to the medical procedure codes of ICD-9-2001. The propensity score match of 1:1 was coordinated, based on the age, previous delivery, and the existence of comorbidities in patients. The primary endpoint was regarded as a pregnancy, including abortion, ectopic pregnancy, and delivery. The follow-up was performed until the end of 2013, or death.

RESULTS

There were 689 patients placed in each group, with a median of 64.8 follow-up months. Following multivariate analysis of the data, bariatric surgery resulted in significantly higher chances for pregnancy (aHR 2.886, p < 0.001) and resulted in a higher chance of successful delivery (aHR 2.775, p < 0.001) and vaginal delivery (aHR = 6.426, p < 0.001) compared with NS group. Moreover, we identified BS has a significantly higher proportion of vaginal delivery (BS 44.74% vs. NS 20%, p = 0.025) with significantly lower overall complications during labor (BS 9.21% vs. NS 33.3%, p = 0.006).

CONCLUSION

Patients suffering from obesity who undergo bariatric surgery have higher chances of pregnancy, successful delivery, vaginal delivery, and lower maternal complications during labor. Bariatric surgery did increase the possibility of pregnancy in obese patients.

Combined thrombogenic effects of vessel injury, pregnancy and procoagulant immune globulin administration in mice

Background

Pregnant women are at increased risk of thrombotic adverse events. Plasma derived immune globulin (IG) products, which are used in pregnancy for various indications, may contain procoagulant impurity activated coagulation factor XI (FXIa). Procoagulant IG products have been associated with increased thrombogenicity but their effect in pregnancy is unknown.

Methods

Late pregnant (gestation days 17–20) or early lactation (days 1–3) and control female mice were treated with IGs supplemented with human FXIa then subjected to ferric chloride (FeCl₃) vessel injury. Occlusion of blood vessel was assessed by recording blood velocity in the femoral vein for 20 min using doppler ultrasound laser imaging. FXIa dose was selected by the ability to increase thrombin generation in mouse plasma in vitro.

Results

FXIa produced robust thrombin generation in mouse plasma ex vivo. Following FeCl₃ injury, pregnant and non-pregnant mice receiving IG + FXIa exhibited faster reduction of blood velocity in femoral vein compared to IG alone or untreated controls. In vitro, thrombin generation in plasma samples collected after thrombosis in FXIa-treated animals was elevated and could be reduced by anti-FXI antibody.

Conclusions

Our results suggest that intravenously-administered FXIa may contribute to thrombosis at the site of vascular injury in both pregnant and non-pregnant animals.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12959-020-00245-8.

Intravitreal anti-vascular endothelial growth factor medications during pregnancy: current perspective

PURPOSE

Anti-vascular endothelial growth factor (VEGF) medications are widely used for treatment of a number of vitreoretinal disorders. However, the evidence for their effect on fetal and maternal health during pregnancy is very limited. The goal of this article is to accumulate evidence for the indications of anti-VEGF medications during pregnancy and their effects on maternal and fetal health.

METHODS

Review of literature regarding anti-VEGF administration during pregnancy and using PubMed database without language or date limit.

RESULTS

The main indications for treatment with intravitreal anti-VEGF medications include choroidal neovascularization (CNV) followed by retinal vascular occlusion (RVO) and complications of diabetes such as neovascular glaucoma, diabetic retinopathy (DR) and diabetic macular edema (DME). Among anti-VEGF medications, only ranibizumab and bevacizumab have been used during pregnancy with latter by far more than the former.

CONCLUSION

Women of childbearing age should be consulted regarding the potential adverse effects of anti-VEGF medications on fetal health and the risk of early pregnancy loss. They should be strongly encouraged to use appropriate contraceptive methods during treatment. A timely obstetrics consultation may help in this situation. Attempt for pregnancy should be withheld for at least 3 months following last injection of ranibizumab and aflibercept, and for at least 6 months following last injection of bevacizumab.

Contemporary best practice in the management of pulmonary embolism during pregnancy

Approximately 1-2 per 1000 pregnancies are complicated by venous thromboembolism (VTE). VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE) and the diagnostic management of pregnancy-related VTE is challenging. Current guidelines vary greatly in their approach to diagnosing PE in pregnancy as they base their recommendations on scarce and weak evidence. The pregnancy-adapted YEARS diagnostic algorithm is well tolerated and is the most efficient diagnostic algorithm for pregnant women with suspected PE, with 39% of women not requiring computed tomographic pulmonary angiography. Low-molecular-weight heparin is the first-choice anticoagulant treatment in pregnancy and should be continued until 6 weeks postpartum and for a minimum of 3 months. Direct oral anticoagulants should be avoided in women who want to breastfeed. Management of delivery needs a multidisciplinary approach in order to decide on an optimal delivery plan. Neuraxial analgesia can be given in most patients, provided time windows since last low-molecular-weight heparin dose are respected. Women with a history of VTE are at risk of recurrence during pregnancy and in the postpartum period. Therefore, in most women with a history of VTE, thromboprophylaxis in subsequent pregnancies is indicated. The reviews of this paper are available via the supplemental material section.

Low molecular weight heparins use in pregnancy: a practice survey from Greece and a review of the literature

Background

Use of LMWH in pregnancy is not only limited to VTE management, but it extends, to the management of vascular gestational complications and the optimization of IVF pregnancies despite the lack of concrete scientific evidence. In this context, we conducted the present study aiming to gain insights regarding the use of LMWH during pregnancy and puerperium. We recorded indication for use, diagnostic work-up as well as the safety and efficacy of the treatment, trying to elucidate the clinical practice in our country.

Methods

We analyzed data regarding 818 pregnant women received LMWH during 2010-2015.Our cohort had a median age of 33.9 years and a BMI of 23.6.There were 4 groups: those with a history of VTE [Group-A: 76], those with pregnancy complications [Group-B: 445], those undergoing IVF [Group-C: 132] and those carrying prothrombotic tendency (thrombophilia, family history of VTE, other) [Group-D: 165]. Mean duration of LMWH administration was 8.6 ± 1.5 months. Out of the total number, 440 received LMWH in fixed prophylactic dose, 272 in higher prophylactic-weight adjusted dose and 106 in therapeutic dose. Moreover, 152 women received in addition low-dose acetylsalicylic acid (ASA). 93.8% of pregnancies were single and 6.2% were multiple ones. Live births occurred in 98.7% of pregnancies.

Results

Anticoagulation was efficacious and well tolerated. Seventeen VTE events were recorded; 7 of them antepartum and 10 postpartum. No major bleeding events were observed while 13 clinical relevant non-major bleeding events were recorded. Regarding gestational vascular complications, 28 IUGR events were recorded, as well as 48 cases of preterm labor of which 12 were concomitant with IUGR (25%). Six early pregnancy losses were recorded; there were 3 fetal deaths and 3 cases of pre-eclampsia/eclampsia.

Conclusions

LMWHs are used extensively during pregnancy and puerperium in Greece for VTE treatment and prophylaxis and for a variety of other indications as well. Although the drug has been shown to be both safe and efficacious, its use for some indications has no proven scientific evidence. In order to clearly define the role of LMWHs in pregnancy, beyond thromboprophylaxis, large prospective studies are required, which could be based on the conclusions of this study.

EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond

These guidelines update the previous EANM 2009 guidelines on the diagnosis of pulmonary embolism (PE). Relevant new aspects are related to (a) quantification of PE and other ventilation/perfusion defects; (b) follow-up of patients with PE; (c) chronic PE; and (d) description of additional pulmonary physiological changes leading to diagnoses of left ventricular heart failure (HF), chronic obstructive pulmonary disease (COPD) and pneumonia. The diagnosis of PE should be reported when a mismatch of one segment or two subsegments is found. For ventilation, Technegas or krypton gas is preferred over diethylene triamine pentaacetic acid (DTPA) in patients with COPD. Tomographic imaging with V/PSPECT has higher sensitivity and specificity for PE compared with planar imaging. Absence of contraindications makes V/PSPECT an essential method for the diagnosis of PE. When V/PSPECT is combined with a low-dose CT, the specificity of the test can be further improved, especially in patients with other lung diseases. Pitfalls in V/PSPECT interpretation are discussed. In conclusion, V/PSPECT is strongly recommended as it accurately establishes the diagnosis of PE even in the presence of diseases like COPD, HF and pneumonia and has no contraindications.

Could the YEARS algorithm be used to exclude pulmonary embolism during pregnancy? Data from the CT-PE-pregnancy study

INTRODUCTION

The recently proposed YEARS algorithm was shown to safely exclude pulmonary embolism (PE) and reduce the use of computed tomography pulmonary angiography (CTPA) among pregnant women with suspected PE. Our aim was to externally validate this finding.

METHODS

We performed a post hoc analysis of a prospective management outcome study for PE diagnosis in pregnant women. PE was diagnosed with an algorithm that combined the revised Geneva score, D-dimer testing, bilateral lower-limb compression ultrasonography, and CTPA. All women had a 3-month follow-up. All of the items necessary to use the YEARS algorithm were prospectively collected at the time of the study.

RESULTS

Of the 395 women included in the original study, 371 were available for the present analysis. The PE prevalence was 6.5%. Ninety-one women had no YEARS items, and 280 had one or more items. When the YEARS items were combined with D-dimer levels (<1000 ng/mL in women with no items, and <500 ng/mL in women with one or more items), 77 women (21%) met the criteria for PE exclusion and would not have undergone CTPA as per the YEARS algorithm. None of these 77 women had PE diagnosed during the initial work-up or 3-month follow-up. Therefore, the failure rate of the YEARS algorithm in our pregnant women population was 0/77 (95% confidence interval 0.0-3.9).

CONCLUSION

In our study, application of the YEARS algorithm would have resulted in safe exclusion of PE in one of five pregnant women without the need for radiation exposure, further supporting the use of the algorithm in this population.

The hemodynamic effects of pregnancy on the lower extremity venous system

OBJECTIVE

Pregnancy has significant effects on the lower extremity venous system. Increasing venous pressure and blood volume, in combination with reduced flow rates within the deep veins, predisposes pregnant women to both primary and secondary chronic venous insufficiency (CVI). This review article highlights the specific physiologic and hemodynamic changes that occur during pregnancy and examines the nonpharmacologic, pharmacologic, and invasive interventions that are appropriate for both prophylaxis and treatment of CVI and venous thromboembolism (VTE).

METHODS

This study is a review article of the key literature related to VTE and CVI in pregnancy.

RESULTS

Significant hemodynamic changes occur in the lower extremities during pregnancy. Although well documented and essential to fetal development, these changes can have a negative impact on the maternal lower extremity venous circulation. Consequences of pregnancy can result in venous disease only during pregnancy or, particularly in the multiparous patient, can progress to CVI. An abundance of literature and guidelines exist for the management of VTE during pregnancy; however, the quality and extent of literature based around the management of primary CVI during pregnancy are modest at best.

CONCLUSIONS

The physiologic changes throughout the arterial and venous systems during pregnancy are well documented. However, there is a paucity of data available to construct guidelines for care, particularly in the pregnant patient with symptomatic superficial venous insufficiency. Further investigation in the form of prospective randomized trials is required to establish appropriate guidelines for treatment.

Diagnosing venous thromboembolism in pregnancy

OBJECTIVE

We report the imaging outcomes of all pregnant patients referred for suspected thromboembolism over a 43-month period.

METHODS

We identified 168 patients who underwent ventilation/perfusion (VQ) single-photon emission CT (SPECT), CT pulmonary angiography (CTPA) or a Doppler ultrasound scan of the lower legs, as well as a control group of 89 non-pregnant age- and sex-matched patients who underwent VQ SPECT during the same period. Imaging outcomes were recorded, and radiation doses were calculated for individual patients.

RESULTS

VQ SPECT and CTPA were equally likely to diagnose pulmonary embolism (PE) in about one patient out of every seven patients investigated. One in three CTPA scans was of suboptimal quality. A Doppler ultrasound examination of the legs will find deep venous thrombosis much less often, in about 1 patient out of every 15 patients investigated. The prevalence of PE in pregnant patients (as diagnosed by VQ SPECT) was similar to that in the non-pregnant, age- and sex-matched control group. The effective dose and the absorbed radiation dose to the maternal breast were lower with VQ SPECT. The foetal dose is comparable for both VQ SPECT and CTPA.

CONCLUSION

VQ SPECT and CTPA provide a similar diagnostic yield for diagnosing PE during pregnancy, but VQ SPECT does so with a lower radiation dose to the mother (effective dose and breast dose).

ADVANCES IN KNOWLEDGE

Ours is the first report of the diagnostic performance of VQ SPECT, rather than planar VQ scans, in pregnancy in a routine clinical setting.

Directed preconception health programs and interventions for improving pregnancy outcomes for women who are overweight or obese

BACKGROUND

Overweight and obesity (body mass index (BMI) ≥ 25.0 to 29.9 kg/m(2) and BMI ≥ 30 kg/m(2,) respectively are increasingly common among women of reproductive age. Overweight and obesity are known to be associated with many adverse health conditions in the preconception period, during pregnancy and during the labour and postpartum period. There are no current guidelines to suggest which preconception health programs and interventions are of benefit to these women and their infants. It is important to evaluate the available evidence to establish which preconception interventions are of value to this population of women.

OBJECTIVES

To evaluate the effectiveness of preconception health programs and interventions for improving pregnancy outcomes in overweight and obese women.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2014) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (including those using a cluster-randomised design), comparing health programs and interventions with routine care in women of reproductive age and a BMI greater then or equal to 25 kg/m(2). Studies published in abstract form only, were not eligible for inclusion. Quasi-randomised trials or randomised trials using a cross-over design were not eligible for inclusion in this review. The intervention in such studies would involve an assessment of preconception health and lead to an individualised preconception program addressing any areas of concern for that particular woman.Preconception interventions could involve any or all of: provision of specific information, screening for and treating obesity-related health problems, customised or general dietary and exercise advice, medical or surgical interventions. Medical interventions may include treatment of pre-existing hypertension, impaired glucose tolerance or sleep apnoea. Surgical interventions may include interventions such as bariatric surgery. The comparator was prespecified to be standard preconception advice or no advice/interventions.

DATA COLLECTION AND ANALYSIS

We identified no studies that met the inclusion criteria for this review. The search identified one study (published in four trial reports) which was independently assessed by two review authors and subsequently excluded.

MAIN RESULTS

There are no included trials.

AUTHORS' CONCLUSIONS

We found no randomised controlled trials that assessed the effect of preconception health programs and interventions in overweight and obese women with the aim of improving pregnancy outcomes. Until the effectiveness of preconception health programs and interventions can be established, no practice recommendations can be made. Further research is required in this area.

Retinal vein occlusion and pregnancy, pre-eclampsia, and eclampsia: the results from a nationwide, population-based study using the national claim database

Objective

To investigate the incidence of retinal vein occlusion (RVO) in pregnant women and in the subpopulation of pregnant women with pre-eclampsia/eclampsia compared to that in the age-matched general female population to determine if there is increased risk of RVO in pregnancy.

Design

Nationwide population-based retrospective study using data entered into the Korean national health claims database from 2007 to 2011.

Setting and Participants

Of the incident RVO cases in the database, RVO cases that occurred during the pregnancy-associated period, which spanned a 52-week period from 40-weeks-before to 12-weeks-after childbirth, were identified. Of these cases, the presence of pre-eclampsia/eclampsia was determined.

Main Outcome and Measure

The standardized incidence ratios (SIRs) of RVO in the general pregnant population and in the pregnant population with pre-eclampsia/eclampsia were determined with respect to the age-matched general female population.

Results

Pregnancy-related RVO was identified in 33 cases from the 1.8 million women who experience childbirth during the study period, while the expected number of cases calculated by the direct standardization to the age-matched general population was 113. Of the 33 patients, 12 patients (36.4%) had pre-eclampsia or eclampsia. The SIR for the general pregnant population in reference to the age-matched general female population was 0.29 (95% CI, 0.20–0.41). In contrast, the SIR for the pregnant population with pre-eclampsia/eclampsia in reference to the age-matched general female population and the age-matched general pregnant population was 67.50 (95% CI, 34.88–117.92) and 246.50 (95% CI, 127.37–430.59), respectively.

Conclusions and Relevance

The results suggest that pre-eclampsia/eclampsia is a risk factor for RVO, while pregnancy itself may not be a risk factor for RVO.

Where are we 10 years after the Women's Health Initiative?

The media attention surrounding the publication of the initial results of WHI in 2002 led to fear and confusion regarding the use of hormonal therapy (HT) after menopause. This led to a dramatic reduction in prescriptions for HT in the United States and around the world. Although in 2002 it was stated that the results pertained to all women receiving HT, subsequent studies from the Women's Health Initiative (WHI) and others clearly showed that younger women and those close to menopause had a very beneficial risk-to-benefit ratio. Indeed, the results showed similar protective effects for coronary disease and a reduction in mortality that had been shown in earlier observational studies, which had also focused on younger symptomatic women. In younger women, the increased number of cases of venous thrombosis and ischemic stroke was low, rendering them "rare" events using World Health Organization nomenclature. Breast cancer rates were also low and were found to be decreased with estrogen alone. In women receiving estrogen and progestogen for the first time in the WHI, breast cancer rates did not increase significantly for 7 years. Other data suggest that other regimens and the use of other progestogens may also be safer. It has been argued that in the 10 years since WHI, many women have been denied HT, including those with severe symptoms, and that this has significantly disadvantaged a generation of women. Some reports have also suggested an increased rate of osteoporotic fractures since the WHI. Therefore, the question is posed as to whether we have now come full circle in our understanding of the use of HT in younger women. Although it is appropriate to treat women with symptoms at the onset of menopause, because there is no proven therapy for primary prevention, in some women the use of HT for this role may at least be entertained.

The skin and hypercoagulable states

Hypercoagulable states (HS) are inherited or acquired conditions that predispose an individual to venous and/or arterial thrombosis. The dermatologist can play a vital role in diagnosing a patient's HS by recognizing the associated cutaneous manifestations, such as purpura, purpura fulminans, livedo reticularis, livedo vasculopathy (atrophie blanche), anetoderma, chronic venous ulcers, and superficial venous thrombosis. The cutaneous manifestations of HS are generally nonspecific, but identification of an abnormal finding can warrant a further workup for an underlying thrombophilic disorder. This review will focus on the basic science of hemostasis, the evaluation of HS, the skin manifestations associated with hypercoagulability, and the use of antiplatelet and anticoagulant therapy in dermatology.