A Quantitative Method to Measure Skin Thickness in Leg Edema in Pregnant Women Using B-Scan Portable Ultrasonography: A Comparison Between Obese and Non-Obese Women

The Effect of Wearing Elastic Compression Stockings on Leg Edema in Pregnant Women in Late Pregnancy as Determined by Measuring the Deep Venous Velocity and Flow

Background: The present study evaluated the objective effectiveness of wearing compression stockings during late pregnancy on leg edema by measuring changes in venous velocity and blood flow. Methods: Using Doppler ultrasonography, we calculated the popliteal venous velocity and blood flow and compared them in the following four groups: (1) 13 non-pregnant women (26 legs) without leg edema, (2) 23 pregnant women (46 legs) in late pregnancy without leg edema, (3) 22 pregnant women (44 legs) in late pregnancy with leg edema who were followed up without treatment, and (4) 21 pregnant women (42 legs) in late pregnancy with leg edema who wore elastic compression stockings for 1 week. Results: Both the average velocity and blood flow of the popliteal vein of pregnant women's legs in late pregnancy were significantly lower than those in non-pregnant women (6.32 ± 0.28 cm/s vs. 9.14 ± 0.37 cm/s; 118.48 ± 8.83 mL/min vs. 177.73 ± 11.74 mL/min, p < 0.0001, respectively). Furthermore, both the average venous velocity and blood flow in edematous legs in late pregnancy were significantly lower than those in non-edematous legs (5.32 ± 0.93 cm/s vs. 6.32 ± 0.28 cm/s; 82.68 ± 35.90 mL/min vs. 118.48 ± 8.83 mL/min, p < 0.0001, respectively). Finally, both the average venous velocity and blood flow were significantly higher in edematous legs in late pregnancy after wearing stockings than without treatment (7.69 ± 0.17 cm/s vs. 5.36 ± 0.17 cm/s; 143.22 ± 48.74 mL/min vs. 97.03 ± 40.07 mL/min, p < 0.0001, respectively). Conclusions: The wearing of elastic compression stockings by women with edematous legs in late pregnancy significantly increases the deep venous velocity and flow. Thus, it is possible to prevent deep vein thrombosis in this population.

Efficacy of compression and phlebotropic therapy varicose veins in pregnant women

Introduction. Pregnancy is the leading cause of varicose veins(VVs) in women. Therapeutic measures during pregnancy include the wearing of compression hosiery and the phlebotropic therapy.

Purpose. To evaluate the clinical effectiveness of graduated elastic compression and phlebotropic therapy in pregnant women with VVs.

Materials and methods. A total of 88 pregnant women were included, 30 of whom used compression stockings (group 1), 28 women received phlebotonics together with compression (group 2) and 30 were controls. VVs severity was determined using the Venous Clinical Severity Score (VCSS). Quality of life (QoL) was calculated using the Chronic Venous Insufficiency Questionnaire (CIVIQ-20). The calf circumference was measured with a measuring tape in an orthostatic position.

Results and discussion. At the end of the study there was a decrease in VCSS (p < 0.001 and p < 0.008) in both treatment groups, whereas the control group showed an increase in VCSS severity (p < 0.001). At the end of follow-up the QOL score in the treatment groups showed a tendency to improve while the control group showed a decrease in QOL. A bilateral decrease in tibial circumference (p < 0.001) was seen in groups 1 and 2 and the adjuvant phlebotropic treatment was found to be superior in controlling the oedema.

Conclusions. The combined use of elastic compression and phlebotonics is more effective in eliminating venous oedema in pregnant women with VVs. 

A Histogram Analysis of the Pixel Grayscale (Luminous Intensity) of B-Mode Ultrasound Images of the Subcutaneous Layer Predicts the Grade of Leg Edema in Pregnant Women

The technique most widely used to quantitatively measure leg edema is only a pitting edema method. It has recently become possible to digitize B-mode ultrasound images and accurately quantify their brightness using an image-analysis software program. The purpose of this study was to find new indices of the grade of leg skin, to study whether or not analyses of the subcutaneous layer of leg skin on ultrasound images using image-editing software program can be used to evaluate it and to digitize it. Images of 282 subcutaneous layers of leg skin in 141 pregnant women were obtained using a B-scan portable ultrasound device. Rectangular photographs (vertical: skin thickness; horizontal: width of probe) were obtained using an image-editing program, and the luminous intensity (pixel grayscale: 0-255) and thickness of the skin were calculated using a histogram. We investigated the correlation between these parameters and the grade of pitting edema (0-3). There was a significant positive correlation between the grade of pitting edema and the average luminous intensity value, its standard deviation, and the skin thickness (ρ = 0.36, ρ = 0.22, ρ = 0.51, p < 0.0001, respectively). In particular, there was strong positive correlation between the grade of pitting edema and both the total number of pixels in a rectangle × (multiplied by) the average luminous intensity value and the total number of pixels in a rectangle × the standard deviation of the average luminous intensity value (ρ = 0.58 and ρ = 0.59, p < 0.0001, respectively). We could quantitatively evaluate the grade of leg edema by analyzing ultrasound photographs of the subcutaneous layer of the leg skin using an image-editing software program and found new indices to digitize it.

Measurement of Skin Thickness Using Ultrasonography to Test the Usefulness of Elastic Compression Stockings for Leg Edema in Pregnant Women

Background: One of the most common treatments for leg edema during pregnancy is the use of compression stockings. The purpose of this study was to evaluate the objective effectiveness in pregnant women, by measuring the changes of skin thickness using ultrasonography. Methods: Pregnant women were diagnosed with leg edema using the pitting edema method at 36 weeks of gestation. Twenty-four pregnant women (48 legs) with leg edema spent time without wearing elastic stockings at 36−37 weeks of gestation. Then, they wore elastic stockings for one week at 37−38 weeks of gestation. We measured the grade of edema (from 0 to 3) and the skin thickness of the lower leg by portable ultrasonography at 36, 37, and 38 weeks of gestation (a before-and-after study). Results: In 24 pregnant women, thigh edema was not detected in any of the 48 legs before or after the use of elastic stockings. All 48 legs in 24 pregnant women had physiological lower leg edema, but not thigh edema. The average grade of pitting edema in each lower leg significantly decreased after using the stockings (36 weeks, 1.77 ± 0.85; 37 weeks, 1.79 ± 0.77; 38 weeks, 1.04 ± 0.74, p < 0.0001). In addition, the skin thickness of the lower legs was significantly decreased after the use of elastic stockings (36 weeks, 7.47 ± 2.45 mm; 37 weeks, 7.93 ± 2.83 mm; 38 weeks, 7.15 ± 2.35 mm, p < 0.0001). Conclusions: The wearing of elastic compression stockings on the lower legs is objectively effective for improving leg edema in pregnant women.

Diagnostic Utility of Point-of-Care Ultrasound in the Pediatric Cardiac Intensive Care Unit

Purpose of Review

Recent Findings

Summary

Supplementary Information

Percepção positiva e eficácia das meias de compressão na prevenção de edema em membros inferiores de gestantes

Background

Pregnancy is characterized by physiological changes that can contribute to development of varicose veins, venous insufficiency, and leg edema.

Objectives

To evaluate the effect of compression stocking on lower limb edema in pregnant women and their perceptions of wearing them.

Methods

This was a randomized, controlled, prospective, parallel, blinded clinical trial conducted with 60 pregnant women randomly distributed into two groups: an intervention group (n = 30) wearing compression stockings and a control group (n = 30). Standardized ankle and calf measurements were taken of all 120 lower limbs using a tape measure. At the end of the study, a questionnaire was administered to identify perceived difficulties and advantages related to wearing compression stockings.

Results

Pregnant women in the intervention group had a significantly smaller increase (p < 0.05) in calf and ankle diameters compared to those in the control group. The mean differences from the beginning to the end of gestation in the diameters of the right calf, left calf, right ankle, and left ankle respectively were 0.30 cm, 0.30 cm, 0.15, cm and 0.15 cm in the intervention group and 1.95 cm, 1.95 cm, 1.73 cm, and 1.87 cm in the control group. Most of the pregnant women had no difficulty wearing the compression stockings and all reported that they felt a difference in leg symptoms and would wear stockings again.

Conclusions

Compression stockings were effective for preventing lower limb edema in pregnant women, who had a positive perception of wearing them.

Semi-automated weak annotation for deep neural network skin thickness measurement

Correctly calculating skin stiffness with ultrasound shear wave elastography techniques requires an accurate measurement of skin thickness. We developed and compared two algorithms, a thresholding method and a deep learning method, to measure skin thickness on ultrasound images. Here, we also present a framework for weakly annotating an unlabeled dataset in a time-effective manner to train the deep neural network. Segmentation labels for training were proposed using the thresholding method and validated with visual inspection by a human expert reader. We reduced decision ambiguity by only inspecting segmentations at the center A-line. This weak annotation approach facilitated validation of over 1000 segmentation labels in 2 hours. A lightweight deep neural network that segments entire 2D images was designed and trained on this weakly-labeled dataset. Averaged over six folds of cross-validation, segmentation accuracy was 57% for the thresholding method and 78% for the neural network. In particular, the network was better at finding the distal skin margin, which is the primary challenge for skin segmentation. Both algorithms have been made publicly available to aid future applications in skin characterization and elastography.

Validation of Point-of-Care Ultrasound to Measure Perioperative Edema in Infants With Congenital Heart Disease

Purpose: Fluid overload is a common post-operative issue in children following cardiac surgery and is associated with increased morbidity and mortality. There is currently no gold standard for evaluating fluid status. We sought to validate the use of point-of-care ultrasound to measure skin edema in infants and assess the intra- and inter-user variability. Methods: Prospective cohort study of neonates (≤30 d/o) and infants (31 d/o to 12 m/o) undergoing cardiac surgery and neonatal controls. Skin ultrasound was performed on four body sites at baseline and daily post-operatively through post-operative day (POD) 3. Subcutaneous tissue depth was manually measured. Intra- and inter-user variability was assessed using intraclass correlation coefficient (ICC). Results: Fifty control and 22 surgical subjects underwent skin ultrasound. There was no difference between baseline surgical and control neonates. Subcutaneous tissue increased in neonates starting POD 1 with minimal improvement by POD 3. In infants, this pattern was less pronounced with near resolution by POD 3. Intra-user variability was excellent (ICC 0.95). Inter-user variability was very good (ICC 0.82). Conclusion: Point-of-care skin ultrasound is a reproducible and reliable method to measure subcutaneous tissue in infants with and without congenital heart disease. Acute increases in subcutaneous tissue suggests development of skin edema, consistent with extravascular fluid overload. There is evidence of skin edema starting POD 1 in all subjects with no substantial improvement by POD 3 in neonates. Point-of-care ultrasound could be an objective way to measure extravascular fluid overload in infants. Further research is needed to determine how extravascular fluid overload correlates to clinical outcomes.

Development and Themes of Diagnostic and Treatment Procedures for Secondary Leg Lymphedema in Patients with Gynecologic Cancers

Patients with leg lymphedema sometimes suffer under constraint feeling leg heaviness and pain, requiring lifelong treatment and psychosocial support after surgeries or radiation therapies for gynecologic cancers. We herein review the current issues (a review of the relevant literature) associated with recently developed diagnostic procedures and treatments for secondary leg lymphedema, and discuss how to better manage leg lymphedema. Among the currently available diagnostic tools, indocyanine green lymphography (ICG-LG) can detect dermal lymph backflow in asymptomatic legs at stage 0. Therefore, ICG-LG is considered the most sensitive and useful tool. At symptomatic stage ≥1, ultrasonography, magnetic resonance imaging-lymphography/computed tomography-lymphography (MRI-LG/CT-LG) and lymphosintiography are also useful. For the treatment of lymphedema, complex decongestive physiotherapy (CDP) including manual lymphatic drainage (MLD), compression therapy, exercise and skin care, is generally performed. In recent years, CDP has often required effective multi-layer lymph edema bandaging (MLLB) or advanced pneumatic compression devices (APCDs). If CDP is not effective, microsurgical procedures can be performed. At stage 1–2, when lymphaticovenous anastomosis (LVA) is performed, lymphaticovenous side-to-side anastomosis (LVSEA) is principally recommended. At stage 2–3, vascularized lymph node transfer (VLNT) is useful. These ingenious procedures can help maintain the patient’s quality of life (QOL) but unfortunately cannot cure lymphedema. The most important concern is the prevention of secondary lymphedema, which is achieved through approaches such as skin care, weight control, gentle limb exercises, avoiding sun and heat, and elevation of the affected leg.