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Varicose Veins in the Legs: The Diagnosis and Management of Varicose Veins

Varicose veins are dilated, often palpable subcutaneous veins with reversed blood flow, most commonly found in the legs. Estimates of the prevalence of varicose veins vary. Visible varicose veins in the lower limbs are estimated to affect at least a third of the population. There is little reliable information available in the literature on the proportion of people with varicose veins who progress to venous ulceration. One study reported that 28.6% of those who had visible varicose veins without oedema or other complications progressed to more serious venous disease after 6.6 years.83 However there was no information about the numbers progressing to ulceration. Other data on the lifetime prevalence of varicose veins estimate that approximately 3–6% of people who have varicose veins in their lifetime will develop venous ulcers.71 Risk factors for developing varicose veins are unclear although prevalence rises with age and they often develop during pregnancy. In some people varicose veins are asymptomatic or cause only mild symptoms, but in others they cause pain, aching or itching and can have a significant effect on their quality of life. Varicose veins may become more severe over time and can lead to complications such as changes in skin pigmentation, eczema, superficial thrombophlebitis, bleeding, loss of subcutaneous tissue, lipodermatosclerosis or venous ulceration.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: July 2013

The Clinical Effectiveness and Cost-Effectiveness of Different Surveillance Mammography Regimens After the Treatment for Primary Breast Cancer: Systematic Reviews, Registry Database Analyses and Economic Evaluation

Following primary breast cancer treatment, the early detection of ipsilateral breast tumour recurrence (IBTR) or ipsilateral secondary cancer in the treated breast and detection of new primary cancers in the contralateral breast is beneficial for survival. Surveillance mammography is used to detect these cancers, but the optimal frequency of surveillance and the length of follow-up are unclear.

Health Technology Assessment - NIHR Journals Library.

Version: September 2011
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Screening tests for Down’s syndrome in first three months of pregnancy

Down's syndrome (also known as Down's or Trisomy 21) is an incurable genetic disorder that causes significant physical and mental health problems, and disabilities. However, there is wide variation in how Down's affects people. Some individuals are severely affected whilst others have mild problems and are able to lead relatively normal lives. There is no way of predicting how badly a baby might be affected.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Pregnancy and birth: Ultrasound scans in pregnancy

Many pregnant women and their partners look forward to ultrasound scans. But getting that prized first picture of your child is of course not the reason that all pregnant women in Germany are offered ultrasound scans. Rather, they are done to make sure that the pregnancy is progressing normally and the child is developing well.In Germany, pregnant women with statutory health insurance are usually offered three standard ultrasound scans at no extra cost. They are sometimes also referred to as screenings.The main purpose of these ultrasound scans is to determine whether the pregnancy and the child's development are progressing normally. As a general rule: 96 to 98 out of 100 pregnant women give birth to a healthy child. But the ultrasound sometimes detects abnormalities that require further examinations – and maybe some difficult decisions as well.Doctors are required to discuss the advantages and disadvantages prior to an ultrasound. The German Federal Joint Committee (G-BA) has published a comprehensive German-language information leaflet to help more women understand the ultrasound scans better. Every pregnant woman has the right to not have one or all of the ultrasound scans without giving a reason. Deciding not to have a scan does not affect insurance cover.It is best to discuss whether you want to see the ultrasound images and which results you want to know with your doctor before the scan. If you do not want to know the sex of your child or other particular findings, it is important to make that clear beforehand.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: March 25, 2015

Management of reported decreased fetal movements during pregnancy

Decreased fetal movements can indicate deterioration in the baby's condition, for example, because of chronic placental insufficiency. Clinical observations indicate that mothers commonly perceive an absence or reduction in the baby's movements for some days before a baby's death. For this reason, fetal movement monitoring is advised by caregivers and is used spontaneously by mothers to assess the baby's well‐being. Women's perception of decreased fetal movement is decreased with cigarette smoking, maternal obesity and if the placenta is at the front of the womb. Management strategies in response to perceived decreased fetal movements include early delivery, expectant management with close surveillance of the baby, cardiotocography (visual or analysed by computer to follow the baby’s heart beat with uterine activity), ultrasound examination including Doppler ultrasound, and fetal arousal tests (either cardiotocographic or clinical observation where electronic fetal assessment methods are not available) to assess the baby’s well‐being. Evidence on the effectiveness of monitoring fetal movements and the subsequent management strategies in improving outcomes is limited. Given the high rate of false positive results for both fetal movement assessment and follow‐up tests, there is a real possibility of risks with unnecessary interventions or the baby being born premature and increased anxiety for the mother.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Screening tests for Down’s syndrome in first 24 weeks of pregnancy

Down's syndrome (also known as Down's or Trisomy 21) is an incurable genetic disorder that causes significant physical and mental health problems, and disabilities. However, there is wide variation in how Down's affects people. Some individuals are severely affected whilst others have mild problems and are able to lead relatively normal lives. There is no way of predicting how badly a baby might be affected.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Cervical ripening before first trimester surgical evacuation for non‐viable pregnancy

Using medications or devices to soften and dilate the cervix can reduce the amount of manual dilation required before the uterus is surgically emptied of a non‐viable pregnancy, or miscarriage. The purpose of this cervical ripening is to reduce the possibility of injury to the uterus and cervix and make the procedure easier to perform, although the ripening agents can have side effects.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Breast Cancer Treatment and Pregnancy (PDQ®): Health Professional Version

Expert-reviewed information summary about the treatment of breast cancer during pregnancy.

PDQ Cancer Information Summaries [Internet] - National Cancer Institute (US).

Version: September 2, 2014

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

The study found that incentives for smoking cessation in pregnancy and breastfeeding provided with other tailored intervention components show promise but that reach is a concern.

Health Technology Assessment - NIHR Journals Library.

Version: April 2015
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Screening and Treatment for Bacterial Vaginosis in Pregnancy: Systematic Review to Update the 2001 U.S. Preventive Services Task Force Recommendation [Internet]

Bacterial vaginosis (BV) is the most common lower genital tract syndrome among women of reproductive age. This report will be used by the United States Preventive Services Task Force (USPSTF) to update its 2001 recommendation on screening and treatment for bacterial vaginosis in pregnancy. This update report will focus on three critical key questions related to screening, treatment, and adverse effects of screening and/or treatment on pregnancy outcomes in women asymptomatic for bacterial vaginosis at low, average, and high risk for preterm delivery. The previous review and recommendations can be downloaded at http://www.ahrq.gov/clinic/uspstf/uspsbvag.htm.

Evidence Syntheses - Agency for Healthcare Research and Quality (US).

Version: January 2008
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Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management in Early Pregnancy of Ectopic Pregnancy and Miscarriage

The guideline covers diagnosis of early pregnancy loss, including the use of ultrasound scanning and biochemical testing. Investigations incur costs and the use of serial measurements may delay decision making. The guideline includes guidance on when senior and/or specialist advice should be sought in order to avoid errors and unnecessary delay.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: December 2012
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Hypertension in Pregnancy: The Management of Hypertensive Disorders During Pregnancy

This clinical guideline concerns the management of hypertensive disorders in pregnancy and their complications from preconception to the postnatal period. For the purpose of this guideline, ‘pregnancy’ includes the antenatal, intrapartum and postpartum (6 weeks after birth) periods. The guideline has been developed with the aim of providing guidance in the following areas: information and advice for women who have chronic hypertension and are pregnant or planning to become pregnant; information and advice for women who are pregnant and at increased risk of developing hypertensive disorders of pregnancy; management of pregnancy with chronic hypertension; management of pregnancy in women with gestational hypertension; management of pregnancy for women with pre-eclampsia before admission to critical care level 2 setting; management of pre-eclampsia and its complications in a critical care setting; information, advice and support for women and healthcare professionals after discharge to primary care following a pregnancy complicated by hypertension; care of the fetus during pregnancy complicated by a hypertensive disorder.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: August 2010
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Antenatal Care: Routine Care for the Healthy Pregnant Woman

The original antenatal care guideline was published by NICE in 2003. Since then a number of important pieces of evidence have become available, particularly concerning gestational diabetes, haemoglobinopathy and ultrasound, so that the update was initiated. This update has also provided an opportunity to look at a number of aspects of antenatal care: the development of a method to assess women for whom additional care is necessary (the ‘antenatal assessment tool’), information giving to women, lifestyle (vitamin D supplementation, alcohol consumption), screening for the baby (use of ultrasound for gestational age assessment and screening for fetal abnormalities, methods for determining normal fetal growth, placenta praevia), and screening for the mother (haemoglobinopathy screening, gestational diabetes, pre-eclampsia and preterm labour, chlamydia).

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: March 2008
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Pregnancy and Complex Social Factors: A Model for Service Provision for Pregnant Women with Complex Social Factors

This guideline aims to: identify and describe best practice for service organisation and delivery that will improve access, acceptability and use of services; identify and describe services that encourage, overcome barriers to and facilitate the maintenance of contact throughout pregnancy; describe additional consultations with and/or support and information for women with complex social factors, and their partners and families, that should be provided during pregnancy, over and above that described in the NICE guideline ‘Antenatal care: routine care for the healthy pregnant woman’ (2008) (clinical guideline 62); identify when additional midwifery care or referral to other members of the maternity team (obstetricians and other specialists) would be appropriate, and what that additional care should be.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: September 2010
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Multiple Pregnancy: The Management of Twin and Triplet Pregnancies in the Antenatal Period

This guideline contains recommendations specific to twin and triplet pregnancies and covers the following clinical areas: optimal methods to determine gestational age and chorionicity; maternal and fetal screening programmes to identify structural abnormalities, chromosomal abnormalities and feto-fetal transfusion syndrome (FFTS), and to detect intrauterine growth restriction (IUGR); the effectiveness of interventions to prevent spontaneous preterm birth; and routine (elective) antenatal corticosteroid prophylaxis for reducing perinatal morbidity. The guideline also advises how to give accurate, relevant and useful information to women with twin and triplet pregnancies and their families, and how best to support them.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: September 2011
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Crohn's Disease: Management in Adults, Children and Young People

This guideline intends to show the place of both new and established treatments in the wider care pathway for Crohn's disease. This will be useful for clinicians and people with Crohn's disease because new drugs have been licensed for Crohn's disease in the last decade. The guideline also deals with those medications which are unlicensed for treatment of the condition, but which have been used in this way (off-label) for many years and their role is recognised in other NICE documents as well as the British National Formulary. They include azathioprine, mercaptopurine and methotrexate. The guideline aims to help improve the care offered to people with Crohn's disease and provide information about the clinical and cost effectiveness of potential care pathways. Management of Crohn's disease in specific populations (for example, in pregnancy) may require special consideration.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: October 10, 2012

Headaches: Diagnosis and Management of Headaches in Young People and Adults [Internet]

Many non-specialist healthcare professionals can find the diagnosis of headache difficult, and both people with headache and their healthcare professionals can be concerned about possible serious underlying causes. This leads to variability in care and may mean that people with headaches are not always offered the most appropriate treatments. People with headache alone are unlikely to have a serious underlying disease. Comparisons between people with headache referred to secondary care and those treated in primary care show that they do not differ in terms of headache impact or disability.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: September 2012
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Screening for Elevated Lead Levels in Childhood and Pregnancy: Update of a 1996 U.S. Preventive Services Task Force Review [Internet]

Members of the US Preventive Services Task Force (USPSTF) defined the scope of this update, in cooperation with the Agency for Healthcare Research and quality (AHRQ) and the Oregon Evidence Based Practice Center (EPC) personnel. The Task Force's goals for this update were to address the gaps in the literature revealed in the 1996 USPSTF recommendations. These gaps related to the accuracy of risk assessment questionnaires in children with varying blood lead levels, the population prevalence at which to change from targeted screening to universal screening, the effectiveness of interventions to lower lead levels, and cost-effectiveness analyses of lead screening programs.

Evidence Syntheses - Agency for Healthcare Research and Quality (US).

Version: December 2006
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Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period

Clinical guidelines have been defined as ‘systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions’. This clinical guideline concerns the management of diabetes and its complications from preconception to the postnatal period. It has been developed with the aim of providing guidance on:

NICE Guideline - National Collaborating Centre for Women's and Children's Health (UK).

Version: February 2015
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Registries for Evaluating Patient Outcomes: A User's Guide [Internet]. 3rd edition

This User's Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care.

Agency for Healthcare Research and Quality (US).

Version: April 2014
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