JPOG December 2014 HK PDF

JOURNAL OF PAEDIATRICS, OBSTETRICS & GYNAECOLOGY
YOUR PARTNER IN PAEDIATRIC AND O&G PRACTICE
HONG KONG
ISSN 1012-8875
nov/dec 2014 Vol. 40 No. 6
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COMMON SYMPTOMS
AND SIGNS DURING
PREGNANCY
PAEDIATRICS
OBSTETRICS
CME ARTICLE
Early Management of
Paediatric Burn Injuries
Sterilisation and Emergency

Contraception
Venous Thromboembolism
in Pregnancy
JPOG NOV/DEC 2014
221
223
NOV/DEC 2014 Vol. 40 No. 6
Journal Watch
Editorial Board
Board Director, Paediatrics
Professor Pik-To Cheung
Associate Professor
Department of Paediatrics
and Adolescent Medicine
The University of Hong Kong
221

Board Director, Obstetrics and Gynaecology
Professor Pak-Chung Ho
Head, Department of
Obstetrics and Gynaecology
Early administration of epidural analgesia during

labour appears to be advantageous
Nicotine replacement therapy during pregnancy
lowers development impairment in infants
222
Professor Biran Affandi
Professor Carmencita D Padilla
Dr Karen Kar-Loen Chan

Professor Seng-Hock Quak

National University of Singapore
Professor Oh Moh Chay
Dr Tatang Kustiman Samsi
University of Indonesia
KK Womens and Childrens Hospital,

Singapore
Associate Professor Anette Jacobsen

Singapore
Professor Rahman Jamal

Singapore
Dr Raman Subramaniam
Dato Dr Ravindran Jegasothy
Professor Walfrido W Sumpaico

Singapore
Dr Siu-Keung Lam
Prestige Medical Centre, Hong Kong
MCU-FDT Medical Foundation,

Philippines

Singapore
Professor Kok Hian Tan
Professor Terence Lao

Dr Kwok-Yin Leung
Professor Surasak
Taneepanichskul
Chulalongkorn University, Thailand
Dr Tak-Yeung Leung
Professor Eng-Hseon Tay
Chinese University of Hong Kong
Professor Tzou-Yien Lin
Chang Gung University, Taiwan
Professor Somsak Lolekha

Ramathibodi Hospital, Thailand
Thomson Women Cancer Centre,

Singapore
Professor PC Wong
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
Adjunct Professor George SH Yeo

Singapore
Professor SC Ng
Professor Hui-Kim Yap

Professor Hextan
Yuen-Sheung Ngan
Professor Tsu-Fuh Yeh

China Medical University, Taiwan
Professor Lucy Chai-See Lum

University of Malaya, Malaysia
223
Professor Cheng Lim Tan

Singapore
Chinese University of Hong Kong
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
Professor Alex Sia
Fetal Medicine and Gynaecology Centre,

Malaysia
Professor Kenneth Kwek
University of Tarumanagara, Indonesia
Universiti Kebangsaan Malaysia

Dean at the Medical Faculty,
MAHSA University, Malaysia
University of the Philippines Manila
JPOG_NovDec_2014_Final_TOC_HK.indd 1
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JPOG NOV/DEC 2014
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233
Review Article
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paediatrics
225
Early Management of Paediatric Burn Injuries
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Burns 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.
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Review Article
Obstetrics
233
Traditional Methods, Sterilisation and
Emergency Contraception - A Practical Guide
to Contraception. Part 3
Traditional 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 longacting reversible contraceptives become more widely available and
accepted.
Mary Stewart, Kathleen McNamee, Caroline Harvey
IN PRACTICE
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Dermatology Clinic: Widespread Rash in a
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Gayle Fischer
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Dermatology Clinic: A Linear Lesion on a
Girls Leg
Gayle Fischer
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Review Article
OBSTETRICS
248
Common Symptoms and Signs During
Pregnancy
During 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
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Management of Venous Thromboembolism
1 POINT
in Pregnancy
Venous 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
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Common Symptoms and Signs During Pregnancy
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JOURNAL WATCH
peer reviewed
JPOG NOV/DEC 2014
221
were excluded. The studies were independently accessed for inclusion criteria
and bias, and the data were extracted
Obstetrics
Early administration
of epidural analgesia
during labour appears
to be advantageous
using a standardised form.

The reviewers did not find a clinically 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-
There is some concern that spinal anaA
algesia was also not found to be significant (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 analgesia 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
Questionnaire
responses
were
analyzed for 891 (88%) of the 1,010 singleton live births, and developmental
outcomes were documented for 888 of
these due to missing data (445 wom-
Women who use nicotine replacement
en in the nicotine replacement therapy
therapy for smoking cessation during
group and 443 placebo recipients). Of
pregnancy are less likely to have infants
the women who underwent nicotine
with developmental impairments 2 years
replacement therapy, 323 (73%) had
after delivery, say UK-based researchers.
infants with no developmental impair-
Their study included 1,050 preg-
ment compared with 290 (65%) placebo
nant women aged 1645 years who were
recipients (odds ratio [OR]=1.40, 95%
at 1224 weeks gestation, had smoked
CI, 1.051.86, p=0.023). Although nic-
10 cigarettes/day before pregnancy,
otine replacement therapy did not have
A Cochrane systematic review suggests
and were smoking at least 5 cigarettes/
any effect on prolonged abstinence
that early administration of epidural anal-
day at the time of the study. The women
from smoking, a temporary doubling of
gesia during labour has similar effects to
were recruited from seven hospitals in
smoking cessation was observed dur-
late administration on all measured lev-
England between May 2007 and Febru-
ing pregnancy shortly after randomiza-
els of outcome.
ary 2010 and were followed up by ques-
tion, and the researchers suggest that

this could explain their findings.
Conducted by researchers in Singa-
tionnaire when their infants were 2 years
pore, this review included 15,752 women
old. The women were randomizsed to
from nine randomized controlled trials.
receive either nicotine replacement ther-
Pregnant term women who requested
apy with 15 mg/16 hour patches (n=521)
epidural in labour were included in this
or matching placebo (n=529) along with
study. Those in preterm labour, with mul-
behavioural smoking cessation support
tiple pregnancies or malposition of fetus,
for up to 8 weeks.
JPOG_NovDec_2014_Final_Combine.indd 221
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/S22132600(14)70157-2.
11/27/14 4:01 PM
222
JOURNAL WATCH
JPOG NOV/DEC 2014
Clomiphene + letrozole
combination therapy effective
in women with PCOS resistant
to each agent alone
peer reviewed
Associations between the frequency
and content of breakfast consumption

and risk factors for type 2 diabetes and
Paediatrics
cardiovascular disease were investigated

in 4,116 UK primary school children aged
Breakfast consumption
ameliorates risk factors for
type 2 diabetes in children
Combination therapy with clomiphene

plus letrozole can induce ovulation
in women with polycystic ovary syndrome (PCOS) who are resistant to clo-
910 years. Data was collected on breakfast frequency, body composition, blood
lipids, insulin, glucose, and HbA1c levels.
In addition, a subgroup of 2,004 children
miphene and letrozole monotherapy,
A cross-sectional study among pri-
say researchers from the United Arab
mary school children in the UK has
Among the 4,116 children studied,
Emirates.
shown that daily breakfast consump-
3,056 (74%) ate breakfast daily, 450
completed a 24 hour dietary recall.
tion reduces levels of fasting insu-
(11%) ate breakfast on most days, 372
who were diagnosed as infertile due to
lin,
(HbA1c),
(9%) on some days, and 238 (6%) did
PCOS. All had initially been placed on
glucose, and urate as well as insulin
not usually eat breakfast. Children who
clomiphene for six cycles followed by
resistance.
did not usually eat breakfast had high-
Their study included 100 women
glycated
haemoglobin
letrozole for four cycles when this proved
er levels of fasting insulin (26.4% differ-
ineffective. When the patients continued to
ence, 95% CI 16.637%), HbA1c (1.2%
be resistant to therapy, they were subse-
difference, 95% CI 0.42%), glucose (1%
quently prescribed a combination of letro-
difference, 95% CI 02%), and urate (6%
zole 5 mg/night and clomiphene 100 mg/
difference, 95% CI 310%) as well as
day (to be taken after lunch) for 5 days.
greater insulin resistance (26.7% differ-
In total, 257 cycles of combination thera-
ence, 95% CI 1737.2%) compared with
py were completed, 213 (82.9%) of which
those who reported having breakfast
were successful in forming a dominant fol-
daily. Moreover, these differences were
licle. The number of mature follicles was
not affected to any great degree by ad-
2.31.1, and the mean endometrial thick-
justments for adiposity, socioeconomic
ness in patients on the day of human cho-
status, and level of physical activity. In-
rionic gonadotropin administration was
sulin resistance was also lower among
8.171.33 mm. A total of 42 pregnancies
children who ate a high fibre cereal
occurred among the 100 patients: 14 dur-
breakfast compared to other types of
ing the first therapy cycle, 15 during the
breakfast.
second, and 13 during the third.

The researchers conclude that in
PCOS patients who are resistant to clomi-
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.
phene and letrozole monotherapy, combination therapy should be trialled before

more aggressive treatments are initiated.
They also suggest that the combination
may be a suitable first-line therapy for inducing ovulation in severe cases of PCOS.
Hajishafiha M et al. Combined letrozole and clomiphene versus
letrozole and clomiphene alone in infertile patients with polycystic ovary syndrome. Drug Des Dev Ther 2014;81427-1431.
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-
11/27/14 4:01 PM
JOURNAL WATCH
peer reviewed
tional intake between the ages of 0 and 5

months, and so a recent study evaluated
the effects of different feeding approaches on nutritional status among this age
JPOG NOV/DEC 2014
Rice and rice products poor

choices for introducing infants
to solid foods, despite their
popularity in Asia Pacific
The
review
analysed
respons-
es from nine studies conducted in five

countries in Asia Pacific: Australia, Vietnam, China, the Maldives, and Japan.
The same questionnaire was adminis-
group in China.
The mother infant nutrition and
Introducing infants to solid foods can be
tered to all participants and included
growth (MING) study was designed to
difficult as both the timing of the intro-
questions on demographics and infant
describe the current nutritional status
duction and the nutritional quality of the
feeding practices.
of pregnant women, lactating mothers,
solid food items introduced have a sig-
The duration of exclusive breast-
infants, and toddlers. Data on 622 in-
nificant impact on infant growth and de-
feeding was less than the optimal 6
fants aged 02 months (225 fed a mix of
velopment. A recent review of common
months recommended by the WHO in
breast milk and complementary foods,
practices in nine countries in Asia Pacific
all studies. The mean age of solid food
144 fed complementary foods alone,
region has highlighted how some choic-
introduction ranged from 3.8 months
and 253 exclusively breastfed) and 456
es, such as rice and rice products, are
in Hangzhou, China, to 5.6 months
infants aged 35 months (145 fed a mix
nutritionally poor. The study also noted
in Japan and the Maldives. The most
of foods, 126 fed, complementary foods
that in some countries infants are com-
common food items chosen for the first
alone and 185 exclusively breastfed) are
monly introduced to solid foods earlier
solid feed were rice or rice products,
reported here. All were obtained using
than recommended by the World Health
except in the Maldives, where a tradi-
24 hour dietary recall in subjects recruit-
Organization (WHO).
tional food containing wheat flour and
ed from eight urban cities in China be-
fish was used, and among Chinese
tween October 2011 and January 2012.
migrants in Australia, who used egg
Among infants aged 02 months
yolk. The researchers comment that
who received a mixture of breast milk
unless fortified, rice and rice products
and complementary foods, approximate-
have insufficient micronutrients and
ly 38.2% received excessive vitamin A
they are lower in energy density than
and 15.6% exceeded the tolerable upper

intake levels of zinc. Conversely, approximately 20% of infants who received only
complementary food had inadequate
223
recommended for infants older than 6

months. They suggest that further education on breastfeeding and healthy
food choices is required.
levels of vitamin A and 12.5% had inadequate levels of zinc. Yet levels of both vitamin A and zinc exceeded the tolerable
Inoue M and Binns CW. Introducing solid foods to infants in the

Asia Pacific region. Nutrients 2014;6:276-288.
upper intake level in half of the remaining

infants. Similar findings were observed
among infants aged 35 months. Compared 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, weightfor-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 cities. Asia Pac J Clin Nutr 2014;23(2):282-292.
Juvenile idiopathic arthritis

associated with pain
hypersensitivity even
in the absence
of active disease
Children with juvenile idiopathic arthritis (JIA) show increased sensitivity to
painful mechanical and thermal stimuli
even in the absence of disease activity
markers.
11/27/14 4:01 PM
224
JOURNAL WATCH
JPOG NOV/DEC 2014
peer reviewed
Children with active and inactive JIA
values to calculate a vaginal health index
had similar sensory detection and pain
before and after the study intervention. In
thresholds and reported low pain scores
addition, symptoms of atrophy and men-
and minimal functional disability. Howev-
opause were evaluated at each study
er, compared with healthy children, those
visit and by daily log books. Circulating
with JIA had generalized hypersensitivity
lipids, liver enzymes, and C-reactive pro-
at the thenar eminence for pressure, light
tein levels were also monitored.
touch, cold, and heat pain.
Significantly better rates of improvement in the integrity of the vaginal epithelium were noted among women who re-
Cornelissen L et al. Pain hypersensitivity in juvenile idiopathic

arthritis: a quantitative sensory testing study. Pediatr Rheumatol 2014;12:39.
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 1.118.95); a ben-
G
Gynaecology
Sea buckthorn oil beneficial
for treating vaginal atrophy
in postmenopausal women
eficial trend was observed when only

compliant participants were evaluated
(OR=2.9, 95% CI 0.998.35).
Larmo PS et al. Effects of sea buckthorn oil intake on vaginal atrophy in postmenopausal women: A randomized, double-blind, placebo-controlled study. Maturitas 2014; http://
dx.doi.org/10.1016/j.maturitas.2014.07.010
Menopause may lead to thinning and

drying of the vaginal mucosa (vaginal atrophy), and the condition is often treated
In a study performed between
with oestrogen therapy. However, oes-
November 2012 and September 2013,
trogen is not appropriate for all women
researchers characterized pain sen-
and sea buckthorn oil appears to be a
sitivity in 60 children aged 717 years
viable alternative, say Finland-based re-
with active JIA by comparing quantita-
searchers.
tive sensory test responses to painful
They investigated the effects of oral
mechanical and thermal stimuli at an
sea buckthorn oil supplementation on
infected inflamed joint with responses
vaginal atrophy among 98 postmeno-
from children in clinical remission. In
pausal women aged 5575 years who
addition, generalized hypersensitivity
were experiencing moderate or severe
was determined by comparing quan-
symptoms of vaginal dryness, itching or
titative sensory test responses at the
burning. The randomized, double-blind
thenar eminence between children with
study was conducted at a private clinic
JIA and healthy controls in Germany
in Finland from October 2012 to March
(n=151) and the US (n=92). Question-
2013, and the women completed 3
naires were also administered to assess
months of treatment with 3 g/day oral sea
pain intensity and frequency, functional
buckthorn oil (n=57) or placebo (n=59).
disability, anxiety, pain catastrophiza-
Vaginal health was assessed by a gynae-
tion, and fatigue.
cologist using vaginal pH and moisture
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L, Mosca M, Fanaro S, Jelinek J, Stahl B, Boehm G. Dosage related bifidogenic e_ects of galacto- and fructo-oligosaccharides in formula-fed term infants. J Pediatr Gastroenterol Nutr 2002;
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10%
Baseline
Week 12
Control Group
Baseline
Week 12
Synbiotics Group
P = 0.012 at Week 12 vs baseline for Synbiotics Group
70%
Week 0
Week 12
Control Group
Week 0
Week 12
Synbiotics Group
P = 0.02 at Week 12 vs Week 0 for Sybiotics Group
For more Cow & Gate scientific evidence, please contact us.
Careline: (852) 3509 2000
www.cowandgate.com.hk
References: 1. Van der Aa LB, Heymans HS, Van Aalderen WM, et al. Effect of a new synbiotic mixture on atopic dermatitis in infants: a
randomized-controlled trial. Clinical & Experimental Allergy, 110 doi: 10.1111/j.1365-2222.2010.03465. 2010 2. Chatchatee P, Rezaiki L, Amor KB,
et al. A synbiotic mixture of scGOS/lcFOS and Bifidobacterium breve M-16V increases faecal bifidobacteria in healthy young children. 2012
3. Chatchatee et al., Presented in International Symposium of Probiotics, Prebiotics in Pediatrics 2012. Istanbul. Turkey. Poster PP-02
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225
Early Management
of Paediatric Burn Injuries
Ioannis Goutos,
BSc (Hons) MBBS (Hons) MRCS;
Michael Tyler,
FRCS (Plast)
Burns 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. 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 reference is made to the provision of optimal pre-hospital first aid and the principles
of specialist management according to UK national guidelines.
EPIDEMIOLOGY AND
PATTERNS OF BURN INJURY
problem accounting for 3.9 deaths per
Burn injuries represent a significant and
ity of paediatric burn injuries affect chil-
potentially preventable epidemiological
dren under the age of 5 years and the
100,000 children worldwide. The major-
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incidence as well as the burns related morbidity
limbs and uniform depth (indicating forced sub-
and mortality are considerably higher in less de-
mersion) as well as the presence of other injuries
veloped parts of the globe including Africa and
(bruising, fractures).
Asia. The mechanisms responsible for paediat-
status. In developed countries, the most com-
PATHOPHYSIOLOGY OF
BURN INJURIES
Cutaneous Changes
mon mechanisms of paediatric thermal injury in
The burned skin exhibits three distinct zones of
descending incidence order include: scalds, con-
circulatory and histological changes as described
tact burns, flame followed by electrical burns and
by Jackson in 1955.
non-accidental injuries.
Zone of coagulation. This represents the area
ric burns vary considerably in different countries

and relate strongly to wealth and socioeconomic
Scalds most commonly affect toddlers and
of skin subject to immediate contact with the
occur in the household setting by spilling a
burning source exhibiting irreversible tissue
container of hot liquid from a height.
necrosis.

Contact burns result from direct contact
Zone of stasis. The immediately surrounding
with hot items left unsupervised and most
area to the zone of coagulation consists of in-
frequently involve the palmar surface of the
jured but viable cells as a result of suboptimal
hand. Young children especially toddlers
perfusion due to oedema and microvascular
are prone to these injuries given that the
damage.
withdrawal reflex is poorly developed and
Zone of hyperaemia. The most outer zone
subsequent freezing of the involved limb is
of the injured skin area shows vasodilata-
observed.
tion, capillary leakage and resulting oedema
Flame injuries tend to affect older children
reaching a zenith at 48 hours post burn; tis-
and occur either as a result of house fires or
sues usually recover within 7-10 days post
ignition of clothing from heating sources.
injury.
Electrical injuries result from placing objects
The Jacksons pathophysiology model un-
into an electricity outlet. A small proportion
derlines the dynamic nature of histological and
of these injuries involve the oral commissure
microcirculatory tissue changes in burns. It is fre-
and occur as a result of children chewing an
quently seen in clinical practice that areas initially
electrical cord.
believed to be superficial in depth declare them-

Non-accidental injuries (NAI) comprise the
selves as deeper areas on repeat assessment.
minority of injuries; nevertheless it is impor-
Optimal management including appropriate first
tant for clinicians involved in paediatric care
aid, resuscitation and dressings/prevention of in-
to identify indicators of such injuries and in-
fection are believed to encourage tissues in the
itiate multidisciplinary liaison incorporating
zone of stasis to recover as opposed to convert
social services.
into the zone of coagulative necrosis.
Pointers in the history of a non-accidental
burn include delayed presentation to healthcare
Systemic Effects of Burn Injuries
facilities, inconsistent history, unusual pattern of
Large burn injuries are associated with a marked
injury/not appropriate for the developmental age
systemic inflammatory response. This is similar
of the child, reported lack of witnesses, and previ-
to the stress response seen in critical illness but
ous involvement of the family with social services.
is characterized by increased severity and dura-
In terms of clinical signs indicating possible
tion. The neuro-hormonal response to the initial
NAI these include symmetrical/crisp margins of
burn injury relies on the release of a variety of
the burn, circumferential nature injuries to lower
vasoactive and inflammatory mediators including
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tumour necrosis factor and interleukins 6, 8.
Inhaling fine carbonaceous material inhaled
These contribute to increased local and systemic
into the lungs causing swelling and cellular
vascular permeability; the augmented secretion
damage. As the chemical pneumonitis pro-
of catabolic hormones (cortisol and catecho-
gresses gaseous exchange worsens and
lamines) as well as the suppression of endog-
thus respiratory distress increases over time
enous activity of anabolic agents (growth hor-
and secondary pneumonia and respiratory
mone and testosterone) contribute to a marked
distress syndrome can follow. Management
increase in metabolic rate, loss of muscle protein
is with humidified oxygen, nebulizers and
and bone mineral density. Interventions that have
physiotherapy, with the respiratory distress
been shown to ameliorate the hypermetabolic
managed sequentially often including intuba-
response to large burn injuries include early
tion in significant cases.
excision of the burned tissue, nutritional support
Inhaling metabolic poisons being inhaled

as well as pharmacological adjuncts including
such as carbon monoxide interrupt cellular
human growth hormone, beta-blockers, and
respiration, leading to headache, confusion
oxandrolone.
and loss of consciousness. Carboxyhaemo-
227
globin measurement is vital in suspected
CLINICAL ASSESSMENT
cases and it is managed by maximizing the
Every burn injury needs to be initially assessed
partial pressure of inspired oxygen. Hydro-
according to the advanced trauma life support
gen cyanide is another metabolic poison
(ATLS) principles with attention to maintaining
found in smoke and can cause mitochondrial
an adequate airway, breathing and circulation.
paralysis leading to profound acidosis. Man-
Once immediately life-threatening problems
agement is supportive.
have been identified and actioned upon, an
Very rarely enough thermal energy is car-
assessment of the total burned surface area
ried to below the vocal cords causing ther-
(TBSA) and depth of injury needs to be under-
mal damage. In reality the heat exchange
taken to allow planning of definitive burn wound
mechanisms above the larynx are so efficient
management.
that only steam caries enough latent heat (of

evaporation) to cause this injury. These cas-
Airway
The presence of possible airway injury in a ther-
es need ventilator support in line with their

respiratory distress.
mally injured child needs to be ruled out as a mat-
Circumferential burns to the torso have the
ter of priority. Swelling of the upper-aero digestive
potential to compromise chest expansion
track can occlude the airway within hours of inju-
and prompt incision through the constricting
ry. Deep burns to the mouth and nose together
burn eschar (escharotomy) is indicated to
with deep burns to the neck will cause such swell-
relieve the limitation on the biomechanics of
ing and therefore must be treated prophylactical-
breathing.
ly with intubation. Late signs of hoarseness and
Mechanisms raising suspicions of airway
stridor require prompt action before endotracheal
or breathing problems include thermal injuries
intubation becomes impossible and emergency
sustained in an enclosed space and decreased
tracheostomy the final resort.
levels of consciousness at the scene of the incident. Pertinent physical findings include burns
Breathing
above the level of the clavicle, singed facial
Exchange of gases within the lung can be disrupted
hair, soot around the mouth and nostrils, car-
in burn injury in four ways, the first and most com-
bonaceous sputum, stridor/wheezing as well as
mon two, can be described as inhalational injuries:
hoarseness.
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Circulation
resuscitation; in clinical practice urine output of
Circumferential deep burns to the limbs can re-
at least 1 ml/kg/hour is the most widely used ad-
sult in ischaemia and irreversible long-term neu-
junct coupled with repeat clinical and biochemical
rological damage and muscle necrosis. Regular
evaluations.
monitoring of the neurovascular status of involved
limbs needs to be initiated and a low threshold
Calculation of TBSA
for escharotomies/ fasciotomies is mandatory to
There is a variety of ways to allow calculation of
avoid catastrophic long-term sequelae.
the total burnt surface area (TBSA). Accurate esti-
Paediatric patients with TBSA of more than
mation of the extent of burns is of paramount im-
10% should be resuscitated with intravenous flu-
portance to allow optimal fluid resuscitation and
ids. The aim of fluid resuscitation is restoration
nutritional support.
of the circulating volume and electrolyte correc-
In the pre-hospital setting the Paediatric
tion avoiding either renal failure and pulmonary
modification of Wallaces rule of nines is fre-
oedema from under and over resuscitation. The
quently used. Wallace divided the body into mul-
most common resuscitation formula used in the
tiple of nines to represent the total body surface
UK is the Parkland formula according to which 4
area in adults (anterior, posterior trunk and each
mL Hartmans solution is given per % TBSA burn
lower limb each corresponding to 18%, each up-
for every kg of weight over the first 24 hours post
per limb and head and neck area 9% and the gen-
burn. The total volume is divided into two aliquots;
itals representing 1%). The head and neck area in
the first is given over the first 8 hours and the next
an infant less than 12 months old is equivalent to
over the following 16 hours.
18% compared to 9% in the adult, while the lower
Maintenance fluid is also required on top of
limbs represent 13.5% as opposed to 18% each.
the resuscitation fluid regimen especially in infants
With each increased year of life, 1% is taken from
less than 3 months old with large (more than 20%
the head and neck area and 0.5% added to each
TBSA) injuries. The most commonly used formula
lower limb until adult proportions are reached at
for calculation of maintenance fluids recommends
the age of 10 years. The modified rule of nines is
100 mL/kg for the first 10 kg of body weight plus
not very accurate in children and should be used
50 mL/kg for the next 10 kg body weight plus 20
to double check the accuracy of TBSA estimation
mL/kg for each extra kg. Most UK burn units use
using other means (e.g. the upper limb cannot
Hartmans solution for resuscitation and 0.45%
represent more than 9% TBSA).
saline and 5% dextrose solution for maintenance
In the hospital setting calculation is made us-
fluids. Normal saline (0.9%) should be avoided
ing a Lund and Browder chart (http://www.cks.
in paediatric resuscitation since there is a risk of
nhs.uk). This is by far the most accurate method
hyperchloraemic acidosis and hypokalaemia and
of calculating the extent of the body surface area
the inclusion of dextrose containing solutions is
involved in burn injuries. The chart represents a
indicated especially in children weighing less
normogram, which assigns certain surface area
than 20 kg to avoid the development of hypogly-
values to individual bodily regions; it takes into ac-
cemia due to the limited glycogen stores in this
count changes in the relative proportions of body
peadiatric patient subgroup. There is controversy
surface area with age and growth. The normo-
regarding the value of colloid use in burns resus-
gram assumes adult values for TBSA at around
citation and currently this should only be com-
the age of 15. The clinician calculates the TBSA
menced in specialist units with the appropriate
by shading the involved regions on the chart and
expertise. A variety of invasive and non-invasive
adding the corresponding body surface areas as
techniques have been described in the literature
indicated by the chart for different age groups to
to allow accurate monitoring of the adequacy of
reach the final TBSA value.
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229
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
patients 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 Depth
Burn 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 categories as described below:
Superficial (1st degree) burns represent injuries
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).
identical to sunburn without blistering; they are

characterized by erythematous painful skin that
heals without scarring with analgesia and mois-
sociated with 92% risk of hypertrophic scarring.
turization.
(Figure 1 shows a typical appearance of a chest

scald with an outer erythematous area of super-
Superficial partial thickness (2
nd
degree) burns
are characterized by the presence of blistering
ficial partial thickness and an inner area of deep

dermal injury).
due to the disruption of the dermoepidermal

junction. They are typically painful, erythematous
Full thickness (4th degree) burns exhibit a leath-
areas of damaged skin with demonstrable capil-
ery dry and anaesthetic appearance and are as-
lary refill on contact and have a wet appearance
sociated with poor functional and aesthetic out-
due to the presence of intact sweat glands. They
comes if not treated with surgical intervention.
normally heal within 2-3 weeks without significant
A very common mistake in the calculation of
scarring; changes in pigmentation (hypo-hyper-
TBSA is the inclusion of simple erythema (denot-
pigmentation) can be seen as a late complication
ing a superficial burn) in calculations by inexpe-
from these injuries. They are mostly treated with
rienced clinicians; only areas corresponding to
regular dressings and analgesia.
superficial partial thickness, deep dermal and full

thickness burns should be accounted for in TBSA
Deep partial thickness (3 degree) injuries are

rd
calculations.
recognized on the basis of lack of capillary refill,
Clinical assessment of the burn depth is
the presence of fixed dermal staining, decreased
challenging with studies reporting accuracy rates
sensation and dry appearance (due to damage
between 50 to 65% and concurrence rates of
of microcirculation, nerves and sweat glands).
only 60 to 80% between experienced surgeons.
Healing typically occurs in weeks to months with
An additional caveat of clinical examination is
dressings hence they are frequently treated with
that burns tend to follow a dynamic course and
excision and split skin grafting. A significant risk
can convert to deeper depths in the first 72 hours
of hypertrophic scarring accompanies these in-
or later based on the Jacksons model of burn
juries, with burns taking over 30 days to heal as-
wound pathophysiology.
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A relatively recent adjunct in assessing burn
In terms of the time lag between the burn
depth is laser doppler imaging (LDI). This modal-
and administration of cooling, it appears that it is
ity relies on indirectly measuring skin blood flow
beneficial even if it is delayed by 1 hour and may
based on the measured frequency shift that hap-
be of benefit up to 3 hours post injury.
pens when moving erythrocytes reflect a near in-
Temporary dressings before transfer to a
frared laser beam emitted from the laser source.
medical facility can include a polyethylene sheet
LDI has a sensitivity of 90% and specificity of 96%
(clingfilm) or a clean cloth; these serve to reduce
in the assessment of paediatric burns when per-
the risk of bacterial colonization, evaporative
formed within 36 and 72 hours from the burn inju-
fluid and heat loss and improve patient comfort
ry. It has additionally been shown to decrease the
by eliminating convective currents across the
time to grafting decision as well as decrease over-
wound surface.
Cooling of the burn wound for 20 minutes with

running water is the gold standard of first aid
all hospital stays by allowing clinicians to make an
HOSPITAL MANAGEMENT
early informed management plan.
The majority of paediatric burn injuries present
Histology of burned tissue is the gold stand-
initially to medical facilities without plastic sur-
ard for depth estimation but can only be used
gery services. The first in- hospital assessment
retrospectively when tissue is sampled for other
is frequently carried out by emergency or paedi-
indications e.g. microbiology cultures as well as
atric physicians. Important steps in accurate as-
in experimental studies. Its clinical application
sessment and management of the burned child
is therefore extremely limited in burn depth eval-
include:
uation.
Approach the paediatric burn victim and

accompanying guardian in a calm and reas-
PRE-HOSPITAL FIRST AID

The pre-hospital management of every burn in-
jury carries a significant bearing on long-term

Ensure that the ambient room and the
outcomes. The recommended first aid steps in-
child are kept warm. In large injuries ne-
clude approaching the victim with care, stopping
cessitating resuscitation, a radiant heater
the burning process (drop and roll if clothing is
should be positioned over the victim to
alight/turn the electricity power off) and provide
minimize heat loss and the risk of hypo-
basic life support. Cooling of the burn wound for
thermia.
Obtain an accurate body weight.
20 minutes with running water is the gold stand-

Opioid-based analgesia (oral or intranasal
ard of first aid; durations of cooling longer than
preparations) are indicated in all but the very
30 minutes have not been found to add any ad-
small injuries to provide comfort during as-
ditional benefit in terms of reducing burn depth.

In paediatric burns affecting a large proportion
of the total body surface area, immediate transfer
suring manner.
sessment and wound cleaning.

Ensure the patient is up to date with tetanus
prophylaxis.
to a medical facility should take priority following
Clean the burn with soap and water to re-
wound coverage with a wet cloth; immersion of a
move loose blisters. This step in initial man-
child in cold water to avert wound depth progres-
agement has multiple functions including the
sion carries an unacceptable risk of hypothermia.
removal of devitalized tissue, prevention of
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burn depth progression (by virtue of eliminating pro-inflammatory cytokines in blisters) 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 undisturbed.
Assess the severity of the injury by calculating the TBSA and depth of the burn.
Liaise with a burns unit/centre regarding further management/transfer and discuss the
need for intravenous access and bladder
catheterization.
Cover the wound with a non-adherent primary dressing e.g. silicone-based product
JPOG NOV/DEC 2014
Table 1. National Network for Burn Care (NNBC) Thresholds for

Referral Paediatric Burn Services
Age: all neonatal burns
TBSA 2% depth: deep dermal and full thickness injuries
Site: 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 injury
Other 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 patients physiology (suggested
parameters include: requirement for inotropic, renal, respiratory
support, base deficit >5 and deteriorating)
along with an absorbent secondary dress-
unwell febrile child with a burn
ing e.g. gauze to minimize heat loss, pro-
burn in association with major trauma
tect from infection and manage burn wound

exudate.
any concern regarding burns in patients with comorbidities which

may affect burn healing
The range of dressings for burn wound man-
suspicion of NAI
agement is vast; the extent (TBSA), depth of burn
231
and physician preferences being key determinants for dressing choice. Superficial partial thick-
areas commonly the thigh/buttock). There is no
ness injuries are commonly treated with silicone-
role for the prophylactic administration of antibiot-
or hydrocolloid-based products if not extensive.
ics in burn injuries.
When the TBSA exceeds 4%, the use of biological

dressings like Biobrane should be considered.
OUTPATIENT MANAGEMENT
Biobrane is a nylon/silicone-based dressing with
The majority of small burn injuries can be man-
impregnated porcine collagen. It is a frequently
aged on an outpatient basis apart from large
used biological product in superficial partial thick-
and deep injuries needing resuscitation, mon-
ness injuries and applied under a general anaes-
itoring and early surgery. A number of injury
thetic following meticulous debridement of blis-
and patient-related factors should prompt re-
ters. It has been shown to reduce discomfort and
ferral to specialist burns facilities according to
hospital visits associated with dressing changes
the UK national network for burn care (NNBC)
using other products including silver sulphadi-
(Table 1).
azine (flamazine) creams.
Once burns are healed, it is vital that appro-
Flamazine still has an important role in man-
priate aftercare is adhered to; this includes mas-
aging infected burn wounds and areas of the
saging and moisturization of the healed wounds/
body difficult to dress including the perineum as
scars, management of sensory symptoms includ-
well as hands and feet.
ing pruritus and psychosocial support to help ad-
Deep dermal and full thickness injuries are
justment and reintegration of victims and families
frequently treated with tangential excision (surgi-
into society. Follow up in plastic surgery clinics
cal removal of non-viable tissue to healthy dermis/
allows the evaluation of burn sequelae including
fat) and application of a split skin graft (harvesting
hypertrophic scarring and the development of
of epidermis and upper dermis from non-burned
contractures.
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Practice Points
peer reviewed
A number of developing countries have initi-

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 nonaccidental 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 patients 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.
PREVENTION
The vast majority of burn injuries in children occur 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 factors. The Haddon matrix considers epidemiological
components
(agent-host-environment
interactions) alongside temporal components

(pre-event, event and post event) to address the
ated national programs for the prevention of burn

injuries focussing on preventative, curative and rehabilitative 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 enabling wider dissemination to local communities.
CONCLUSION
Burn injuries represent a significant and potentially preventable source of morbidity and mortality
worldwide. Optimal management of these injuries
rests on appropriate first aid at the scene of the injury, meticulous assessment at the first receiving
medical facility and referral to specialist burn services according to well-defined national criteria.
In cases of non-accidental injury, multidisciplinary
liaison between the medical team and psychosocial services is of vital importance to safeguard
the welfare of affected children.
Further Reading
1. 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;105:6265.
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 paediatric burns due to scald injury. Burns 2006;32:992999.
4. Greenbaum AR, Donne J, Wilson D, Dunn KW. Intentional burn injury: an
evidence-based, clinical and forensic review. Burns 2004;30:628642.
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;328:14871489.
7. Kim LH, Ward D, Lam L, Holland AJ. The impact of laser Doppler imaging on time to grafting decisions in pediatric burns. J Burn Care Res
2010;31:328332.
8. National Burn Care Review. National burn injury referral guidelines,
Standards and strategy for burn care. London: NBCR, 2001:6869.
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;34:312319.
10. WHO. Facts about injuries: burns. www.who.int/violence_injury) prevention/publications/other_injury/en/burns_factsheet.pdf.
large number of factors contributing to injury and

poor outcomes; this model has been employed to
2013 Elsevier Ltd. Initially published in Paediatrics and Child Health

2013;23(9):391396.
help devise general interventions to prevent accidental burns from all sources across the devel-
About the Authors
oping world. Two of the key components of pre-
Ioannis 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.
ventative interventions include state legislation as

well as education.
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233
A Practical Guide
to Contraception. Part 3:
Traditional Methods,
Sterilisation and
Emergency Contraception
Mary Stewart
MB BS, DFFP, MPH(HEALTH PROMOTION);
Caroline Harvey
Kathleen McNamee
MB BS, FRACGP, DIPVEN, GRADDIPEPIBIO, MEPI;
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 efficacy rates but is being used less as long-acting reversible contraceptives become more widely available and accepted. Emergency contraception has a vital
role in reducing the number of unintended pregnancies.
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Practical information about the barrier methods,
thin latex rubber. Nonlatex condoms are available
the fertility awareness-based methods (FABMs)
in Australia and are an acceptable alternative for
and the withdrawal and lactational amenorrhoea
people with a latex allergy or an aversion or reluc-
methods of contraception as well as permanent
tance to use latex condoms. These polyurethane
methods of fertility control are discussed in this
condoms are more expensive and may be more
third and final article in a series on contraception.
susceptible to breakage than latex types. Polyiso-
Apart from sterilisation, each of these methods
prene condoms are another alternative but are
has a relatively low typical-use efficacy compared
generally only available over the internet. Polyiso-
with modern methods, in particular the long-act-
prene is a synthetic version of latex and condoms
ing reversible contraceptives (LARCs). However,
made of this material may be suitable for people
it is important to acknowledge their role within the
with a latex allergy.
range of contraceptive options available to wom-
Although the male condom is self-lubricated,
en and their partners. Women may value the non-
additional water-based lubricant may be applied
hormonal nature of these methods but should be
to the outside. Oil-based lubricants such as vase-
aware of the more effective nonhormonal copper
line should be avoided with latex products be-
IUD as a highly effective, reversible alternative.
cause they increase breakage.
Emergency contraception is also discussed
Importantly, the male condom is also effec-
in this article. It plays a vital backup role in the
tive at reducing the risk of sexually transmissible
case of unprotected intercourse as well as contra-
infections (STIs) and can be doubled up with
ceptive failure. Informing women about the availa-
another method of contraception to provide dual
bility of emergency contraception is an important
protection against STIs and unintended pregnan-
part of all contraceptive consultations.
cy. It can be used at the same time as all other
The first article in this series covered the
contraceptive methods except for the female con-
short-acting hormonal contraceptives (the com-
dom (there is an increased chance of breakage
bined hormonal methods and the progesto-
and slippage if the two condom types are used
gen-only pill) and the second article discussed the
together). It can also be used to back up other
LARCs. These articles were published in the July/
methods where potential for reduced effective-
August 2014 and the September/October 2014
ness exists, such as when contraceptive pills
issue of the Journal of Paediatrics, Obstetrics &
have been missed or a liver enzyme-inducing
Gynaecology, respectively. The series is based
drug is being used concurrently.
on the publication Contraception: an Australian
Male condoms can be an effective contra-
Clinical Practice Handbook. 3rd ed., published by
ceptive method when used correctly and con-
the Family Planning Organisations of New South
sistently. Effectiveness, with reduced breakage
Wales, Queensland and Victoria.
and slippage, increases with user familiarity and
experience.3 Correct use, including removal
BARRIER METHODS: MALE AND

FEMALE CONDOMS, DIAPHRAGMS
The Male Condom
and disposal, should be demonstrated explic-
The male condom is a single-use sheath that is
important strategy to increase effective condom
rolled on to the erect penis before intercourse and
use.
condom negotiation skills and self-efficacy is an
collects ejaculate and pre-ejaculate secretions in
Emergency contraception can be advised if
the space at its tip. It has the advantage of being
there is condom breakage or slippage. Figures
readily available and relatively inexpensive.
for the percentage of pregnancies occurring in
Male condoms are available in different sizes, colours and flavours, and most are made of
itly, preferably with a penis model. Improving
the first year of use of male condoms are 2% in

perfect use and 18% in typical use.
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235
Figure 1. The Female Condom.
The Female Condom
Emergency contraception is advised if the
The female condom is a loose-fitting lubricated
condom is displaced or torn during intercourse.
polyurethane sheath with a flexible ring at each
Figures for the percentage of pregnancies oc-
end, and collects ejaculate and pre-ejaculate se-
curring in the first year of use of female con-
cretions (Figure 1). It is available in a single size
doms are 5% in perfect use and 21% in typical
and recommended for single use only. It is insert-
use.1
ed into the vagina prior to intercourse, and the
As with the male condom, using the female
penis is guided into the sheath. The inner ring at
condom requires negotiation and, to be effective,
the closed end of the sheath is firm and slides into
requires consistent and correct use. Features that
the vagina to act as an anchor; the outer ring at
can make the female condom an attractive option
the open end spreads over the vulva. Allergy and
for some couples include:
irritation are very rare, and additional water- or oil-
enhanced transmission of body heat by use
based lubricant can be used if required. The con-
of polyurethane rather than latex may im-
doms are quite slippery so practice before inter-
prove sensitivity
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
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
time as other contraceptive methods (except for
condom include:
the male condom) to provide dual protection

more expensive than male condoms (ap-
against STIs and unintended pregnancy.
proximately $3 each)
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Case Study 1. Diaphragms and Emergency Contraception
peer reviewed
serting it intermittently prior to intercourse, some

women choose to use their diaphragm almost con-
Johara comes to see you as she wants to discuss using a diaphragm

for contraception.
tinuously, with removal for washing once in every
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.
struating women because of the small theoretical
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.
are advised to remove it as soon as practical after
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.
30 hours. This practice is only advised for nonmenrisk of toxic shock syndrome during menstruation.
Women using the diaphragm during menstruation
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 advised if the diaphragm is displaced or damaged

limited availability in pharmacies (they are
during or after intercourse (see case study 1). Fig-
also available from family planning clinics
ures for the percentage of pregnancies occurring
and online).
in the first year of use of the diaphragm are 6% in
It is likely that new and more cost-effective fe-
perfect use and 12% in typical use.1
male condoms will be available in Australia in the

future. The potential advantages of a female-con-
Contraindications
trolled device that simultaneously prevents STIs
The diaphragm has no significant medical con-
and unintended pregnancy are significant on a
traindications to its use apart from a history of toxic
global scale. The challenge lies in developing a
shock syndrome. Although toxic shock syndrome
device that is effective and cost-effective at the
is extremely rare, a small case-control study sug-
same time as being acceptable to women and
gested a possible increased risk in women using
their partners.
a diaphragm or cervical cap, particularly during

menses.4 Allergy to silicone is extremely rare.
The Diaphragm
Vaginal or uterine anatomic anomalies in-
The diaphragm is a silicone dome with a flexi-
cluding prolapse may compromise the correct
ble rim that is inserted into the vagina to cover
placement of the device. Some studies suggest
the cervix. The diaphragm acts to prevent sperm
an increased risk of urinary tract infection (UTI)
transport through the cervix and must be kept in
with diaphragm use, particularly in women with
place for at least six hours after intercourse in or-
recurrent infections, although it is difficult to as-
der for the spermatozoa to be incapacitated in the
sess the strength of the association as intercourse
acidic vaginal environment.
itself can result in UTIs.5,6 A diaphragm of a size
A diaphragm costs approximately $90 and

lasts for up to two years. Cervical caps and latex
that does not put undue pressure on the urethra

should be chosen.
diaphragms are no longer available in Australia.

The diaphragm can be inserted many hours
Finding the Correct Fit
before sex and therefore does not necessarily
To use a diaphragm correctly, a woman must
interfere with sexual spontaneity. Rather than in-
feel comfortable about inserting the device and
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confident about feeling the cervix through the dia-
Healthcare,7 spermicidal products are not availa-
phragm to ensure it is covered.
ble in Australia. The additional use of spermicide
Diaphragms are available in sizes 65, 70,
theoretically increases the effectiveness of the
75 and 80 mm diameter. A consultation with a
method, but no study has had sufficient num-
trained practitioner is advised to determine the
bers to show a significant effect.8 It is therefore
correct size and to ensure the woman is able to
recommended by Family Planning Organisations
correctly insert and remove the device. Fitting
that diaphragms can be used without spermi-
after a pregnancy should be deferred until six
cide but that women should be advised that this
weeks postpartum.
method of contraception is less effective than
The correct size is assessed by estimating

the distance from the posterior fornix to the poste-
237
other methods, regardless of the use or nonuse

of spermicide.
rior aspect of the pubic symphysis on pelvic exam-
Women should also be aware that spermi-
ination. Fitting sets are available from the manu-
cides containing nonoxynol-9 as the active ingre-
facturer to aid the consultation. The size should
dient have been shown to cause vaginal mucosal
be reviewed when a diaphragm is replaced, after
irritation leading to an increased susceptibility to
a pregnancy, if the diaphragm becomes uncom-
HIV acquisition.9 Spermicides are therefore not
fortable for either partner or with a weight change
advised in women at high risk of STIs and are not
of 3 kg or more (this may be overly conservative
recommended as a contraceptive on their own
but is based on the recommendations of the UK
because of their low efficacy.1
Faculty of Sexual and Reproductive Healthcare).

phragm varies between women, with some pre-
FERTILITY AWARENESS-BASED
METHODS
ferring to stand with one foot elevated and others
FABMs include all methods based on the identifi-
preferring to squat or lie down. The diaphragm is
cation of the fertile phase of the menstrual cycle.
inserted along the posterior aspect of the vaginal
They rely on predicting times in the menstrual
wall towards the coccyx to cover the cervix; the
cycle when the couple should abstain from un-
cervix should be palpable through the diaphragm.
protected vaginal intercourse. FABMs provide
A correctly fitted diaphragm just allows the inser-
an alternative means of contraception for wom-
tion of a fingertip between the diaphragm rim and
en who prefer to avoid other methods and those
the pubic arch. After successfully inserting and re-
with religious beliefs that discourage the use of
moving the diaphragm in the clinic, women may
other contraceptives. They do, however, require a
wish to trial the diaphragm for a week or so before
thorough understanding of the female reproduc-
review to check its fit and comfort.
tive cycle and commitment to maintaining daily
The most suitable position to insert the dia-
Maintenance of the diaphragm requires

rinsing with warm water and mild unperfumed
vigilance regarding physical changes, signs and

symptoms.
soap after use, patting it dry and storing in its
FABMs are unsuitable for women with irreg-
case away from direct heat. The use of additional
ular or anovulatory menstrual cycles, including
lubricants may lead to slippage but evidence is
those who are breastfeeding or perimenopau-
lacking. The diaphragm should be checked reg-
sal. Their effectiveness may also be affected by
ularly for holes.
life events that have physiological impact on the

menstrual cycle (such as illness).
Spermicidal Use
The effectiveness of FABMs has not been
Although the use of a spermicide with the dia-
documented in the same way as for other meth-
phragm is advised in the product information and
ods of contraception. Perfect and typical effec-
by the UK Faculty of Sexual and Reproductive
tiveness rates are not available for all FABMs.
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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://naturalfertility australia.org.au/about-us).
Symptoms-based Methods
Temperature Method
The temperature method is based on detecting
the rise in body temperature of 0.2 to 0.5C due
to increased levels of progesterone following ovuFigure 2. A Fertility Chart used to Record the Menstrual Cycle and Basal Body
Temperature to Estimate the Fertile Days each Month.
lation. This temperature will remain elevated until

the next period.
In this method, the basal body temperature must be taken immediately on waking and
Percentages of pregnancies occurring in the first
is recorded on a fertility chart (Figure 2). Illness,
year of use of the various methods are quoted to
alcohol, too much or too little sleep and electric
vary from 0.4 to 25%.
blankets can all raise the temperature. The begin-
ning of the fertile time cannot be identified; ovula-
Identification of the Fertile Phase of the

Cycle: Broad Principles
tion is determined retrospectively. Intercourse is
The WHO defines the days of potential fertility for
are three consecutive days of recorded tempera-
a couple during each menstrual cycle as the time
tures that are higher than the preceding six days.
from the first act of intercourse that may lead to
This is the end of the fertile time, and after this it
pregnancy to the demise of the ovum.
is considered safe to have unprotected sex. Use
The survival of sperm in the female genital

tract depends on the presence of alkaline cer-
avoided from the start of menstruation until there
of this method alone may require many days of

abstinence.
vical mucus. Although sperm survive for only a

few hours in the more acidic environment of the
Mucus Methods
vagina, if there are fertile cervical secretions they
Mucus methods are based on daily observation
can typically live to a maximum of five days in the
of the mucus discharge at the vaginal introitus
upper reproductive tract. By seven days, there is
as well as a sensation of wetness or dryness at
a less than 1% probability of sperm survival. By
the vulva. Variations include the Billings Ovulation
contrast, the average life span of the ovum is 12
Method and the 2 Day Method.
10
to 24 hours, with successful fertilisation unlikely

beyond 12 hours after ovulation.
Three patterns of mucus are recognised:

postmenstrual infertile pattern with dense,
flaky, sticky mucus and a feeling of dryness
Overview of FABMs
at the introitus
The several documented FABMs can be broadly

ovulatory or fertile pattern, with rising oes-
classified as symptoms-based methods, calen-
trogen levels as ovulation approaches with
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clearer, more watery and elastic mucus (sim-
Standard Days Method
ilar to egg white) with a feeling of wetness at
The standard days method is a variant of the cal-
the vaginal introitus
endar method. Women who record two cycles
postovulatory pattern related to the rising

that are outside the range of 26 to 32 days in any
level of progesterone immediately after ovu-
year should not use this method. Taking day 1
lation causing the mucus to become cloudy,
as the first day of bleeding, the first fertile day is
thicker and sticky with a feeling of dryness at
considered to be day 8 and the last fertile day is
the introitus.
considered to be day 19; intercourse is avoided
Intercourse is avoided on the days of sub-
239
on days 8 to 19 of the cycle.
jective heavy menstrual bleeding. Intercourse is

permitted on alternate evenings during the time of
WITHDRAWAL
the postmenstrual infertile mucus pattern, and then
Also known as coitus interruptus, the withdraw-
avoided once the fertile pattern is detected and un-
al method is widely used. Although not well re-
til three consecutive dry days have occurred.
searched, it may be relatively effective for those

experienced with its use. It needs to be used con-
Symptothermal Method
sistently, can interfere with sexual spontaneity and
The symptothermal method uses a combination
requires the male partner to have awareness and
of two or more signs of fertility, including chang-
control over his ejaculation. Despite correct use,
es in temperature and cervical mucus secretions.
failure can occur because approximately 40% of
The primary indicator of the beginning of the fer-
men have sperm present in the pre-ejaculate.11
tile phase is the presence of fertile mucus (clear,

phase is confirmed by a combination of basal
LACTATIONAL AMENORRHOEA
METHOD
body temperature and mucus changes.
The lactational amenorrhoea method (LAM) is the
watery, elastic mucus), and the end of the fertile
informed use of breastfeeding for contraception.
Calendar-based Methods
Breastfeeding delays the resumption of ovulation
Because of variability in the day of ovulation be-
postpartum due to prolactin-induced inhibition of
tween cycles, calendar methods of contraception
the release of gonadotropin-releasing hormone
are inherently less effective than symptoms-based
from the hypothalamus and hence luteinising hor-
methods. There are several tools to help with cal-
mone from the pituitary.
endar methods, including a colour-coded system
LAM is an important contraceptive method
of beads (www.cyclebeads.com) and smart-
worldwide, especially in countries where access
phone applications.
to modern methods is limited. Its effectiveness

can be relatively high, up to 98% when all of the
Calendar Method
following criteria are met:
In the calendar (or rhythm) method, at least three
consecutive menstrual cycles must be used to
the woman is less than six months post-delivery
calculate an acceptable range of fertile days. A
the baby is fully breastfed (no supplements)
womans fertile days are calculated by selecting
and there are no long intervals between
the shortest and longest cycle lengths, subtract-
feeds (no more than four hours during the
ing 21 from the shortest cycle and subtracting 10
day or six hours at night, although no defini-
from the longest cycle. Unprotected sex should
tive guidance exists).
be avoided on the fertile days.

The calculation should be reviewed each
month if there is variation in cycle length.
the woman remains amenorrhoeic postpartum
If one or more of these criteria are not met,

the woman should be advised to switch to an alternative method of contraception.
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Female Sterilisation and Vasectomy: Considerations Before Referral
peer reviewed
in the consultation, it is important to talk with

the individual alone about the decision.
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 circumstances 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?
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 possible 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 before the procedure may be a consideration.
Female and male sterilisations are both classified 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
In breastfeeding women, the mean time for
or territory authority.
the return of menses is 28.4 weeks, with a range

from 15 to 48 weeks. However, as some women
Female Sterilisation
may ovulate before the onset of menses, use
Female sterilisation is achieved through occluding
of an additional method of contraception can
or disrupting fallopian tubal patency prevent the
be advised to reduce the risk of a further preg-
sperm fertilising the egg. Techniques include ligat-
nancy.
ing or removing a section of the fallopian tubes,

mechanical blockage using clips, rings, coils or
PERMANENT METHODS:
FEMALE AND MALE STERILISATION
plugs and coagulation induced blockage using
The uptake of female and male sterilisation ap-
will depend on the expertise and preference of the
pears to be decreasing as the use of LARCs is
local gynaecologist as well as the womans medi-
increasing. Despite the potential for reversal of
cal, surgical and obstetric history and preference.
electrical current or chemicals. The method used
some sterilisation methods, success in reversal
Filshie clip application or other tubal ligation,
is both limited and costly. Sterilisation should,
obstruction or destruction methods can be car-
therefore, be regarded as both permanent and
ried out laparoscopically or via laparotomy under
irreversible.
general anaesthetic. They can be performed via

mini laparotomy for postpartum sterilisation or at
Decision-making About Sterilisation
the time of a caesarean section. These methods
The decision to have a sterilisation procedure is
have a failure rate of less than 0.5% per year al-
the individuals alone and does not require part-
though some studies show an increased failure
ner consent. Although a partner may be present
rate in younger women.1,15
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Hysteroscopic transcervical occlusive methods avoid the need for surgical incision and can
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241
Female sterilisation methods are not associated with a change to the menstrual cycle.
be performed under local anaesthetic or light sedation. The Essure technique involves insertion
Reversal
into each fallopian tube of a flexible microinsert
The method of female sterilisation affects the out-
that expands to fill and occlude the tube as a re-
come of reversal. Reversal is most likely if clips
sult of microblast invasion. Complete occlusion
have been applied to the mid-isthmus portion of
and correct positioning of the microinserts should
the tube and much less likely with tubal destruc-
be confirmed radiologically 12 weeks after place-
tive or excisional procedures. Hysteroscopic tran-
ment, and an alternative method of contraception
scervical occlusive methods are completely irre-
must be used during this time. Hysteroscopic
versible. Even after a reversal, only about 50% of
transcervical occlusive sterilisation is complete-
women will achieve a pregnancy.18
ly irreversible. The effectiveness of the Essure

method appears similar to that of other sterilisa-
Male Sterilisation (Vasectomy)
tion methods provided the follow-up protocol is
A vasectomy interrupts the vas deferens to pre-
observed.
vent sperm travelling to the ampulla to mix with
16
Although there are no medical conditions
the prostatic and seminal vesicle fluids. Each
that should restrict a woman from voluntarily
vas is mobilised and transacted through a sin-
undergoing sterilisation, careful consideration is
gle or bilateral scrotal incision. In no-scalpel
required for women younger than 30 years, nul-
vasectomy, a puncture is made through the
liparous women and postpartum women. Women
scrotum and widened sufficiently to external-
who have elevated risks for surgery and general
ise and transect the vas. Vasectomy is usually
anaesthesia may be better suited to a hystero-
carried out in the outpatient or clinic setting by
scopic transcervical occlusive method performed
trained practitioners. Significant medical prob-
under sedation.
lems or a history of scrotal or inguinal surgery
Vasectomy is usually carried out in the outpatient or clinic

setting by trained practitioners
Risks and Side Effects
or trauma usually requires referral to a special-
Tubal sterilisation carries surgical and anaesthetic
ist setting.
risks, including injury to the bowel, bladder or ure-
Careful consideration of the procedure is re-
ter and unsatisfactory placement of clips. Perfo-
quired for men younger than 30 years, men who
ration of the uterus or fallopian tubes, pelvic pain
have not had children and men who are anxious
and failure to achieve microinsert placement can
about sexual function post procedure. Precau-
occur with hysteroscopic transcervical occlusion.
tions are required for previous scrotal injury, a
Mortality rates for tubal sterilisation are low (ap-
large varicocele or hydrocele, inguinal hernia,
proximately four in 100,000 procedures).17
cryptorchidism or clotting disorders. Examination
There is a small risk of failure with female
is appropriate in the primary care setting to ex-
sterilisation and if a pregnancy does occur, the
clude these conditions and to ensure the vasa are
probability of an ectopic pregnancy is increased.
easily palpable. Referral to the specialist setting
Women who have had a pregnancy after sterilisa-
is warranted if the vasa are impalpable or other
tion are at increased risk of another failure.
relative contraindications are present.
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large haematoma usually requires surgical drainage. Infection can result in an abscess requiring
surgical drainage. Epididymo-orchitis results in rapid painful enlargement of the scrotum and is treated
with antibiotics and scrotal support. Haematospermia 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 insignificant. 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 undergone vasectomy. They are not associated with
immunological or other disease but are thought
to reduce the chance of successful pregnancy on
vasectomy reversal.
Reversal
Vasectomy reversal with microsurgical techniques results in a return of sperm to the ejaculate
In no-scalpel vasectomy, a puncture is made through the scrotum and

widened sufficiently to externalise and transect the vas
in 85 to 90% of men. However, only about 60%

of couples achieve a pregnancy after reversal because of the presence of antisperm antibodies,
Semen analysis is performed at 12 weeks

and after a minimum of 20 ejaculations to en-
and rates decline with increasing time since the

original procedure.
sure there are no sperm present in the ejaculate.
In vitro fertilisation (IVF) with intracytoplas-
A small proportion of men do not achieve azoo-
mic sperm injection (ICSI) may also be consid-
spermia but have very low counts of nonmotile
ered by couples wanting to reverse the effects
sperm; in these cases, cautious assurance can
of vasectomy. However, the procedure does not
be provided in consultation with the vasectomy
attract a Medicare rebate for this purpose and an-
provider.
tisperm antibodies may also reduce the chance of
Failure can occur due to technical errors,
a successful pregnancy with IVF.
recanalisation (occurs in about 0.2% of procedures) or unprotected intercourse before confir-
EMERGENCY CONTRACEPTION
mation of azoospermia with semen analysis at
Emergency contraception (EC) is a safe way to
three months.
reduce the risk of pregnancy after unprotected
Vasectomy has a failure rate of 0.1 to 0.15%.
sexual intercourse, sexual assault or potential

contraceptive failure. All women at risk of unin-
Risks and Side Effects
tended pregnancy should be aware of the avail-
The risk of immediate complications with vasecto-
ability of EC methods and be provided with infor-
my procedures is low but may include pain, local
mation about how they work.
bruising, infection and haematoma. A small hae-
The first-line EC method in Australia is a sin-
matoma can be managed with bed rest, elevation
gle dose 1.5 mg tablet of levonorgestrel (LNG-
and support, cold compresses and analgesia. A
EC) taken as soon as possible after unprotected
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Emergency Contraception: Advantages/Disadvantages of Different Types

LNG-EC
Advantages
Cu-IUD
Advantages
No absolute contraindications
Highly effective up to 120 hours postcoitally
Easy dosage schedule
May be used for ongoing contraception
No prescription required
Not affected by drug interactions or gastrointestinal

problems
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
Disadvantages
Disadvantages
Cost may be prohibitive for some women (around $20

to $30, or more)
Inserted and removed by trained practitioner which

limits access
Limited evidence for efficacy between 96 and 120

hours after unprotected sexual intercourse
Contraindications as for Cu-IUDs
Does not provide ongoing contraception
Cost of the device and the insertion procedure may

be prohibitive for some women
Is affected by liver enzyme-inducing drugs (double

dose is recommended)
Nonmenstrual bleed may be mistaken for menses
ABBREVIATIONS: Cu-IUD = copper intrauterine device; EC = emergency contraception; LNG = levonorgestrel.
sexual intercourse, although it is effective if taken
LNG-EC (85%) and provides ongoing long-acting
up to five days after the event. The most important
reversible contraception. Despite these advantag-
issue is that effectiveness declines with time since
es, it is acknowledged that accessing a Cu-IUD
the unprotected sexual intercourse.
quickly can be challenging.
The hormonal EC method using oestrogen as
A new EC method in the form of a selective
well as progestogen (the Yuzp regimen) is no longer
progesterone receptor modulator ulipristal ace-
recommended as it is less effective and associated
tate, has been available in Europe since 2009 and
with a higher risk of vomitin (a 20% risk compared
should be available in Australia in 2015. Ulipristal
with 1% with LNG-EC).19 It should only be used if
acetate provides effective emergency contracep-
LNG-EC is not available. This method requires two
tion up to five days after unprotected sexual in-
doses of combined oral contraceptive pills taken 1
tercourse and appears to have superior effective-
hour apart, each dose containing at least 100 mcg
ness to LN EC at 24, 72 and 120 hours.20
of ethinyloestradiol and 500 mcg of LNG.

A copper intrauterine device (Cu-IUD) provides EC if it is inserted up to five days after un-
A summary of the advantages and disadvantages of available EC methods is provided in the

box on this page.
protected sexual intercourse. It interferes with

sperm movement, inhibits fertilisation by direct
Levonorgestrel EC
toxicity and may prevent implantation of a fertil-
LNG-EC can be taken as a stat 1.5 mg dose of
ised egg. The Cu-IUD is more effective (99%) than
LNG, provided by a single 1.5 mg LNG tablet or
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OBSTETRICS
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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 developing 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 intercourse 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 contraindications 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
Women at risk of unintended pregnancy should be aware of the available
emergency contraception methods
are no medical reason for restricting its use in

very young women. Women who are breastfeeding may continue to feed as the infants exposure
two 0.75 g LNG tablets. Alternatively, two 0.75

mg LNG doses, each made up of twenty-five 30
Women who are currently using or are with-
mcg LNG tablets (progestogen- only contracep-
in 28 days of stopping a liver enzyme inducing
tive pills), can be taken 12 hours apart (or all 50
medication (such as carbamazepine and some
tablets can be taken in one dose). The 1.5 mg
antiretroviral medications) are advised to take
LNG-EC tablet can be purchased without a pre-
a double dose (3.0 mg) of LNG-EC. The cop-
scription at pharmacies as an S3 medication.
per-IUD is the EC method of choice for women
Increasing EC access in the pharmacy setting is
using a potent liver enzyme-inducing medication
supported by the latest Pharmaceutical Society of
such as rifampicin. Common nonliver enzyme-in-
Australia guidelines for the supply of LNG-EC.21
ducing antibiotics do not reduce the effectiveness
LNG-EC primarily acts to prevent or delay
of LNG-EC.
ovulation by interfering with follicular develop-
LNG-EC does not increase the risk of an ec-
ment. It appears to have no effect once the lute-
topic pregnancy and is not associated with reduc-
inising hormone surge has commenced. There is
tion in future fertility.27 It is well tolerated with few
no evidence that it prevents fertilisation or inhibits
side effects. Headache and nausea may occur,
implantation once ovulation has occurred.
with vomiting in approximately 1% of women (the
22
LNG-EC is 85% effective (the effectiveness

of EC is the estimated percentage of pregnan-
dose should be repeated if vomiting occurs within

two hours of administration).
cies prevented which would otherwise have oc-
Menstrual disturbance is common after hor-
curred). It is approved for use up to 72 hours after
monal EC. Most women have a menstrual bleed
23
to LNG is very low.26
11/27/14 4:01 PM
OBSTETRICS
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JPOG NOV/DEC 2014
within seven days of the expected time, but it may
245
Review after Hormonal EC
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-
Review is usually not necessary after LNG-EC but is advised in

some situations.
low-up pregnancy test three weeks after unpro-
Advise a review with a pregnancy test in three to four weeks if:
tected sexual intercourse should be considered.
there is a high risk of pregnancy when hormonal EC is given
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.
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.
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 seven days of use.
Guidance for instances where review after
the provision of LNG-EC may be required is provided in the box on this page, and the practical
application of the advice is illustrated in case
study 2.
CONCLUSION
Although barrier methods of contraception, fertility
awareness-based methods, the lactational amenorrhoea 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 women and their partners. Male and female sterilisation, however, have similar efficacy rates to the
LARCs but are permanent, and their use seems to
Case Study 2. Emergency Contraception

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.
be decreasing with the increasing availability and

acceptability of LARCs. Emergency contraception
has a vital role in the case of unprotected sexual
It is hoped that the three articles in this series
intercourse as well as contraceptive failure, and
A practical guide to contraception will assist in
all women at risk of unintended pregnancy should
raising awareness of all methods of contraception
be aware of it, understand how it works and know
available in Australia. Women in this country have
how to access it.
access to multiple methods of contraception, and
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OBSTETRICS
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Key Points
peer reviewed
an immediate or quick start. Written and webbased information should be provided and is
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.
available through the state and territory Family

Planning Organisations.
The benefit of the LARCs should not be underestimated. 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
Fertility awareness-based methods require an understanding of

the female reproductive cycle and a commitment to daily vigilance
of physical changes, signs and symptoms.
services in Australia. Ensuring that women and
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.
tended pregnancies. Planned pregnancies can
couples have access to effective and acceptable

contraception can reduce the number of uninoptimise 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.
the role of the healthcare practitioner is to provide balanced information in order to facilitate
About the Authors
choice. Consideration of individual medical, so-
Dr 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.
cial and cultural factors as well as personal preferences is essential, and the use of a validated
framework can help in choosing an appropriate
contraceptive method. Some women may prefer to consider their options before initiating a
particular method, whereas others benefit from
Competing Interests
Dr Stewart: None. Dr McNamee and Dr Harvey have provided expert opinion 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.
REFERENCES
1. Trussell J. Contraceptive failure in the
United States. Contraception 2011;83:397
404.
2. Bateson D, Harvey C, McNamee K. Contraception: an Australian clinical practice
handbook. 3rd ed. Brisbane: Family Planning New South Wales, Family Planning
Queensland, Family Planning Victoria;2012.
Messiah A, Dart T, Spencer BE,
3.
Warszawski J. Condom breakage and slippage during heterosexual intercourse: a
French national survey. French National Survey on Sexual Behavior Group (ACSF). Am
J Public Health 1997;87:421424.
4. Schwartz B, Gaventa S, Broome CV, et
al. Nonmenstrual toxic shock syndrome
associated with barrier contraceptives: report of a case-control study. Rev Infect Dis
1989;11(Suppl 1):S43S49.
5. Fihn SD, Latham RH, Roberts P, Running K, Stamm WE. Association between
diaphragm use and urinary tract infection.
JAMA 1985;254:240245.
6. Foxman B, Gillespie B, Koopman J, et al.
Risk factors for second urinary tract infection
among college women. Am J Epidemiol
2000;151:11941205.
7. Clinical Effectiveness Unit. Barrier methods for contraception and STI prevention.
London: Faculty of Sexual and Reproductive
Healthcare;2012.
8. Cook L, Nanda K, Grimes D. The diaphragm with and without spermicide for contraception: a Cochrane review. Hum Reprod
2002;17:867869.
9. Wilkinson D, Tholandi M, Ramjee G, Rutherford GW. Nonoxynol-9 spermicide for
prevention of vaginally acquired HIV and other sexually transmitted infections: systematic
review and meta-analysis of randomised
controlled trials including more than 5000
women. Lancet Infect Dis 2002;2:613617.
10. Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception,
survival of the pregnancy, and sex of the
baby. N Engl J Med 1995;333:15171521.
11. Killick SR, Leary C, Trussell J, Guthrie KA.
Sperm content of pre-ejaculatory fluid. Hum
Fertil (Camb) 2011;14:4852.
12. Curtis KM, Mohllajee AP, Peterson HB.
Regret following female sterilization at a
young age: a systematic review. Contraception 2006;73:205210.
13. Kariminia A, Saunders DM, Chamberlain
M. Risk factors for strong regret and subsequent IVF request after having tubal ligation.
Aust N Z J Obstet Gynaecol 2002;42:526529.
14. Moseman CP, Robinson RD, Bates GW
Jr, Propst AM. Identifying women who will request sterilization reversal in a military population. Contraception 2006;73:512515.
15. Peterson HB, Xia Z, Hughes JM, Wilcox

LS, Tylor LR, Trussell J. The risk of pregnancy after tubal sterilization: findings from the
U.S. Collaborative Review of Sterilization.
Am J Obstet Gynecol 1996;174:11611168;
discussion 11681170.
16. Levy B, Levie MD, Childers ME. A summary of reported pregnancies after hysteroscopic sterilization. J Minim Invasive Gynecol 2007;14:271274.
Peterson HB, DeStefano F, Greenspan
17.
JR, Ory HW. Mortality risk associated with
tubal sterilization in United States hospitals.
Am J Obstet Gynecol 1982;143:125129.
18. Trussell J, Guilbert E, Hedley A. Sterilization failure, sterilization reversal, and pregnancy after sterilization reversal in Quebec.
Obstet Gynecol 2003;101:677684.
19. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency
contraception. Task Force on Postovulatory Methods of Fertility Regulation. Lancet
1998;352:428433.
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;375:555562.
Pharmaceutical Society of Australia.
21.
Guidance for provision of a pharmacist only
medicine: levonorgestrel. Approved indication: emergency contraception. Canberra:

Pharmaceutical Society of Australia;2011.
22. Noe G, Croxatto HB, Salvatierra AM, et al.
Contraceptive efficacy of emergency contraception 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;360:18031810.
24. Piaggio G, Kapp N, von Hertzen H. Effect
on pregnancy rates of the delay in the administration of levonorgestrel for emergency
contraception: a combined analysis of four
WHO trials. Contraception 2011;84:3539.
25. Brent RL. Nongenital malformations following exposure to progestational drugs: the last
chapter of an erroneous allegation. Birth Defects Res A Clin Mol Teratol 2005;73:906918.
26. Gainer E, Massai R, Lillo S, et al. Levonorgestrel pharmacokinetics in plasma and
milk of lactating women who take 1.5 mg
for emergency contraception. Hum Reprod
2007;22:15781584.
27. Cleland K, Raymond E, Trussell J, Cheng
L, Zhu H. Ectopic pregnancy and emergency
contraceptive pills: a systematic review. Obstet Gynecol 2010;115:12631266.
11/27/14 4:01 PM
IN PRACTICE
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247
Dermatology Clinic:
Widespread Rash in a 6-Year-Old Boy

Gayle Fischer
MB BS, MD, FACD
CASE PRESENTATION
A 6-year-old boy presents with a rash that
Figure 1. The Rash on the Patients Trunk at Presentation.
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 macules; 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
been worried that he may have a conta-
night. Nevertheless, his mother is con-
gious condition. The rash has persisted
cerned about it and the boy has been sent
despite treatment with antifungal creams,
home from school by teachers who have
oral antibiotics and topical corticosteroids.
What is the cause of this

boys sudden rash onset?
(Answer on p.255)
Dermatology Clinic:
A Linear Lesion on a Girls Leg

Gayle Fischer
MB BS, MD, FACD
CASE PRESENTATION
An 8-year-old girl presents with a six-
Figure 2. The Linear Lesion on the Girls Leg.
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 despite treatment with mometasone furoate
0.1% cream and miconazole cream.
What is this asymptomatic

lesion occurring on the
girls leg?
(Answer on p.256)
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OBSTETRICS
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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 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, which can result in changes that overlap with those
seen in disease. Additionally, sub-clinical disease can be unmasked during pregnancy, when the physiological adaptation to pregnancy provides an additional stress test.
Common symptoms may include palpitations, dyspnoea, peripheral oedema, 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 investigation 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.
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INTRODUCTION
JPOG NOV/DEC 2014
249
Table 1. Cardiovascular Changes in Normal Pregnancy
During pregnancy, a woman may notice the deof these are widely accepted as a normal part of
Physiological
Variable
Direction
of Change
uncomplicated pregnancy but others may be of
Cardiac output
20% during 1st trimester

40% by 3rd trimester
changes that accompany normal pregnancy are
Heart rate
10-20 beats per minute
profound, and it is therefore not surprising that
Stroke volume
25-30%
as the various systems adapt; this can result in
Plasma volume
30-50%
Red blood cell mass
15-20%
velopment of a number of new symptoms. Many
more concern. The anatomical and physiological
changes which overlap with those seen in disease.

Awareness of the physiological adaptations
during pregnancy is important. The clinician
Blood pressure
3rd trimester
10 mmHg by 2nd trimester

Returns to pre-pregnancy
levels by term
25-30%
Pulmonary vascular
resistance (PVR)
25-30%
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 introduced 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 unmasked during pregnancy, when the physiological adaptation to pregnancy provides an additional stress test.
1st, 2nd trimester
Magnitude
Systemic vascular
resistance (SVR)
Central venous
pressure (CVP)
Unchanged
Pulmonary capillary Unchanged

wedge pressure
(PCWP)
Serum colloid
osmotic pressure
Water and sodium

retention
10-15%
PHYSIOLOGICAL ADAPTATIONS
DURING PREGNANCY
Cardiovascular System
of women, typically along the left sternal edge. A
In normal pregnancy, women may experience
due to cardiac output through the internal jugular
breathlessness, palpitations, decreased exercise
veins) and a mammary souffl (a blowing sound
tolerance, presyncope/syncope, ankle swelling
heard over the breasts) may be found in ~14% of
and may complain of fatigue.
women especially during late pregnancy and lac-
venous hum (heard in upper chest near clavicles
Clinical examination may demonstrate a
tation. This is usually heard continuously through-
sinus tachycardia and there may be a collaps-
out the cardiac cycle but in 30% of women may be
ing pulse. The apex beat may be forceful and
heard only in diastole. In such circumstances, this
displaced (lateral and upwards) and the heart
sign may be misinterpreted as a diastolic murmur.
sounds are louder. Wide splitting of the first heart
The jugular venous pulse may be more conspic-
sound and second heart sounds may be heard
uous in pregnancy but characteristics of the jug-
during the 3rd trimester and a third heart sound
ular venous pressure wave remains unchanged.
may also be present. The presence of a fourth
Peripheral oedema is virtually universal in late
heart sound is usually pathological.
pregnancy. Blood pressure falls in the 1st and 2nd
An ejection systolic murmur (up to grade 2/6)

is heard throughout the praecordium in up to 95%
trimesters, and then increases again in the 3rd trimester, reaching non-pregnant values by term.
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Box 1. Results of Cardiac and Respiratory Investigations during

Normal Pregnancy
peer reviewed
constrict. This predisposes the pregnant woman

to presyncope/ syncope. Overall, plasma volume
is increased, and to a lesser degree red blood cell
Cardio-respiratory Investigations Electrocardiogram (ECG)
mass, which results in reduced haematocrit and
Left axis deviation
a physiological dilutional anaemia. Additionally, a

reduced colloid oncotic pressure and pulmonary
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
capillary wedge pressure gradient increases the

susceptibility of pregnant women to pulmonary
oedema.
Pregnant women are more likely to complain of palpitations than non-pregnant women.
Although asymptomatic arrhythmias are not uncommon in age-matched non-pregnant popu-
Echocardiogram
Valves mildly regurgitant
lations, the combination of haemodynamic, hormonal and autonomic changes may heighten
Valvular annular dilatation
awareness to a previously asymptomatic arrhyth-
Chamber enlargement
mia in pregnancy. Additionally, any pre-existing
Small pericardial effusion
arrhythmia substrate may be more capable of

sustaining an arrhythmia. The most common arrhythmias are simple ventricular or atrial ectopy.
Chest X-ray
Increased cardiothoracic ratio
Increased vascular markings
Most of the cardiovascular adaptations begin early in the 1st trimester, then peak at the end
of the 2nd trimester and are then maintained until term. In later pregnancy, maternal positioning
may have a major effect on cardiac output with
The main cardiovascular changes induced
a marked reduction in venous return, and thus
by pregnancy, that lead to symptoms and signs
stroke volume in the supine as compared to the
are summarised in Table 1. They include in-
lateral position. This has important implications
creased cardiac output, sodium and water re-
for uteroplacental blood flow and placental per-
tention leading to plasma volume expansion, de-
fusion, and can lead to fetal compromise. During
creased systemic vascular resistance (SVR) and
labour, there is an increase in cardiac output and
blood pressure. In early pregnancy, the rise in
rise in blood pressure. Following delivery this
cardiac output is secondary to increased stroke
gradually return to pre-pregnancy levels, but this
volume, whilst with advancing pregnancy, a rise
may take many weeks or even months.
in heart rate occurs to compensate for reduced
It is important to consider alternative diag-
SVR. There is also an increase in vascular com-
noses before dismissing a symptom as physio-
pliance, which is secondary to the alterations in
logical. The use of further investigations should
collagen with smooth muscle remodelling which
be selective but with a high index of suspicion,
underpin the reduction in peripheral vascular
particularly in women with underlying disease or
resistance. As a result of these changes, blood
if symptoms have a sudden onset. Chest pain,
pressure (cardiac output x SVR) falls in the 1st
wheeze or other unexplained symptoms, particu-
and 2nd trimesters, returning to non-pregnancy
larly in women who may originate from areas with
values by term. In addition, decreased barore-
a high incidence of rheumatic fever warrant further
ceptor sensitivity leads to blunted ability of the
investigation. When clinical examination reveals a
sympathetic nervous system to peripherally vaso-
murmur with grade >2/6, or a late- or pan-systol-
11/27/14 4:01 PM
OBSTETRICS
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ic, or any diastolic murmur, further investigation is
JPOG NOV/DEC 2014
251
Table 2. Respiratory Changes in Normal Pregnancy
indicated. Normal changes on ECG, echocardiogram and chest x-ray are shown in Box 1.
Physiological
Variable
Direction
of Change
Respiratory System
Respiratory rate
Unchanged
A common respiratory symptom in up to 70% of
Tidal volume
Up to 40%
pregnant women is dyspnoea or air hunger. This
Minute ventilation
Up to 50%
Vital capacity
Residual volume
Functional residual
capacity
20%
Oxygen
consumption
20%
to the effects of rising progesterone levels, which
FEV1
Unchanged
increases the laxity of ligaments, and the thoracic
PEF
circumference increases by around 8%.
FVC
Respiratory drive
and CO2 sensitivity
minute ventilation (respiratory rate per minute x
PaO2
tidal volume) is increased by up to 40 to 50%
PaCO2
by term. During pregnancy, there is an increase
Arterial pH
is more common in later pregnancy but may develop early in pregnancy, often occurring at rest
or when talking, and may even improve with exercise. As pregnancy advances, anatomical changes 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
Although the respiratory rate remains unchanged in pregnancy, there is a large increase
in tidal volume (from 500 mL to 700 mL), so the
in oxygen consumption giving a relative hyper-
Magnitude
Compensated
respiratory alkalosis
ventilation, which some women may become

aware of. This hyperventilation leads to a rise in
PaO2 and fall in PaCO2, with the latter facilitating
changes in FVC occurring during pregnancy
gas exchange with the fetus. This stimulus for
may persist postpartum.
hyperventilation may be mediated by progester-
Other respiratory symptoms which may be
one, which may lower the threshold or increase
experienced in normal pregnancy overlap with
the sensitivity of the respiratory centre to CO2.
those described in the cardiac section. The pos-
More recently, it has been shown that hyper-
sibility of underlying disease should always be
ventilation results from alterations in acid-base
considered, before a label of physiological dysp-
balance as well as increased wakefulness drive
noea is applied. Any worrying features should
to breathe, increased central chemoreflex sen-
prompt further investigation (Box 2).
sitivity, metabolism and decreased cerebral

blood flow, all of which directly affect ventila-
Renal System
tion. Other changes to the respiratory system
During pregnancy, the kidneys increase by 1 cm
are summarised in Table 2. Of note, there is no
in size with enlargement of the renal pelvis, cal-
change in FEV1 (forced expiratory volume in 1
yces and ureters mediated by changes in blood
second). One recent longitudinal study during
volume and the effects of progesterone. By the
pregnancy has shown that FVC and peak expir-
third trimester, the majority of women will have
atory flow increases from 14-16 weeks gestation
physiological hydronephrosis caused by pres-
and is significantly higher in multiparous women
sure of the gravid uterus and it is important to
compared with primips. This suggests that any
consider this when any renal imaging is undertak-
11/27/14 4:01 PM
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OBSTETRICS
JPOG NOV/DEC 2014
Box 2. Associated Red Flag Features Requiring Further Investigation
peer reviewed
oedema. The cause of urgency and incontinence

is also multifactorial, and both uterine pressure on
Cardio-respiratory Red Flag Symptoms and Signs

Sudden onset
the bladder and hormonal effects on the urethral

suspensory ligaments are implicated.
Peripheral oedema is common, and occurs
Onset near term
in 80% of pregnant women by the end of preg-
Increased respiratory rate
nancy. This is due to increased sodium and water
Chest pain
retention and decreased ability to excrete a sodi-
Sputum production
um and water load, as well as venous stasis relat-
Haemoptysis
ed to the gravid uterus.
Tachycardia (above that of normal pregnancy change)
Haemodynamic and other renal changes are
Cough
summarised in Table 3, and should be consid-
Wheeze
ered when interpreting renal biochemical blood

results in pregnancy.
Fever
Crackles on examination
Pre-existing lung or cardiac disease
Gastrointestinal System
Nausea and vomiting are the most common
symptoms of pregnancy and affect 50 to 90% of
pregnant women. In most cases, this is self-lim-
Table 3. Renal Changes in Normal Pregnancy
iting with resolution by 16-20 weeks gestation.

A more severe form of nausea and vomiting in
pregnancy (hyperemesis gravidarum) affects 0.3
Haemodynamics
Renal blood flow
Glomerular filtration rate (GFR)
Other
to 3% of women.
As pregnancy progresses, the enlarging
uterus alters the function of the gastrointestinal
(GI) tract. Furthermore, progesterone may have
Serum creatinine
effects on the smooth muscle function within the
Plasma osmolality
GI tract, leading to increased relaxation of the
Plasma sodium
lower oesophageal sphincter, increased gas-
Urinary protein excretion
Tubular function
can lead to glycosuria and

aminoaciduria
tro-oesophageal reflux and heartburn. Additionally, 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
en during pregnancy. Common renal symptoms
in around 40% and up to 80% of pregnant women
in pregnancy include urinary frequency, nocturia,
respectively.
urgency and stress incontinence. Up to 95% of
During pregnancy, bile is also more lithogen-
pregnant women complain of frequency, the
ic, predisposing to gallstone formation. Pregnan-
cause of which appears to be multifactorial, sec-
cy has little effect on GI secretion or absorption.
ondary to alteration in bladder function, as well
Women may notice the development of pal-
as the effects of the gravid uterus. There is also
mar erythema or spider naevi during pregnancy.
an increased risk of infection secondary to urinary
These are usually the result of the high oestrogen
stasis. Nocturia is related to increased sodium
levels, and resolve after delivery. Further investi-
and water excretion during the night in pregnan-
gation is only required if there are other features
cy; in part this is due to mobilisation of dependent
of liver disease.
11/27/14 4:01 PM
OBSTETRICS
peer reviewed
Changes in liver biochemistry occur during
JPOG NOV/DEC 2014
253
Table 4. Hepatic Changes in Normal Pregnancy
pregnancy; these must be taken into account
Direction
of Change
Magnitude
Serum albumin falls progressively during preg-
Physiological
Variable
nancy. Alkaline phosphatase rises due to placen-
Serum Albumin
20 to 40% due to
haemodilution
times higher than non-pregnant values; this rise
Total protein
mainly occurs in the third trimester during placen-
ATP
tal growth.
ALT,AST and GGT
Bilirubin
Bile acids
Unchanged
Endocrine
Amylase
Unchanged/slight
There are a variety of changes that occur to endo-
Prothrombin time
Unchanged
crine organs in pregnancy. The pituitary gland en-
Total cholesterol
and lipids
larges with increasing prolactin levels. Pancreatic

tissue undergoes significant change with b-cell
Fibrinogen
Caeruloplasmin
and transferring
Specific binding
proteins
when interpreting hepatic blood results (Table 4).
tal isoenzyme production and may be up to three
[Further information can be found in GI and

liver disorders 2013;23(12):359363.]
hyperplasia and advancing pregnancy leads to

an insulin resistant state that may unmask women
at risk of subsequent type 2 diabetes who develop gestational diabetes.
The thyroid gland undergoes significant
2-4 x (placental)
changes in physiology and size. As a result, pregnant women may complain of neck swelling, as
recognised. [This is described further in the arti-
a small smooth thyroid goitre appears during
cle on Thyroid and other endocrine disorders in
pregnancy. This is rare in areas of adequate io-
pregnancy in edition 2013;23(6):171179].
dine intake but may occur in up to 70% of pregnant women in iodine-deficient areas. Any clinical
Skin
abnormalities in thyroid examination (such as a
Skin changes that are frequently noticed during
nodular gland or sinister features) necessitate
pregnancy include hyperpigmentation, striae, and
further investigation. Thyroid biochemistry is
increased hair growth. Pruritus is also a common
markedly altered during pregnancy with a fall in
symptom.
thyroid stimulating hormone (TSH) during the first
Hyperpigmentation usually occurs in dis-
trimester; this is in part related to the weak thyroid
crete, localised areas, e.g. melasma on the face,
stimulating activity of the structurally homologous
and darkening of the linea alba on the abdomen
Skin changes that are frequently noticed during pregnancy

include hyperpigmentation, striae, and increased hair growth
human chorionic gonadotropin (hCG). In ad-
and skin around the areola. It may be due to oes-
dition, changing trimester specific levels of both
trogen and progesterone stimulation of melano-
TSH and free T4/T3 (with increased total T4/T3
cytes. Generalised hyperpigmentation is more
secondary to raised thyroid binding globulin) are
unusual, and should be investigated further for
11/27/14 4:01 PM
254
OBSTETRICS
JPOG NOV/DEC 2014
Practice Points
peer reviewed
liver-related cause [see article on GI and liver

disorders 2013;23(12):359363]. [The differen-

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.
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):7180.]
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.
CONCLUSION
This is particularly important for cardiovascular and respiratory

symptoms such as dyspnoea and palpitations.
and signs which may overlap with those asso-
The clinician must have a good understanding of the adaptations in

physiology during pregnancy and how these may affect laboratory
results.
tions allows the clinician to reassure the woman

Normal ranges for biochemical and haematological variables
may also be altered in pregnancy, and this should be taken into
account when interpreting blood results.
embarking on pregnancy, the potential impact of
Normal pregnancy requires major systemic and

local organ adaption and may result in symptoms
ciated with disease. Knowledge of these alterain most cases, and to promptly investigate further
where indicated. In those with known disease
physiological pregnancy-induced changes must
be considered with individually tailored management plan.
causes. Generalised hyperpigmentation in sun

and pressure exposed sites, palmar creases or
oral mucosa in the context of symptoms of fatigue, weight loss, nausea, vomiting, postural hypotension or an autoimmune history may suggest
adrenal insufficiency.
Striae are common due to a combination of
physical and hormonal effects on connective tissue. Pathological causes such as Cushings syndrome are rare and striae are typically violaceous
with a variety of other stigmata. This should only
be considered if there are other relevant symptoms 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
Further Reading
1. Adamson DL, Nelson-Piercy C. Managing palpitations and arrhythmias

during pregnancy. Heart 2007;93:16301636.
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 monitoring. Best Pract Res Clin Obstet Gynaecol 2008;22:801823.
4. Expert consensus document on management of cardiovascular diseases during pregnancy. The task force on the management of cardiovascular disease during pregnancy of the European Society of Cardiology.
Eur Heart J 2003;24:761781.
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;104:246250.
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 Maternal Deaths in the UK. BJOG 2011;118 (suppl 1):1621.
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 pulmonary function during pregnancy: a longitudinal cohort study. BJOG
2012;119:94101.
the telogen (resting) phase of the hair cycle. The

percentage of telogen hairs then increases again
post-partum when hair loss is common.
2014 Elsevier Ltd. Initially published in Obstetrics, Gynaecology and Reproductive Medicine2014;24(8):245249.
Pruritus occurs in about 20% of pregnant
women and most commonly affects skin around
About the Authors
the abdomen. Pruritus involving the palms and
Sheba Jarvis is an Academic Specialist Registrar in Endocrinology, Diabe-
soles without a rash may be due to intrahepatic
Conflicts of interest: none declared. Catherine Nelson-Piercy is a Consult-
tes and Obstetric Medicine at Imperial College Healthcare NHS Trust, UK.
cholestasis of pregnancy in which total serum bile
ant Obstetric Physician at Guys and St Thomas Foundation Trust, Impe-
acid levels are raised or may be due to another
College London, UK. Conflicts of interest: none declared.
rial College Healthcare Trust and Professor of Obstetric Medicine at Kings
11/27/14 4:01 PM
IN PRACTICE
peer reviewed
JPOG NOV/DEC 2014
255
Dermatology Clinic:
Widespread Rash in a 6-Year-Old Boy

Gayle Fischer
MB BS, MD, FACD
Answer:
DIFFERENTIAL DIAGNOSIS
Conditions to consider in the differential
diagnosis include the following.

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.
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 usually have other signs of psoriasis.
Guttate psoriasis has a strong genetic component and there is often
a family history.
Pityriasis rosea. The cause of pityri-
dren. Its protean manifestations
clinical diagnosis. However, a confident
asis rosea is controversial, but most
include vesicles, but the most com-
diagnosis can be made by dermatolo-
experts agree that it behaves like a
mon presentation is multiple, flat-
gists, particularly in children, based on
viral exanthem.1 However, it may be
topped, nonscaly papules.
the combination of scaly macules and
a reaction pattern with more than

Pityriasis lichenoides chronica
papules, as well as hypopigmentation
one viral cause. The classic pres-
(PLC). This is the correct diagno-
and vesicles when present. The uncom-
entation is sudden onset of a sin-
sis in the case described above.
mon nature of the rash makes it difficult
gle lesion (herald patch), which is
PLC is a relatively uncommon con-
for GPs to identify.
followed seven to 14 days later by
dition of unknown aetiology, with
The initial rash of PLC is papulove-
smaller similar scaly patches that
clinical presentations that range
sicular and it is often mistaken for chick-
can last up to six weeks. Patches
from acute to very chronic. In the
enpox. However, chickenpox resolves in
are erythematous and ovoid to cir-
vesicular phase, it is often referred
a few weeks, whereas the lesions of PLC
cular in shape, with a collarette of
to as pityriasis lichenoides et variol-
evolve to crusted papules associated
scale. Itch is usually absent. Many
iformis acute (PLEVA). It has been
with pigment change.
variants of pityriasis rosea have
hypothesised that the condition
been described, including a vesicu-
represents a hypersensitivity reac-
MANAGEMENT
lar one, but the condition is invaria-
tion to a viral antigen.
The rash of PLC, although harmless, is
often very persistent and can last from
bly self-limiting.
DIAGNOSIS
six weeks to months or years. It has
not uncommon in adults but it is
PLC has a classic appearance on skin
been reported to respond to prolonged
an extremely rare eruption in chil-
biopsy, which can be used to confirm a
treatment with erythromycin and tetracy-

Lichen planus. Lichen planus is
11/27/14 4:01 PM
256
IN PRACTICE
JPOG NOV/DEC 2014
cline, but UVB phototherapy is more reliable. Oral retinoids are useful in severe,
persistent cases.
About the Author
Associate Professor Fischer is Associate Professor of

Dermatology at Sydney Medical School Northern, University
of Sydney,Royal North Shore Hospital, Sydney, NSW, Australia.
peer reviewed
REFERENCES
1. Drago F, Broccolo F, Rebora A. Pityriasis rosea: an update with a critical appraisal of its possible herpesviral
etiology. J Am Acad Dermatol 2009;61:303318.
2. Ersoy-Evans S, Greco MF, Mancini AJ, Subai N, Paller AS.
2014 Medicine Today Pty Ltd. Initially published in Medicine

Today August 2014;15(8):64-65. Reprinted with permission.
Competing Interests
None.
Pityriasis lichenoides in childhood: a retrospective review of

124 patients. J Am Acad Dermatol 2007;56:205210
Dermatology Clinic:
A Linear Lesion on a Girls Leg

Gayle Fischer MB BS, MD, FACD
Answer:
DIAGNOSIS

Linear epidermal naevus. This un-
migrans presents as a linear lesion, it
Many skin conditions can manifest as
common lesion usually causes the
is not scaly and usually has a very dif-
linear lesions. The most likely cause
most diagnostic confusion for linear
ferent appearance to lichen striatus.
of the sudden onset of such a lesion
lesions in young children because
Dariers disease. This rare genoder
in an 8-year-old child is lichen stria-
it is not always obvious at birth and
matosis usually presents for the first
tus, a benign, transient linear eruption
may present for the first time in tod-
time in adolescence or young adult
that follows the developmental lines of
dlers. Linear epidermal naevi may
life as hyperkeratotic papules on the
Blaschko (embryonal lines along which
be erythematous or hyperpigment-
trunk and limbs associated with nail
the skin develops). Lichen striatus is a
ed and persist for life. They may be
changes and sometimes blistering. It
self-limiting condition that lasts from a
very difficult to differentiate from li-
has been described, rarely, as a line-
few months to three years and may at
chen striatus on clinical grounds; a
ar lesion but would be highly unlikely
times relapse. It is not rare and is much
biopsy will usually differentiate the
in an 8-year-old child.
more common in children than adults
two conditions. However, it would
(the median patient age is 2 years).
be most unlikely for an epidermal
MANAGEMENT
naevus to appear suddenly in an
There is no effective treatment for lichen
8-year-old child.
striatus. The condition is harmless and
Lichen striatus is usually erythematous but it may be hypopigmented or hyperpigmented, particularly in children with
Psoriasis. It is well described that

dark skin. It most commonly occurs on
psoriasis can present as a linear le-
the limbs but can occur anywhere on the
sion. However, this is rare and a pa-
skin surface. It is generally asymptomatic.
tient will often have other signs of
The cause of lichen striatus is un-
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.
psoriasis.
About the Author
known. However, it has been postulated

Cutaneous larva migrans. This is a
that children who develop it have a ge-
cutaneous infestation by the larvae of
Associate Professor Fischer is Associate Professor of Der-
netically different clone of cells as a result
hookworm, most often acquired from
Sydney, Royal North Shore Hospital, Sydney, NSW, Australia.
of a postzygotic mutation that reacts to
dogs and cats. Children may contract
viral triggers with a persistent eruption.
the infestation from sitting in contam-
inated sand or soil. The migration of
DIFFERENTIAL DIAGNOSIS
the larvae produces a thin, raised lin-
Conditions to consider in the differential
ear lesion that often has a vesicle at
diagnosis include the following.
the advancing edge. Although larva
matology at Sydney Medical School Northern, University of
Competing Interests
None.
REFERENCES
1.
Patrizi A, Neri I, Fiorentini C, Bonci A, Ricci G. Lichen
striatus: clinical and laboratory features of 115 children.
Pediatr Dermatol 2004;21:197204.
11/27/14 4:01 PM
JPOG NOV/DEC 2014
CONTINUING MEDICAL EDUCATION
Management of Venous
Thromboembolism
in Pregnancy
257
1 POINT
Tam Wing Hung, MBChB (CUHK), MD (CUHK), FRCOG, FHKCOG, FHKAM (O&G)
INTRODUCTION
Pregnancy is a proinflammatory state
with activation of endothelial cells while
operative delivery and genital tract injury can result in endothelial damage.
Venous dilatation and compression of
pelvic veins by the gravid uterus encourages venous formation in the lower
limbs. The increased levels of coagulant 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 components of the classic Virchows 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
Venous thromboembolism (VTE) is still a major cause of maternal death in many developed
countries.
deaths per 100,000 maternities; but the

figures show a recent reduction to 0.79
mortality appears to have declined from
Data from the US Agency for Healthcare
per 100,000 maternities in the latest tri-
1.0 to 0.4 per 100,000 live births from the
Research and Quality showed VTE rate
ennium (Confidential Enquiry into Ma-
1970s to 1990s.
of 1.72 per 1,000 deliveries.5 The risk
ternal and Child Health, 2011). Maternal
The overall incidence of pregnan-
was 38% higher for women aged above
mortality of 1.1 to 2.3 per 100,000 mater-
cy-related VTE reported worldwide is 1 to
35 and was 64% higher among black
nities was reported in the US. 2,4,5 A lower
2/1,000 and pregnancy increases a wom-
women.5 Recent data from the National
figure is reported was Sweden and the
ans VTE risk by 4 to 10 times in general.
Hospital Discharge Survey database and
JPOG_NovDec_2014_CME_HK_Final_Management of Venous Thromboembolism in Pregnancy.indd 257
11/24/14 1:44 PM
258
JPOG NOV/DEC 2014
Table 1. Changes in the Coagulant Factors in Pregnancy (ACOG Practice

Bulletin no.123)1
Coagulant Factors
2010.11 A recent study from Japan also

reported an increasing trend in PE related
to pregnancy and gynaecological surgery
Changes in Pregnancy
during 1991 and 2000. PE occurred in 0.2
Procoagulants
per 1,000 maternities and the rate is 22

times higher after CS. The mortality rate
Fibrinogen
Factor VII
Factor VIII
Factor X
sessment Service database also showed
Von Willebrand factor
an increasing trend of pregnancy associ-
Plasminogen activator inhibitor-1
Plasminogen activator inhibitor-2
Factor II
Factor V
Factor IX
was 2.5 per 100,000 deliveries.12 In Korea,

a nationwide survey using data from the
Korean Health Insurance Review and As-
ated VTE from 0.7 to 1.1 per 10,000 deliveries from 2006 to 2010 and is associated
with increasing maternal age.13
CLINICAL PRESENTATION
AND RISK FACTORS
VTE can be presented as leg pain, leg
Anticoagulants
swelling, lower abdominal pain, low-
Free Protein S
grade pyrexia, dyspnoea, chest pain,
Protein C
haemoptysis and collapse. In a recent
Antithrombin III
meta-analysis including 27 publications,

57.5% of VTE occurred postpartum,
increase ; decrease; no change
while 21.3%, 22.7% and 56.0% of VTE

occurred during the 1st, 2nd and 3rd tri-
the US Agency for Healthcare Research
antenatal deep vein thrombosis (DVT)
mesters in pregnancy; DVT was reported
and Quality consistently suggest an in-
from 0.88 to 1.22 per 1,000 deliveries
to occur in the left, right and both lower
creasing trend in pregnancy related VTE
and PE from 0.15 to 0.30 per 1,000 deliv-
limbs in 73%, 22% and 5% of the cases,
The latest figure from the
eries. Postnatal DVT, on the other hand,
respectively.14 In Caucasians, the ma-
US Agency for Healthcare Research and
declined from 0.42 to 0.27 per 1,000 de-
jority of VTE related pregnancy present
Quality reported a 14% increase in the
liveries. The use of thromboprophylaxis
as iliofemoral thrombosis, predominant-
rate of overall VTE-associated pregnan-
following emergency caesarean section
ly affecting the left lower limb possibly
cy hospitalisations, pulmonary embo-
(CS) may explain such reduction in the
because the right iliac artery crosses
lism (PE); antepartum and postpartum
postnatal period.
anatomically and compresses onto the
in the US.
5,7,8
hospitalisations with VTE increased by
Earlier observations showed that
left iliac vein. However, the study also
17% and 47%, respectively, from 1994
VTE was rare among Asians, especially
showed that distal DVT could be a com-
to 2009.8 A temporal increase in the like-
those living in the tropical region. How-
mon presentation of VTE among Chi-
lihood of a VTE diagnosis in pregnancy
ever, a study conducted by a tertiary unit
nese in pregnancy.10 Similar findings of
was observed for antepartum hospital-
in Hong Kong reported an incidence of
predominantly distal DVTs were reported
isations from 2006 to 2009 when com-
1.6 per 1,000 deliveries, but the clinical
in asymptomatic non-obstetric patients
pared with antepartum hospitalisations
10
presentation and patterns are different.
at the postoperative period.15-18 Most of
in 1994 to 1997 (adjusted odds ratio,
An epidemiology study from the Guang-
the clots resolved without anticoagu-
1.62;95% CI,1.48-1.78).
dong province in the southern part of
lant while a small proportion did propa-
In Scotland, VTE incidence rose
China showed a prevalence rate of 1.3
gate.15,16 The discrepancy in the pattern
from 1.37 to 1.83 per 1,000 deliveries,
per 1,000 maternities between 2005 and
of presentation could be related to the
11/24/14 1:44 PM
JPOG NOV/DEC 2014
vigilance in searching for below-knee

DVT in the unit, as it is still debatable
259
Table 2. Fetal Radiation and Maternal Doses Associated With Imaging for
the Diagnosis of Pulmonary Embolism.20
whether below-knee DVT should be de-
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
crease the risk of pregnancy-related VTE
Single slice CTPA
0.03-0.06
1.6-4.0
by 2.7 to 24.8 times. Other significant
Multi slice CTPA
0.003-0.1
2-6
risk factors include thrombophilia, med-
Pulmonary angiography
>0.5
5-30
tected.19
Previous VTE, immobility, obesity
(BMI >30), smoking, assisted reproduction, pre-eclampsia, preterm delivery
and caesarean sections significantly in-
ical conditions such as lupus, heart disease, sickle cell disease, fluid and electrolyte imbalance, postpartum infection,
giogram (CTPA) should be performed.
scan. The committee also recommends
and transfusion. The risk factor with the
On the other hand, the American Tho-
CTPA over digital subtraction angiog-
highest odds ratio, 51.8 (38.7-69.2), was
racic Society and the Society of Thoracic
raphy (DSA) in case the V/Q scan is
thrombophilia.5
Radiology (ATS/STR) committee on Pul-
non-diagnostic.21
monary Embolism in Pregnancy suggest
RCOG suggests that women with
DIAGNOSIS AND TREATMENT

OF ACUTE VTE
proceeding to imaging of the pulmonary
suspected PE should be advised that
vasculature directly instead of CUS in
V/Q scan carries a slightly increased risk
The Royal College of Obstetricians and
pregnant women with suspected PE
of childhood cancer compared to CTPA
Gynaecologists (RCOG) suggest that
without signs and symptoms of DVT.21
(1/280,000 vs < 1/1,000,000) but carries
woman with signs and symptoms of VTE
Both RCOG and ACOG have no
a lower risk of maternal breast cancer
should undergo compression ultrasound
preference on V/Q lung scan over
(lifetime risk increased by up to 13.6%
(CUS) with Doppler as soon as possible
CTPA.
Hence the choice between
with CTPA based on a background risk
and treatment with low-molecular-weight
V/Q scan and CTPA will depend on lo-
heparin (LMWH) until the diagnosis is ex-
cal availability and guidelines. RCOG
Although D-dimer can be a useful
cluded by objective testing.17 LMWH can
also recommends that the ventilation
tool to exclude VTE in the non-pregnant
be discontinued if ultrasound is negative
component of the V/Q scan can be
population, D-dimer could neither predict
and there is a low level of clinical sus-
omitted in order to minimize the radia-
nor exclude VTE as its level increases
picion. However, woman should remain
tion dose for the fetus. CTPA may have
progressively during pregnancy. Recent
anticoagulated if a high level of clinical
advantages over V/Q scan because of
studies have shown a modest but steady
suspicion still exists; a repeat CUS or an
better sensitivity and specificity, and a
rise in D-dimer concentration during the
alternative diagnostic test is required.
lower radiation dose to the fetus.
trimesters in both Chinese and UK popu-
1,20
17
of 1/200).20
Magnetic resonance venography can be
CTPA carries a fetal radiation expo-
lations. More than 70% and almost 100%
considered when iliac vein thrombosis is
sure of approximately 0.013 mSv, com-
of these women had D-dimer level com-
suspected.1,20
pared to 0.026 for single detector row
parable to the cut-off for a positive test
CT, and at least 0.11 mSv for perfusion
for non-pregnant women by the 2nd and
component of the V/Q scan 21 (Table 2).
3rd trimesters.24,25 Both RCOG and ATS/
In a situation where clinical suspicion of acute PE exists, a chest x-ray

CUS
On the contrary, ATS/STR recom-
STR conclude that D-dimer should not
should be performed when CXR is nor-
mend V/Q scan over CTPA in pregnant
be performed to diagnose acute VTE
mal.20 If both tests are negative with per-
women with suspected PE and a normal
and be used to exclude PE.20,21
sistent clinical suspicion of acute PE,
CXR.21 However, in case the CXR is ab-
ventilationperfusion (V/Q) lung scan or
normal in pregnant women with suspect-
LMWH is the preferred choice for treat-
a computed tomography pulmonary an-
ed PE, CTPA is preferred instead of V/Q
ing women with acute VTE in pregnancy
(CXR) should be performed.
1,20,21
Subcutaneous
adjusted
dose
11/24/14 1:44 PM
260
JPOG NOV/DEC 2014
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
5000 IU bd
6000 IU bd
8000 IU bd
10000 IU bd
or
100 IU/kg Q12h
Tinzaparin
175 IU/kg once daily
as the drug does not cross the placenta
LMWH is associated with a substantially
hold injection once they have symptoms
and is safe for the fetus. In general, a
lower risk of thrombocytopenia, haemor-
of labour. Both RCOG and ACCP recom-
twice-daily dosage regimen is recom-
rhage, and osteoporosis.27
mend discontinuation of LMWH at least 24
mended for enoxaparin and dalteparin
Both RCOG and American College
hours prior to induction of labour or caesar-
because of the changes in the pharma-
of Chest Physicians (ACCP) do not rec-
ean section (or expected time of neuraxial
cokinetics of LMWH during pregnan-
ommend the use of vitamin K antago-
anesthesia).20,28 RCOG, ACCP, ACOG and
cy. A recent study also suggests that
nists to treat acute VTE in pregnancy and
the American Society of Regional Anes-
once-daily administration of tinzaparin
recommend LMWH over adjusted dose
thesia and Pain Medicine guidelines rec-
can be an alternative to the commonly
UFH.
20,28
ommend withholding neuraxial blockage
used twice-daily regimen (Table 3). A
In massive PE, where the patient
for 10-12 hours after the last prophylactic
multicentre study reviewing 254 preg-
collapses, RCOG guidelines suggest that
dose of LMWH or 24 hours after the last
nant women treated with tinzaparin (175
a team of experienced clinicians should
therapeutic dose of LMWH. 1,20,28,29
units/kg) once daily for VTE reported a
be involved in deciding the treatment
low recurrence rate of 2%.26 A patient
course whether it be intravenous (IV)
posed of heparin sulphate, dermatan
who developed PE whilst receiving
UFH, thrombolytic therapy or surgical
sulphate and chondroitin sulphate) and
treatment for DVT and two women who
embolectomy.
IV UFH is the preferred
Fondaparinux (a synthetic pentasaccha-
suffered from recurrent PE were sub-
treatment in massive PE with cardiovas-
ride acts through specific inhibition of
sequently managed with a higher daily
cular compromise.
factor Xa via antithrombin) are seldom
20
Danaparoid
(heparinoid
com-
dose of tinzaparin without complication;
There has been no study to as-
used during pregnancy, therefore, clini-
two other cases recurred only after ces-
sess the optimal duration of antico-
cal experience in this regard is limited.
sation of treatment.26
agulant therapy for the treatment VTE
Animal experiments and human case
Monitoring of anti-Xa activity for pa-
during pregnancy. A minimal duration
reports suggest minimal transport of
tients on LMWH for treatment of acute
of 3 months is based on the evidence
danaparoid across the placenta. On the
VTE in pregnancy or postpartum is not
from studies in non-pregnant patients.
contrary, anti-Xa activity about 10% of
necessary except in women at extremes
RCOG/ACCP suggest that therapeutic
that in maternal plasma was found in the
of body weight (<50 kg and 90 kg) or
anticoagulant therapy should be con-
umbilical cord plasma in five newborns
with other complicating factors (eg, renal
tinued for at least 6 weeks postpartum
of mothers treated with fondaparinux.
impairment or recurrent VTE).20 Routine
together with a minimum total duration
Both RCOG and ACCP suggest limiting
platelet count monitoring is not neces-
of 3 months.
their use to heparin induced thrombocy-
20,28
sary except when unfractionated hep-
Women taking LMWH for mainte-
topenia (HIT) and skin allergy to hepa-
arin (UFH) is used. Compared to UFH,
nance therapy should be advised to with-
rin. However, danaparoid was withdrawn
11/24/14 1:44 PM
JPOG NOV/DEC 2014
261
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
Antenatal high dose LMWH and at least 6 weeks
Antithrombin deficiency
Postnatal LMWH/warfarin
Antiphospholipid syndrome with previous VTE
Requires specialist management by experts in

haemostasis and pregnancy
Previous recurrent or unprovoked VTE
Antenatal 6 weeks postnatal prophylactic LMWH
High
Previous oestrogen-provoked (pill or pregnancy) VTE

Previous VTE + thrombophilia
Previous VTE + family history of VTE
Asymptomatic thrombophilia (combined defects,
homozygous FVL)
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
from the US market in 2002.20,28 Newer
measures like weight control, hydration,
of thromboprophylaxis during pregnan-
anticoagulants, namely oral direct throm-
leg care and mobility. Women at high
cy and puerperium (Table 4). ACCP
bin (eg, dabigatran) and anti-Xa (eg, ri-
risk of VTE in pregnancy, eg, previous
also has a similar recommendation on
varoxaban, apixaban) inhibitors should
VTE, should be offered pre-pregnancy
thromboprophylaxis.28 However, there
Both
counselling to discuss thromboprophy-
are neither large prospective trials nor
dabigatran and its prodrug were found
laxis. Women with a prior history of VTE
randomized clinical trials that compare
to have significant placental transfer in a
have a relative risk of 3.5 times recur-
different doses of thromboprophylaxis in
rence during subsequent pregnancies.
pregnant women with prior VTE.
be avoided during pregnancy.
28
study based on perfusion model.
30
This
31
may suggest a potential adverse effect
The absolute risk of recurrent VTE during
Despite the fact that there have not
on the fetal coagulation.
pregnancy without the use of antithrom-
been any large randomized-controlled
botic prophylaxis is between 2.4% and
trials to prove that either antenatal or
In order to reduce the risk of postthrombotic syndrome, women with DVT
7.5%.
The rate of recurrence was
postnatal thromboprophylaxis is effec-
should be advised to wear class II compres-
15.5% if the first VTE was unprovoked,
tive,34 successive reports from the con-
sion stocking on the affected leg for 2 years
related to pregnancy or oral contracep-
fidential enquiry into maternal deaths
if swelling persists after the acute event.20
tive use, whereas no recurrence oc-
have suggested that VTE related mortali-
curred if the first VTE was related to other
ty is preventable.
PREVENTION OF VTE
32,33
transient risk factors.
32
RCOG defined certain antenatal
Women should be assessed for the risk
The RCOG guideline ranks women
clinical risk factors of VTE and suggests
of thrombosis, either in early pregnan-
with a history of VTE into very high, high
considering antenatal LMWH prophylax-
cy or before pregnancy, and should be
and moderate risk on the basis of any
is in case there are three or such more
reassessed if circumstances change
associating factors of previous VTE, the
risk factors.35 RCOG also recommends
or if hospital admission is required. All
presence of thrombophilia and/or family
at least 7 days postnatal prophylaxic
women should be educated on general
history of VTE to recommend the choice
LMWH for women who have intrapartum
11/24/14 1:44 PM
262
JPOG NOV/DEC 2014
Table 5. Clinical Risk Factors and their Adjusted Odds Ratio.36
high-risk patients in whom significant risk

factors persist following delivery, ACCP
Risk Factor for VTE
Adjusted Odds Ratio (95%CI)
suggest extended prophylaxis (up to 6
Age >35
1.4-1.7
weeks after delivery) following discharge
BMI >30
1.7-5.3
Parity 3
1.6-2.9
Smoker
1.7-3.4
or intermediate-dose LMWH (Table 6) or
Immobility
7.7-10.1
vitamin K antagonists.28
Gross varicose veins
2.4
Preeclampsia
3-5.8
Multiple pregnancy
1.6-4.2
patients may give an indication of risk of
Assisted reproductive techniques
2.6-4.3
recurrence following completion of anti-
from the hospital. For all pregnant women

with prior VTE, they suggest postpartum
prophylaxis for 6 weeks with prophylactic-
Testing for heritable thrombophilia

in selected patients may be helpful to
identify women at risk. Testing selected
coagulant therapy, eg, those presenting

with VTE at an early age (<40 years)
Table 6. Recommendations to Prevent a First or Recurrent Pregnancy-related

VTE (Prophylaxis Could be Prophylactic or Intermediate dose LMWH).35
and who are from apparent thrombosis-prone families (ie, more than two
other symptomatic family members).37
This may also influence decisions re-
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
inative approach in screening heritable
91-130
60 mg daily*
7500 IU daily*
7000 unit daily
thrombophilas. Women with a previous
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
garding the duration of anticoagulation.

The British Committee for Standards in
Haematology suggests a more discrim-
4500 IU Q12 h
VTE due to a minor provoking factor, eg,

travel, should be screened and considered for prophylaxis if a thrombophilia is
found. Moreover, asymptomatic women

with a family history of venous thrombosis may be tested if an event in a
may be given in two divided doses
Prophylactic and intermediate dosages recommended by ACCP 2012.28

*
first-degree relative was unprovoked or

provoked by pregnancy, COC exposure
or a minor risk factor. The result will be
caesarean section, asymptomatic inher-
pneumatic compression) for women at in-
more relevant if the first-degree relative
ited or acquired thrombophilia, BMI>40
creased risk of VTE after caesarean sec-
has known thrombophilia.37 The commit-
kg/m2, prolonged hospital admission or
tion because of the presence of one major
tee does not support testing for unse-
medical comorbidities. The duration of
or at least two minor risk factors. ACCP
lected patients with upper limb venous
thromboprophylaxis should be extend-
also recommends prophylactic LMWH
thrombosis, patients with central venous
ed if there are more than three factors or
combined with elastic stockings and/or
catheter-related thrombosis, after a first
Table 5 lists some of the
intermittent pneumatic compression over
episode of cerebral vein thrombosis, ret-
LMWH alone in women at very high risk
inal vein occlusion or after a first episode
they persist.
35
risk factors with their adjusted OR.36
28
Similarly, ACCP also recommends
for VTE and who have multiple addition-
of intra-abdominal vein thrombosis, as
prophylactic LMWH or mechanical proph-
al risk factors for thromboembolism that
they are of uncertain predictive value for
ylaxis (elastic stockings or intermittent
persist in the puerperium. For selected
recurrence.
28
11/24/14 1:44 PM
JPOG NOV/DEC 2014
CONCLUSION
Asian countries. There are insufficient
laxis are predominantly based on con-
VTE is a common cause of maternal
large studies to address the effect of
sensus from expert opinion. Because
mortality. Although with the more fre-
evidence on which to base recommen-
of the high case fatality associated
quent use of thromboprophylaxis there
dations for thromboprophylaxis during
with PE, all obstetric units should have
appears to be a reduction in the inci-
pregnancy and the early postnatal peri-
guidelines on the objective test for diag-
dence of VTE in Western countries, this
od. Therefore, recommendations on the
nosis and a protocol with anticoagulant
trend appears to be rising in several
prevention of VTE with thromboprophy-
treatment.
263
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The risk of recurrent venous thromboembolism in pregnancy and puerperium without
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and embolism during pregnancy and the
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of pregnancy-associated venous thromboembolism. The Australian & New Zealand journal of obstetrics & gynaecology
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11/24/14 1:44 PM
264
JPOG NOV/DEC 2014
CME QUESTIONS
This continuing medical education service is brought to you by MIMS. Read the article
Management of Venous Thromboembolism in Pregnancy and answer the following questions.
Answers are shown at the bottom of this page. We hope you enjoy learning with JPOG.
CME ARTICLE
1 POINT
Management of Venous
Thromboembolism in Pregnancy
Answer True or False to the questions below.
True False
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.
Name in BLOCK CAPITALS: ______________________________

Signature: ______________________________________________
Date: ___________________________________________________
Please mail your completed answer sheet back to:
The Secretariat
Hong Kong College of Obstetricians & Gynaecologists
Room 805, Hong Kong Academy of Medicine Jockey Club Building
99 Wong Chuk Hang Road, Aberdeen, Hong Kong
CME Answers
for JPOG Sep/Oct 2014
HKCOG 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
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