Lesbian and bisexual women's likelihood of becoming pregnant: a systematic review and meta-analysis.

BACKGROUND: Few data exist regarding pregnancy in lesbian and bisexual (LB) women. OBJECTIVES: To determine the likelihood of LB women becoming pregnant, naturally or assisted, in comparison with heterosexual women SEARCH STRATEGY: Systematic review of papers published 1 January 2000 to 23 June 2015. SELECTION CRITERIA: Studies contained details of pregnancy rates among LB women compared with heterosexual women. No restriction on study design. DATA COLLECTION AND ANALYSIS: Inclusion decisions, data extraction and quality assessment were conducted in duplicate. Meta-analyses were carried out, with subgroups as appropriate. MAIN RESULTS: Of 6859 papers identified, 104 full-text articles were requested, 30 papers (28 studies) were included. The odds ratio (OR) of ever being pregnant was 0.19 (95% CI 0.18-0.21) in lesbian women and 1.22 (95% CI 1.15-1.29) in bisexual women compared with heterosexual women. In the general population, the odds ratio for pregnancy was nine-fold lower among lesbian women and over two-fold lower among bisexual women (0.12 [95% CI 0.12-0.13] and 0.50 [95% CI 0.45-0.55], respectively). Odds ratios for pregnancy were higher for both LB adolescents (1.37 [95% CI 1.18-1.59] and 1.98 [95% CI 1.85, 2.13], respectively). There were inconsistent results regarding abortion rates. Lower rates of previous pregnancies were found in lesbian women undergoing artificial insemination (OR 0.17 [95% CI 0.11-0.26]) but there were higher assisted reproduction success rates compared with heterosexual women (OR 1.56 [95% CI 1.24-1.96]). CONCLUSIONS: Heterosexuality must not be assumed in adolescents, as LB adolescents are at greater risk of unwanted pregnancies and terminations. Clinicians should provide appropriate information to all women, without assumptions about LB patients' desire for, or rejection of, fertility and childbearing. TWEETABLE ABSTRACT: Review of likelihood of LB women becoming pregnant: LB teenagers at greater risk of unwanted pregnancies.

Lesbian and bisexual women's gynaecological conditions: a systematic review and exploratory meta-analysis.

BACKGROUND: Little is known about the gynaecological health of lesbian and bisexual (LB) women. OBJECTIVES: To examine differences in incidence and/or prevalence of gynaecological conditions in LB compared with heterosexual women. SEARCH STRATEGY: The systematic review protocol was prospectively registered (PROSPERO-CRD42015027091) and searches conducted in seven databases. SELECTION CRITERIA: Comparative studies published 2000-2015, reporting any benign (non-infectious) and/or malignant gynaecological conditions with no language or setting restrictions. DATA COLLECTION AND ANALYSIS: Inclusions, data extraction and quality assessment were conducted in duplicate. Meta-analyses of condition prevalence rates were conducted where ≥3 studies reported results. MAIN RESULTS: From 567 records, 47 full papers were examined and 11 studies of mixed designs included. No studies directly addressing the question were found. Two chronic pelvic pain studies reported higher rates in bisexual compared with heterosexual women (38.5 versus 28.2% and 18.6 versus 6.4%). Meta-analyses showed no statistically significant differences in polycystic ovarian syndrome, endometriosis and fibroids. There was a higher rate of cervical cancer in bisexual than heterosexual women [odds ratio (OR) = 1.94; 95% CI 1.46-2.59] but no difference overall (OR = 0.76; 95% CI 0.15-3.92). There was a lower rate of uterine cancer in lesbian than heterosexual women (OR = 0.28; 95% CI 0.11-0.73) and overall (OR = 0.36; 95% CI 0.13-0.97), but no difference in bisexual women (OR = 0.43; 95% CI 0.06-3.07). CONCLUSIONS: More bisexual women may experience chronic pelvic pain and cervical cancer than heterosexual women. There is no information on potential confounders. Better evidence is required, preferably monitoring sexual orientation in research using the existing validated measure and fully reporting results. TWEETABLE ABSTRACT: Lesbians have less uterine cancer than heterosexual women; bisexuals have more pelvic pain and cervical cancer.

Shock index: an effective predictor of outcome in postpartum haemorrhage?

OBJECTIVES: To compare the predictive value of the shock index (SI) with conventional vital signs in postpartum haemorrhage (PPH), and to establish 'alert' thresholds for use in low-resource settings. DESIGN: Retrospective cohort study. SETTING: UK tertiary centre. POPULATION: Women with PPH ≥ 1500 ml (n = 233). METHODS: Systolic blood pressure (BP), diastolic BP, mean arterial pressure, pulse pressure, heart rate (HR) and SI (HR/systolic BP) were measured within the first hour following PPH. Values measured at the time of highest SI were selected for analysis. The area under the receiver operating characteristic curve (AUROC) for each parameter, used to predict admission to an intensive care unit and other adverse outcomes, was calculated. Sensitivity, specificity and negative/positive predictive values determined thresholds of the best predictor. MAIN OUTCOME MEASURES: Intensive care unit (ICU) admission, blood transfusion ≥ 4 iu, haemoglobin level <7 g/dl, and invasive surgical procedures. RESULTS: Shock index has the highest AUROC to predict ICU admissions (0.75 for SI [95% CI 0.63-0.87] compared with 0.64 [95% CI 0.44-0.83] for systolic BP). SI compared favourably for other outcomes: SI ≥ 0.9 had 100% sensitivity (95% CI 73.5-100) and 43.4% specificity (95% CI 36.8-50.3), and SI ≥ 1.7 had 25.0% sensitivity (95% CI 5.5-57.2) and 97.7% specificity (CI 94.8-99.3), for predicting ICU admission. CONCLUSIONS: Shock index compared favourably with conventional vital signs in predicting ICU admission and other outcomes in PPH, even after adjusting for confounding; SI <0.9 provides reassurance, whereas SI ≥ 1.7 indicates a need for urgent attention. In low-resource settings this simple parameter could improve outcomes. It was not possible to adjust for resuscitative measures administered following vital sign measurement that may have influenced the outcome.

Reporting errors, incidence and risk factors for postpartum haemorrhage and progression to severe PPH: a prospective observational study.

OBJECTIVE: To quantify reporting errors, measure incidence of postpartum haemorrhage (PPH) and define risk factors for PPH (≥500 ml) and progression to severe PPH (≥1500 ml). DESIGN: Prospective observational study. SETTING: Two UK maternity services. POPULATION: Women giving birth between 1 August 2008 and 31 July 2009 (n = 10 213). METHODS: Weighted sampling with sequential adjustment by multivariate analysis. MAIN OUTCOME MEASURES: Incidence and risk factors for PPH and progression to severe PPH. RESULTS: Errors in transcribing blood volume were frequent (14%) with evidence of threshold preference and avoidance. The incidences of PPH ≥500, ≥1500 and ≥2500 ml were 33.7% (95% CI 31.2-36.2), 3.9% (95% CI 3.3-4.6) and 0.8% (95% CI 0.6-1.0). New independent risk factors predicting PPH ≥ 500 ml included Black African ethnicity (adjusted odds ratio [aOR] 1.77, 95% CI 1.31-2.39) and assisted conception (aOR 2.93, 95% CI 1.30-6.59). Modelling demonstrated how prepregnancy- and pregnancy-acquired factors may be mediated through intrapartum events, including caesarean section, elective (aOR 24.4, 95% CI 5.53-108.00) or emergency (aOR 40.5, 95% CI 16.30-101.00), and retained placenta (aOR 21.3, 95% CI 8.31-54.7). New risk factors were identified for progression to severe PPH, including index of multiple deprivation (education, skills and training) (aOR 1.75, 95% CI 1.11-2.74), multiparity without caesarean section (aOR 1.65, 95% CI 1.20-2.28) and administration of steroids for fetal reasons (aOR 2.00, 95% CI 1.24-3.22). CONCLUSIONS: Sequential, interacting, traditional and new risk factors explain the highest rates of PPH and severe PPH reported to date.

Smoking cessation in pregnant women with mental disorders: a cohort and nested qualitative study.

OBJECTIVE: To investigate whether 1) pregnant smokers with mental disorders are less likely to accept referrals to smoking cessation services compared with pregnant smokers without disorders; 2) they experience specific barriers to smoking cessation. DESIGN: Cohort study supplemented by cross-sectional survey and nested qualitative study. SETTING: Three maternity services, London, UK. POPULATION: Pregnant smokers with and without mental disorders. METHODS: Case notes were examined on a cohort of 400 consecutive pregnant smokers; data were triangulated with routinely collected data on 845 pregnant smokers at two other sites; 27 pregnant smokers were interviewed using qualitative methods. MAIN OUTCOME MEASURES: Acceptance of referral to smoking cessation services; perceived barriers to quitting. RESULTS: Pregnant smokers with a mental disorder recorded by midwives were one-quarter of the cohort (97, 23%), were more likely to accept referral to smoking cessation services (69% versus 56%, adjusted odds ratio 1.70, 95% confidence interval 1.03-2.79), but more likely to still smoke at delivery (69% versus 56%, adjusted odds ratio 2.63, 95% confidence interval 1.41-4.92). Discussion about smoking was documented in 7.7% of subsequent antenatal visits in women with or without mental disorders. Pregnant smokers with diagnosed mental disorders reported that they and health practitioners did not prioritise smoking advice because of concern about adversely impacting mental health. CONCLUSIONS: Pregnant women with mental disorders appear more motivated, yet find it more difficult, to stop smoking. Prioritisation of mental health over smoking may therefore lead to increasing health inequality for this group. Research into effective smoking cessation interventions is required for those with mental disorders.

Pregnancy outcome in different clinical phenotypes of antiphospholipid syndrome.

Women with antiphospholipid syndrome (APS) may have diverse pregnancy outcomes. The objective of this study was to evaluate pregnancy outcome in women with APS according to their clinical phenotype, i.e. thrombotic and obstetric APS. Eighty-three pregnancies in 67 women with APS were included in the study, including 21 with recurrent miscarriage (Group 1), 21 with late fetal loss or early delivery due to placental dysfunction (Group 2) and 41 with thrombotic APS (Group 3). Group 3 had higher rates of preterm delivery (26.8% versus 4.7%, p = 0.05) than Group 1 and more small for gestational age (SGA) babies than Group 2 (39.5% versus 4.8%, p = 0.003). Group 2 had significantly longer gestations compared with their pretreatment pregnancies (38.4 [28.4-41.4] versus 24.0 [18-35] weeks, p < 0.0001) and 100% live birth rate after treatment with aspirin and low-molecular-weight heparin (LMWH). In conclusion, women with thrombotic APS (Group 3) have higher rates of pregnancy complications than those with obstetric APS (Groups 1 and 2). Treatment with aspirin and LMWH is associated with improved outcomes for women with previous late fetal loss or early delivery due to placental dysfunction (Group 2).

Developing a community-based maternal obesity intervention: a qualitative study of service providers' views.

The aim of this study was to explore healthcare professionals' views on the development of multicomponent interventions for obese pregnant women. A cohort of 22 healthcare professionals was interviewed. The interview transcripts were analysed thematically. Three key themes were highlighted by the interviews: (1) the lack of existing services for obese pregnant women in south-east London; (2) the barriers and challenges that need to be overcome (e.g. ethnic and cultural) when considering the creation of a new service for obese women who are pregnant; (3) the possible components of a new intervention. The findings of this study will inform the design of a programme to combat maternal obesity.

Achieving continuous improvement in routine questioning about domestic violence with an embedded advocacy service.

Domestic violence (DV) is a common but underreported cause of morbidity in pregnant women. A retrospective review of maternity notes of 103 women who delivered October-November 2007, followed by prospective review of records after feedback intervention of 168 pregnant women who had nuchal a scan in February 2008 was undertaken. The aim was to determine: (1) the proportion of women who were asked abuse questions at any time during pregnancy and postnatally; (2) the prevalence of disclosed domestic violence; (3) the sociodemographic predictors of a pregnant woman being asked about DV; (4) if feedback is associated with improved routine questioning. Routine enquiry about DV in pregnancy significantly increased from 53% in 2007 to 66% in 2008 (p < 0.05). Current DV was disclosed by 3.6% of women in both surveys. Domestic violence is common in pregnancy. After implementation of training and an embedded DV advocacy service, routine enquiry demonstrated significant increase over time.

Estimating intrapartum-related perinatal mortality rates for booked home births: when the 'best' available data are not good enough.

OBJECTIVE: To critically appraise a recent study on the safety of home birth (Mori R, Dougherty M, Whittle M. BJOG 2008;115:554) and assess its contribution to the debate about risks and benefits of planned home birth for women at low risk of complications. DESIGN: Critical appraisal of a published paper. SETTING: England and Wales. POPULATION OR SAMPLE: Home births from 1994-2003 and all women giving birth in the same time period. METHODS: Six members of a multidisciplinary group appraised the paper independently. Comments were collated and synthesised. MAIN OUTCOME MEASURES: Assessment of: overall methodology; assumptions used in estimating figures; methods used for calculations; conclusions drawn from the results and reliability and consistency of data. RESULTS: Although there were some positive aspects to the study, there were weaknesses in design and an inaccurate estimate of risk. Our evidence suggests that the conclusions drawn did not reflect the results and the methodological weaknesses found in the study rendered both the results and conclusions invalid. CONCLUSIONS: On the basis of our critical appraisal, the study does not contribute to the existing evidence about the safety of home birth to inform decision-making or provision of care. The limitations could have been identified by the peer review process and the problems were compounded by an inaccurate press release. Great care needs to be taken by journals to ensure the accuracy of information before dissemination to the scientific community, clinicians and the public. These data should not have been used to inform national guidelines.

Defining obstetric terms: the need for gold standards.

To test the hypotheses that: (1) standard definitions of common obstetric terms exist and (2) frontline workers in daily obstetric practice have common understandings of these terms, we undertook (a) a review of definitions for nine common terms from latest editions of standard texts and resources, and (b) an exploratory questionnaire survey of these definitions applied in a work setting among four groups; trainee and consultant obstetricians, student and qualified midwives (five of each). Definitions for nine selected obstetric terms in common use (labour, parity, precipitate labour, primary postpartum haemorrhage, primiparity, PROM, secondary postpartum haemorrhage, term and viability) were inconsistent in standard texts. Obstetric staff had no agreed perception of the precise definitions. There is a potentially hazardous lack of clarity about obstetric terms, and a need to develop standard definitions. This would benefit students, practitioners, information technology experts and, most importantly, patients.

Platelet count as a predictor of the severity of sickle cell disease during pregnancy.

Recent evidence implicates the immune system and the clotting mechanisms in the pathophysiology of sickle cell disease (SCD). This study investigates the association of steady state platelet count with the severity of SCD in pregnancy. A total of 40 SCD women who were asymptomatic early in pregnancy were studied retrospectively: 14 remained asymptomatic throughout pregnancy and 26 developed at least one SCD-related complication. The early pregnancy platelet count was compared between the two groups using t-test and its ability to predict SCD-related complications in pregnancy was investigated using Receiver-Operator Characteristics (ROC) curve. Compared with asymptomatic patients, women who developed SCD-related complications had significantly higher early-pregnancy platelet count [328x10(9)/l (95% CI: 268-389) vs 210x10(9)/l (146-275), p < 0.01]. The area under the ROC curve was 76.4% (95% CI 59.7-93.2). These indicate that the platelet count in early pregnancy is significantly higher in SCD patients who subsequently develop SCD-related complications and may be used for screening.

Innovation in immediate neonatal care: development of the Bedside Assessment, Stabilisation and Initial Cardiorespiratory Support (BASICS) trolley.

OBJECTIVE: Babies receive oxygen through their umbilical cord while in the uterus and for a few minutes after birth. Currently, if the baby is not breathing well at birth, the cord is cut so as to transfer the newborn to a resuscitation unit. We sought to develop a mobile resuscitation trolley on which newly born babies can be resuscitated while still receiving oxygenated blood and the 'placental transfusion' through the umbilical cord. This would also prevent separation of the mother and baby in the first minutes after birth. DESIGN: Multidisciplinary iterative product development. SETTING: Clinical Engineering Department of a University Teaching Hospital. METHODS: Following an initial design meeting, a series of prototypes were developed. At each stage, the prototype was reviewed by a team of experts in the laboratory and in the hospital delivery suite to determine ease of use and fitness for purpose. A commercial company was identified to collaborate on the trolley's development and secure marking with the Conformité Européenne mark, allowing the trolley to be introduced into clinical practice. RESULTS: The trolley is a small mobile resuscitation unit based on the concept of an overbed hospital table. It can be manoeuvred to within 50 cm of the mother's pelvis so that the umbilical cord can remain intact during resuscitation, irrespective of whether the baby is born naturally, by instrumental delivery or by caesarean section. Warmth for the newborn comes from a heated mattress and the trolley has the facility to provide suction, oxygen and air. CONCLUSIONS: This is the first mobile resuscitation device designed specifically to facilitate newborn resuscitation at the bedside and with an intact cord. The next step is to assess its safety, its acceptability to clinicians and parents, and to determine whether it allows resuscitation with an intact cord.

Specificity of the fivefold increase in AD in mothers of adults with Down syndrome.

BACKGROUND: In a previous study, the authors found that the risk of AD among mothers who were 35 years or younger when their children with Down syndrome (DS) were born was five times that of mothers of children with other forms of mental retardation. The current study investigated the specificity of the familial aggregation of DS and AD by examining whether mothers who gave birth to children with DS before age 35 are also at increased risk of other age-related neurologic or medical disorders. METHODS: The authors used survival methods to compare cumulative incidence and relative risk of AD, other dementias, and common age-related disorders in parents of 200 adults with DS and parents of 252 adults with other forms of mental retardation. RESULTS: Mothers who were < or =35 years of age when their children with DS were born were four to five times as likely to develop AD as control mothers (rate ratio = 4.8, 95% CI 2.1, 11.2), whereas risk of AD among mothers who were >35 years when their children with DS were born was not significantly increased (rate ratio = 1.8, 95% CI 0.6, 5.1). Risk of AD among fathers of probands with DS was similar to that of control fathers, and did not vary by age at proband birth. Risk of other dementias and of other age-related medical condition was similar among mothers and fathers of probands with DS and control parents, regardless of age at proband birth. CONCLUSION: These findings suggest that the increased risk of AD among mothers who gave birth to children with DS before age 35 appears to represent a specific vulnerability to AD, as opposed to other age-related degenerative disorders.

The relationship of uterine and umbilical Doppler resistance to fetal and placental protein synthesis in the second trimester.

The relation of uteroplacental and umbilical Doppler resistance index (RI) to peripheral levels of alphafetoprotein (AFP), human chorionic gonadotrophin (hCG), human placental lactogen (HPL), Schwangerswaft protein (SP1), pregnancy-associated placental protein A (PAPP-A) and insulin-like growth factor binding protein 1 (IGP-BP1) at 16-24 weeks was established in a cross-sectional study of 183 unselected singleton pregnancies. There was an association between high values of uteroplacental RI and high hCG levels, and high umbilical RI values with high hCG and HPL levels. Thus, in the mid-trimester, the levels of some placental proteins seem to be related to placental resistance.