Homelessness in pregnancy.

OBJECTIVES: To evaluate the association, if any, of homelessness or refuge accommodation on delivery and short term perinatal outcomes in an Irish tertiary maternity hospital. METHODS: A retrospective cohort study of 133 singleton pregnancies in women reporting to be homeless or living in refuge at their booking antenatal appointment between 2013 and 2022. Analysis compared sociodemographic characteristics and perinatal outcomes in this cohort to a reference population of 76,858 women with stable living arrangements. RESULTS: Women in the homeless/refuge population were statistically more likely to be single (75.2 % vs 39.5 %, p < 0.001), have an unplanned pregnancy (73.7 % vs 27.2 %, p < 0.001), report a history of psychiatric illness (42.9 % vs 22.4 %, p < 0.001), domestic violence (18.8 % vs 0.9 %, p < 0.001) alcohol consumption in pregnancy (3.0 % vs 0.8 %, p < 0.001) or smoking in pregnancy (41.3 % vs 9.7 %, p < 0.001). They were significantly more likely to have a preterm birth (adjusted OR 1.71 (1.01-2.87) p = 0.04). They also had a significantly lower median birth weight compared to the reference population (birthweight 3270 g vs 3420 g, p < 0.001). CONCLUSION: Women in the homeless and refuge population are more likely to experience poorer perinatal outcomes compared to women with stable living arrangements.

A cross-sectional survey of women's views and preferences for preterm birth screening and treatment.

OBJECTIVES: Primary outcomes were to determine; 1) the desire for more patient information from healthcare professionals on preterm birth (PTB) prevention 2) the desire for PTB screening surveillance or participation in research or 3) the acceptability of transvaginal ultrasound (TVUS) or vaginal examinations to predict spontaneous PTB. METHODS: A 19-question, piloted, self-administered survey was completed by unselected pregnant women in a tertiary maternity hospital in Dublin, Ireland. Data was collected to include maternal socio-demographics, past obstetric history, and current pregnancy details, in addition to views and preferences on PTB screening and preventative treatments. Statistical analysis to include binary and multinomial regression was performed by IBM SPSS Statistics for Windows (Version 29.0). RESULTS: 277 women completed the study survey. 9.4% of women had attended the preterm birth surveillance clinic (PSC). 75.1% of respondents indicated a preference for more information from healthcare professionals about PTB. 65% reported that TVUS and vaginal examinations were acceptable in pregnancy. The acceptability of antenatal examinations was significantly influenced by ethnicity; white European (OR 2.58, CI 1.12-5.95, p = 0.003) and Asian (OR 3.39, CI 1.18-9.67, p = 0.02). Discomfort (25.3%) and vaginal bleeding (11.9%) were the most frequently reported concerns about TVUS. 95.7% of unselected women indicated that they would accept treatment to prevent PTB. Vaginal progesterone (53.8%) was preferred treatment compared to cervical cerclage (15.9%) or cervical pessary (16.6%). 55.6% of respondents stated they attend or wish to attend for additional appointments or research opportunities for PTB screening. Women with a previous PTB or second trimester miscarriage were more likely to attend or wish to attend for PTB screening (OR 3.23, CI 1.34-7.79, p = 0.009). CONCLUSION: PTB is an important healthcare priority for pregnant women in Ireland. However, women require more information, counselling and reassurance about the utility and safety of TVUS in PSCs.

Demographic changes in primiparae of Irish ethnicity between 2000 and 2020.

BACKGROUND: Trends in maternal demographic changes linked to lifestyle and socio-economic conditions reflect greatly on maternal, perinatal and infant mortality rates. Hospital data reflect a heterogenous population where specific demographic changes may not be obvious. OBJECTIVES: To report yearly demographic changes in Irish primiparae from 2000 to 2020, specifically looking at age, BMI, smoking and marital status of patients attending the Coombe Women and Infant's University Hospital (CWIUH). METHODS: Retrospective report of demographic details contemporaneously documented on the CWIUH data base. FINDINGS: In the years 2000 to 2020 inclusive there were 47,659 primiparous women of Irish ethnicity delivered at the CWIUH (70.2% of the total primiparae), of those 99.3% were Caucasian. There was a significant rise in mean age at first delivery in Irish mothers; 26.0 years old in the 2000 to 30.9 years old in 2020 associated with a rise in mean BMI of 9.1%. Smoking rates (ever smoked) showed a significant reduction from 53.9% in 2000 to 39.3% in 2020. There was a significant decrease in rates of marriage, with 61.9% married in 2000 compared to 46.3% in 2020. Birth weight and prematurity rates remained unchanged, with fall in mean gestational age at first delivery from 279.3 days in 2000 to 275.8 days in 2020. CONCLUSION: This study highlights that Irish primiparae are older, heavier, less likely to smoke and to be married than they were 20 years ago. These trends are an interesting glimpse into changing economic and cultural climate over just the past 2 decades.

Pregnancy outcomes following elective abdominal cerclage following cervical excision surgery for neoplastic disease.

BACKGROUND: Local excisional treatment of neoplastic disease of the cervix in the form of loop excision (LLETZ) and conisation has been associated with adverse pregnancy outcomes including prelabour premature rupture of membranes (PPROM) and spontaneous preterm birth (SPTB). Insertion of a cervical cerclage is indicated for women with a short cervix <25 mm between 16 and 24 weeks gestation who also have a history of either PPROM or a history of cervical excisional treatment. The optimum timing of the cerclage and surgical technique used are both open to debate. This retrospective review of cases was performed to examine the outcomes of elective pre pregnancy placement of abdominal cervical cerclage in women who have undergone cervical excision surgery for neoplastic disease. METHODS: This was a retrospective review of case notes. Over a 10 year period 20 women who had previous cervical excision surgery had pre-pregnancy abdominal cerclage placed became pregnant with 26 pregnancies. One woman had a cone biopsy, 9 had a single LLETZ procedure, 8 had 2 LLETZ procedures and 2 women had 3 LLETZ procedures prior to the cerclage. RESULTS: 21 pregnancies were achieved spontaneously, 1 by intrauterine insemination (IUI) and 4 were conceived by in-vitro fertilisation (IVF). Overall, 22 of 26 (84.6 %) pregnancies were delivered at term. There was a single 7 week miscarriage and 3 premature deliveries (12 %) including 1 preterm birth at 29 + 4 weeks gestation after an antepartum haemorrhage (APH) and 2 late preterm births at 36 + 3 (following APH) and 36 + 4 weeks gestation following preterm labour. All 25 women were delivered by Caesarean section and all 25 babies survived. CONCLUSION: There results of prophylactic minimally invasive insertion of a transabdominal cerclage in women with LLETZ treatments or cone biopsy prior to pregnancy demonstrated 84.6 % of pregnancies resulted in a live birth. The premature delivery rate was 12 %.

Fluvastatin reduces oxidative damage in human vascular endothelial cells by upregulating Bcl-2.

BACKGROUND: 3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) have been widely used in clinical practise and their efficacy in reducing cardiovascular risk has been well described. OBJECTIVES: To investigate the effect of low doses of fluvastatin (nanomolar) on H(2)O(2)-induced cell damage and the underlying mechanism. METHODS AND RESULTS: Primary cultures of human umbilical vein endothelial cells were used, and the effects of fluvastatin on H(2)O(2)-induced apoptosis, necrosis, and proliferation were observed. H(2)O(2) at a concentration of 100 mum significantly induced apoptotic cell death after 24-h cell culture. Fluvastatin at low concentrations (10-100 nm) prevented H(2)O(2)-induced apoptosis, as determined by a DNA fragmentation assay and by cell counting with trypan blue and Hoechst 33342 nuclei staining. The protective effect of fluvastatin was mediated by the upregulation of Bcl-2 expression as probed by real-time polymerase chain reaction and Western blotting. Using siRNA to knock down the expression of Bcl-2, the protective effect of fluvastatin was abolished. Fluvastatin had no direct effect on the H(2)O(2)-sensitive TRPM2 calcium channel. CONCLUSIONS: These results suggest that fluvastatin has a potent protective effect against H(2)O(2)-induced apoptosis via upregulation of Bcl-2 expression. The findings provide a new insight into the mechanism by which fluvastatin is able to modulate the influence of oxidative stress on vascular endothelial cells.

Should we continue screening rhesus D positive women for the development of atypical antibodies in late pregnancy?

OBJECTIVE: The purpose of this study was to calculate the incidence of the new development of atypical antibodies (other than anti-rhesus D) in women attending for antenatal care, and to assess the clinical impact and cost-effectiveness of a second test to detect these antibodies. METHOD: A three-year retrospective analysis was undertaken to calculate the number of rhesus positive women who developed new antibodies in the last trimester of pregnancy. RESULTS: Of 13,143 rhesus positive women, 20 (0.15%) developed new antibodies; fetal outcome was not compromised in any of these cases. CONCLUSION: Repeat testing in late pregnancy would appear an unnecessary expense in our population.

The prevalence of emotional abuse in gynaecology patients and its association with gynaecological symptoms.

AIM: To determine the lifetime prevalence of emotional abuse in a population of women attending a gynaecology outpatient clinic and also to investigate whether women who reported emotional abuse were more likely to complain of certain gynaecological symptoms. SETTING: A gynaecology outpatient clinic in a North of England Hospital. METHODS: Anonymous confidential questionnaire given to women. RESULTS: Nine hundred and twenty consecutive women were included, 825 questionnaires were returned (90% response rate). The prevalence of emotional abuse was 24% (198/825). Emotional abuse is four times less common in women over 50 years old. Of the fifteen presenting symptoms reported by the women, referral for termination of pregnancy, cervical smear abnormality, worry about cancer and urinary incontinence were significantly more common in the group who reported emotional abuse. The women with emotional abuse also had significantly more consultations; however, the duration of their symptoms was not significantly different. CONCLUSION: The prevalence of emotional abuse in a group of women attending the gynaecology outpatient clinic in a North of England Hospital was 24%. Women who are subjected to emotional abuse tend to have more consultations and are more likely to complain of certain symptoms.

The development of a scoring system for symphysis pubis dysfunction.

Based on a review of the literature, a questionnaire was developed to create a scoring system for pregnancy-related symphysis pubis dysfunction (SPD) and completed by 150 (100 without SPD and 50 with SPD) peri-partum women. The questionnaire was tested for reliability in a sub-set of 21 women. Symptoms that were significantly associated with SPD were identified and used in a scoring system in order to diagnose patients with SPD. SPD was reported by 12% of patients in the first trimester, 34% in the second trimester and 52% in the third trimester. Significant symptoms in patients with SPD were: pubic bone pain on walking, turning over in bed, climbing stairs, standing on one leg, and previous damage to back or pelvis. Using a score of 1 for each of the above symptoms, a score of 2 and above was considered diagnostic of SPD. There was 1 false positive score. As SPD is a clinical condition with no definitive diagnostic test, there is a need for a scoring system that will allow patients to be assessed in terms of their symptoms. This system has the potential to facilitate screening, diagnosis and management of SPD as well as allow monitoring of the patient and assessment of the success of various interventions.

Somatostatin receptors 2 and 5 are preferentially expressed in proliferating endothelium.

Angiogenesis is characterised by activation, migration and proliferation of endothelial cells and is central to the pathology of cancer, cardiovascular disease and chronic inflammation. Somatostatin is an inhibitory polypeptide that acts through five receptors (sst 1, 2, 3, 4, 5). Sst has previously been reported in endothelium, but their role remains obscure. Here, we report the expression of sst in human umbilical vein endothelial cells (HUVECs) in vitro, during proliferation and quiescence. A protocol for culturing proliferating and quiescent HUVECs was established, and verified by analysing cell cycle distribution in propidium-iodide-stained samples using flow cytometry. Sst mRNA was then quantified in nine proliferating and quiescent HUVEC lines using quantitative reverse transcriptase-polymerase chain reaction. Sst 2 and 5 were preferentially expressed in proliferating HUVECs. All samples were negative for sst 4. Sst 1 and 3 expression and cell cycle progression were unrelated. Immunostaining for sst 2 and 5 showed positivity in proliferating but not quiescent cells, confirming sst 2 and 5 protein expression. Inhibition of proliferating cells with somatostatin analogues Octreotide and SOM230, which have sst 5 activity, was found (Octreotide 10(-10)-10(-6) M: 48.5-70.2% inhibition; SOM230 10(-9)-10(-6) M: 44.9-65.4% inhibition) in a dose-dependent manner, suggesting that sst 5 may have functional activity in proliferation. Dynamic changes in sst 2 and 5 expression during the cell cycle and the inhibition of proliferation with specific analogues suggest that these receptors may have a role in angiogenesis.

Domestic violence: prevalence and association with gynaecological symptoms.

OBJECTIVE: To determine the prevalence of domestic violence in a population of women attending a gynaecology outpatient clinic in the United Kingdom and also to investigate whether women who reported domestic violence were more likely to complain of certain gynaecological symptoms. DESIGN: Questionnaire survey. SETTING: A gynaecology outpatient clinic in a North of England Hospital. SAMPLE: Nine hundred and twenty consecutive clinic attenders. METHODS: Anonymous confidential questionnaire given to women. MAIN OUTCOME MEASURES: Disclosure of a past history of domestic violence and gynaecological complaints. RESULTS: Nine hundred and twenty consecutive women were included and 825 questionnaires were returned (90% response rate). The prevalence of physical abuse was 21% (171/825). Thirty-four (4%) had experienced violence in the past year. Domestic violence is three times less common in women over 50 years old. Ex-husbands (32%) and ex-boyfriends (29%) were the main perpetrators. Forty-eight percent women who had experienced physical violence also had forced sexual activity. Of the 15 presenting symptoms reported by the women, lower abdominal pain, dysmenorrhoea, dyspareunia, smear abnormalities, cancer worries and bowel symptoms were significantly more common complaints in the group who reported domestic violence. The women with domestic violence also had significantly more consultations; however, the duration of their symptoms was not significantly different. CONCLUSION: The prevalence of domestic violence in a cohort of women who attended the gynaecology outpatient clinic in a North of England Hospital was 21%. Women who are subjected to domestic violence tend to have more consultations and are more likely to complain of certain symptoms.

Thromboprophylaxis for caesarean section--how can uptake and coverage be improved?

The objective of this study was to determine the proportion of patients requiring thromboprophylaxis and evaluate adherence to local protocols on thromboprophylaxis after caesarean section. This was a retrospective audit of 200 consecutive patients undergoing caesarean section between January and March 2002. The study was carried out at two obstetric units in Hull. We evaluated the proportion of patients requiring prophylaxis, appropriate and inappropriate treatment given and those omitted from receiving prophylaxis. Adherence to a risk assessment protocol was also assessed. The majority of women (84.5%) had at least one risk factor for thromboembolism. Use of a checklist did not increase the appropriate use of thromboprophylaxis and did not reduce inappropriate use. The checklist was used appropriately in only 54% of cases. Thromboprophylaxis has not been associated with problems if given after operation, thus the inappropriate administration is probably not a serious mistake. Universal prophylaxis with low molecular weight heparin would prevent at-risk women being missed and should be considered.

A randomised controlled trial of the closure or non-closure of peritoneum at caesarean section: effect on post-operative pain.

OBJECTIVE: To compare the analgesic requirement in the post-operative period after closure or non-closure of the peritoneum at the caesarean delivery with a standardised anaesthetic and surgical technique. DESIGN: A randomised double-blind controlled trial was performed on 100 women who underwent elective caesarean delivery. MAIN OUTCOME MEASURES: Analgesic requirement assessed by morphine usage via patient controlled analgesia pump over the first 24-hour period after surgery, oral analgesia used during the first four days, postoperative pain assessed by a visual analogue scale and a verbal rating scale, and patient satisfaction assessed by verbal rating scale were the main outcome measures. RESULTS: Pain scores at 24 hours were similar in both groups (43.5 in closure and 40.5 in non-closure) but during the first 24 hours the non-closure group had used significantly less morphine than the closure group (0.64 mg/kg of body weight vs 0.82 mg/kg, P = 0.04). The patients in non-closure group had significantly higher satisfaction scores after 24 hours than the closure group. CONCLUSION: Non-closure of both visceral and parietal peritoneum at the caesarean section produces a significant reduction in the post-operative use of patient controlled analgesia pump morphine and significantly higher patient satisfaction at 24 hours post-operatively.

Spontaneous recovery of chemotherapy-induced primary ovarian failure: implications for management.

A 14-year-old female patient presented with a swelling, which was excised, over the left forearm. Histology revealed a poorly differentiated rhabdomyosarcoma and she was treated with multiple chemotherapy for 2 years, including cyclophosphamide, cisplatin and vincristine. She developed secondary amenorrhoea shortly after commencing treatment which persisted on its completion. Biochemical investigations were consistent with ovarian failure, which was assumed to be chemotherapy-induced and permanent. She was given hormone replacement with a conjugated equine oestrogen/norgestrel combination, resulting in regular withdrawal bleeding. At 22 years of age; she presented with amenorrhoea for 3 months. Investigations revealed FSH 2.7 IU/l, LH > 50 IU/l and oestradiol > 1320 pmol/l. A pregnancy test was positive and subsequent ultrasound scanning confirmed the presence of a foetus of 18 weeks gestation. The patient initially considered a termination as she had been unprepared for this event but later elected to continue the pregnancy which proceeded uneventfully and resulted in the birth of a normal infant. Ovarian function should be reassessed periodically in patients with chemotherapy-induced gonadal damage and/or the oral contraceptive pill should be used as hormone replacement unless fertility is desired.

Ectopic pregnancy: analysis of 100 cases.

This study of 100 consecutive ectopic pregnancies in Zulu patients emphasises the role of less sophisticated diagnostic methods such as colpopuncture when beta human chorionic gonadotrophin (beta HCG) assay is not available. Infertility (61%) and previous pelvic infection (32%) were associated factors. The ectopic gestation was ruptured in 93% of cases.

Spontaneous regression of large theca lutein cysts in a twin pregnancy. A case report.

A case of bilateral theca lutein cysts in a twin pregnancy is presented. Under ultrasound surveillance the cysts were seen to undergo spontaneous regression which was not matched by a falling human chorionic gonadotrophin titre.