JPOG_December_2014_HK.pdf

JOURNAL OF PAEDIATRICS, OBSTETRICS & GYNAECOLOGY

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YOUR PARTNER IN PAEDIATRIC AND O&G PRACTICE NOv/DEC 2014 vol. 40 No. 6

COMMON SYMPTOMS AND SIGNS DURING PREGNANCY

HONG KONGISSN 1012-8875

PAEDIATRICS

Early Management of Paediatric Burn Injuries

OBSTETRICS

Sterilisation and Emergency Contraception

CME ARTICLE

Venous Thromboembolism in Pregnancy

JPOG NOV/DEC 2014 i

NOV/DEC 2014 VOl. 40 NO. 6

Board Director, Paediatrics

Professor Pik-To CheungAssociate ProfessorDepartment of Paediatrics and Adolescent MedicineThe University of Hong Kong

Board Director, Obstetrics and Gynaecology

Professor Pak-Chung HoHead, Department of Obstetrics and GynaecologyThe University of Hong Kong

Editorial Board

Professor Biran AffandiUniversity of Indonesia

Dr Karen Kar-Loen ChanThe University of Hong Kong

Professor Oh Moh ChayKK Women’s and Children’s Hospital, Singapore

Associate Professor Anette JacobsenKK Women’s and Children’s Hospital, Singapore

Professor Rahman JamalUniversiti Kebangsaan Malaysia

Dato’ Dr Ravindran JegasothyDean at the Medical Faculty, MAHSA University, Malaysia

Professor Kenneth KwekKK Women’s and Children’s Hospital, Singapore

Dr Siu-Keung LamPrestige Medical Centre, Hong Kong

Professor Terence LaoChinese University of Hong Kong

Dr Kwok-Yin LeungThe University of Hong Kong

Dr Tak-Yeung LeungChinese University of Hong Kong

Professor Tzou-Yien LinChang Gung University, Taiwan

Professor Somsak LolekhaRamathibodi Hospital, Thailand

Professor Lucy Chai-See LumUniversity of Malaya, Malaysia

Professor SC NgNational University of Singapore

Professor Hextan Yuen-Sheung NganThe University of Hong Kong

Professor Carmencita D PadillaUniversity of the Philippines Manila

Professor Seng-Hock QuakNational University of Singapore

Dr Tatang Kustiman SamsiUniversity of Tarumanagara, Indonesia

Professor Alex SiaKK Women’s and Children’s Hospital, Singapore

Dr Raman SubramaniamFetal Medicine and Gynaecology Centre, Malaysia

Professor Walfrido W Sumpaico MCU-FDT Medical Foundation, Philippines

Professor Cheng Lim TanKK Women’s and Children’s Hospital, Singapore

Professor Kok Hian TanKK Women’s and Children’s Hospital, Singapore

Professor Surasak TaneepanichskulChulalongkorn University, Thailand

Professor Eng-Hseon TayThomson Women Cancer Centre, Singapore

Professor PC WongNational University of Singapore

Adjunct Professor George SH YeoKK Women’s and Children’s Hospital, Singapore

Professor Hui-Kim YapNational University of Singapore

Professor Tsu-Fuh YehChina Medical University, Taiwan

221 223

Journal Watch

221

• Early administration of epidural analgesia during labour appears to be advantageous

• Nicotine replacement therapy during pregnancy lowers development impairment in infants

222

• Clomiphene + letrozole combination therapy effective in women with PCOS resistant to each agent alone

• Breakfast consumption ameliorates risk factors for type 2 diabetes in children

223

• Nutrient intake among Chinese infants generally adequate, but some at risk of imbalanced vitamin A and zinc intake

• Rice and rice products poor choices for introducing infants to solid foods, despite their popularity in Asia Pacific

• Juvenile idiopathic arthritis associated with pain hypersensitivity even in the absence of active disease

224

• Sea buckthorn oil beneficial for treating vaginal atrophy in postmenopausal women

JPOG_NovDec_2014_Final_TOC_HK.indd 1 11/27/14 4:05 PM

JPOG NOV/DEC 2014 iii


225 233

rEviEW articlEpaediatrics

225

Early Management of Paediatric Burn InjuriesBurns are common injuries in the paediatric population and comprise a significant epidemiological problem worldwide. This article describes the most common patterns of burn injuries encountered in clinical practice as well as the basic principles of burn wound pathophysiology.

Ioannis Goutos, Michael Tyler

rEviEW articlEObstetrics

233

Traditional Methods, Sterilisation and Emergency Contraception - A Practical Guide to Contraception. Part 3Traditional methods of contraception have lower efficacies in typical use than modern methods but are valued contraceptive options. Sterilisation has high efficacy rates but is being used less as long-acting reversible contraceptives become more widely available and accepted.

Mary Stewart, Kathleen McNamee, Caroline Harvey

in PracticE247

Dermatology Clinic: Widespread Rash in a 6-Year-Old BoyGayle Fischer

247

Dermatology Clinic: A Linear Lesion on a Girl’s LegGayle Fischer

Enquiries and correspondence

Publisher Ben YeoManaging Editor Greg TownMedical Editor Kavitha MPublication Manager Marisa LamDesigners Agnes Chieng, Sam ShumProduction Edwin Yu, Ho Wai Hung, Steven CheungCirculation Christine ChokAccounting Manager Minty KwanAdvertising Coordinator Jasmine Chay

Published by: MIMS (Hong Kong) Limited27th Floor, OTB Building, 160 Gloucester Road, Wan Chai, Hong KongTel: (852) 2559 5888 | Email: [email protected]

pUbLisHer: Journal of Paediatrics, Obstetric & Gynaecology (JPOG) is published 6 times a year by MIMS Pte Ltd. circULatiON: JPOG is a controlled circulation for medical practitioners in South East Asia. It is also available on subscription to members of allied professions. sUbscriptiON: The price per annum is US$42 (surface mail, students US$21) and US$48 (overseas airmail, students US$24); back issues US$8 per copy. editOriaL Matter published herein has been prepared by professional editorial staff. Views expressed are not necessarily those of MIMS Pte Ltd. Although great care has been taken in compiling and checking the information given in this publication to ensure that it is accurate, the authors, the publisher and their servants or agents shall not be responsible or in any way liable for the continued currency of the information or for any errors, omissions or inaccuracies in this publication whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. The inclusion or exclusion of any product does not mean that the publisher advocates or rejects its use either generally or in any particular field or fields. cOpYriGHt: © 2014 MIMS Pte Ltd. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, in any language, without written consent of copyright owner. Permission to reprint must be obtained from the publisher. adVertiseMeNts are subject to editorial acceptance and have no influence on editorial content or presentation. MIMS Pte Ltd does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature. philippine edition: Entered as second-class mail at the Makati Central Post Office under Permit No. PS-326-01 NCR, dated 9 Feb 2001. printed by Fortune Printing International Ltd, 3rd Floor, Chung On Industrial Building, 28 Lee Chung Street, Chai Wan, Hong Kong.

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20-22 August 2015 • Singapore • Raffles City Convention Centre

The Synthesis of Evidence, Experience, and Choice in Women’s Health Call for Abstracts, Registration,and Programme atwww.sicog2015.com

JPOG NOV/DEC 2014iv


1 pOiNt

H O N G K O N G

Lisa Low, Illustrator

JPOG welcomes papers in the following categories:

Review ArticlesComprehensive reviews providing the latest clinical information on all aspects of the management of medical conditions affecting children and women.

Case StudiesInteresting cases seen in general practice and their management.

Pictorial MedicineVignettes of illustrated cases with clinical photographs.

For more information, please refer to the Instructions for Authors on our website www.jpog.com, or contact:

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The Cover:Common Symptoms and Signs During Pregnancy

© 2014 MIMS Pte Ltd

rEviEW articlEObstetrics

248

Common Symptoms and Signs During PregnancyDuring pregnancy, a woman may notice the development of a number of new symptoms. Many of these are widely accepted as a normal part of uncomplicated pregnancy but others may be of more concern.

Sheba Jarvis, Catherine Nelson-Piercy

255

In Practice (Answers)

continuing MEdical Education

257

Management of Venous Thromboembolism in PregnancyVenous thromboembolism (VTE) is a common cause of maternal mortality. Although, with the more frequent use of thromboprophylaxis, there appears to be a reduction in the incidence of VTE in Western countries this trend appears to be rising in several Asian countries. This article outlines the clinical presentation, risk factors and treatment of acute VTE.

Tam Wing Hung

257248


MIMSmobileapp206x276_0314.indd 1 3/10/14 2:23 PM

221JPOG NOV/DEC 2014JOURNAL WATCH peer reviewed

were excluded. The studies were inde-

pendently accessed for inclusion criteria

and bias, and the data were extracted

using a standardised form.

The reviewers did not find a clin-

ically meaningful difference in the risk

of a caesarean between early or late

initiation of epidural analgesia (risk

ratio [RR] = 1.02; 95% CI, 0.96-1.08).

Difference in risk of instrumental birth

in early or late initiation of epidural an-

algesia was also not found to be sig-

nificant (RR = 0.93;95% CI, 0.86-1.01).

Sng BL, Leong WL, Zeng Y, Siddiqui FJ, Assam PN, Lim Y, Chan ESY, Sia AT. Early versus late initiation of epidural an-algesia for labour. Cochrane Database of Systematic Reviews 2014, Issue 10 . Art. No.:CD007238. DOI: 10.1002/14651858.CD007238.pub2 .

Nicotine replacement therapy during pregnancy

lowers development impairment in infants

Women who use nicotine replacement

therapy for smoking cessation during

pregnancy are less likely to have infants

with developmental impairments 2 years

after delivery, say UK-based researchers.

Their study included 1,050 preg-

nant women aged 16–45 years who were

at 12–24 weeks’ gestation, had smoked

≥10 cigarettes/day before pregnancy,

and were smoking at least 5 cigarettes/

day at the time of the study. The women

were recruited from seven hospitals in

England between May 2007 and Febru-

ary 2010 and were followed up by ques-

tionnaire when their infants were 2 years

old. The women were randomizsed to

receive either nicotine replacement ther-

apy with 15 mg/16 hour patches (n=521)

or matching placebo (n=529) along with

behavioural smoking cessation support

for up to 8 weeks.

Questionnaire responses were

analyzed for 891 (88%) of the 1,010 sin-

gleton live births, and developmental

outcomes were documented for 888 of

these due to missing data (445 wom-

en in the nicotine replacement therapy

group and 443 placebo recipients). Of

the women who underwent nicotine

replacement therapy, 323 (73%) had

infants with no developmental impair-

ment compared with 290 (65%) placebo

recipients (odds ratio [OR]=1.40, 95%

CI, 1.05–1.86, p=0.023). Although nic-

otine replacement therapy did not have

any effect on prolonged abstinence

from smoking, a temporary doubling of

smoking cessation was observed dur-

ing pregnancy shortly after randomiza-

tion, and the researchers suggest that

this could explain their findings.

Cooper S et al. Effect of nicotine patches in pregnancy on infant and maternal outcomes at 2 years: follow-up from the randomised, double-blind, placebo-controlled SNAP trial. Lancet Respir Med 2014; http://dx.doi.org/10.1016/S2213-2600(14)70157-2.

O

Obstetrics

Early administration of epidural analgesia

during labour appears to be advantageous

There is some concern that spinal anaA

221JOURNAL WATCH peer reviewed

A Cochrane systematic review suggests

that early administration of epidural anal-

gesia during labour has similar effects to

late administration on all measured lev-

els of outcome.

Conducted by researchers in Singa-

pore, this review included 15,752 women

from nine randomized controlled trials.

Pregnant term women who requested

epidural in labour were included in this

study. Those in preterm labour, with mul-

tiple pregnancies or malposition of fetus,

JPOG_NovDec_2014_Final_Combine.indd 221 11/27/14 4:01 PM

222 JPOG NOV/DEC 2014 JOURNAL WATCH peer reviewed

Clomiphene + letrozole combination therapy effective in women with PCOS resistant

to each agent alone

Combination therapy with clomiphene

plus letrozole can induce ovulation

in women with polycystic ovary syn-

drome (PCOS) who are resistant to clo-

miphene and letrozole monotherapy,

say researchers from the United Arab

Emirates.

Their study included 100 women

who were diagnosed as infertile due to

PCOS. All had initially been placed on

clomiphene for six cycles followed by

letrozole for four cycles when this proved

ineffective. When the patients continued to

be resistant to therapy, they were subse-

quently prescribed a combination of letro-

zole 5 mg/night and clomiphene 100 mg/

day (to be taken after lunch) for 5 days.

In total, 257 cycles of combination thera-

py were completed, 213 (82.9%) of which

were successful in forming a dominant fol-

licle. The number of mature follicles was

2.3±1.1, and the mean endometrial thick-

ness in patients on the day of human cho-

rionic gonadotropin administration was

8.17±1.33 mm. A total of 42 pregnancies

occurred among the 100 patients: 14 dur-

ing the first therapy cycle, 15 during the

second, and 13 during the third.

The researchers conclude that in

PCOS patients who are resistant to clomi-

phene and letrozole monotherapy, com-

bination therapy should be trialled before

more aggressive treatments are initiated.

They also suggest that the combination

may be a suitable first-line therapy for in-

ducing ovulation in severe cases of PCOS.

Hajishafiha M et al. Combined letrozole and clomiphene versus letrozole and clomiphene alone in infertile patients with poly-cystic ovary syndrome. Drug Des Dev Ther 2014;81427-1431.

P

Paediatrics

Breakfast consumption ameliorates risk factors for type 2 diabetes in children

A cross-sectional study among pri-

mary school children in the UK has

shown that daily breakfast consump-

tion reduces levels of fasting insu-

lin, glycated haemoglobin (HbA1c),

glucose, and urate as well as insulin

resistance.

Associations between the frequency

and content of breakfast consumption

and risk factors for type 2 diabetes and

cardiovascular disease were investigated

in 4,116 UK primary school children aged

9–10 years. Data was collected on break-

fast frequency, body composition, blood

lipids, insulin, glucose, and HbA1c levels.

In addition, a subgroup of 2,004 children

completed a 24 hour dietary recall.

Among the 4,116 children studied,

3,056 (74%) ate breakfast daily, 450

(11%) ate breakfast on most days, 372

(9%) on some days, and 238 (6%) did

not usually eat breakfast. Children who

did not usually eat breakfast had high-

er levels of fasting insulin (26.4% differ-

ence, 95% CI 16.6–37%), HbA1c (1.2%

difference, 95% CI 0.4–2%), glucose (1%

difference, 95% CI 0–2%), and urate (6%

difference, 95% CI 3–10%) as well as

greater insulin resistance (26.7% differ-

ence, 95% CI 17–37.2%) compared with

those who reported having breakfast

daily. Moreover, these differences were

not affected to any great degree by ad-

justments for adiposity, socioeconomic

status, and level of physical activity. In-

sulin resistance was also lower among

children who ate a high fibre cereal

breakfast compared to other types of

breakfast.

Donin AS. Regular breakfast consumption and type 2 diabetes risk markers in 9- to 10-year-old children in the Child Heart and Health Study in England (CHASE): a cross-sectional analysis. PLoS Med 2014;11(9):e1001703.

Nutrient intake among Chinese infants generally

adequate, but some at risk of imbalanced vitamin A

and zinc intake

The growth and development of infants

is most adversely affected by poor nutri-


223JPOG NOV/DEC 2014JOURNAL WATCH peer reviewed

tional intake between the ages of 0 and 5

months, and so a recent study evaluated

the effects of different feeding approach-

es on nutritional status among this age

group in China.

The mother infant nutrition and

growth (MING) study was designed to

describe the current nutritional status

of pregnant women, lactating mothers,

infants, and toddlers. Data on 622 in-

fants aged 0–2 months (225 fed a mix of

breast milk and complementary foods,

144 fed complementary foods alone,

and 253 exclusively breastfed) and 456

infants aged 3–5 months (145 fed a mix

of foods, 126 fed, complementary foods

alone and 185 exclusively breastfed) are

reported here. All were obtained using

24 hour dietary recall in subjects recruit-

ed from eight urban cities in China be-

tween October 2011 and January 2012.

Among infants aged 0–2 months

who received a mixture of breast milk

and complementary foods, approximate-

ly 38.2% received excessive vitamin A

and 15.6% exceeded the tolerable upper

intake levels of zinc. Conversely, approx-

imately 20% of infants who received only

complementary food had inadequate

levels of vitamin A and 12.5% had inade-

quate levels of zinc. Yet levels of both vi-

tamin A and zinc exceeded the tolerable

upper intake level in half of the remaining

infants. Similar findings were observed

among infants aged 3–5 months. Com-

pared to exclusively breastfed infants,

infants fed a mixture of breast milk and

complementary foods or the latter alone

had a higher prevalence of disease and

lower Z scores for length-for-age, weight-

for-age, and weight-for-length.

Ma D et al. Nutritional status of breast-fed and non-exclusively breast-fed infants from birth to age 5 months in 8 Chinese cit-ies. Asia Pac J Clin Nutr 2014;23(2):282-292.

Rice and rice products poor choices for introducing infants

to solid foods, despite their popularity in Asia Pacific

Introducing infants to solid foods can be

difficult as both the timing of the intro-

duction and the nutritional quality of the

solid food items introduced have a sig-

nificant impact on infant growth and de-

velopment. A recent review of common

practices in nine countries in Asia Pacific

region has highlighted how some choic-

es, such as rice and rice products, are

nutritionally poor. The study also noted

that in some countries infants are com-

monly introduced to solid foods earlier

than recommended by the World Health

Organization (WHO).

The review analysed respons-

es from nine studies conducted in five

countries in Asia Pacific: Australia, Viet-

nam, China, the Maldives, and Japan.

The same questionnaire was adminis-

tered to all participants and included

questions on demographics and infant

feeding practices.

The duration of exclusive breast-

feeding was less than the optimal 6

months recommended by the WHO in

all studies. The mean age of solid food

introduction ranged from 3.8 months

in Hangzhou, China, to 5.6 months

in Japan and the Maldives. The most

common food items chosen for the first

solid feed were rice or rice products,

except in the Maldives, where a tradi-

tional food containing wheat flour and

fish was used, and among Chinese

migrants in Australia, who used egg

yolk. The researchers comment that

unless fortified, rice and rice products

have insufficient micronutrients and

they are lower in energy density than

recommended for infants older than 6

months. They suggest that further ed-

ucation on breastfeeding and healthy

food choices is required.

Inoue M and Binns CW. Introducing solid foods to infants in the Asia Pacific region. Nutrients 2014;6:276-288.

Juvenile idiopathic arthritis associated with pain hypersensitivity even

in the absence of active disease

Children with juvenile idiopathic arthri-

tis (JIA) show increased sensitivity to

painful mechanical and thermal stimuli

even in the absence of disease activity

markers.


224 JPOG NOV/DEC 2014 JOURNAL WATCH peer reviewed

In a study performed between

November 2012 and September 2013,

researchers characterized pain sen-

sitivity in 60 children aged 7–17 years

with active JIA by comparing quantita-

tive sensory test responses to painful

mechanical and thermal stimuli at an

infected inflamed joint with responses

from children in clinical remission. In

addition, generalized hypersensitivity

was determined by comparing quan-

titative sensory test responses at the

thenar eminence between children with

JIA and healthy controls in Germany

(n=151) and the US (n=92). Question-

naires were also administered to assess

pain intensity and frequency, functional

disability, anxiety, pain catastrophiza-

tion, and fatigue.

224 JOURNAL WATCH peer reviewed

values to calculate a vaginal health index

before and after the study intervention. In

addition, symptoms of atrophy and men-

opause were evaluated at each study

visit and by daily log books. Circulating

lipids, liver enzymes, and C-reactive pro-

tein levels were also monitored.

Significantly better rates of improve-

ment in the integrity of the vaginal epithe-

lium were noted among women who re-

ceived the sea buckthorn oil supplement

compared to the placebo when both

compliant and noncompliant participants

were included in the analysis (odds ratio

[OR]=3.1, 95% CI 1.11–8.95); a ben-

eficial trend was observed when only

compliant participants were evaluated

(OR=2.9, 95% CI 0.99–8.35).

Larmo PS et al. Effects of sea buckthorn oil intake on vagi-nal atrophy in postmenopausal women: A randomized, dou-ble-blind, placebo-controlled study. Maturitas 2014; http://dx.doi.org/10.1016/j.maturitas.2014.07.010

Children with active and inactive JIA

had similar sensory detection and pain

thresholds and reported low pain scores

and minimal functional disability. Howev-

er, compared with healthy children, those

with JIA had generalized hypersensitivity

at the thenar eminence for pressure, light

touch, cold, and heat pain.

Cornelissen L et al. Pain hypersensitivity in juvenile idiopathic arthritis: a quantitative sensory testing study. Pediatr Rheuma-tol 2014;12:39.

G

Gynaecology

Sea buckthorn oil beneficial for treating vaginal atrophy in postmenopausal women

Menopause may lead to thinning and

drying of the vaginal mucosa (vaginal at-

rophy), and the condition is often treated

with oestrogen therapy. However, oes-

trogen is not appropriate for all women

and sea buckthorn oil appears to be a

viable alternative, say Finland-based re-

searchers.

They investigated the effects of oral

sea buckthorn oil supplementation on

vaginal atrophy among 98 postmeno-

pausal women aged 55–75 years who

were experiencing moderate or severe

symptoms of vaginal dryness, itching or

burning. The randomized, double-blind

study was conducted at a private clinic

in Finland from October 2012 to March

2013, and the women completed 3

months of treatment with 3 g/day oral sea

buckthorn oil (n=57) or placebo (n=59).

Vaginal health was assessed by a gynae-

cologist using vaginal pH and moisture


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225JPOG NOV/DEC 2014PAEDIATRICS peer reviewed

Burns are common injuries in the paediatric population and comprise a signifi-

cant epidemiological problem worldwide. This article describes the most com-

mon patterns of burn injuries encountered in clinical practice as well as the basic

principles of burn wound pathophysiology. Key aspects of clinical management

including assessment of burn depth and total burn surface area are described

and issues pertinent to paediatric fluid resuscitation are discussed. Particular ref-

erence is made to the provision of optimal pre-hospital first aid and the principles

of specialist management according to UK national guidelines.

Early Management of Paediatric Burn InjuriesIoannis Goutos, BSc (Hons) MBBS (Hons) MRCS; Michael Tyler, FRCS (Plast)

EPIDEMIOLOGY AND PATTERNS OF BURN INJURYBurn injuries represent a significant and

potentially preventable epidemiological

problem accounting for 3.9 deaths per

100,000 children worldwide. The major-

ity of paediatric burn injuries affect chil-

dren under the age of 5 years and the


226 JPOG NOV/DEC 2014 PAEDIATRICS peer reviewed

incidence as well as the burns related morbidity

and mortality are considerably higher in less de-

veloped parts of the globe including Africa and

Asia. The mechanisms responsible for paediat-

ric burns vary considerably in different countries

and relate strongly to wealth and socioeconomic

status. In developed countries, the most com-

mon mechanisms of paediatric thermal injury in

descending incidence order include: scalds, con-

tact burns, flame followed by electrical burns and

non-accidental injuries.

• Scalds most commonly affect toddlers and

occur in the household setting by spilling a

container of hot liquid from a height.

• Contact burns result from direct contact

with hot items left unsupervised and most

frequently involve the palmar surface of the

hand. Young children especially toddlers

are prone to these injuries given that the

withdrawal reflex is poorly developed and

subsequent ‘freezing’ of the involved limb is

observed.

• Flame injuries tend to affect older children

and occur either as a result of house fires or

ignition of clothing from heating sources.

• Electrical injuries result from placing objects

into an electricity outlet. A small proportion

of these injuries involve the oral commissure

and occur as a result of children chewing an

electrical cord.

• Non-accidental injuries (NAI) comprise the

minority of injuries; nevertheless it is impor-

tant for clinicians involved in paediatric care

to identify indicators of such injuries and in-

itiate multidisciplinary liaison incorporating

social services.

Pointers in the history of a non-accidental

burn include delayed presentation to healthcare

facilities, inconsistent history, unusual pattern of

injury/not appropriate for the developmental age

of the child, reported lack of witnesses, and previ-

ous involvement of the family with social services.

In terms of clinical signs indicating possible

NAI these include symmetrical/crisp margins of

the burn, circumferential nature injuries to lower

limbs and uniform depth (indicating forced sub-

mersion) as well as the presence of other injuries

(bruising, fractures).

PATHOPHYSIOLOGY OF BURN INJURIESCutaneous ChangesThe burned skin exhibits three distinct zones of

circulatory and histological changes as described

by Jackson in 1955.

• Zone of coagulation. This represents the area

of skin subject to immediate contact with the

burning source exhibiting irreversible tissue

necrosis.

• Zone of stasis. The immediately surrounding

area to the zone of coagulation consists of in-

jured but viable cells as a result of suboptimal

perfusion due to oedema and microvascular

damage.

• Zone of hyperaemia. The most outer zone

of the injured skin area shows vasodilata-

tion, capillary leakage and resulting oedema

reaching a zenith at 48 hours post burn; tis-

sues usually recover within 7-10 days post

injury.

The Jackson’s pathophysiology model un-

derlines the dynamic nature of histological and

microcirculatory tissue changes in burns. It is fre-

quently seen in clinical practice that areas initially

believed to be superficial in depth declare them-

selves as deeper areas on repeat assessment.

Optimal management including appropriate first

aid, resuscitation and dressings/prevention of in-

fection are believed to encourage tissues in the

zone of stasis to recover as opposed to convert

into the zone of coagulative necrosis.

Systemic Effects of Burn Injuries Large burn injuries are associated with a marked

systemic inflammatory response. This is similar

to the ‘stress response’ seen in critical illness but

is characterized by increased severity and dura-

tion. The neuro-hormonal response to the initial

burn injury relies on the release of a variety of

vasoactive and inflammatory mediators including



tumour necrosis factor and interleukins 6, 8.

These contribute to increased local and systemic

vascular permeability; the augmented secretion

of catabolic hormones (cortisol and catecho-

lamines) as well as the suppression of endog-

enous activity of anabolic agents (growth hor-

mone and testosterone) contribute to a marked

increase in metabolic rate, loss of muscle protein

and bone mineral density. Interventions that have

been shown to ameliorate the hypermetabolic

response to large burn injuries include early

excision of the burned tissue, nutritional support

as well as pharmacological adjuncts including

human growth hormone, beta-blockers, and

oxandrolone.

CLINICAL ASSESSMENTEvery burn injury needs to be initially assessed

according to the advanced trauma life support

(ATLS) principles with attention to maintaining

an adequate airway, breathing and circulation.

Once immediately life-threatening problems

have been identified and actioned upon, an

assessment of the total burned surface area

(TBSA) and depth of injury needs to be under-

taken to allow planning of definitive burn wound

management.

Airway The presence of possible airway injury in a ther-

mally injured child needs to be ruled out as a mat-

ter of priority. Swelling of the upper-aero digestive

track can occlude the airway within hours of inju-

ry. Deep burns to the mouth and nose together

with deep burns to the neck will cause such swell-

ing and therefore must be treated prophylactical-

ly with intubation. Late signs of hoarseness and

stridor require prompt action before endotracheal

intubation becomes impossible and emergency

tracheostomy the final resort.

Breathing Exchange of gases within the lung can be disrupted

in burn injury in four ways, the first and most com-

mon two, can be described as inhalational injuries:

• Inhaling fine carbonaceous material inhaled

into the lungs causing swelling and cellular

damage. As the chemical pneumonitis pro-

gresses gaseous exchange worsens and

thus respiratory distress increases over time

and secondary pneumonia and respiratory

distress syndrome can follow. Management

is with humidified oxygen, nebulizers and

physiotherapy, with the respiratory distress

managed sequentially often including intuba-

tion in significant cases.

• Inhaling metabolic poisons being inhaled

such as carbon monoxide interrupt cellular

respiration, leading to headache, confusion

and loss of consciousness. Carboxyhaemo-

globin measurement is vital in suspected

cases and it is managed by maximizing the

partial pressure of inspired oxygen. Hydro-

gen cyanide is another metabolic poison

found in smoke and can cause mitochondrial

paralysis leading to profound acidosis. Man-

agement is supportive.

• Very rarely enough thermal energy is car-

ried to below the vocal cords causing ther-

mal damage. In reality the heat exchange

mechanisms above the larynx are so efficient

that only steam caries enough latent heat (of

evaporation) to cause this injury. These cas-

es need ventilator support in line with their

respiratory distress.

• Circumferential burns to the torso have the

potential to compromise chest expansion

and prompt incision through the constricting

burn eschar (escharotomy) is indicated to

relieve the limitation on the biomechanics of

breathing.

Mechanisms raising suspicions of airway

or breathing problems include thermal injuries

sustained in an enclosed space and decreased

levels of consciousness at the scene of the inci-

dent. Pertinent physical findings include burns

above the level of the clavicle, singed facial

hair, soot around the mouth and nostrils, car-

bonaceous sputum, stridor/wheezing as well as

hoarseness.



CirculationCircumferential deep burns to the limbs can re-

sult in ischaemia and irreversible long-term neu-

rological damage and muscle necrosis. Regular

monitoring of the neurovascular status of involved

limbs needs to be initiated and a low threshold

for escharotomies/ fasciotomies is mandatory to

avoid catastrophic long-term sequelae.

Paediatric patients with TBSA of more than

10% should be resuscitated with intravenous flu-

ids. The aim of fluid resuscitation is restoration

of the circulating volume and electrolyte correc-

tion avoiding either renal failure and pulmonary

oedema from under and over resuscitation. The

most common resuscitation formula used in the

UK is the Parkland formula according to which 4

mL Hartman’s solution is given per % TBSA burn

for every kg of weight over the first 24 hours post

burn. The total volume is divided into two aliquots;

the first is given over the first 8 hours and the next

over the following 16 hours.

Maintenance fluid is also required on top of

the resuscitation fluid regimen especially in infants

less than 3 months old with large (more than 20%

TBSA) injuries. The most commonly used formula

for calculation of maintenance fluids recommends

100 mL/kg for the first 10 kg of body weight plus

50 mL/kg for the next 10 kg body weight plus 20

mL/kg for each extra kg. Most UK burn units use

Hartman’s solution for resuscitation and 0.45%

saline and 5% dextrose solution for maintenance

fluids. Normal saline (0.9%) should be avoided

in paediatric resuscitation since there is a risk of

hyperchloraemic acidosis and hypokalaemia and

the inclusion of dextrose containing solutions is

indicated especially in children weighing less

than 20 kg to avoid the development of hypogly-

cemia due to the limited glycogen stores in this

peadiatric patient subgroup. There is controversy

regarding the value of colloid use in burns resus-

citation and currently this should only be com-

menced in specialist units with the appropriate

expertise. A variety of invasive and non-invasive

techniques have been described in the literature

to allow accurate monitoring of the adequacy of

resuscitation; in clinical practice urine output of

at least 1 ml/kg/hour is the most widely used ad-

junct coupled with repeat clinical and biochemical

evaluations.

Calculation of TBSAThere is a variety of ways to allow calculation of

the total burnt surface area (TBSA). Accurate esti-

mation of the extent of burns is of paramount im-

portance to allow optimal fluid resuscitation and

nutritional support.

In the pre-hospital setting the Paediatric

modification of Wallace’s rule of nine’s is fre-

quently used. Wallace divided the body into mul-

tiple of nine’s to represent the total body surface

area in adults (anterior, posterior trunk and each

lower limb each corresponding to 18%, each up-

per limb and head and neck area 9% and the gen-

itals representing 1%). The head and neck area in

an infant less than 12 months old is equivalent to

18% compared to 9% in the adult, while the lower

limbs represent 13.5% as opposed to 18% each.

With each increased year of life, 1% is taken from

the head and neck area and 0.5% added to each

lower limb until adult proportions are reached at

the age of 10 years. The modified rule of nines is

not very accurate in children and should be used

to double check the accuracy of TBSA estimation

using other means (e.g. the upper limb cannot

represent more than 9% TBSA).

In the hospital setting calculation is made us-

ing a Lund and Browder chart (http://www.cks.

nhs.uk). This is by far the most accurate method

of calculating the extent of the body surface area

involved in burn injuries. The chart represents a

normogram, which assigns certain surface area

values to individual bodily regions; it takes into ac-

count changes in the relative proportions of body

surface area with age and growth. The normo-

gram assumes adult values for TBSA at around

the age of 15. The clinician calculates the TBSA

by shading the involved regions on the chart and

adding the corresponding body surface areas as

indicated by the chart for different age groups to

reach the final TBSA value.



For small (less than 15%) or large (more

than 85%) burn injuries and to help fill in the Lund

and Browder chart clinicians can use the fact that

patient’s hand (palm and fingers) represents

roughly 1% of the total body surface area. A

considerably extensive burn can be calculated

by estimating the area of uninjured skin and

subtracting from 100.

Estimation of DepthBurn injuries are further categorized according to

their depth. Older numerical degree categories

(first to fourth degrees) have been superceded in

most European countries by descriptive catego-

ries as described below:

Superficial (1st degree) burns represent injuries

identical to sunburn without blistering; they are

characterized by erythematous painful skin that

heals without scarring with analgesia and mois-

turization.

Superficial partial thickness (2nd degree) burns

are characterized by the presence of blistering

due to the disruption of the dermoepidermal

junction. They are typically painful, erythematous

areas of damaged skin with demonstrable capil-

lary refill on contact and have a ‘wet’ appearance

due to the presence of intact sweat glands. They

normally heal within 2-3 weeks without significant

scarring; changes in pigmentation (hypo-hyper-

pigmentation) can be seen as a late complication

from these injuries. They are mostly treated with

regular dressings and analgesia.

Deep partial thickness (3rd degree) injuries are

recognized on the basis of lack of capillary refill,

the presence of fixed dermal staining, decreased

sensation and dry appearance (due to damage

of microcirculation, nerves and sweat glands).

Healing typically occurs in weeks to months with

dressings hence they are frequently treated with

excision and split skin grafting. A significant risk

of hypertrophic scarring accompanies these in-

juries, with burns taking over 30 days to heal as-

sociated with 92% risk of hypertrophic scarring.

(Figure 1 shows a typical appearance of a chest

scald with an outer erythematous area of super-

ficial partial thickness and an inner area of deep

dermal injury).

Full thickness (4th degree) burns exhibit a ‘leath-

ery’ dry and anaesthetic appearance and are as-

sociated with poor functional and aesthetic out-

comes if not treated with surgical intervention.

A very common mistake in the calculation of

TBSA is the inclusion of simple erythema (denot-

ing a superficial burn) in calculations by inexpe-

rienced clinicians; only areas corresponding to

superficial partial thickness, deep dermal and full

thickness burns should be accounted for in TBSA

calculations.

Clinical assessment of the burn depth is

challenging with studies reporting accuracy rates

between 50 to 65% and concurrence rates of

only 60 to 80% between experienced surgeons.

An additional caveat of clinical examination is

that burns tend to follow a dynamic course and

can convert to deeper depths in the first 72 hours

or later based on the Jackson’s model of burn

wound pathophysiology.

Figure 1. picture of a chest scald demonstrating an erythematous outer zone of superficial partial thickness depth and an inner zone of deep dermal depth with small patches of dermal staining. (please note the deroofed blisters at the periphery of the injured area; picture taken before wound debridement).



A relatively recent adjunct in assessing burn

depth is laser doppler imaging (LDI). This modal-

ity relies on indirectly measuring skin blood flow

based on the measured frequency shift that hap-

pens when moving erythrocytes reflect a near in-

frared laser beam emitted from the laser source.

LDI has a sensitivity of 90% and specificity of 96%

in the assessment of paediatric burns when per-

formed within 36 and 72 hours from the burn inju-

ry. It has additionally been shown to decrease the

time to grafting decision as well as decrease over-

all hospital stays by allowing clinicians to make an

early informed management plan.

Histology of burned tissue is the gold stand-

ard for depth estimation but can only be used

retrospectively when tissue is sampled for other

indications e.g. microbiology cultures as well as

in experimental studies. Its clinical application

is therefore extremely limited in burn depth eval-

uation.

PRE-HOSPITAL FIRST AIDThe pre-hospital management of every burn in-

jury carries a significant bearing on long-term

outcomes. The recommended first aid steps in-

clude approaching the victim with care, stopping

the burning process (drop and roll if clothing is

alight/turn the electricity power off) and provide

basic life support. Cooling of the burn wound for

20 minutes with running water is the ‘gold stand-

ard’ of first aid; durations of cooling longer than

30 minutes have not been found to add any ad-

ditional benefit in terms of reducing burn depth.

In paediatric burns affecting a large proportion

of the total body surface area, immediate transfer

to a medical facility should take priority following

wound coverage with a wet cloth; immersion of a

child in cold water to avert wound depth progres-

sion carries an unacceptable risk of hypothermia.

In terms of the time lag between the burn

and administration of cooling, it appears that it is

beneficial even if it is delayed by 1 hour and may

be of benefit up to 3 hours post injury.

Temporary dressings before transfer to a

medical facility can include a polyethylene sheet

(clingfilm) or a clean cloth; these serve to reduce

the risk of bacterial colonization, evaporative

fluid and heat loss and improve patient comfort

by eliminating convective currents across the

wound surface.

HOSPITAL MANAGEMENTThe majority of paediatric burn injuries present

initially to medical facilities without plastic sur-

gery services. The first in- hospital assessment

is frequently carried out by emergency or paedi-

atric physicians. Important steps in accurate as-

sessment and management of the burned child

include:

• Approach the paediatric burn victim and

accompanying guardian in a calm and reas-

suring manner.

• Obtain an accurate body weight.

• Ensure that the ambient room and the

child are kept warm. In large injuries ne-

cessitating resuscitation, a radiant heater

should be positioned over the victim to

minimize heat loss and the risk of hypo-

thermia.

• Opioid-based analgesia (oral or intranasal

preparations) are indicated in all but the very

small injuries to provide comfort during as-

sessment and wound cleaning.

• Ensure the patient is up to date with tetanus

prophylaxis.

• Clean the burn with soap and water to re-

move loose blisters. This step in initial man-

agement has multiple functions including the

removal of devitalized tissue, prevention of

Cooling of the burn wound for 20 minutes withrunning water is the ‘gold standard’ of first aid



burn depth progression (by virtue of elim-

inating pro-inflammatory cytokines in blis-

ters) and permission of accurate estimation

of depth and TBSA. If the blisters are small

(less than 1 cm2) or appear to be adherent to

the underlying dermis, they can be left undis-

turbed.

• Assess the severity of the injury by calculat-

ing the TBSA and depth of the burn.

• Liaise with a burns unit/centre regarding fur-

ther management/transfer and discuss the

need for intravenous access and bladder

catheterization.

• Cover the wound with a non-adherent pri-

mary dressing e.g. silicone-based product

along with an absorbent secondary dress-

ing e.g. gauze to minimize heat loss, pro-

tect from infection and manage burn wound

exudate.

The range of dressings for burn wound man-

agement is vast; the extent (TBSA), depth of burn

and physician preferences being key determi-

nants for dressing choice. Superficial partial thick-

ness injuries are commonly treated with silicone-

or hydrocolloid-based products if not extensive.

When the TBSA exceeds 4%, the use of biological

dressings like Biobrane should be considered.

Biobrane is a nylon/silicone-based dressing with

impregnated porcine collagen. It is a frequently

used biological product in superficial partial thick-

ness injuries and applied under a general anaes-

thetic following meticulous debridement of blis-

ters. It has been shown to reduce discomfort and

hospital visits associated with dressing changes

using other products including silver sulphadi-

azine (flamazine) creams.

Flamazine still has an important role in man-

aging infected burn wounds and areas of the

body difficult to dress including the perineum as

well as hands and feet.

Deep dermal and full thickness injuries are

frequently treated with tangential excision (surgi-

cal removal of non-viable tissue to healthy dermis/

fat) and application of a split skin graft (harvesting

of epidermis and upper dermis from non-burned

areas commonly the thigh/buttock). There is no

role for the prophylactic administration of antibiot-

ics in burn injuries.

OUTPATIENT MANAGEMENTThe majority of small burn injuries can be man-

aged on an outpatient basis apart from large

and deep injuries needing resuscitation, mon-

itoring and early surgery. A number of injury

and patient-related factors should prompt re-

ferral to specialist burns facilities according to

the UK national network for burn care (NNBC)

(Table 1).

Once burns are healed, it is vital that appro-

priate aftercare is adhered to; this includes mas-

saging and moisturization of the healed wounds/

scars, management of sensory symptoms includ-

ing pruritus and psychosocial support to help ad-

justment and reintegration of victims and families

into society. Follow up in plastic surgery clinics

allows the evaluation of burn sequelae including

hypertrophic scarring and the development of

contractures.

Table 1. National Network for Burn Care (NNBC) Thresholds for Referral Paediatric Burn Services

Age: all neonatal burnsTBSA ≥2% depth: deep dermal and full thickness injuriesSite: any significant burn to special areas i.e. hands, feet, face, perineum/genitalia (significant can mean injuries, which the referral source feels necessitates greater multidisciplinary team expertise)Mechanism: any chemical, electrical, friction, cold injuryOther factors:

• any burn not healed in 2 weeks

• predicted or actual need for high dependency/intensive treatment unit e.g. inhalation injury cases

• any significant deterioration in patient’s physiology (suggested parameters include: requirement for inotropic, renal, respiratory support, base deficit >5 and deteriorating)

• unwell febrile child with a burn

• burn in association with major trauma

• any concern regarding burns in patients with comorbidities which may affect burn healing

• suspicion of NAi



Practice Points

• Burns injuries are common in the paediatric population and represent a significant epidemiological problem worldwide.

• in developed countries, the most common mechanisms of paediatric thermal injury include in descending incidence order: scalds, contact burns, flame followed by electrical burns and non-accidental injuries.

• Cooling of the burn wound for 20 minutes with running water is the ‘gold standard’ of first aid, shown to prevent progression of burn depth.

• initial assessment of burn injuries should focus on the recognition of potentially life threatening problems including airway obstruction and circulatory shock.

• estimation of the total burn surface area in the hospital setting is reliably undertaken using a Lund Browder chart or by the ‘hand rule’ (with the patient’s palm and fingers representing 1% of the total body surface area).

• Clinical evaluation of burn depth relies on descriptive terms according to the proportion of dermis affected by the injury (superficial partial thickness, deep dermal, full thickness).

• A number of injury and patient-related factors dictate referral to specialist burns facilities according to the UK national network for burn care (NNBC).

• Non-accidental injury patterns need to be recognized by all clinicians involved in the assessment and management of burn injuries and should initiate multidisciplinary liaison involving social services input.

PREVENTIONThe vast majority of burn injuries in children oc-

cur in the domestic environment and hence are

potentially preventable. Strategies targeting the

global reduction of burn injury incidence need

to address a large number of interrelated fac-

tors. The Haddon matrix considers epidemio-

logical components (agent-host-environment

interactions) alongside temporal components

(pre-event, event and post event) to address the

large number of factors contributing to injury and

poor outcomes; this model has been employed to

help devise general interventions to prevent acci-

dental burns from all sources across the devel-

oping world. Two of the key components of pre-

ventative interventions include state legislation as

well as education.

A number of developing countries have initi-

ated national programs for the prevention of burn

injuries focussing on preventative, curative and re-

habilitative aspects of burns injuries at local, district

and tertiary levels. Education can only be effective

if it is culturally appropriate and widely accessible

to the public. In developing countries, train the

trainer models rely on dissemination of information

from experts to groups of paraprofessionals ena-

bling wider dissemination to local communities.

CONCLUSIONBurn injuries represent a significant and potential-

ly preventable source of morbidity and mortality

worldwide. Optimal management of these injuries

rests on appropriate first aid at the scene of the in-

jury, meticulous assessment at the first receiving

medical facility and referral to specialist burn ser-

vices according to well-defined national criteria.

In cases of non-accidental injury, multidisciplinary

liaison between the medical team and psychoso-

cial services is of vital importance to safeguard

the welfare of affected children.

Further Reading1. Barret JP, Dziewulski P, Ramzy PI, Wolf SE, Desai MH, Herndon DN.

Biobran versus 1% silver sulfadiazine in second-degree pediatric burns. Plast Reconstr Surg 2000;105:62–65.

2. British Burn Association. Emergency management of severe burns course manual, UK version. Manchester: Wythenshaw Hospital, 2008.

3. Cubison TC, Pape SA, Parkhouse N. Evidence for the link between healing time and the development of hypertrophic scars (HTS) in pae-diatric burns due to scald injury. Burns 2006;32:992–999.

4. Greenbaum AR, Donne J, Wilson D, Dunn KW. Intentional burn injury: an evidence-based, clinical and forensic review. Burns 2004;30:628–642.

5. http://www.specialisedservices.nhs.uk/library/35/National_Burn_Care_Referral_Guidance.pdf.

6. Hudspith J, Rayatt S. First aid and treatment of minor burns. BMJ 2004;328:1487–1489.

7. Kim LH, Ward D, Lam L, Holland AJ. The impact of laser Doppler im-aging on time to grafting decisions in pediatric burns. J Burn Care Res 2010;31:328–332.

8. National Burn Care Review. National burn injury referral guidelines, Standards and strategy for burn care. London: NBCR, 2001:68–69.

9. Peck MD, Kruger GE, van der Merwe AE, et al. Burns and fires from nonelectric domestic appliances in low- and middle-income countries Part II. A strategy for intervention using the Haddon matrix. Burns 2008;34:312–319.

10. WHO. Facts about injuries: burns. www.who.int/violence_injury) pre-vention/publications/other_injury/en/burns_factsheet.pdf.

© 2013 Elsevier Ltd. Initially published in Paediatrics and Child Health 2013;23(9):391–396.

About the AuthorsIoannis Goutos is Specialist Registrar in Plastic & Reconstructive Surgery at Stoke Mandeville Hospital, Buckinghamshire, UK. Conflict of interest: none declared. Michael Tyler is Consultant Plastic & Reconstructive Surgeon at Stoke Mandeville Hospital, Buckinghamshire, UK. Conflict of interest: none declared.


233JPOG NOV/DEC 2014OBSTETRICS peer reviewed

A Practical Guide to Contraception. Part 3:Traditional Methods, Sterilisation and Emergency Contraception Mary Stewart MB BS, DFFP, MPH(HEALTH PROMOTION); Kathleen McNamee MB BS, FRACGP, DIPVEN, GRADDIPEPIBIO, MEPI;

Caroline Harvey MB BS(HONS), FRACGP, DRANZOG, MPM, MPH

Traditional methods of contraception have lower efficacies in typical use than

modern methods but are valued contraceptive options. Sterilisation has high ef-

ficacy rates but is being used less as long-acting reversible contraceptives be-

come more widely available and accepted. Emergency contraception has a vital

role in reducing the number of unintended pregnancies.


234 JPOG NOV/DEC 2014 OBSTETRICS peer reviewed

Practical information about the barrier methods,

the fertility awareness-based methods (FABMs)

and the withdrawal and lactational amenorrhoea

methods of contraception as well as permanent

methods of fertility control are discussed in this

third and final article in a series on contraception.

Apart from sterilisation, each of these methods

has a relatively low typical-use efficacy compared

with modern methods, in particular the long-act-

ing reversible contraceptives (LARCs).1 However,

it is important to acknowledge their role within the

range of contraceptive options available to wom-

en and their partners. Women may value the non-

hormonal nature of these methods but should be

aware of the more effective nonhormonal copper

IUD as a highly effective, reversible alternative.

Emergency contraception is also discussed

in this article. It plays a vital backup role in the

case of unprotected intercourse as well as contra-

ceptive failure. Informing women about the availa-

bility of emergency contraception is an important

part of all contraceptive consultations.

The first article in this series covered the

short-acting hormonal contraceptives (the com-

bined hormonal methods and the progesto-

gen-only pill) and the second article discussed the

LARCs. These articles were published in the July/

August 2014 and the September/October 2014

issue of the Journal of Paediatrics, Obstetrics &

Gynaecology, respectively. The series is based

on the publication Contraception: an Australian

Clinical Practice Handbook. 3rd ed., published by

the Family Planning Organisations of New South

Wales, Queensland and Victoria.2

BARRIER METHODS: MALE AND FEMALE CONDOMS, DIAPHRAGMSThe Male CondomThe male condom is a single-use sheath that is

rolled on to the erect penis before intercourse and

collects ejaculate and pre-ejaculate secretions in

the space at its tip. It has the advantage of being

readily available and relatively inexpensive.

Male condoms are available in different siz-

es, colours and flavours, and most are made of

thin latex rubber. Nonlatex condoms are available

in Australia and are an acceptable alternative for

people with a latex allergy or an aversion or reluc-

tance to use latex condoms. These polyurethane

condoms are more expensive and may be more

susceptible to breakage than latex types. Polyiso-

prene condoms are another alternative but are

generally only available over the internet. Polyiso-

prene is a synthetic version of latex and condoms

made of this material may be suitable for people

with a latex allergy.

Although the male condom is self-lubricated,

additional water-based lubricant may be applied

to the outside. Oil-based lubricants such as vase-

line should be avoided with latex products be-

cause they increase breakage.

Importantly, the male condom is also effec-

tive at reducing the risk of sexually transmissible

infections (STIs) and can be ‘doubled up’ with

another method of contraception to provide dual

protection against STIs and unintended pregnan-

cy. It can be used at the same time as all other

contraceptive methods except for the female con-

dom (there is an increased chance of breakage

and slippage if the two condom types are used

together). It can also be used to back up other

methods where potential for reduced effective-

ness exists, such as when contraceptive pills

have been missed or a liver enzyme-inducing

drug is being used concurrently.

Male condoms can be an effective contra-

ceptive method when used correctly and con-

sistently. Effectiveness, with reduced breakage

and slippage, increases with user familiarity and

experience.3 Correct use, including removal

and disposal, should be demonstrated explic-

itly, preferably with a penis model. Improving

condom negotiation skills and self-efficacy is an

important strategy to increase effective condom

use.

Emergency contraception can be advised if

there is condom breakage or slippage. Figures

for the percentage of pregnancies occurring in

the first year of use of male condoms are 2% in

perfect use and 18% in typical use.



Figure 1. The Female Condom.

The Female CondomThe female condom is a loose-fitting lubricated

polyurethane sheath with a flexible ring at each

end, and collects ejaculate and pre-ejaculate se-

cretions (Figure 1). It is available in a single size

and recommended for single use only. It is insert-

ed into the vagina prior to intercourse, and the

penis is guided into the sheath. The inner ring at

the closed end of the sheath is firm and slides into

the vagina to act as an anchor; the outer ring at

the open end spreads over the vulva. Allergy and

irritation are very rare, and additional water- or oil-

based lubricant can be used if required. The con-

doms are quite slippery so practice before inter-

course may be useful. Also, couples may need to

get used to their slight rustling noise during use.

The female condom, like the male condom,

protects against STIs. It can be used at the same

time as other contraceptive methods (except for

the male condom) to provide dual protection

against STIs and unintended pregnancy.

Emergency contraception is advised if the

condom is displaced or torn during intercourse.

Figures for the percentage of pregnancies oc-

curring in the first year of use of female con-

doms are 5% in perfect use and 21% in typical

use.1

As with the male condom, using the female

condom requires negotiation and, to be effective,

requires consistent and correct use. Features that

can make the female condom an attractive option

for some couples include:

• enhanced transmission of body heat by use

of polyurethane rather than latex may im-

prove sensitivity

• use does not rely on a male erection so may

be useful with erectile dysfunction

• it can be inserted many hours before sex.

Features that may limit the use of the female

condom include:

• more expensive than male condoms (ap-

proximately $3 each)



• limited availability in pharmacies (they are

also available from family planning clinics

and online).

It is likely that new and more cost-effective fe-

male condoms will be available in Australia in the

future. The potential advantages of a female-con-

trolled device that simultaneously prevents STIs

and unintended pregnancy are significant on a

global scale. The challenge lies in developing a

device that is effective and cost-effective at the

same time as being acceptable to women and

their partners.

The DiaphragmThe diaphragm is a silicone dome with a flexi-

ble rim that is inserted into the vagina to cover

the cervix. The diaphragm acts to prevent sperm

transport through the cervix and must be kept in

place for at least six hours after intercourse in or-

der for the spermatozoa to be incapacitated in the

acidic vaginal environment.

A diaphragm costs approximately $90 and

lasts for up to two years. Cervical caps and latex

diaphragms are no longer available in Australia.

The diaphragm can be inserted many hours

before sex and therefore does not necessarily

interfere with sexual spontaneity. Rather than in-

serting it intermittently prior to intercourse, some

women choose to use their diaphragm almost con-

tinuously, with removal for washing once in every

30 hours. This practice is only advised for nonmen-

struating women because of the small theoretical

risk of toxic shock syndrome during menstruation.

Women using the diaphragm during menstruation

are advised to remove it as soon as practical after

the six-hour minimum requirement.

The diaphragm has a lower effectiveness,

even with perfect use, than nonbarrier methods,

and offers limited, if any, protection against STIs.

Effectiveness depends on sustained motivation to

use the diaphragm with each act of intercourse and

it is a method best suited to women with reduced

fertility or those who are accepting of the relatively

high failure rate. Emergency contraception is ad-

vised if the diaphragm is displaced or damaged

during or after intercourse (see case study 1). Fig-

ures for the percentage of pregnancies occurring

in the first year of use of the diaphragm are 6% in

perfect use and 12% in typical use.1

ContraindicationsThe diaphragm has no significant medical con-

traindications to its use apart from a history of toxic

shock syndrome. Although toxic shock syndrome

is extremely rare, a small case-control study sug-

gested a possible increased risk in women using

a diaphragm or cervical cap, particularly during

menses.4 Allergy to silicone is extremely rare.

Vaginal or uterine anatomic anomalies in-

cluding prolapse may compromise the correct

placement of the device. Some studies suggest

an increased risk of urinary tract infection (UTI)

with diaphragm use, particularly in women with

recurrent infections, although it is difficult to as-

sess the strength of the association as intercourse

itself can result in UTIs.5,6 A diaphragm of a size

that does not put undue pressure on the urethra

should be chosen.

Finding the Correct ‘Fit’To use a diaphragm correctly, a woman must

feel comfortable about inserting the device and

Johara comes to see you as she wants to discuss using a diaphragm for contraception.

She is 32 years old, has a 2-year old son and is planning another baby in a year or two. Johara and her partner have been using condoms or the withdrawal method since their son was born and would like to try a different nonhormonal method.

After discussing the use and efficacy of the diaphragm compared with other methods (including the copper intrauterine device), Johara is happy to have a diaphragm fitted for size and is comfortable inserting, checking and removing it.

You discuss emergency contraception with her as a ‘back-up plan’ in case she has intercourse without the device in place or it is displaced or damaged during intercourse. She is initially concerned about using the emergency contraceptive pill as she was under the misapprehension that it was an abortifacient. You give her written information about effective diaphragm use and hormonal emergency contraception.

Case Study 1. Diaphragms and Emergency Contraception



confident about feeling the cervix through the dia-

phragm to ensure it is covered.

Diaphragms are available in sizes 65, 70,

75 and 80 mm diameter. A consultation with a

trained practitioner is advised to determine the

correct size and to ensure the woman is able to

correctly insert and remove the device. Fitting

after a pregnancy should be deferred until six

weeks postpartum.

The correct size is assessed by estimating

the distance from the posterior fornix to the poste-

rior aspect of the pubic symphysis on pelvic exam-

ination. ‘Fitting sets’ are available from the manu-

facturer to aid the consultation. The size should

be reviewed when a diaphragm is replaced, after

a pregnancy, if the diaphragm becomes uncom-

fortable for either partner or with a weight change

of 3 kg or more (this may be overly conservative

but is based on the recommendations of the UK

Faculty of Sexual and Reproductive Healthcare).

The most suitable position to insert the dia-

phragm varies between women, with some pre-

ferring to stand with one foot elevated and others

preferring to squat or lie down. The diaphragm is

inserted along the posterior aspect of the vaginal

wall towards the coccyx to cover the cervix; the

cervix should be palpable through the diaphragm.

A correctly fitted diaphragm just allows the inser-

tion of a fingertip between the diaphragm rim and

the pubic arch. After successfully inserting and re-

moving the diaphragm in the clinic, women may

wish to trial the diaphragm for a week or so before

review to check its fit and comfort.

Maintenance of the diaphragm requires

rinsing with warm water and mild unperfumed

soap after use, patting it dry and storing in its

case away from direct heat. The use of additional

lubricants may lead to slippage but evidence is

lacking. The diaphragm should be checked reg-

ularly for holes.

Spermicidal UseAlthough the use of a spermicide with the dia-

phragm is advised in the product information and

by the UK Faculty of Sexual and Reproductive

Healthcare,7 spermicidal products are not availa-

ble in Australia. The additional use of spermicide

theoretically increases the effectiveness of the

method, but no study has had sufficient num-

bers to show a significant effect.8 It is therefore

recommended by Family Planning Organisations

that diaphragms can be used without spermi-

cide but that women should be advised that this

method of contraception is less effective than

other methods, regardless of the use or nonuse

of spermicide.

Women should also be aware that spermi-

cides containing nonoxynol-9 as the active ingre-

dient have been shown to cause vaginal mucosal

irritation leading to an increased susceptibility to

HIV acquisition.9 Spermicides are therefore not

advised in women at high risk of STIs and are not

recommended as a contraceptive on their own

because of their low efficacy.1

FERTILITY AWARENESS-BASED METHODSFABMs include all methods based on the identifi-

cation of the fertile phase of the menstrual cycle.

They rely on predicting times in the menstrual

cycle when the couple should abstain from un-

protected vaginal intercourse. FABMs provide

an alternative means of contraception for wom-

en who prefer to avoid other methods and those

with religious beliefs that discourage the use of

other contraceptives. They do, however, require a

thorough understanding of the female reproduc-

tive cycle and commitment to maintaining daily

vigilance regarding physical changes, signs and

symptoms.

FABMs are unsuitable for women with irreg-

ular or anovulatory menstrual cycles, including

those who are breastfeeding or perimenopau-

sal. Their effectiveness may also be affected by

life events that have physiological impact on the

menstrual cycle (such as illness).

The effectiveness of FABMs has not been

documented in the same way as for other meth-

ods of contraception. Perfect and typical effec-

tiveness rates are not available for all FABMs.



Percentages of pregnancies occurring in the first

year of use of the various methods are quoted to

vary from 0.4 to 25%.1

Identification of the Fertile Phase of the Cycle: Broad PrinciplesThe WHO defines the days of potential fertility for

a couple during each menstrual cycle as the time

from the first act of intercourse that may lead to

pregnancy to the demise of the ovum.

The survival of sperm in the female genital

tract depends on the presence of alkaline cer-

vical mucus. Although sperm survive for only a

few hours in the more acidic environment of the

vagina, if there are fertile cervical secretions they

can typically live to a maximum of five days in the

upper reproductive tract. By seven days, there is

a less than 1% probability of sperm survival.10 By

contrast, the average life span of the ovum is 12

to 24 hours, with successful fertilisation unlikely

beyond 12 hours after ovulation.

Overview of FABMsThe several documented FABMs can be broadly

classified as symptoms-based methods, calen-

dar-based methods or combinations of these.

If desired and acceptable, some FABMs can

be used in combination with barrier methods to

enhance effectiveness and to increase the days

during which the couple can have sex.

Women who choose to use FABMs should

be encouraged to seek advice and coaching from

an expert educator. Contact details can be found

at the Natural Fertility Australia website (http://nat-

uralfertility australia.org.au/about-us).

Symptoms-based MethodsTemperature MethodThe temperature method is based on detecting

the rise in body temperature of 0.2 to 0.5°C due

to increased levels of progesterone following ovu-

lation. This temperature will remain elevated until

the next period.

In this method, the basal body tempera-

ture must be taken immediately on waking and

is recorded on a fertility chart (Figure 2). Illness,

alcohol, too much or too little sleep and electric

blankets can all raise the temperature. The begin-

ning of the fertile time cannot be identified; ovula-

tion is determined retrospectively. Intercourse is

avoided from the start of menstruation until there

are three consecutive days of recorded tempera-

tures that are higher than the preceding six days.

This is the end of the fertile time, and after this it

is considered safe to have unprotected sex. Use

of this method alone may require many days of

abstinence.

Mucus MethodsMucus methods are based on daily observation

of the mucus discharge at the vaginal introitus

as well as a sensation of wetness or dryness at

the vulva. Variations include the Billings Ovulation

Method and the 2 Day Method.

Three patterns of mucus are recognised:

• postmenstrual infertile pattern with dense,

flaky, sticky mucus and a feeling of dryness

at the introitus

• ovulatory or fertile pattern, with rising oes-

trogen levels as ovulation approaches with

Figure 2. A Fertility Chart used to record the Menstrual Cycle and Basal Body Temperature to estimate the Fertile days each Month.



clearer, more watery and elastic mucus (sim-

ilar to egg white) with a feeling of wetness at

the vaginal introitus

• postovulatory pattern related to the rising

level of progesterone immediately after ovu-

lation causing the mucus to become cloudy,

thicker and sticky with a feeling of dryness at

the introitus.

Intercourse is avoided on the days of sub-

jective heavy menstrual bleeding. Intercourse is

permitted on alternate evenings during the time of

the postmenstrual infertile mucus pattern, and then

avoided once the fertile pattern is detected and un-

til three consecutive dry days have occurred.

Symptothermal MethodThe symptothermal method uses a combination

of two or more signs of fertility, including chang-

es in temperature and cervical mucus secretions.

The primary indicator of the beginning of the fer-

tile phase is the presence of fertile mucus (clear,

watery, elastic mucus), and the end of the fertile

phase is confirmed by a combination of basal

body temperature and mucus changes.

Calendar-based MethodsBecause of variability in the day of ovulation be-

tween cycles, calendar methods of contraception

are inherently less effective than symptoms-based

methods. There are several tools to help with cal-

endar methods, including a colour-coded system

of beads (www.cyclebeads.com) and smart-

phone applications.

Calendar MethodIn the calendar (or rhythm) method, at least three

consecutive menstrual cycles must be used to

calculate an acceptable range of fertile days. A

woman’s fertile days are calculated by selecting

the shortest and longest cycle lengths, subtract-

ing 21 from the shortest cycle and subtracting 10

from the longest cycle. Unprotected sex should

be avoided on the fertile days.

The calculation should be reviewed each

month if there is variation in cycle length.

Standard Days MethodThe standard days method is a variant of the cal-

endar method. Women who record two cycles

that are outside the range of 26 to 32 days in any

year should not use this method. Taking day 1

as the first day of bleeding, the first fertile day is

considered to be day 8 and the last fertile day is

considered to be day 19; intercourse is avoided

on days 8 to 19 of the cycle.

WITHDRAWALAlso known as coitus interruptus, the withdraw-

al method is widely used. Although not well re-

searched, it may be relatively effective for those

experienced with its use. It needs to be used con-

sistently, can interfere with sexual spontaneity and

requires the male partner to have awareness and

control over his ejaculation. Despite correct use,

failure can occur because approximately 40% of

men have sperm present in the pre-ejaculate.11

LACTATIONAL AMENORRHOEA METHODThe lactational amenorrhoea method (LAM) is the

informed use of breastfeeding for contraception.

Breastfeeding delays the resumption of ovulation

postpartum due to prolactin-induced inhibition of

the release of gonadotropin-releasing hormone

from the hypothalamus and hence luteinising hor-

mone from the pituitary.

LAM is an important contraceptive method

worldwide, especially in countries where access

to modern methods is limited. Its effectiveness

can be relatively high, up to 98% when all of the

following criteria are met:

• the woman remains amenorrhoeic postpartum

• the woman is less than six months post-delivery

• the baby is fully breastfed (no supplements)

and there are no long intervals between

feeds (no more than four hours during the

day or six hours at night, although no defini-

tive guidance exists).

If one or more of these criteria are not met,

the woman should be advised to switch to an al-

ternative method of contraception.



In breastfeeding women, the mean time for

the return of menses is 28.4 weeks, with a range

from 15 to 48 weeks. However, as some women

may ovulate before the onset of menses, use

of an additional method of contraception can

be advised to reduce the risk of a further preg-

nancy.

PERMANENT METHODS: FEMALE AND MALE STERILISATIONThe uptake of female and male sterilisation ap-

pears to be decreasing as the use of LARCs is

increasing. Despite the potential for reversal of

some sterilisation methods, success in reversal

is both limited and costly. Sterilisation should,

therefore, be regarded as both permanent and

irreversible.

Decision-making About SterilisationThe decision to have a sterilisation procedure is

the individual’s alone and does not require part-

ner consent. Although a partner may be present

in the consultation, it is important to talk with

the individual alone about the decision.

The important considerations that should be

raised in the primary care setting before referral

for a sterilisation procedure are listed in the box

on this page in the form of questions One of the

more important considerations is that of future

regret, which is more likely in younger women,

nulliparous women and when there is relationship

disharmony.12-14 Women requesting intrapartum,

postpartum or postabortion procedures should

be aware of the increased rate of regret and pos-

sible increased failure rate in these situations, and

deferred sterilisation is advised where possible.13

The possibility of future regret is also applicable

to men, and sperm storage in a fertility clinic be-

fore the procedure may be a consideration.

Female and male sterilisations are both clas-

sified by law in all states and territories of Australia

as special medical treatments. If a person lacks

the capacity to consent to the procedure himself

or herself, the decision to proceed can only be

made under the direction to the appropriate state

or territory authority.

Female SterilisationFemale sterilisation is achieved through occluding

or disrupting fallopian tubal patency prevent the

sperm fertilising the egg. Techniques include ligat-

ing or removing a section of the fallopian tubes,

mechanical blockage using clips, rings, coils or

plugs and coagulation induced blockage using

electrical current or chemicals. The method used

will depend on the expertise and preference of the

local gynaecologist as well as the woman’s medi-

cal, surgical and obstetric history and preference.

Filshie clip application or other tubal ligation,

obstruction or destruction methods can be car-

ried out laparoscopically or via laparotomy under

general anaesthetic. They can be performed via

mini laparotomy for postpartum sterilisation or at

the time of a caesarean section. These methods

have a failure rate of less than 0.5% per year al-

though some studies show an increased failure

rate in younger women.1,15

Female Sterilisation and Vasectomy: Considerations Before Referral

• what has led to the decision to seek sterilisation?

• who initiated the idea and for how long has sterilisation been considered?

• is there awareness of long-acting reversible contraceptives and their benefits?

• what are the couple currently using for contraception (there can be a significant delay before the procedure will take place)?

• How far along is the decision-making process and are there any signs of ambivalence or coercion by the partner or others?

• How much does the patient know about the procedure and its effects and complications?

• is there a clear understanding about the permanent nature of the procedure?

• Has the risk of future regret been considered, should circum-stances change (such as death of children/partner, break-up of relationship)?

• what role does fertility play in relation to sexuality?

• Are there concerns about the effect of the sterilisation method on sexual function?



Hysteroscopic transcervical occlusive meth-

ods avoid the need for surgical incision and can

be performed under local anaesthetic or light se-

dation. The Essure technique involves insertion

into each fallopian tube of a flexible microinsert

that expands to fill and occlude the tube as a re-

sult of microblast invasion. Complete occlusion

and correct positioning of the microinserts should

be confirmed radiologically 12 weeks after place-

ment, and an alternative method of contraception

must be used during this time. Hysteroscopic

transcervical occlusive sterilisation is complete-

ly irreversible. The effectiveness of the Essure

method appears similar to that of other sterilisa-

tion methods provided the follow-up protocol is

observed.16

Although there are no medical conditions

that should restrict a woman from voluntarily

undergoing sterilisation, careful consideration is

required for women younger than 30 years, nul-

liparous women and postpartum women. Women

who have elevated risks for surgery and general

anaesthesia may be better suited to a hystero-

scopic transcervical occlusive method performed

under sedation.

Risks and Side EffectsTubal sterilisation carries surgical and anaesthetic

risks, including injury to the bowel, bladder or ure-

ter and unsatisfactory placement of clips. Perfo-

ration of the uterus or fallopian tubes, pelvic pain

and failure to achieve microinsert placement can

occur with hysteroscopic transcervical occlusion.

Mortality rates for tubal sterilisation are low (ap-

proximately four in 100,000 procedures).17

There is a small risk of failure with female

sterilisation and if a pregnancy does occur, the

probability of an ectopic pregnancy is increased.

Women who have had a pregnancy after sterilisa-

tion are at increased risk of another failure.

Female sterilisation methods are not associ-

ated with a change to the menstrual cycle.

ReversalThe method of female sterilisation affects the out-

come of reversal. Reversal is most likely if clips

have been applied to the mid-isthmus portion of

the tube and much less likely with tubal destruc-

tive or excisional procedures. Hysteroscopic tran-

scervical occlusive methods are completely irre-

versible. Even after a reversal, only about 50% of

women will achieve a pregnancy.18

Male Sterilisation (Vasectomy)A vasectomy interrupts the vas deferens to pre-

vent sperm travelling to the ampulla to mix with

the prostatic and seminal vesicle fluids. Each

vas is mobilised and transacted through a sin-

gle or bilateral scrotal incision. In ‘no-scalpel’

vasectomy, a puncture is made through the

scrotum and widened sufficiently to external-

ise and transect the vas. Vasectomy is usually

carried out in the outpatient or clinic setting by

trained practitioners. Significant medical prob-

lems or a history of scrotal or inguinal surgery

or trauma usually requires referral to a special-

ist setting.

Careful consideration of the procedure is re-

quired for men younger than 30 years, men who

have not had children and men who are anxious

about sexual function post procedure. Precau-

tions are required for previous scrotal injury, a

large varicocele or hydrocele, inguinal hernia,

cryptorchidism or clotting disorders. Examination

is appropriate in the primary care setting to ex-

clude these conditions and to ensure the vasa are

easily palpable. Referral to the specialist setting

is warranted if the vasa are impalpable or other

relative contraindications are present.

Vasectomy is usually carried out in the outpatient or clinic setting by trained practitioners



Semen analysis is performed at 12 weeks

and after a minimum of 20 ejaculations to en-

sure there are no sperm present in the ejaculate.

A small proportion of men do not achieve azoo-

spermia but have very low counts of nonmotile

sperm; in these cases, cautious assurance can

be provided in consultation with the vasectomy

provider.

Failure can occur due to technical errors,

recanalisation (occurs in about 0.2% of proce-

dures) or unprotected intercourse before confir-

mation of azoospermia with semen analysis at

three months.

Vasectomy has a failure rate of 0.1 to 0.15%.1

Risks and Side EffectsThe risk of immediate complications with vasecto-

my procedures is low but may include pain, local

bruising, infection and haematoma. A small hae-

matoma can be managed with bed rest, elevation

and support, cold compresses and analgesia. A

large haematoma usually requires surgical drain-

age. Infection can result in an abscess requiring

surgical drainage. Epididymo-orchitis results in rap-

id painful enlargement of the scrotum and is treated

with antibiotics and scrotal support. Haematosper-

mia and haematuria are rare and usually settle.

In the longer term, tender or nontender

sperm granulomas may develop at the site of

the vas division but are usually clinically insignif-

icant. There is no evidence for an increased risk

of testicular or other cancers, nor any association

with subsequent sexual dysfunction. Antisperm

antibodies are found in most men who have un-

dergone vasectomy. They are not associated with

immunological or other disease but are thought

to reduce the chance of successful pregnancy on

vasectomy reversal.

ReversalVasectomy reversal with microsurgical tech-

niques results in a return of sperm to the ejaculate

in 85 to 90% of men. However, only about 60%

of couples achieve a pregnancy after reversal be-

cause of the presence of antisperm antibodies,

and rates decline with increasing time since the

original procedure.

In vitro fertilisation (IVF) with intracytoplas-

mic sperm injection (ICSI) may also be consid-

ered by couples wanting to reverse the effects

of vasectomy. However, the procedure does not

attract a Medicare rebate for this purpose and an-

tisperm antibodies may also reduce the chance of

a successful pregnancy with IVF.

EMERGENCY CONTRACEPTIONEmergency contraception (EC) is a safe way to

reduce the risk of pregnancy after unprotected

sexual intercourse, sexual assault or potential

contraceptive failure. All women at risk of unin-

tended pregnancy should be aware of the avail-

ability of EC methods and be provided with infor-

mation about how they work.

The first-line EC method in Australia is a sin-

gle dose 1.5 mg tablet of levonorgestrel (LNG-

EC) taken as soon as possible after unprotected

in ‘no-scalpel’ vasectomy, a puncture is made through the scrotum and widened sufficiently to externalise and transect the vas



sexual intercourse, although it is effective if taken

up to five days after the event. The most important

issue is that effectiveness declines with time since

the unprotected sexual intercourse.

The hormonal EC method using oestrogen as

well as progestogen (the Yuzp regimen) is no longer

recommended as it is less effective and associated

with a higher risk of vomitin (a 20% risk compared

with 1% with LNG-EC).19 It should only be used if

LNG-EC is not available. This method requires two

doses of combined oral contraceptive pills taken 1

hour apart, each dose containing at least 100 mcg

of ethinyloestradiol and 500 mcg of LNG.

A copper intrauterine device (Cu-IUD) pro-

vides EC if it is inserted up to five days after un-

protected sexual intercourse. It interferes with

sperm movement, inhibits fertilisation by direct

toxicity and may prevent implantation of a fertil-

ised egg. The Cu-IUD is more effective (99%) than

LNG-EC (85%) and provides ongoing long-acting

reversible contraception. Despite these advantag-

es, it is acknowledged that accessing a Cu-IUD

quickly can be challenging.

A new EC method in the form of a selective

progesterone receptor modulator ulipristal ace-

tate, has been available in Europe since 2009 and

should be available in Australia in 2015. Ulipristal

acetate provides effective emergency contracep-

tion up to five days after unprotected sexual in-

tercourse and appears to have superior effective-

ness to LN EC at 24, 72 and 120 hours.20

A summary of the advantages and disadvan-

tages of available EC methods is provided in the

box on this page.

Levonorgestrel ECLNG-EC can be taken as a stat 1.5 mg dose of

LNG, provided by a single 1.5 mg LNG tablet or

Emergency Contraception: Advantages/Disadvantages of Different Types

LNG-EC Advantages

Cu-IUD Advantages

• No absolute contraindications

• easy dosage schedule

• No prescription required

• Can be used any time in the cycle

• well tolerated with low incidence of side effects (only 1% incidence of vomiting)

• May be provided as ‘advance supply’ by a pharmacist or with a script from a doctor

• Highly effective up to 120 hours postcoitally

• May be used for ongoing contraception

• Not affected by drug interactions or gastrointestinal problems

Disadvantages Disadvantages

• Cost may be prohibitive for some women (around $20 to $30, or more)

• Limited evidence for efficacy between 96 and 120 hours after unprotected sexual intercourse

• does not provide ongoing contraception

• is affected by liver enzyme-inducing drugs (double dose is recommended)

• Nonmenstrual bleed may be mistaken for menses

• inserted and removed by trained practitioner which limits access

• Contraindications as for Cu-iUds

• Cost of the device and the insertion procedure may be prohibitive for some women

ABBreviATiONS: Cu-iUd = copper intrauterine device; eC = emergency contraception; LNG = levonorgestrel.



two 0.75 g LNG tablets. Alternatively, two 0.75

mg LNG doses, each made up of twenty-five 30

mcg LNG tablets (progestogen- only contracep-

tive pills), can be taken 12 hours apart (or all 50

tablets can be taken in one dose). The 1.5 mg

LNG-EC tablet can be purchased without a pre-

scription at pharmacies as an S3 medication.

Increasing EC access in the pharmacy setting is

supported by the latest Pharmaceutical Society of

Australia guidelines for the supply of LNG-EC.21

LNG-EC primarily acts to prevent or delay

ovulation by interfering with follicular develop-

ment. It appears to have no effect once the lute-

inising hormone surge has commenced. There is

no evidence that it prevents fertilisation or inhibits

implantation once ovulation has occurred.22

LNG-EC is 85% effective (the effectiveness

of EC is the estimated percentage of pregnan-

cies prevented which would otherwise have oc-

curred).23 It is approved for use up to 72 hours after

unprotected sexual intercourse but it has proven

effectiveness for up to 96 hours. Extending its use

to 120 hours (five days) postcoitally is not harmful

although the risk of pregnancy is approximately

five times higher if LNG-EC is taken on the fifth day

compared to within the first 24 hours.24

There is no evidence for harm to a develop-

ing fetus if LNG-EC is inadvertently taken when

the woman is already pregnant. 25 LNG-EC does

not provide ongoing contraception and the dose

should be repeated if unprotected sexual inter-

course occurs more than 12 hours after it was

taken. Repeat use of LNG-EC is not harmful but

may be associated with menstrual disturbance.

Information about ongoing alternative methods of

contraception should be provided to women who

repeatedly use EC.

There are no evidence-based contraindica-

tions to the use of LNG-EC except for allergy and

known pregnancy (although it is not harmful to an

existing pregnancy). It can be used by women of

any age who are at risk of pregnancy, and there

are no medical reason for restricting its use in

very young women. Women who are breastfeed-

ing may continue to feed as the infant’s exposure

to LNG is very low.26

Women who are currently using or are with-

in 28 days of stopping a liver enzyme inducing

medication (such as carbamazepine and some

antiretroviral medications) are advised to take

a double dose (3.0 mg) of LNG-EC. The cop-

per-IUD is the EC method of choice for women

using a potent liver enzyme-inducing medication

such as rifampicin. Common nonliver enzyme-in-

ducing antibiotics do not reduce the effectiveness

of LNG-EC.

LNG-EC does not increase the risk of an ec-

topic pregnancy and is not associated with reduc-

tion in future fertility.27 It is well tolerated with few

side effects. Headache and nausea may occur,

with vomiting in approximately 1% of women (the

dose should be repeated if vomiting occurs within

two hours of administration).

Menstrual disturbance is common after hor-

monal EC. Most women have a menstrual bleed

women at risk of unintended pregnancy should be aware of the available emergency contraception methods



Sara is a 19-year-old student. She started university earlier in the year and has just started a sexual relationship with a 21-year-old male student. She has had two other sexual partners this year. She usually uses condoms but occasionally relies on withdrawal. She comes to see you to discuss contraception as she recently had a ‘pregnancy scare’.

Sara and her partner were using condoms but one came off during sex. She bought the emergency contraceptive pill from a pharmacy the next day and took it immediately. As her period was a week late, she did a pregnancy test (it was negative). After the anxiety of thinking she might be pregnant, Sara has come to see you to discuss contraception as she does not wish to get pregnant for at least three to five years.

You discuss all options of contraception with Sara. She considers ‘quick start’ with the pill or the vaginal ring but instead takes away information sheets on the contraceptive implant and hormonal iUd as she says she has trouble remembering the pill and the vaginal ring is too expensive. You obtain a urine sample for a chlamydia test and Sara arranges to come back after her next period. You also give her a script for the etonogestrel implant and she plans to have it inserted at the next appointment. You discuss continuing condom use with Sara as future STi protection.

ABBreviATiONS: iUd = intrauterine device; STi = sexually transmitted infection.

Case Study 2. Emergency Contraception

within seven days of the expected time, but it may

occur a few days earlier or later than expected.23

It may be difficult to distinguish nonmenstrual

and menstrual bleeding after LNG-EC, and a fol-

low-up pregnancy test three weeks after unpro-

tected sexual intercourse should be considered.

The standard urine pregnancy test (sensitive to

a beta human chorionic gonadotropin level of 25

mIU/mL) performed less than three weeks after

unprotected sexual intercourse may give a false

negative result.

Women may choose to initiate an ongoing

method of contraception immediately rather than

waiting for the next menses. Using the ‘quick

start’ initiation regimen, a hormonal method can

be initiated on the same day as LNG-EC is taken.

Additional precautions will be required for seven

days if initiated at a time other than day 1 to 5 of

the menstrual cycle, and a follow-up pregnancy

test at four weeks is important to determine EC

failure or contraceptive failure during the first sev-

en days of use.

Guidance for instances where review after

the provision of LNG-EC may be required is pro-

vided in the box on this page, and the practical

application of the advice is illustrated in case

study 2.

CONCLUSIONAlthough barrier methods of contraception, fertility

awareness-based methods, the lactational amen-

orrhoea method and withdrawal have relatively

low typical-use efficacies compared with modern

methods, in particular the LARCs, they each have

a role as a contraceptive option available to wom-

en and their partners. Male and female sterilisa-

tion, however, have similar efficacy rates to the

LARCs but are permanent, and their use seems to

be decreasing with the increasing availability and

acceptability of LARCs. Emergency contraception

has a vital role in the case of unprotected sexual

intercourse as well as contraceptive failure, and

all women at risk of unintended pregnancy should

be aware of it, understand how it works and know

how to access it.

It is hoped that the three articles in this series

‘A practical guide to contraception’ will assist in

raising awareness of all methods of contraception

available in Australia. Women in this country have

access to multiple methods of contraception, and

review is usually not necessary after LNG-eC but is advised in some situations.

Advise a review with a pregnancy test in three to four weeks if:

• there is a high risk of pregnancy when hormonal eC is given

• hormonal contraception is started immediately after taking eC (Quick Start method)

• hormonal eC has been used more than once in a cycle

• the next menstrual period is more than seven days late or is unusual (e.g. unusually light, painful or prolonged).

Advise a review for STi testing in two to three weeks if an STi risk is identified or if symptoms consistent with an STi develop.

ABBreviATiONS: eC = emergency contraception; LNG = levonorgestrel; STi = sexually transmitted infection.

Review after Hormonal EC



REFERENCES1. Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397–404.2. Bateson D, Harvey C, McNamee K. Con-traception: an Australian clinical practice handbook. 3rd ed. Brisbane: Family Plan-ning New South Wales, Family Planning Queensland, Family Planning Victoria;2012.3. Messiah A, Dart T, Spencer BE, Warszawski J. Condom breakage and slip-page during heterosexual intercourse: a French national survey. French National Sur-vey on Sexual Behavior Group (ACSF). Am J Public Health 1997;87:421–424.4. Schwartz B, Gaventa S, Broome CV, et al. Nonmenstrual toxic shock syndrome associated with barrier contraceptives: re-port of a case-control study. Rev Infect Dis 1989;11(Suppl 1):S43–S49.5. Fihn SD, Latham RH, Roberts P, Run-ning K, Stamm WE. Association between diaphragm use and urinary tract infection. JAMA 1985;254:240–245.6. Foxman B, Gillespie B, Koopman J, et al. Risk factors for second urinary tract infection among college women. Am J Epidemiol 2000;151:1194–1205.7. Clinical Effectiveness Unit. Barrier meth-ods for contraception and STI prevention. London: Faculty of Sexual and Reproductive Healthcare;2012.

8. Cook L, Nanda K, Grimes D. The dia-phragm with and without spermicide for con-traception: a Cochrane review. Hum Reprod 2002;17:867–869.9. Wilkinson D, Tholandi M, Ramjee G, Ru-therford GW. Nonoxynol-9 spermicide for prevention of vaginally acquired HIV and oth-er sexually transmitted infections: systematic review and meta-analysis of randomised controlled trials including more than 5000 women. Lancet Infect Dis 2002;2:613–617.10. Wilcox AJ, Weinberg CR, Baird DD. Tim-ing of sexual intercourse in relation to ovula-tion. Effects on the probability of conception, survival of the pregnancy, and sex of the baby. N Engl J Med 1995;333:1517–1521.11. Killick SR, Leary C, Trussell J, Guthrie KA. Sperm content of pre-ejaculatory fluid. Hum Fertil (Camb) 2011;14:48–52.12. Curtis KM, Mohllajee AP, Peterson HB. Regret following female sterilization at a young age: a systematic review. Contracep-tion 2006;73:205–210.13. Kariminia A, Saunders DM, Chamberlain M. Risk factors for strong regret and subse-quent IVF request after having tubal ligation. Aust N Z J Obstet Gynaecol 2002;42:526–529.14. Moseman CP, Robinson RD, Bates GW Jr, Propst AM. Identifying women who will re-quest sterilization reversal in a military popu-lation. Contraception 2006;73:512–515.

15. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of pregnan-cy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996;174:1161–1168; discussion 1168–1170.16. Levy B, Levie MD, Childers ME. A sum-mary of reported pregnancies after hystero-scopic sterilization. J Minim Invasive Gyne-col 2007;14:271–274.17. Peterson HB, DeStefano F, Greenspan JR, Ory HW. Mortality risk associated with tubal sterilization in United States hospitals. Am J Obstet Gynecol 1982;143:125–129.18. Trussell J, Guilbert E, Hedley A. Steriliza-tion failure, sterilization reversal, and preg-nancy after sterilization reversal in Quebec. Obstet Gynecol 2003;101:677–684.19. Randomised controlled trial of levonorg-estrel versus the Yuzpe regimen of com-bined oral contraceptives for emergency contraception. Task Force on Postovulato-ry Methods of Fertility Regulation. Lancet 1998;352:428–433.20. Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet 2010;375:555–562.21. Pharmaceutical Society of Australia. Guidance for provision of a pharmacist only

medicine: levonorgestrel. Approved indica-tion: emergency contraception. Canberra: Pharmaceutical Society of Australia;2011.22. Noe G, Croxatto HB, Salvatierra AM, et al. Contraceptive efficacy of emergency contra-ception with levonorgestrel given before or after ovulation. Contraception 2011;84:486–492.23. von Hertzen H, Piaggio G, Ding J, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet 2002;360:1803–1810.24. Piaggio G, Kapp N, von Hertzen H. Effect on pregnancy rates of the delay in the ad-ministration of levonorgestrel for emergency contraception: a combined analysis of four WHO trials. Contraception 2011;84:35–39.25. Brent RL. Nongenital malformations follow-ing exposure to progestational drugs: the last chapter of an erroneous allegation. Birth De-fects Res A Clin Mol Teratol 2005;73:906–918.26. Gainer E, Massai R, Lillo S, et al. Levo-norgestrel pharmacokinetics in plasma and milk of lactating women who take 1.5 mg for emergency contraception. Hum Reprod 2007;22:1578–1584.27. Cleland K, Raymond E, Trussell J, Cheng L, Zhu H. Ectopic pregnancy and emergency contraceptive pills: a systematic review. Ob-stet Gynecol 2010;115:1263–1266.

the role of the healthcare practitioner is to pro-

vide balanced information in order to facilitate

choice. Consideration of individual medical, so-

cial and cultural factors as well as personal pref-

erences is essential, and the use of a validated

framework can help in choosing an appropriate

contraceptive method. Some women may pre-

fer to consider their options before initiating a

particular method, whereas others benefit from

an immediate or ‘quick start’. Written and web-

based information should be provided and is

available through the state and territory Family

Planning Organisations.

The benefit of the LARCs should not be un-

derestimated. They have a clear role in effective

contraception for women of all ages.

Eliminating all unintended pregnancy is an

unrealistic goal and there will always remain a

need for safe accessible pregnancy termination

services in Australia. Ensuring that women and

couples have access to effective and acceptable

contraception can reduce the number of unin-

tended pregnancies. Planned pregnancies can

optimise the health of the woman and her baby.

© 2013 Medicine Today Pty Ltd. Initially published in Medicine Today September 2013;14(9):55-65. Reprinted with permission.

About the AuthorsDr Stewart is Acting Medical Director, Family Planning NSW, Sydney, NSW. Dr McNamee is Medical Director, Family Planning Victoria, Box Hill, and Adjunct Senior Lecturer, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Vic. Dr Harvey is Medical Director, Family Planning Queensland, Brisbane, Qld.

Competing InterestsDr Stewart: None. Dr McNamee and Dr Harvey have provided expert opin-ion for Bayer Health Care and Merck Sharp & Dohme as part of their roles with their respective organisations. Dr Harvey has received support to attend conferences.

Key Points

• The traditional methods of contraception – the barrier, fertility awareness-based, withdrawal and lactational amenorrhoea methods – are not as effective as modern methods but have a role as contraceptive options.

• The use of sterilisation is decreasing with the increasing availability and acceptability of long-acting reversible contraceptives.

• Barrier methods such as male and female condoms and diaphragms require sustained motivation and correct use to be effective contraceptives.

• Fertility awareness-based methods require an understanding of the female reproductive cycle and a commitment to daily vigilance of physical changes, signs and symptoms.

• All women who are at risk of unintended pregnancy should be aware of emergency contraception, understand how it works and know how to access it.


247JPOG NOV/DEC 2014IN PRACTICE peer reviewed

(Answer on p.255)

CASE PRESENTATIONA 6-year-old boy presents with a rash that

appeared two months ago and spread to

involve his whole skin within a week. It is

most severe on his trunk (Figure 1) but

also involves his face and limbs.

At this presentation, the rash has a

polymorphic appearance consisting of

papules, vesicles and small scaly mac-

ules; there are some areas of pigment

loss. At a previous presentation, the rash

had been vesicular and thought by the

doctor who assessed the patient at this

stage to probably be chickenpox.

Currently, the rash is not severely

itchy and does not wake the patient at

night. Nevertheless, his mother is con-

cerned about it and the boy has been sent

home from school by teachers who have

Figure 1. The Rash on the Patient’s Trunk at Presentation.

been worried that he may have a conta-

gious condition. The rash has persisted

despite treatment with antifungal creams,

oral antibiotics and topical corticosteroids.

What is the cause of this boy’s sudden rash onset?

CASE PRESENTATIONAn 8-year-old girl presents with a six-

week history of an erythematous linear

lesion on her left thigh (Figure 2). It is

slightly raised and scaly but not itchy.

The girl has been previously well and

the lesion developed quite suddenly,

over a few days, and has persisted de-

spite treatment with mometasone furoate

0.1% cream and miconazole cream.

Figure 2. The Linear Lesion on the Girl’s Leg.

What is this asymptomatic lesion occurring on the girl’s leg?

(Answer on p.256)

Dermatology Clinic: Widespread Rash in a 6-Year-Old BoyGayle Fischer MB BS, MD, FACD

Dermatology Clinic: A Linear Lesion on a Girl’s LegGayle Fischer MB BS, MD, FACD


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Common Symptoms and Signs During Pregnancy Sheba Jarvis, MBBS BSc MRCP; Catherine Nelson-Piercy, MA FRCP FRCOG

During pregnancy, a woman may notice the development of a number of new symp-

toms. Many of these are widely accepted as a normal part of uncomplicated pregnan-

cy but others may be of more concern. The anatomical and physiological changes

that accompany normal pregnancy are profound, and it is therefore not surprising

that as the various systems adapt, which can result in changes that overlap with those

seen in disease. Additionally, sub-clinical disease can be unmasked during pregnan-

cy, when the physiological adaptation to pregnancy provides an additional stress test.

Common symptoms may include palpitations, dyspnoea, peripheral oede-

ma, nausea, vomiting and pruritus. Underlying alterations in major organs can

explain a large number of symptoms and signs, which are benign. It is prudent

that clinicians are aware of those symptoms and signs that warrant further inves-

tigation and that may be associated with disease. Furthermore, biochemical and

haematological variables may also be altered in pregnancy, and this should be

taken into account when interpreting blood results.



INTRODUCTIONDuring pregnancy, a woman may notice the de-

velopment of a number of new symptoms. Many

of these are widely accepted as a normal part of

uncomplicated pregnancy but others may be of

more concern. The anatomical and physiological

changes that accompany normal pregnancy are

profound, and it is therefore not surprising that

as the various systems adapt; this can result in

changes which overlap with those seen in disease.

Awareness of the physiological adaptations

during pregnancy is important. The clinician

needs to be able to discern benign symptoms

and signs and reassure women appropriately

whilst recognising abnormal findings, which may

indicate underlying disease and warrant further

investigation. The ‘back to basics’ chapter intro-

duced in the 2011 ‘saving mothers’ lives’ report

provides useful guidance in this area.

For women with pre-existing diseases, these

physiological changes will affect how well they

can tolerate pregnancy. This includes women

who may have sub-clinical disease that is un-

masked during pregnancy, when the physiologi-

cal adaptation to pregnancy provides an addition-

al stress test.

PHYSIOLOGICAL ADAPTATIONS DURING PREGNANCYCardiovascular SystemIn normal pregnancy, women may experience

breathlessness, palpitations, decreased exercise

tolerance, presyncope/syncope, ankle swelling

and may complain of fatigue.

Clinical examination may demonstrate a

sinus tachycardia and there may be a collaps-

ing pulse. The apex beat may be forceful and

displaced (lateral and upwards) and the heart

sounds are louder. Wide splitting of the first heart

sound and second heart sounds may be heard

during the 3rd trimester and a third heart sound

may also be present. The presence of a fourth

heart sound is usually pathological.

An ejection systolic murmur (up to grade 2/6)

is heard throughout the praecordium in up to 95%

of women, typically along the left sternal edge. A

venous hum (heard in upper chest near clavicles

due to cardiac output through the internal jugular

veins) and a mammary soufflé (a ‘blowing sound’

heard over the breasts) may be found in ~14% of

women especially during late pregnancy and lac-

tation. This is usually heard continuously through-

out the cardiac cycle but in 30% of women may be

heard only in diastole. In such circumstances, this

sign may be misinterpreted as a diastolic murmur.

The jugular venous pulse may be more conspic-

uous in pregnancy but characteristics of the jug-

ular venous pressure wave remains unchanged.

Peripheral oedema is virtually universal in late

pregnancy. Blood pressure falls in the 1st and 2nd

trimesters, and then increases again in the 3rd tri-

mester, reaching non-pregnant values by term.

Table 1. Cardiovascular Changes in Normal Pregnancy

Physiological Variable

Direction of Change Magnitude

Cardiac output ↑ 20% during 1st trimester40% by 3rd trimester

Heart rate ↑ 10-20 beats per minute

Stroke volume ↑ 25-30%

plasma volume ↑ 30-50%

red blood cell mass ↑ 15-20%

Blood pressure ↓1st, 2nd trimester

↑ 3rd trimester

10 mmHg by 2nd trimesterreturns to pre-pregnancy levels by term

Systemic vascularresistance (Svr)

↓ 25-30%

pulmonary vascular resistance (pvr)

↓ 25-30%

Central venous pressure (Cvp)

Unchanged

pulmonary capillary wedge pressure (pCwp)

Unchanged

Serum colloid osmotic pressure

↓ 10-15%

water and sodium retention

↑



The main cardiovascular changes induced

by pregnancy, that lead to symptoms and signs

are summarised in Table 1. They include in-

creased cardiac output, sodium and water re-

tention leading to plasma volume expansion, de-

creased systemic vascular resistance (SVR) and

blood pressure. In early pregnancy, the rise in

cardiac output is secondary to increased stroke

volume, whilst with advancing pregnancy, a rise

in heart rate occurs to compensate for reduced

SVR. There is also an increase in vascular com-

pliance, which is secondary to the alterations in

collagen with smooth muscle remodelling which

underpin the reduction in peripheral vascular

resistance. As a result of these changes, blood

pressure (cardiac output x SVR) falls in the 1st

and 2nd trimesters, returning to non-pregnancy

values by term. In addition, decreased barore-

ceptor sensitivity leads to blunted ability of the

sympathetic nervous system to peripherally vaso-

constrict. This predisposes the pregnant woman

to presyncope/ syncope. Overall, plasma volume

is increased, and to a lesser degree red blood cell

mass, which results in reduced haematocrit and

a physiological dilutional anaemia. Additionally, a

reduced colloid oncotic pressure and pulmonary

capillary wedge pressure gradient increases the

susceptibility of pregnant women to pulmonary

oedema.

Pregnant women are more likely to com-

plain of palpitations than non-pregnant women.

Although asymptomatic arrhythmias are not un-

common in age-matched non-pregnant popu-

lations, the combination of haemodynamic, hor-

monal and autonomic changes may heighten

awareness to a previously asymptomatic arrhyth-

mia in pregnancy. Additionally, any pre-existing

arrhythmia substrate may be more capable of

sustaining an arrhythmia. The most common ar-

rhythmias are simple ventricular or atrial ectopy.

Most of the cardiovascular adaptations be-

gin early in the 1st trimester, then peak at the end

of the 2nd trimester and are then maintained un-

til term. In later pregnancy, maternal positioning

may have a major effect on cardiac output with

a marked reduction in venous return, and thus

stroke volume in the supine as compared to the

lateral position. This has important implications

for uteroplacental blood flow and placental per-

fusion, and can lead to fetal compromise. During

labour, there is an increase in cardiac output and

rise in blood pressure. Following delivery this

gradually return to pre-pregnancy levels, but this

may take many weeks or even months.

It is important to consider alternative diag-

noses before dismissing a symptom as physio-

logical. The use of further investigations should

be selective but with a high index of suspicion,

particularly in women with underlying disease or

if symptoms have a sudden onset. Chest pain,

wheeze or other unexplained symptoms, particu-

larly in women who may originate from areas with

a high incidence of rheumatic fever warrant further

investigation. When clinical examination reveals a

murmur with grade >2/6, or a late- or pan-systol-

Box 1. Results of Cardiac and Respiratory Investigations during Normal Pregnancy

Cardio-respiratory Investigations Electrocardiogram (ECG)

• Left axis deviation

• Sinus tachycardia

• Atrial and ventricular ectopics

• runs of supra-ventricular tachycardia

• Transient ST depression and T wave inversion in inferior/ lateral leads

• Q wave and inverted T wave in Lead iii

Echocardiogram

• valves mildly regurgitant

• valvular annular dilatation

• Chamber enlargement

• Small pericardial effusion

Chest X-ray

• increased cardiothoracic ratio

• increased vascular markings



ic, or any diastolic murmur, further investigation is

indicated. Normal changes on ECG, echocardio-

gram and chest x-ray are shown in Box 1.

Respiratory SystemA common respiratory symptom in up to 70% of

pregnant women is dyspnoea or ‘air hunger’. This

is more common in later pregnancy but may de-

velop early in pregnancy, often occurring at rest

or when talking, and may even improve with exer-

cise. As pregnancy advances, anatomical chang-

es include diaphragmatic elevation (up to 4 cm).

The shape of the chest wall changes, partly due

to the increasing size of the uterus, but also due

to the effects of rising progesterone levels, which

increases the laxity of ligaments, and the thoracic

circumference increases by around 8%.

Although the respiratory rate remains un-

changed in pregnancy, there is a large increase

in tidal volume (from 500 mL to 700 mL), so the

minute ventilation (respiratory rate per minute x

tidal volume) is increased by up to 40 to 50%

by term. During pregnancy, there is an increase

in oxygen consumption giving a relative hyper-

ventilation, which some women may become

aware of. This hyperventilation leads to a rise in

PaO2 and fall in PaCO2, with the latter facilitating

gas exchange with the fetus. This stimulus for

hyperventilation may be mediated by progester-

one, which may lower the threshold or increase

the sensitivity of the respiratory centre to CO2.

More recently, it has been shown that hyper-

ventilation results from alterations in acid-base

balance as well as increased wakefulness drive

to breathe, increased central chemoreflex sen-

sitivity, metabolism and decreased cerebral

blood flow, all of which directly affect ventila-

tion. Other changes to the respiratory system

are summarised in Table 2. Of note, there is no

change in FEV1 (forced expiratory volume in 1

second). One recent longitudinal study during

pregnancy has shown that FVC and peak expir-

atory flow increases from 14-16 weeks gestation

and is significantly higher in multiparous women

compared with primips. This suggests that any

changes in FVC occurring during pregnancy

may persist postpartum.

Other respiratory symptoms which may be

experienced in normal pregnancy overlap with

those described in the cardiac section. The pos-

sibility of underlying disease should always be

considered, before a label of ‘physiological dysp-

noea’ is applied. Any worrying features should

prompt further investigation (Box 2).

Renal SystemDuring pregnancy, the kidneys increase by 1 cm

in size with enlargement of the renal pelvis, cal-

yces and ureters mediated by changes in blood

volume and the effects of progesterone. By the

third trimester, the majority of women will have

‘physiological hydronephrosis’ caused by pres-

sure of the gravid uterus and it is important to

consider this when any renal imaging is undertak-

Table 2. Respiratory Changes in Normal Pregnancy


Direction of Change Magnitude

respiratory rate Unchanged

Tidal volume ↑ Up to 40%

Minute ventilation ↑ Up to 50%

vital capacity ↓

residual volume ↓

Functional residual capacity

↓ 20%

Oxygen consumption

↑ 20%

Fev1 Unchanged

peF ↑

FvC ↑

respiratory drive and CO2 sensitivity

↑

paO2↑

paCO2↓

Arterial pH ↑ Compensated respiratory alkalosis



en during pregnancy. Common renal symptoms

in pregnancy include urinary frequency, nocturia,

urgency and stress incontinence. Up to 95% of

pregnant women complain of frequency, the

cause of which appears to be multifactorial, sec-

ondary to alteration in bladder function, as well

as the effects of the gravid uterus. There is also

an increased risk of infection secondary to urinary

stasis. Nocturia is related to increased sodium

and water excretion during the night in pregnan-

cy; in part this is due to mobilisation of dependent

oedema. The cause of urgency and incontinence

is also multifactorial, and both uterine pressure on

the bladder and hormonal effects on the urethral

suspensory ligaments are implicated.

Peripheral oedema is common, and occurs

in 80% of pregnant women by the end of preg-

nancy. This is due to increased sodium and water

retention and decreased ability to excrete a sodi-

um and water load, as well as venous stasis relat-

ed to the gravid uterus.

Haemodynamic and other renal changes are

summarised in Table 3, and should be consid-

ered when interpreting renal biochemical blood

results in pregnancy.

Gastrointestinal SystemNausea and vomiting are the most common

symptoms of pregnancy and affect 50 to 90% of

pregnant women. In most cases, this is self-lim-

iting with resolution by 16-20 weeks’ gestation.

A more severe form of nausea and vomiting in

pregnancy (hyperemesis gravidarum) affects 0.3

to 3% of women.

As pregnancy progresses, the enlarging

uterus alters the function of the gastrointestinal

(GI) tract. Furthermore, progesterone may have

effects on the smooth muscle function within the

GI tract, leading to increased relaxation of the

lower oesophageal sphincter, increased gas-

tro-oesophageal reflux and heartburn. Additional-

ly, there are changes in gastric emptying during

pregnancy, with increased transit time throughout

the GI tract. Thus, constipation and heartburn are

common symptoms during pregnancy, and occur

in around 40% and up to 80% of pregnant women

respectively.

During pregnancy, bile is also more lithogen-

ic, predisposing to gallstone formation. Pregnan-

cy has little effect on GI secretion or absorption.

Women may notice the development of pal-

mar erythema or spider naevi during pregnancy.

These are usually the result of the high oestrogen

levels, and resolve after delivery. Further investi-

gation is only required if there are other features

of liver disease.

Table 3. Renal Changes in Normal Pregnancy

Haemodynamics

renal blood flow ↑

Glomerular filtration rate (GFr) ↑

Other

Serum creatinine ↓

plasma osmolality ↓

plasma sodium ↓

Urinary protein excretion ↑

Tubular function ↓ can lead to glycosuria and aminoaciduria

Box 2. Associated ‘Red Flag’ Features Requiring Further Investigation

Cardio-respiratory Red Flag Symptoms and Signs

• Sudden onset

• Onset near term

• increased respiratory rate

• Chest pain

• Sputum production

• Haemoptysis

• Tachycardia (above that of normal pregnancy change)

• Cough

• wheeze

• Fever

• Crackles on examination

• pre-existing lung or cardiac disease



Changes in liver biochemistry occur during

pregnancy; these must be taken into account

when interpreting hepatic blood results (Table 4).

Serum albumin falls progressively during preg-

nancy. Alkaline phosphatase rises due to placen-

tal isoenzyme production and may be up to three

times higher than non-pregnant values; this rise

mainly occurs in the third trimester during placen-

tal growth.

[Further information can be found in GI and

liver disorders 2013;23(12):359–363.]

EndocrineThere are a variety of changes that occur to endo-

crine organs in pregnancy. The pituitary gland en-

larges with increasing prolactin levels. Pancreatic

tissue undergoes significant change with b-cell

hyperplasia and advancing pregnancy leads to

an insulin resistant state that may unmask women

at risk of subsequent type 2 diabetes who devel-

op gestational diabetes.

The thyroid gland undergoes significant

changes in physiology and size. As a result, preg-

nant women may complain of neck swelling, as

a small smooth thyroid goitre appears during

pregnancy. This is rare in areas of adequate io-

dine intake but may occur in up to 70% of preg-

nant women in iodine-deficient areas. Any clinical

abnormalities in thyroid examination (such as a

nodular gland or sinister features) necessitate

further investigation. Thyroid biochemistry is

markedly altered during pregnancy with a fall in

thyroid stimulating hormone (TSH) during the first

trimester; this is in part related to the weak thyroid

stimulating activity of the structurally homologous

b human chorionic gonadotropin (bhCG). In ad-

dition, changing trimester specific levels of both

TSH and free T4/T3 (with increased total T4/T3

secondary to raised thyroid binding globulin) are

recognised. [This is described further in the arti-

cle on ‘Thyroid and other endocrine disorders in

pregnancy’ in edition 2013;23(6):171–179].

SkinSkin changes that are frequently noticed during

pregnancy include hyperpigmentation, striae, and

increased hair growth. Pruritus is also a common

symptom.

Hyperpigmentation usually occurs in dis-

crete, localised areas, e.g. melasma on the face,

and darkening of the linea alba on the abdomen

and skin around the areola. It may be due to oes-

trogen and progesterone stimulation of melano-

cytes. Generalised hyperpigmentation is more

unusual, and should be investigated further for


Direction of Change

Magnitude

Serum Albumin ↓ 20 to 40% due tohaemodilution

Total protein ↓

ATp ↑ 2-4 x (placental)

ALT,AST and GGT ↓

Bilirubin ↓

Bile acids Unchanged

Amylase Unchanged/slight ↑

prothrombin time Unchanged

Total cholesterol and lipids

↑

Fibrinogen ↓

Caeruloplasmin and transferring

↑

Specific binding proteins

↑

Table 4. Hepatic Changes in Normal Pregnancy

Skin changes that are frequently noticed during pregnancy include hyperpigmentation, striae, and increased hair growth



causes. Generalised hyperpigmentation in sun

and pressure exposed sites, palmar creases or

oral mucosa in the context of symptoms of fa-

tigue, weight loss, nausea, vomiting, postural hy-

potension or an autoimmune history may suggest

adrenal insufficiency.

Striae are common due to a combination of

physical and hormonal effects on connective tis-

sue. Pathological causes such as Cushing’s syn-

drome are rare and striae are typically violaceous

with a variety of other stigmata. This should only

be considered if there are other relevant symp-

toms or signs [see article on ‘Thyroid and other

endocrine disorders in pregnancy’].

Women usually notice increased scalp

hair growth during pregnancy, due to a slowing

of progression from the anagen (growing) to

the telogen (resting) phase of the hair cycle. The

percentage of telogen hairs then increases again

post-partum when hair loss is common.

Pruritus occurs in about 20% of pregnant

women and most commonly affects skin around

the abdomen. Pruritus involving the palms and

soles without a rash may be due to intrahepatic

cholestasis of pregnancy in which total serum bile

acid levels are raised or may be due to another

liver-related cause [see article on GI and liver

disorders 2013;23(12):359–363]. [The differen-

tial diagnosis of a pruritic skin rash in pregnancy

is discussed further in the article on ‘Connective

tissue disorders and dermatological disorders in

pregnancy’ 2013;23(3):71–80.]

CONCLUSIONNormal pregnancy requires major systemic and

local organ adaption and may result in symptoms

and signs which may overlap with those asso-

ciated with disease. Knowledge of these altera-

tions allows the clinician to reassure the woman

in most cases, and to promptly investigate further

where indicated. In those with known disease

embarking on pregnancy, the potential impact of

physiological pregnancy-induced changes must

be considered with individually tailored manage-

ment plan.

Further Reading1. Adamson DL, Nelson-Piercy C. Managing palpitations and arrhythmias

during pregnancy. Heart 2007;93:1630–1636.2. Bergman H, Melamed N, Koren G. Pruritus in pregnancy: treatment of

dermatoses unique to pregnancy. Can Fam Physician 2013;59:1290–1294.

3. Carlin A, Alfirevic Z. Physiological changes of pregnancy and monitor-ing. Best Pract Res Clin Obstet Gynaecol 2008;22:801–823.

4. Expert consensus document on management of cardiovascular diseas-es during pregnancy. The task force on the management of cardiovas-cular disease during pregnancy of the European Society of Cardiology. Eur Heart J 2003;24:761–781.

5. Girling JC, Dow E, Smith JH. Liver function tests in pre-eclampsia: importance of comparison with a reference range derived for normal pregnancy. BJOG 1997;104:246–250.

6. Jarvis S, Nelson-Piercy C. Nausea and vomiting in pregnancy. BMJ 2011;342:d3606.

7. Nelson-Piercy C. Handbook of obstetric medicine. 4th edn. London: Informa Healthcare, 2010.

8. Oates M, Harper A, Shakespeare J, Nelson-Piercy C. Back to basics. In: Lewis G, ed. Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Mater-nal Deaths in the UK. BJOG 2011;118 (suppl 1):16–21.

9. Walker I, Chappell LC, Williamson C. Abnormal liver function tests in pregnancy. BMJ 201;347:f6055.

10. Grindheim G, Toska K, Estensen ME, Rosseland LA. Changes in pul-monary function during pregnancy: a longitudinal cohort study. BJOG 2012;119:94–101.

© 2014 Elsevier Ltd. Initially published in Obstetrics, Gynaecology and Re-productive Medicine2014;24(8):245–249.

About the AuthorsSheba Jarvis is an Academic Specialist Registrar in Endocrinology, Diabe-

tes and Obstetric Medicine at Imperial College Healthcare NHS Trust, UK.

Conflicts of interest: none declared. Catherine Nelson-Piercy is a Consult-

ant Obstetric Physician at Guy’s and St Thomas’ Foundation Trust, Impe-

rial College Healthcare Trust and Professor of Obstetric Medicine at King’s

College London, UK. Conflicts of interest: none declared.

Practice Points

• Maternal anatomical and physiological adaptation to normal pregnancy is profound and includes changes in multiple organs from increased cardiac output to reduced gastrointestinal motility.

• pregnancy is commonly associated with new symptoms and/or signs that are associated with disease outside of pregnancy.

• Most of these symptoms and signs are benign and women can be reassured, but clinicians looking after pregnant women should be aware of those which can indicate significant disease and require further investigation.

• This is particularly important for cardiovascular and respiratory symptoms such as dyspnoea and palpitations.

• The clinician must have a good understanding of the adaptations in physiology during pregnancy and how these may affect laboratory results.

• Normal ranges for biochemical and haematological variables may also be altered in pregnancy, and this should be taken into account when interpreting blood results.


255JPOG NOV/DEC 2014IN PRACTICE peer reviewed

Dermatology Clinic: Widespread Rash in a 6-Year-Old BoyGayle Fischer MB BS, MD, FACD

Pityriasis lichenoides chronica (PLC). Note the inflammatory infiltrate obscuring the dermoepidermal junction, apoptotic keratinocytes, and invasion of the epidermis with red blood cells and lymphocytes.

DIFFERENTIAL DIAGNOSISConditions to consider in the differential

diagnosis include the following.

• Guttate psoriasis. This is a very

common form of psoriasis in young

children and is usually precipitated

by a streptococcal throat infection.

The lesions are monomorphous,

red and scaly, but there is never a

vesicular component. This condition

can be of sudden onset and persist

until actively treated. Children usu-

ally have other signs of psoriasis.

Guttate psoriasis has a strong ge-

netic component and there is often

a family history.

• Pityriasis rosea. The cause of pityri-

asis rosea is controversial, but most

experts agree that it behaves like a

viral exanthem.1 However, it may be

a ‘reaction pattern’ with more than

one viral cause. The classic pres-

entation is sudden onset of a sin-

gle lesion (‘herald patch’), which is

followed seven to 14 days later by

smaller similar scaly patches that

can last up to six weeks. Patches

are erythematous and ovoid to cir-

cular in shape, with a ‘collarette of

scale’. Itch is usually absent. Many

variants of pityriasis rosea have

been described, including a vesicu-

lar one, but the condition is invaria-

bly self-limiting.

• Lichen planus. Lichen planus is

not uncommon in adults but it is

an extremely rare eruption in chil-

dren. Its protean manifestations

include vesicles, but the most com-

mon presentation is multiple, flat-

topped, nonscaly papules.

• Pityriasis lichenoides chronica

(PLC). This is the correct diagno-

sis in the case described above.

PLC is a relatively uncommon con-

dition of unknown aetiology, with

clinical presentations that range

from acute to very chronic. In the

vesicular phase, it is often referred

to as pityriasis lichenoides et variol-

iformis acute (PLEVA). It has been

hypothesised that the condition

represents a hypersensitivity reac-

tion to a viral antigen.2

DIAGNOSISPLC has a classic appearance on skin

biopsy, which can be used to confirm a

clinical diagnosis. However, a confident

diagnosis can be made by dermatolo-

gists, particularly in children, based on

the combination of scaly macules and

papules, as well as hypopigmentation

and vesicles when present. The uncom-

mon nature of the rash makes it difficult

for GPs to identify.

The initial rash of PLC is papulove-

sicular and it is often mistaken for chick-

enpox. However, chickenpox resolves in

a few weeks, whereas the lesions of PLC

evolve to crusted papules associated

with pigment change.

MANAGEMENTThe rash of PLC, although harmless, is

often very persistent and can last from

six weeks to months or years. It has

been reported to respond to prolonged

treatment with erythromycin and tetracy-

Answer:


256 JPOG NOV/DEC 2014 IN PRACTICE peer reviewed

Dermatology Clinic: A Linear Lesion on a Girl’s LegGayle Fischer MB BS, MD, FACD

DIAGNOSISMany skin conditions can manifest as

linear lesions. The most likely cause

of the sudden onset of such a lesion

in an 8-year-old child is lichen stria-

tus, a benign, transient linear eruption

that follows the developmental lines of

Blaschko (embryonal lines along which

the skin develops). Lichen striatus is a

self-limiting condition that lasts from a

few months to three years and may at

times relapse. It is not rare and is much

more common in children than adults

(the median patient age is 2 years).

Lichen striatus is usually erythema-

tous but it may be hypopigmented or hy-

perpigmented, particularly in children with

dark skin. It most commonly occurs on

the limbs but can occur anywhere on the

skin surface. It is generally asymptomatic.

The cause of lichen striatus is un-

known. However, it has been postulated

that children who develop it have a ge-

netically different clone of cells as a result

of a postzygotic mutation that reacts to

viral triggers with a persistent eruption.1

DIFFERENTIAL DIAGNOSISConditions to consider in the differential

diagnosis include the following.

• Linear epidermal naevus. This un-

common lesion usually causes the

most diagnostic confusion for linear

lesions in young children because

it is not always obvious at birth and

may present for the first time in tod-

dlers. Linear epidermal naevi may

be erythematous or hyperpigment-

ed and persist for life. They may be

very difficult to differentiate from li-

chen striatus on clinical grounds; a

biopsy will usually differentiate the

two conditions. However, it would

be most unlikely for an epidermal

naevus to appear suddenly in an

8-year-old child.

• Psoriasis. It is well described that

psoriasis can present as a linear le-

sion. However, this is rare and a pa-

tient will often have other signs of

psoriasis.

• Cutaneous larva migrans. This is a

cutaneous infestation by the larvae of

hookworm, most often acquired from

dogs and cats. Children may contract

the infestation from sitting in contam-

inated sand or soil. The migration of

the larvae produces a thin, raised lin-

ear lesion that often has a vesicle at

the advancing edge. Although larva

migrans presents as a linear lesion, it

is not scaly and usually has a very dif-

ferent appearance to lichen striatus.

• Darier’s disease. This rare genoder-

matosis usually presents for the first

time in adolescence or young adult

life as hyperkeratotic papules on the

trunk and limbs associated with nail

changes and sometimes blistering. It

has been described, rarely, as a line-

ar lesion but would be highly unlikely

in an 8-year-old child.

MANAGEMENTThere is no effective treatment for lichen

striatus. The condition is harmless and

self-limiting, so reassurance is all that is

usually needed.

© 2014 Medicine Today Pty Ltd. Initially published in Medicine Today June 2014;15(6):73. Reprinted with permission.

About the AuthorAssociate Professor Fischer is Associate Professor of Der-

matology at Sydney Medical School – Northern, University of

Sydney, Royal North Shore Hospital, Sydney, NSW, Australia.

Competing InterestsNone.

REFERENCES1. Patrizi A, Neri I, Fiorentini C, Bonci A, Ricci G. Lichen

striatus: clinical and laboratory features of 115 children. Pediatr Dermatol 2004;21:197–204.

Answer:

cline, but UVB phototherapy is more reli-

able. Oral retinoids are useful in severe,

persistent cases.

© 2014 Medicine Today Pty Ltd. Initially published in Medicine Today August 2014;15(8):64-65. Reprinted with permission.

About the AuthorAssociate Professor Fischer is Associate Professor of Dermatology at Sydney Medical School – Northern, University of Sydney,Royal North Shore Hospital, Sydney, NSW, Australia.

Competing InterestsNone.

REFERENCES1. Drago F, Broccolo F, Rebora A. Pityriasis rosea: an up-

date with a critical appraisal of its possible herpesviral

etiology. J Am Acad Dermatol 2009;61:303–318.

2. Ersoy-Evans S, Greco MF, Mancini AJ, Subai N, Paller AS.

Pityriasis lichenoides in childhood: a retrospective review of

124 patients. J Am Acad Dermatol 2007;56:205–210


Accr

edite

d C

M E

Accr

edite

dC

ME

257JPOG NOV/DEC 2014CONTINUING MEDICAL EDUCATION

Management of Venous Thromboembolism in PregnancyTam Wing Hung, MBChB (CUHK), MD (CUHK), FRCOG, FHKCOG, FHKAM (O&G)

INTRODUCTIONPregnancy is a proinflammatory state

with activation of endothelial cells while

operative delivery and genital tract in-

jury can result in endothelial damage.

Venous dilatation and compression of

pelvic veins by the gravid uterus en-

courages venous formation in the lower

limbs. The increased levels of coagu-

lant factors such as factors VII and VIII,

fibrinogen, von Willebrand factor and

decreased levels of free protein S favor

coagulation while increased synthesis of

plasminogen activator inhibitors 1 and 2

prohibit fibrinolysis (Table 1). All compo-

nents of the classic Virchow’s triad are

present in pregnancy.

EPIDEMIOLOGY Venous thromboembolism (VTE) is still a

major cause of maternal death in many

developed countries.2-4 It has been the

leading direct cause of maternal death in

the UK since 1985, accounting for 1.94

deaths per 100,000 maternities; but the

figures show a recent reduction to 0.79

per 100,000 maternities in the latest tri-

ennium (Confidential Enquiry into Ma-

ternal and Child Health, 2011). Maternal

mortality of 1.1 to 2.3 per 100,000 mater-

nities was reported in the US. 2,4,5 A lower

figure is reported was Sweden and the

mortality appears to have declined from

1.0 to 0.4 per 100,000 live births from the

1970s to 1990s.6

The overall incidence of pregnan-

cy-related VTE reported worldwide is 1 to

2/1,000 and pregnancy increases a wom-

an’s VTE risk by 4 to 10 times in general.

Data from the US Agency for Healthcare

Research and Quality showed VTE rate

of 1.72 per 1,000 deliveries.5 The risk

was 38% higher for women aged above

35 and was 64% higher among black

women.5 Recent data from the National

Hospital Discharge Survey database and

Venous thromboembolism (VTE) is still a major cause of maternal death in many developed countries.

1 POINT

JPOG_NovDec_2014_CME_HK_Final_Management of Venous Thromboembolism in Pregnancy.indd 257 11/24/14 1:44 PM

258 JPOG NOV/DEC 2014CONTINUING MEDICAL EDUCATION

the US Agency for Healthcare Research

and Quality consistently suggest an in-

creasing trend in pregnancy related VTE

in the US.5,7,8 The latest figure from the

US Agency for Healthcare Research and

Quality reported a 14% increase in the

rate of overall VTE-associated pregnan-

cy hospitalisations, pulmonary embo-

lism (PE); antepartum and postpartum

hospitalisations with VTE increased by

17% and 47%, respectively, from 1994

to 2009.8 A temporal increase in the like-

lihood of a VTE diagnosis in pregnancy

was observed for antepartum hospital-

isations from 2006 to 2009 when com-

pared with antepartum hospitalisations

in 1994 to 1997 (adjusted odds ratio,

1.62;95% CI,1.48-1.78).8

In Scotland, VTE incidence rose

from 1.37 to 1.83 per 1,000 deliveries,

antenatal deep vein thrombosis (DVT)

from 0.88 to 1.22 per 1,000 deliveries

and PE from 0.15 to 0.30 per 1,000 deliv-

eries. Postnatal DVT, on the other hand,

declined from 0.42 to 0.27 per 1,000 de-

liveries. The use of thromboprophylaxis

following emergency caesarean section

(CS) may explain such reduction in the

postnatal period.9

Earlier observations showed that

VTE was rare among Asians, especially

those living in the tropical region. How-

ever, a study conducted by a tertiary unit

in Hong Kong reported an incidence of

1.6 per 1,000 deliveries, but the clinical

presentation and patterns are different.10

An epidemiology study from the Guang-

dong province in the southern part of

China showed a prevalence rate of 1.3

per 1,000 maternities between 2005 and

2010.11 A recent study from Japan also

reported an increasing trend in PE related

to pregnancy and gynaecological surgery

during 1991 and 2000. PE occurred in 0.2

per 1,000 maternities and the rate is 22

times higher after CS. The mortality rate

was 2.5 per 100,000 deliveries.12 In Korea,

a nationwide survey using data from the

Korean Health Insurance Review and As-

sessment Service database also showed

an increasing trend of pregnancy associ-

ated VTE from 0.7 to 1.1 per 10,000 deliv-

eries from 2006 to 2010 and is associated

with increasing maternal age.13

CLINICAL PRESENTATION AND RISK FACTORSVTE can be presented as leg pain, leg

swelling, lower abdominal pain, low-

grade pyrexia, dyspnoea, chest pain,

haemoptysis and collapse. In a recent

meta-analysis including 27 publications,

57.5% of VTE occurred postpartum,

while 21.3%, 22.7% and 56.0% of VTE

occurred during the 1st, 2nd and 3rd tri-

mesters in pregnancy; DVT was reported

to occur in the left, right and both lower

limbs in 73%, 22% and 5% of the cases,

respectively.14 In Caucasians, the ma-

jority of VTE related pregnancy present

as iliofemoral thrombosis, predominant-

ly affecting the left lower limb possibly

because the right iliac artery crosses

anatomically and compresses onto the

left iliac vein. However, the study also

showed that distal DVT could be a com-

mon presentation of VTE among Chi-

nese in pregnancy.10 Similar findings of

predominantly distal DVTs were reported

in asymptomatic non-obstetric patients

at the postoperative period.15-18 Most of

the clots resolved without anticoagu-

lant while a small proportion did propa-

gate.15,16 The discrepancy in the pattern

of presentation could be related to the

Table 1. Changes in the Coagulant Factors in Pregnancy (ACOG Practice Bulletin no.123)1

Coagulant Factors Changes in Pregnancy

Procoagulants

Fibrinogen ⇑

Factor VII ⇑

Factor VIII ⇑

Factor X ⇑

Von Willebrand factor ⇑

Plasminogen activator inhibitor-1 ⇑

Plasminogen activator inhibitor-2 ⇑

Factor II ⇔

Factor V ⇔

Factor IX ⇔

Anticoagulants

Free Protein S ⇓

Protein C ⇔

Antithrombin III ⇔

⇑ increase ; ⇓ decrease; ⇔ no change



vigilance in searching for below-knee

DVT in the unit, as it is still debatable

whether below-knee DVT should be de-

tected.19

Previous VTE, immobility, obesity

(BMI >30), smoking, assisted reproduc-

tion, pre-eclampsia, preterm delivery

and caesarean sections significantly in-

crease the risk of pregnancy-related VTE

by 2.7 to 24.8 times. Other significant

risk factors include thrombophilia, med-

ical conditions such as lupus, heart dis-

ease, sickle cell disease, fluid and elec-

trolyte imbalance, postpartum infection,

and transfusion. The risk factor with the

highest odds ratio, 51.8 (38.7-69.2), was

thrombophilia.5

DIAGNOSIS AND TREATMENT OF ACUTE VTEThe Royal College of Obstetricians and

Gynaecologists (RCOG) suggest that

woman with signs and symptoms of VTE

should undergo compression ultrasound

(CUS) with Doppler as soon as possible

and treatment with low-molecular-weight

heparin (LMWH) until the diagnosis is ex-

cluded by objective testing.17 LMWH can

be discontinued if ultrasound is negative

and there is a low level of clinical sus-

picion. However, woman should remain

anticoagulated if a high level of clinical

suspicion still exists; a repeat CUS or an

alternative diagnostic test is required.

Magnetic resonance venography can be

considered when iliac vein thrombosis is

suspected.1,20

In a situation where clinical sus-

picion of acute PE exists, a chest x-ray

(CXR) should be performed. 1,20,21 CUS

should be performed when CXR is nor-

mal.20 If both tests are negative with per-

sistent clinical suspicion of acute PE,

ventilation–perfusion (V/Q) lung scan or

a computed tomography pulmonary an-

giogram (CTPA) should be performed.

On the other hand, the American Tho-

racic Society and the Society of Thoracic

Radiology (ATS/STR) committee on Pul-

monary Embolism in Pregnancy suggest

proceeding to imaging of the pulmonary

vasculature directly instead of CUS in

pregnant women with suspected PE

without signs and symptoms of DVT.21

Both RCOG and ACOG have no

preference on V/Q lung scan over

CTPA.1,20 Hence the choice between

V/Q scan and CTPA will depend on lo-

cal availability and guidelines. RCOG

also recommends that the ventilation

component of the V/Q scan can be

omitted in order to minimize the radia-

tion dose for the fetus. CTPA may have

advantages over V/Q scan because of

better sensitivity and specificity, and a

lower radiation dose to the fetus.17

CTPA carries a fetal radiation expo-

sure of approximately 0.013 mSv, com-

pared to 0.026 for single detector row

CT, and at least 0.11 mSv for perfusion

component of the V/Q scan 21 (Table 2).

On the contrary, ATS/STR recom-

mend V/Q scan over CTPA in pregnant

women with suspected PE and a normal

CXR.21 However, in case the CXR is ab-

normal in pregnant women with suspect-

ed PE, CTPA is preferred instead of V/Q

scan. The committee also recommends

CTPA over digital subtraction angiog-

raphy (DSA) in case the V/Q scan is

non-diagnostic.21

RCOG suggests that women with

suspected PE should be advised that

V/Q scan carries a slightly increased risk

of childhood cancer compared to CTPA

(1/280,000 vs < 1/1,000,000) but carries

a lower risk of maternal breast cancer

(lifetime risk increased by up to 13.6%

with CTPA based on a background risk

of 1/200).20

Although D-dimer can be a useful

tool to exclude VTE in the non-pregnant

population, D-dimer could neither predict

nor exclude VTE as its level increases

progressively during pregnancy. Recent

studies have shown a modest but steady

rise in D-dimer concentration during the

trimesters in both Chinese and UK popu-

lations. More than 70% and almost 100%

of these women had D-dimer level com-

parable to the cut-off for a positive test

for non-pregnant women by the 2nd and

3rd trimesters.24,25 Both RCOG and ATS/

STR conclude that D-dimer should not

be performed to diagnose acute VTE

and be used to exclude PE.20,21

Subcutaneous adjusted dose

LMWH is the preferred choice for treat-

ing women with acute VTE in pregnancy

Table 2. Fetal Radiation and Maternal Doses Associated With Imaging for the Diagnosis of Pulmonary Embolism.20

Radiological Procedure Fetal Dose (mSv) Maternal Dose (mSv)

Chest x-ray 0.001-0.01 <0.01

Ventilation scan 99mTc 0.01-0.1 0.5

Perfusion scan 99mTc 0.1-0.6 0.6-1

Single slice CTPA 0.03-0.06 1.6-4.0

Multi slice CTPA 0.003-0.1 2-6

Pulmonary angiography >0.5 5-30



as the drug does not cross the placenta

and is safe for the fetus. In general, a

twice-daily dosage regimen is recom-

mended for enoxaparin and dalteparin

because of the changes in the pharma-

cokinetics of LMWH during pregnan-

cy. A recent study also suggests that

once-daily administration of tinzaparin

can be an alternative to the commonly

used twice-daily regimen (Table 3). A

multicentre study reviewing 254 preg-

nant women treated with tinzaparin (175

units/kg) once daily for VTE reported a

low recurrence rate of 2%.26 A patient

who developed PE whilst receiving

treatment for DVT and two women who

suffered from recurrent PE were sub-

sequently managed with a higher daily

dose of tinzaparin without complication;

two other cases recurred only after ces-

sation of treatment.26

Monitoring of anti-Xa activity for pa-

tients on LMWH for treatment of acute

VTE in pregnancy or postpartum is not

necessary except in women at extremes

of body weight (<50 kg and ≥90 kg) or

with other complicating factors (eg, renal

impairment or recurrent VTE).20 Routine

platelet count monitoring is not neces-

sary except when unfractionated hep-

arin (UFH) is used. Compared to UFH,

LMWH is associated with a substantially

lower risk of thrombocytopenia, haemor-

rhage, and osteoporosis.27

Both RCOG and American College

of Chest Physicians (ACCP) do not rec-

ommend the use of vitamin K antago-

nists to treat acute VTE in pregnancy and

recommend LMWH over adjusted dose

UFH.20,28

In massive PE, where the patient

collapses, RCOG guidelines suggest that

a team of experienced clinicians should

be involved in deciding the treatment

course whether it be intravenous (IV)

UFH, thrombolytic therapy or surgical

embolectomy.20 IV UFH is the preferred

treatment in massive PE with cardiovas-

cular compromise.

There has been no study to as-

sess the optimal duration of antico-

agulant therapy for the treatment VTE

during pregnancy. A minimal duration

of 3 months is based on the evidence

from studies in non-pregnant patients.

RCOG/ACCP suggest that therapeutic

anticoagulant therapy should be con-

tinued for at least 6 weeks postpartum

together with a minimum total duration

of 3 months.20,28

Women taking LMWH for mainte-

nance therapy should be advised to with-

hold injection once they have symptoms

of labour. Both RCOG and ACCP recom-

mend discontinuation of LMWH at least 24

hours prior to induction of labour or caesar-

ean section (or expected time of neuraxial

anesthesia).20,28 RCOG, ACCP, ACOG and

the American Society of Regional Anes-

thesia and Pain Medicine guidelines rec-

ommend withholding neuraxial blockage

for 10-12 hours after the last prophylactic

dose of LMWH or 24 hours after the last

therapeutic dose of LMWH. 1,20,28,29

Danaparoid (heparinoid com-

posed of heparin sulphate, dermatan

sulphate and chondroitin sulphate) and

Fondaparinux (a synthetic pentasaccha-

ride acts through specific inhibition of

factor Xa via antithrombin) are seldom

used during pregnancy, therefore, clini-

cal experience in this regard is limited.

Animal experiments and human case

reports suggest minimal transport of

danaparoid across the placenta. On the

contrary, anti-Xa activity about 10% of

that in maternal plasma was found in the

umbilical cord plasma in five newborns

of mothers treated with fondaparinux.

Both RCOG and ACCP suggest limiting

their use to heparin induced thrombocy-

topenia (HIT) and skin allergy to hepa-

rin. However, danaparoid was withdrawn

Table 3. Initial Doses and Regimens of Low Molecular Weight Heparin in Treating Acute VTE Recommended by ACOG, ACCP and RCOG.1,20,28

ACOG 2010 /ACCP 2012

RCOG 2010

Early Pregnancy Weight (kg)

<50 50-69 70-89 >90

Enoxaparin 1 mg/kg Q12h 40 mg bd 60 mg bd 80 mg bd 100 mg bd

Dalteparin 200 IU/kg QD

or

100 IU/kg Q12h

5000 IU bd 6000 IU bd 8000 IU bd 10000 IU bd

Tinzaparin 175 IU/kg once daily



from the US market in 2002.20,28 Newer

anticoagulants, namely oral direct throm-

bin (eg, dabigatran) and anti-Xa (eg, ri-

varoxaban, apixaban) inhibitors should

be avoided during pregnancy.28 Both

dabigatran and its prodrug were found

to have significant placental transfer in a

study based on perfusion model.30 This

may suggest a potential adverse effect

on the fetal coagulation.

In order to reduce the risk of post-

thrombotic syndrome, women with DVT

should be advised to wear class II compres-

sion stocking on the affected leg for 2 years

if swelling persists after the acute event.20

PREVENTION OF VTEWomen should be assessed for the risk

of thrombosis, either in early pregnan-

cy or before pregnancy, and should be

reassessed if circumstances change

or if hospital admission is required. All

women should be educated on general

measures like weight control, hydration,

leg care and mobility. Women at high

risk of VTE in pregnancy, eg, previous

VTE, should be offered pre-pregnancy

counselling to discuss thromboprophy-

laxis. Women with a prior history of VTE

have a relative risk of 3.5 times recur-

rence during subsequent pregnancies.31

The absolute risk of recurrent VTE during

pregnancy without the use of antithrom-

botic prophylaxis is between 2.4% and

7.5%.32,33 The rate of recurrence was

15.5% if the first VTE was unprovoked,

related to pregnancy or oral contracep-

tive use, whereas no recurrence oc-

curred if the first VTE was related to other

transient risk factors.32

The RCOG guideline ranks women

with a history of VTE into very high, high

and moderate risk on the basis of any

associating factors of previous VTE, the

presence of thrombophilia and/or family

history of VTE to recommend the choice

of thromboprophylaxis during pregnan-

cy and puerperium (Table 4). ACCP

also has a similar recommendation on

thromboprophylaxis.28 However, there

are neither large prospective trials nor

randomized clinical trials that compare

different doses of thromboprophylaxis in

pregnant women with prior VTE.

Despite the fact that there have not

been any large randomized-controlled

trials to prove that either antenatal or

postnatal thromboprophylaxis is effec-

tive,34 successive reports from the con-

fidential enquiry into maternal deaths

have suggested that VTE related mortali-

ty is preventable.

RCOG defined certain antenatal

clinical risk factors of VTE and suggests

considering antenatal LMWH prophylax-

is in case there are three or such more

risk factors.35 RCOG also recommends

at least 7 days postnatal prophylaxic

LMWH for women who have intrapartum

Table 4. RCOG Guideline for Thromboprophylaxis in Women with Previous VTE and/or Thrombophilia.35

Risk History Prophylaxis

Very high Previous VTE on long-term warfarin

Antithrombin deficiency

Antiphospholipid syndrome with previous VTE

Antenatal high dose LMWH and at least 6 weeks

Postnatal LMWH/warfarin

Requires specialist management by experts in haemostasis and pregnancy

High Previous recurrent or unprovoked VTE

Previous oestrogen-provoked (pill or pregnancy) VTE

Previous VTE + thrombophilia

Previous VTE + family history of VTE

Asymptomatic thrombophilia (combined defects, homozygous FVL)

Antenatal 6 weeks postnatal prophylactic LMWH

Immediate Single previous VTE associated with transient risk factor no longer present without thrombophilia, family history or other risk factors

Asymptomatic thrombophilia (except antithrombin deficiency, combined defects, homozygous FVL)

Consider antenatal LMWH (but not routinely recommended)

Recommend 6 weeks postnatal prophylactic LMWH

Recommend 7 days (or 6 weeks if family history or other risk factors) postnatal prophylactic LMWH



caesarean section, asymptomatic inher-

ited or acquired thrombophilia, BMI>40

kg/m2, prolonged hospital admission or

medical comorbidities. The duration of

thromboprophylaxis should be extend-

ed if there are more than three factors or

they persist.35 Table 5 lists some of the

risk factors with their adjusted OR.36

Similarly, ACCP also recommends

prophylactic LMWH or mechanical proph-

ylaxis (elastic stockings or intermittent

pneumatic compression) for women at in-

creased risk of VTE after caesarean sec-

tion because of the presence of one major

or at least two minor risk factors.28 ACCP

also recommends prophylactic LMWH

combined with elastic stockings and/or

intermittent pneumatic compression over

LMWH alone in women at very high risk

for VTE and who have multiple addition-

al risk factors for thromboembolism that

persist in the puerperium.28 For selected

high-risk patients in whom significant risk

factors persist following delivery, ACCP

suggest extended prophylaxis (up to 6

weeks after delivery) following discharge

from the hospital. For all pregnant women

with prior VTE, they suggest postpartum

prophylaxis for 6 weeks with prophylactic-

or intermediate-dose LMWH (Table 6) or

vitamin K antagonists.28

Testing for heritable thrombophilia

in selected patients may be helpful to

identify women at risk. Testing selected

patients may give an indication of risk of

recurrence following completion of anti-

coagulant therapy, eg, those presenting

with VTE at an early age (<40 years)

and who are from apparent thrombo-

sis-prone families (ie, more than two

other symptomatic family members).37

This may also influence decisions re-

garding the duration of anticoagulation.

The British Committee for Standards in

Haematology suggests a more discrim-

inative approach in screening heritable

thrombophilas. Women with a previous

VTE due to a minor provoking factor, eg,

travel, should be screened and consid-

ered for prophylaxis if a thrombophilia is

found. Moreover, asymptomatic women

with a family history of venous throm-

bosis may be tested if an event in a

first-degree relative was unprovoked or

provoked by pregnancy, COC exposure

or a minor risk factor. The result will be

more relevant if the first-degree relative

has known thrombophilia.37 The commit-

tee does not support testing for unse-

lected patients with upper limb venous

thrombosis, patients with central venous

catheter-related thrombosis, after a first

episode of cerebral vein thrombosis, ret-

inal vein occlusion or after a first episode

of intra-abdominal vein thrombosis, as

they are of uncertain predictive value for

recurrence.

Table 5. Clinical Risk Factors and their Adjusted Odds Ratio.36

Risk Factor for VTE Adjusted Odds Ratio (95%CI)

Age >35 1.4-1.7

BMI >30 1.7-5.3

Parity ≥3 1.6-2.9

Smoker 1.7-3.4

Immobility 7.7-10.1

Gross varicose veins 2.4

Preeclampsia 3-5.8

Multiple pregnancy 1.6-4.2

Assisted reproductive techniques 2.6-4.3

Table 6. Recommendations to Prevent a First or Recurrent Pregnancy-related VTE (Prophylaxis Could be Prophylactic or Intermediate dose LMWH).35

Weight Enoxaparin Dalteparin Tinzaparin (75 IU/kg/day)

<50 20 mg daily 2500 IU daily 3500 IU daily

50-90 40 mg daily† 5000 IU daily† 4500 unit daily†

91-130 60 mg daily* 7500 IU daily* 7000 unit daily

131-170 80 mg daily* 10000 IU daily* 9000 unit daily*

>170 0.6 mg/kg/day* 75 IU/kg/day* 75 IU/kg/day*

Intermediate dose for women (50-90 kg)

40 mg Q12 h† 5000 IU Q12 h† 4500 IU Q12 h†

*may be given in two divided doses †Prophylactic and intermediate dosages recommended by ACCP 2012.28



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20. RCOG. The acute management thrombo-sis and embolism during pregnancy and the puerperium. Green top guideline No. 37b. 2010.21. Leung AN, Bull TM, Jaeschke R, et al. An official American Thoracic Society/Soci-ety of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmo-nary embolism in pregnancy. American jour-nal of respiratory and critical care medicine 2011;184(10):1200–1208.22. Middeldorp S. Thrombosis in women: what are the knowledge gaps in 2013? Jour-nal of thrombosis and haemostasis : JTH 2013;11 Suppl 1:180–191.23. McLintock C, Brighton T, Chunilal S, et al. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. The Australian & New Zealand journal of obstetrics & gynaecology 2012;52(1):14–22.24. Wang M, Lu S, Li S, Shen F. Reference in-tervals of D-dimer during the pregnancy and puerperium period on the STA-R evolution coagulation analyzer. Clinica chimica acta; international journal of clinical chemistry 2013;425:176–180.25. Murphy N, Broadhurst D, Khashan A, Gilligan O, Kenny L, O’Donoghue K. Ges-tation-specific D-dimer reference ranges: a cross-sectional study. BJOG : an interna-tional journal of obstetrics and gynaecology 2014.26. Nelson-Piercy C, Powrie R, Borg JY, et al. Tinzaparin use in pregnancy: an interna-tional, retrospective study of the safety and efficacy profile. European journal of obstet-rics, gynecology, and reproductive biology 2011;159(2):293–299.27. Greer IA, Nelson-Piercy C. Low-molecu-lar-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy. Blood 2005;106(2):401–407.28. Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic thera-py, and pregnancy: Antithrombotic Thera-py and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Ev-

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REFERENCES

CONCLUSIONVTE is a common cause of maternal

mortality. Although with the more fre-

quent use of thromboprophylaxis there

appears to be a reduction in the inci-

dence of VTE in Western countries, this

trend appears to be rising in several

Asian countries. There are insufficient

large studies to address the effect of

evidence on which to base recommen-

dations for thromboprophylaxis during

pregnancy and the early postnatal peri-

od. Therefore, recommendations on the

prevention of VTE with thromboprophy-

laxis are predominantly based on con-

sensus from expert opinion. Because

of the high case fatality associated

with PE, all obstetric units should have

guidelines on the objective test for diag-

nosis and a protocol with anticoagulant

treatment.


264 JPOG NOV/DEC 2014CME QUESTIONS

CME ARTICLE

Management of Venous Thromboembolism in PregnancyAnswer True or False to the questions below.

1. The incidence of pregnancy-related VTE is 1-2/1,000 in developed countries.

2. Iliofemoral is the most common site for deep vein thrombosis in pregnancy.

3. CXR is the first line of investigation in a case of suspected pulmonary embolism.

4. CT pulmonary angiography carries a higher fetal radiation dose than just a perfusion component of the V/Q scan.

5. D-dimer is a useful test to screen VTE during pregnancy.

6. Recent studies suggest that once-daily administration of tinzaparin can be used to treat VTE in pregnancy.

7. For the treatment of VTE in pregnancy, the anticoagulant should be continued for at least 6 weeks postpartum for a minimum duration of 3 months.

8. It is considered safe to administer epidural anaesthesia if the low molecular weight heparin has been stopped for more than 24 hours.

9. Fondaparinux does not cross the human placenta.

10. Post-thrombotic syndrome is common after DVT in pregnancy and this can be prevented by using a class II compression stocking.

True False

CME Answers for JPOG Sep/Oct 2014HKCOG CME Article: Human Papillomavirus and Cervical Cancer

Answers

1.F 2.F 3.T 4.F 5.T 6.F 7.T 8.T 9.F 10.T

Name in BLOCK CAPITALS: ______________________________

Signature: ______________________________________________

Date: ___________________________________________________Please mail your completed answer sheet back to:The SecretariatHong Kong College of Obstetricians & GynaecologistsRoom 805, Hong Kong Academy of Medicine Jockey Club Building99 Wong Chuk Hang Road, Aberdeen, Hong Kong

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