We have developed a simple risk stratification score that can separate, preoperatively, patients into risk groups with markedly different rates of severe postoperative bleeding.

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SummaryPneumothorax during pregnancy is uncommon. Recently ambulatory chest drainage has been advised to treat the pneumothorax and to cover the delivery period. This imposes restrictions on the mother with associated co-morbidity. The authors present a case of recurrent chest-tube resistant pneumothorax during pregnancy which had persisted for 4-weeks .To guide management of a patient referred in the third trimester of pregnancy the authors undertook a systematic review. This led to defi nitive video assisted thoracoscopic surgery (VATS) for bullectomy and pleurodesis which was successful without either peri-operative or peri-partum complications or recurrence of pneumothorax. Our review suggests that a VATS approach during pregnancy is both safe and effective. chest drain insertion there was a continued air leak for 4 days. At this point, and after discussion between chest physicians and obstetricians, a high resolution CT (HR-CT) scan was performed. The HR-CT scan showed left apical bullae, the lung was not fully infl ated with the intercostal drain in situ (fi gure 2). Serial foetal ultrasound scanning over this period found a viable breech presentation singleton foetus with parameters in keeping with gestational age. Liquor volume and foetal movements and heart rate variability were within normal limits. She was then referred for thoracic surgery management. TREATMENTThe 2003 British Thoracic Society guidelines on the management of pneumothorax 2 did not include presentation in pregnancy suggesting the rarity of the condition. The 2010 guidelines for the management of pneumothorax 3 state that there is level C evidence that simple observation and aspiration are usually effective during pregnancy, with elective assisted delivery and regional anaesthesia at or near term. The guidelines also state level D evidence that a VATS procedure should be considered after birth.After discussion between the patient, her family and all professionals it was decided to offer a surgical resolution to this recurrent problem to which she gave informed consent.We chose to undertake VATS pneumothorax surgery because:It is our preferred technique for pneumothorax surgery ▶ as it has smaller incisions than open surgery A dose of 12 mg intramuscular betamethasone was given to aid foetal lung maturity in the event of operative complications necessitating delivery. Foetal ultrasound examination was again normal.At 34 weeks gestation the patient underwent a left sided VATS procedure. Three ports were used (2 × 1 cm and 1 × 1.5 cm). Peri-operative foetal cardiotocography remained normal. The surgical procedure took 15 min (after induction of anaesthesia) and was uncomplicated. The left apical bulla was resected and a mechanical pleural abrasion was performed. Two 24 French intercostal chest drains were inserted and connected to 4kPa suction. Chest x-ray confi rmed satisfactory placement of the chest tubes with full re-infl ation of the lung. Suction to the chest drains was applied continuously for 48 h and the drains were removed at 72...

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significant reduction in length of recovery stay and 14-day readmission rate, probably as a result of better glucose control. We accept that this is only an abstract evidence but it does support the idea that improving glucose monitoring compliance may lead to improvement in glucose control.Future research should consider the optimal frequency of glucose measurement and novel techniques to do so. Until we successfully tackle the very practical issue of how to monitor glucose effectively, achieving good perioperative glycaemic control in our patients may remain a utopic dream.