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.

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.

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.

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.

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). Lupus (2010) 19, 58—64.

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.

Coping with placenta praevia and accreta in a DGH setting and words of caution

The incidence of placenta praevia and accreta has been increasing with rising caesarean section rates. We highlight the increasing incidence of severe post-partum haemorrhage due to placenta accreta. Four cases occurred within 3 years (2002--2004) in a small District General Hospital (DGH) with a delivery rate of 1,800 per year. All of the cases had previous caesarean sections and three had an associated anterior low-lying placenta. These patients were diagnosed to have placenta accreta in the third stage of labour, as the placenta was completely adherent and was difficult to remove. However, two of them had a provisional diagnosis made of placenta accreta and prophylactic measures had been taken in the form of counselling and consent for possible hysterectomy. Patients were counselled regarding this condition, and the possible need for hysterectomy was discussed. Two of them had to be managed by post-partum hysterectomy and the other two were treated conservatively. The purpose of writing these case reports is to warn others of the need for vigilance, particularly in keeping their primary caesarean section rates down and being prepared for long-term complications.

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.

Anaesthetic management of two different modes of delivery in patients with dystrophic epidermolysis bullosa

Dystrophic epidermolysis bullosa is an inherited severe bullous condition characterised by extreme skin fragility and blistering in response to minor trauma. We present two obstetric cases with recessive dystrophic epidermolysis bullosa, one who underwent elective caesarean section, the other who delivered vaginally. The key points in the anaesthetic management of the obstetric patient with dystrophic epidermolysis bullosa include multidisciplinary preassessment, airway management strategies and the role of regional anaesthesia.

Obstetric hysterectomy in a population of South East England

The aim of this study was to estimate the incidence and outcome of obstetric hysterectomy. Of 48,865 women who delivered after 24 weeks' gestation in the South East Thames Region between March 1997 and February 1998, 22 women with obstetric hysterectomy were identified, and 15 prospectively followed-up (71% response rate). The incidence of obstetric hysterectomy was 0.45/1,000 deliveries with one maternal death (4.5%). Identified risk factors were delivery by caesarean section (68%), previous caesarean section (33%) and placenta praevia (24%). Mean blood loss and replacement were 5.2 l and 17 units, with a 38% risk of re-operation and 21% risk of urinary tract injury. Follow-up showed poor general health 6-9 months after delivery with 10 women (67%) attending outpatients and four (27%) requiring emergency admission to hospital. This population survey found a low rate of obstetric hysterectomy but severe morbidity. Obstetric hysterectomy is a good candidate for a national morbidity audit.

'Near-miss' obstetric enquiry

A near-miss maternal mortality enquiry was performed at University College Obstetric Hospital, London, by reviewing retrospectively all 30 obstetric admissions to the intensive care unit (ITU) over a two-year period. The obstetric admission rate to ITU was 0.5 (95% CI 0.32-0.67%), or one per 200 women delivered. Haemorrhage and severe pre-eclampsia were the two commonest causes of admission. Sub-standard care was identified in 52% of cases. Blood loss was often massive ( 2000 ml), underestimated and required large volume transfusions (mean transfusion 6.4 units, range 1-24). Although there are problems with definitions, ascertainment and validity, 'near-miss' review is feasible. It is worthwhile for every hospital to carry out its own 'near-miss' enquiry using appropriate local criteria to identify potential areas for improvements. 'Near-misses' are more prevalent than deaths and are dominated by conditions that are amenable to treatment. They may be even more sensitive to improvement or deterioration in obstetric services than mortality data.

Antiphospholipid antibodies do not a syndrome make

The association of antiphospholipid antibodies (aPLs) with a poor obstetric history and/or thrombotic event is typical of the antiphospholipid syndrome (APS). We report four cases of poor pregnancy outcome where a diagnostic label of APS resulted in delayed recognition of other causes of pregnancy loss. Pregnancy outcomes in these women were not improved with antithrombotic therapy alone. Successful outcomes were achieved only when other causes of recurrent miscarriage were considered and treated.

Periodontal health of London women during early pregnancy

OBJECTIVES

A descriptive cross-sectional study to determine the severity of periodontal disease in early pregnancy and its relation to demographic variables in a South East London population.

METHODS

2,027 pregnant women attending Guy's Hospital for an ultrasound scan at 10 to 14 weeks gestation were assessed. Data were collected via questionnaire and periodontal examination, including plaque and bleeding scores, pocket probing depth and loss of attachment.

RESULTS

Mean age was 29.8 years (sd 5.5). Of these, 61.8% were white, 28.5% black, and 9.7% of other ethnic group. A total of 15% reported smoking during pregnancy. The mean number of teeth present was 28 (sd 2) per subject, mean percentage of sites with plaque present was 60.5% (sd 22.6), mean pocket depth was 2.0 mm (sd 0.4), mean loss of attachment was 0.4 mm (sd 0.3), and the mean percentage of sites bleeding on probing was 20.2% (sd 16.3). Linear regression demonstrated that probing depth was related to age, ethnicity, socioeconomic status and plaque score but not to smoking whereas loss of attachment demonstrated relationships with age, smoking status and plaque score but not ethnicity or socioeconomic status.

CONCLUSION

There was a relatively high proportion of subjects with deep periodontal pockets in this pregnant population compared to the Adult Dental Health Survey 1998 but with similar levels of loss of attachment and percentage of sites with plaque present. Several demographic factors were associated with the level of periodontal disease in this population.

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.

Incidence and predictors of severe obstetric morbidity: case-control study

OBJECTIVE

To estimate the incidence and predictors of severe obstetric morbidity.

DESIGN

Development of definitions of severe obstetric morbidity by literature review. Case-control study from a defined delivery population with four randomly selected pregnant women as controls for every case.

SETTING

All 19 maternity units within the South East Thames region and six neighbouring hospitals caring for pregnant women from the region between 1 March 1997 and 28 February 1998.

PARTICIPANTS

48 865 women who delivered during the time frame.

RESULTS

There were 588 cases of severe obstetric morbidity giving an incidence of 12.0/1000 deliveries (95% confidence interval 11.2 to 13.2). During the study there were five maternal deaths attributed to conditions studied. Disease specific morbidities per 1000 deliveries were 6.7 (6.0 to 7.5) for severe haemorrhage, 3.9 (3.3 to 4.5) for severe pre-eclampsia, 0.2 (0.1 to 0.4) for eclampsia, 0.5 (0.3 to 0.8) for HELLP (Haemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, 0.4 (0.2 to 0.6) for severe sepsis, and 0.2 (0.1 to 0.4) for uterine rupture. Age over 34 years, non-white ethnic group, past or current hypertension, previous postpartum haemorrhage, delivery by emergency caesarean section, antenatal admission to hospital, multiple pregnancy, social exclusion, and taking iron or anti-depressants at antenatal booking were all independently associated with morbidity after adjustment.

CONCLUSION

Severe obstetric morbidity and its relation to mortality may be more sensitive measures of pregnancy outcome than mortality alone. Most events are related to obstetric haemorrhage and severe pre-eclampsia. Caesarean section quadruples the risk of morbidity. Development and evaluation of ways of predicting and reducing risk are required with particular emphasis paid on the management of haemorrhage and pre-eclampsia.

Abortion, relationship, and property in labor: a clinical case study

This article will explore a pregnant woman's experience of relationship with the fetus, using a clinical case study in which abortion would have been clinically indicated because of severe fetal abnormality. Emphasizing the pregnant woman's actual experience in this case study helps to highlight inadequacies in how the debate about abortion is usually conducted.