Interventions for varicose veins and leg oedema in pregnancy.

BACKGROUND: Pregnancy is presumed to be a major contributory factor in the increased incidence of varicose veins in women, which can in turn lead to venous insufficiency and leg oedema. The most common symptom of varicose veins and oedema is the substantial pain experienced, as well as night cramps, numbness, tingling, the legs may feel heavy, achy, and possibly be unsightly. Treatments for varicose veins are usually divided into three main groups: surgery, pharmacological and non-pharmacological treatments. Treatments of leg oedema comprise mostly symptom reduction rather than cure and use of pharmacological and non-pharmacological approaches. OBJECTIVES: To assess any form of intervention used to relieve the symptoms associated with varicose veins and leg oedema in pregnancy. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised trials of treatments for varicose veins or leg oedema, or both, in pregnancy. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: We included seven trials (involving 326 women). The trials were largely unclear for selection bias and high risk for performance and detection bias.Two studies were placebo-controlled trials. The first one compared a phlebotonic (rutoside) with placebo for the reduction in symptoms of varicose veins; the second study evaluated the efficacy of troxerutin in comparison to placebo among 30 pregnant women in their second trimester with symptomatic vulvar varicosities and venous insufficiency in their lower extremities. Data from this study were not in useable format, so were not included in the analysis. Two trials compared either compression stockings with resting in left lateral position or reflexology with rest for 15 minutes for the reduction of leg oedema. One trial compared standing water immersion for 20 minutes with sitting upright in a chair with legs elevated for 20 minutes. Women standing in water were allowed to stand or walk in place. One trial compared 20 minutes of daily foot massage for five consecutive days and usual prenatal care versus usual prenatal care. The final trial compared three treatment groups for treating leg oedema in pregnancy. The first group was assigned to lateral supine bed rest at room temperature, women in the second group were asked to sit in a bathtub of waist-deep water at 32 ± 0.5 C with their legs horizontal and the third group included the women who were randomised to sitting immersed in shoulder-deep water at 32 ± 0.5 C with legs extended downward. We did not include this study in the analysis as outcomes reported in the paper were not pre-specified outcomes of this review.We planned to use GRADE methods to assess outcomes for two different comparisons and assign a quality rating. However, only two out of three outcomes for one comparison were reported and could be assessed. Evidence from one trial (rutoside versus placebo) for the outcomes of reduction in symptoms and incidence of complications associated with varicose veins and oedema was assessed as of moderate quality. Rutoside versus placeboOne trial involving 69 women, reported that rutoside significantly reduced the symptoms associated with varicose veins (risk ratio (RR) 1.89, 95% confidence interval (CI) 1.11 to 3.22; moderate quality evidence). The incidence of complications (deep vein thrombosis) did not differ significantly between the two groups (risk ratio (RR) 0.17, 95% CI 0.01 to 3.49; moderate quality evidence). There were no significant differences in side-effects (RR 1.30, 95% CI 0.23 to 7.28). Women's perception of pain was not reported in this trial. External pneumatic intermittent compression versus restOne trial, involving 35 women, reported no significant difference in lower leg volume when compression stockings were compared against rest (mean difference (MD) -258.80, 95% CI -566.91 to 49.31). Reflexology versus restingAnother trial, involving 55 women, compared reflexology with rest. Reflexology significantly reduced the symptoms associated with oedema (reduction in symptoms: RR 9.09, 95% CI 1.41 to 58.54). The same study showed a trend towards satisfaction and acceptability with the intervention (RR 6.00, 95% CI 0.92 to 39.11). Water immersion versus leg elevationThere was evidence from one trial, involving 32 women, to suggest that water immersion for 20 minutes in a swimming pool reduces leg volume (RR 0.43, 95% CI 0.22 to 0.83). Foot massage versus routine careOne trial, involving 80 women reported no significant difference in lower leg circumference when foot massage was compared against routine care (MD -0.11, 95% CI -1.02 to 0.80).No other primary or secondary outcomes were reported in the trials. AUTHORS' CONCLUSIONS: There is moderate quality evidence to suggest that rutosides appear to help relieve the symptoms of varicose veins in late pregnancy. However, this finding is based on one study (69 women) and there are not enough data presented in the study to assess its safety in pregnancy. Reflexology or water immersion appears to help improve symptoms for women with leg oedema, but again this is based on two small studies (43 and 32 women, respectively).

Closure versus non-closure of the peritoneum at caesarean section: short- and long-term outcomes.

BACKGROUND: Caesarean section is a very common surgical procedure worldwide. Suturing the peritoneal layers at caesarean section may or may not confer benefit, hence the need to evaluate whether this step should be omitted or routinely performed. OBJECTIVES: The objective of this review was to assess the effects of non-closure as an alternative to closure of the peritoneum at caesarean section on intraoperative and immediate- and long-term postoperative outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 November 2013). SELECTION CRITERIA: Randomised controlled trials comparing leaving the visceral or parietal peritoneum, or both, unsutured at caesarean section with a technique which involves suturing the peritoneum in women undergoing elective or emergency caesarean section. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked it for accuracy. MAIN RESULTS: A total of 29 trials were included in this review and 21 trials (17,276 women) provided data that could be included in an analysis. The quality of the trials was variable. 1. Non-closure of visceral and parietal peritoneum versus closure of both parietal layersSixteen trials involving 15,480 women, were included and analysed, when both parietal peritoneum was left unclosed versus when both peritoneal surfaces were closed. Postoperative adhesion formation was assessed in only four trials with 282 women, and no difference was found between groups (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.76 to 1.29). There was significant reduction in the operative time (mean difference (MD) -5.81 minutes, 95% CI -7.68 to -3.93). The duration of hospital stay in a total of 13 trials involving 14,906 women, was also reduced (MD -0.26, 95% CI -0.47 to -0.05) days. In a trial involving 112 women, reduced chronic pelvic pain was found in the peritoneal non-closure group. 2. Non-closure of visceral peritoneum only versus closure of both peritoneal surfacesThree trials involving 889 women were analysed. There was an increase in adhesion formation (two trials involving 157 women, RR 2.49, 95% CI 1.49 to 4.16) which was limited to one trial with high risk of bias.There was reduction in operative time, postoperative days in hospital and wound infection. There was no significant reduction in postoperative pyrexia. 3. Non-closure of parietal peritoneum only versus closure of both peritoneal layersThe two identified trials involved 573 women. Neither study reported on postoperative adhesion formation. There was reduction in operative time and postoperative pain with no difference in the incidence of postoperative pyrexia, endometritis, postoperative duration of hospital stay and wound infection. In only one study, postoperative day one wound pain assessed by the numerical rating scale, (MD -1.60, 95% CI -1.97 to -1.23) and chronic abdominal pain d by the visual analogue score (MD -1.10, 95% CI -1.39 to -0.81) was reduced in the non-closure group. 4. Non-closure versus closure of visceral peritoneum when parietal peritoneum is closed.There was reduction in all the major urinary symptoms of frequency, urgency and stress incontinence when the visceral peritoneum is left unsutured. AUTHORS' CONCLUSIONS: There was a reduction in operative time across all the subgroups. There was also a reduction in the period of hospitalisation post-caesarean section except in the subgroup where parietal peritoneum only was not sutured where there was no difference in the period of hospitalisation. The evidence on adhesion formation was limited and inconsistent. There is currently insufficient evidence of benefit to justify the additional time and use of suture material necessary for peritoneal closure. More robust evidence on long-term pain, adhesion formation and infertility is needed.

Local anaesthetic wound infiltration and abdominal nerves block during caesarean section for postoperative pain relief.

BACKGROUND: Caesarean section delivery is becoming more frequent. Childbirth is an emotion-filled event and the mother needs to bond with her newborn baby as early as possible. Any intervention that leads to improvement in pain relief is worthy of investigation. Local anaesthetics, either on their own or in combination with opioids or nonsteroidal antiinflammatory drugs, have been employed as an adjunct to other postoperative pain relief strategies. Conflicting reports were noted. OBJECTIVES: To assess the effects of local anaesthetic agent wound infiltration/irrIgation and/or abdominal nerve blocks on post-caesarean section pain and the mother's well being and interaction with her baby. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009). SELECTION CRITERIA: Randomised controlled trials of pre-emptive local analgesia during caesarean section. DATA COLLECTION AND ANALYSIS: One author extracted data. The second author checked the data. MAIN RESULTS: Twenty studies (1150 women) were included. Women who had caesarean section performed under regional analgesia and had wound infiltration had a decrease in morphine consumption at 24 hours (SMD -1.70mg; 95% confidence interval (CI) -2.75 to -0.94) compared to placebo.In women under general anaesthesia, with caesarean section wound infiltration and peritoneal spraying with local anaesthetic (one study, 100 participants), the need for opioid rescue was reduced (risk ratio (RR) 0.51; 95% CI 0.38 to 0.69). The numerical pain score (0 to10) within the first hour was also reduced (mean difference (MD) -1.46; 95% CI -2.60 to -0.32).Women with regional analgesia who had local anaesthetic and non-steriodal anti-inflammatory cocktail wound infiltration consumed less morphine (one study, 60 participants; MD -7.40 mg; 95% CI -9.58 to -5.22) compared to local anaesthetic control.Women who had regional analgesia with abdominal nerves blocked had decreased opioid consumption (four studies, 175 participants; MD -25.80 mg; 95% CI -50.39 to -5.37).For the outcome of visual analogue scale 0 to 10 over 24 hours, no advantage was demonstrated in the single study of 50 participants who had wound infiltrated with a mixture of local analgesia and narcotics versus local analgesia.Addition of ketamine to the local analgesia in women who had regional analgesia does not confer any advantage. AUTHORS' CONCLUSIONS: Local analgesia infiltration and abdominal nerve blocks as adjuncts to regional analgesia and general anaesthesia are of benefit in caesarean section by reducing opioid consumption. Nonsteroidal anti-inflammatory drugs as an adjuvant may confer additional pain relief.

Ropivacaine abdominal wound infiltration and peritoneal spraying at cesarean delivery for preemptive analgesia.

OBJECTIVE: To determine whether ropivacaine infiltration into all layers of the abdominal cesarean wound and spraying of the peritoneum decreases postoperative pain. METHODS: A randomized controlled trial of women undergoing cesarean delivery under general anesthetic allocated to receive either 30 mL of 0.75% ropivacaine or 30 mL of saline into the wound, including spraying of the peritoneum. Postoperative pain and need for rescue opioids were assessed. RESULTS: Of the 50 women in the ropivacaine group, 24 (48%) required pethidine or experienced severe pain within 1 hour postoperatively compared with 47 (94%) of 50 women in the control group (relative risk 0.51, 95% CI, 0.38-0.69). The amount of pethidine used in the first hour was reduced in the ropivacaine group (mean difference -58, 95% CI, -73.53 to -42.40). Use of diclofenac and tramadol/paracetamol was also reduced in the ropivacaine group. CONCLUSION: Ropivacaine wound infiltration and peritoneal spraying during cesarean delivery under general anesthetic reduces severe pain and need for opioids.