Obstetric and neonatal outcomes for women ≥ 45 years of age: a cohort study.

OBJECTIVE: To evaluate outcomes in women ≥ 45 years of age in comparison to a group of women aged 40 to 44 years. MATERIALS AND METHODS: A cohort study was conducted including women ≥ 45 years who delivered at > 24 weeks gestation during the period (1989-2011). Women aged 40 to 44 years formed the comparison group. The maternal demographics, mode of conception, maternal complications, timing and mode of delivery, neonatal features and postpartum complications were included as outcomes. Statistical analyses were performed using the t-test and Chi-square test. RESULTS: There were 67,278 deliveries; 140 occurred in women ≥ 45 years of age, (2.1/1,000). Compared with the 40 to 44 year age group (n = 139), women ≥ 45 years had higher body mass index (26.7 ± 4.7 vs. 24.6 ± 7.1, p = 0.01), and were more likely to have a previous pregnancy loss at < 24 weeks gestation (57.9 vs. 44.6%, p = 0.03). There was no difference in the incidence of maternal complications, preterm delivery, birthweight, Apgar scores or admission to neonatal intensive care. The presence of pre-existing maternal hypertension was associated with a poor outcome. Women ≥ 45 years were more likely to be delivered by cesarean section (45 vs. 30.2%, p = 0.01). CONCLUSION: Women aged ≥ 45 years have comparable outcomes to those aged 40 to 44 years, albeit the presence of pre-existing maternal disease is higher and associated with a poor outcome.

Anticoagulation in the obese patient with COVID-19-associated venous thromboembolism.

A 61-year-old obese man who had recently tested positive for COVID-19 presented to the emergency department following an unwitnessed collapse, with a brief period of unresponsiveness. CT pulmonary angiography confirmed the presence of extensive bilateral pulmonary embolism despite the patient reporting full compliance with long-term dabigatran. The patient was initially anticoagulated with low-molecular-weight heparin and was treated with non-invasive ventilation and dexamethasone for COVID-19 pneumonia. He made a full recovery and was discharged on oral rivaroxaban. His case highlighted some of the common problems encountered when selecting an anticoagulation strategy for obese patients, as well as the lack of definitive evidence to guide treatment decisions. These challenges were further complicated by our incomplete understanding of the underlying mechanisms of COVID-19 coagulopathy, with limited data available regarding the optimal management of thromboembolic complications.

First recurrence of small cell lung cancer presenting as subacute monoarticular arthritis.

We describe a case of recurrent small cell lung cancer presenting as an acute monoarticular arthritis. This patient had recently undergone comprehensive review and surveillance imaging under a local oncology unit, 18 months after undergoing chemoradiotherapy for limited disease small cell lung cancer. He had presented to the emergency department on multiple occasions and been managed as an outpatient for a provisional diagnosis of spontaneous haemarthrosis in the setting of rivaroxaban therapy. Subsequent investigation revealed occult fracture of the distal femur with joint effusion, secondary to isolated metastatic disease from recurrent small cell lung cancer. This case demonstrates the importance of reconsidering differential diagnoses when a patient's symptoms do not respond to appropriate treatment as expected. It also highlights the limitations of surveillance protocols and the influence that recent specialist input can have on diagnostic processes.