Gillian C. Penney

Over the past decade, there has been increasing interest internationally in studying maternal near misses, or severe morbidity, to complement traditional audit of maternal mortality. This review summarizes studies in this field published during 2005-2006. There is wide variation among published studies in terms of definitions of near miss, sources of data, and assessment of quality of care. Some investigators focus on single categories of near miss (e.g. postpartum haemorrhage, obstetric hysterectomy, intensive care unit admission), whereas others include multiple categories (ranging from two to 14). Some groups identify cases from routinely collected administrative data; whereas others search hospital registers and individual case records. Many investigators make no attempt to assess quality of care or preventability, but restrict their studies to the reporting of rates of severe morbidity. Others assess care by means of interviews with survivors or case note review, but study only a sample of cases and cannot report incidence rates. A minority of investigators both report incidence rates and assess quality of care. Near miss audit is increasingly used to complement maternal mortality review. Standardization of inclusion criteria and of methods for case assessment would facilitate comparisons over time and among countries.

To determine the impact of a national strategy to promote implementation of a guideline on the management of mild, non-proteinuric hypertension in pregnancy. Simple, interrupted time series analysis. Four maternity units in Scotland. Women delivering a live or stillborn baby. Dissemination of the guideline under the auspices of a national clinical effectiveness programme, supported by a national launch meeting and feedback from a survey of obstetricians highlighting aspects of care that could be improved. Appropriateness of initial investigation and subsequent clinical management, and costs of guideline development and implementation activities. Twenty-four months pre-intervention and 12 months post-intervention data were abstracted from a random sample of case notes. Initial investigation was consistent with recommendations for 59.9% out of 1263 women and subsequent clinical management for 67.6% out of 1081 in whom a diagnosis could be made from available data. There were no significant changes in the appropriateness of initial investigation (10.6%; 95% confidence interval [CI] -0.1% to 19.3%; decreasing by 1.2% per month post-implementation, 95% CI -2.5% to 0.1%) or clinical management (-0.3%; 95% CI -8.7% to 11.2%). Guideline development and implementation cost an estimated pound 2784 per maternity unit in Scotland. Clinical care of mild hypertension in pregnancy remains highly inconsistent. The lack of the intervention effect may be related to the complexity of the guideline recommendations and the nature of the implementation strategy.

To determine the outcomes of pregnancies in women with pre-existing, type 1 diabetes. Prospective, population-based cohort. Scotland. All 273 women with type 1 diabetes with a pregnancy ending (in miscarriage, abortion or delivery) during the 12 months (from April 1, 1998 to March 31, 1999). Pregnancies identified prospectively by clinicians in each hospital; outcome data collected from case records and from Scottish national data sets. Perinatal and infant mortality, congenital anomaly and birthweight. Of the 273 pregnancies, 40 (14.7%) ended in miscarriage, 20 (7.3%) in abortion and 213 (78%) in delivery. Three deliveries were twin births, thus 216 babies were born. Stillbirth rate (4/216): 18.5 (95% CI 5.1-46.8) per 1000 total births; perinatal mortality rate (6/216): 27.8 (95% CI 10.2-59.4) per 1000 births. There were 13 verified congenital anomalies (in six abortions and seven live births), anomaly rate: 60 (95% CI 32-101) per 1000 total births. Among 208 singleton, live born infants, the mean birthweight was 3427 g. Standardised birthweight scores, relative to a reference population, showed a unimodal distribution, shifted to the right (mean, 1.57 SD). In an unselected population, adverse outcomes remain more common among the infants of mothers with type 1 diabetes than in the general population. The targets of the St Vincent Declaration of 1989 have not been met. Improvements may be gained by increases in provision of prepregnancy care and in the proportion of pregnancies that are planned. However, further research is needed to clarify the root causes of adverse outcomes in the pregnancies of women with diabetes.

Aim  To examine the relationships between maternal HbA_1c concentration at different time points and birth weight in pregnancies complicated by pre‐existing Type 1 diabetes.Methods  A comprehensive audit dataset was collected prospectively on all deliveries in Scotland to women with pre‐existing Type 1 diabetes occurring between 1 April 1998 and 31 March 1999. Data items included HbA_1c concentrations prior to conception and in each of the three trimesters of pregnancy, and birth weight. Relationships between standardized birth weight and HbA_1c concentrations at each of the four time points were examined using correlation analysis.Results  Standardized birth weight (Z scores) could be calculated for 203 of 208 singleton liveborn infants. HbA_1c concentrations, standardized to correct for assay differences among hospitals, at different time points were available for between 134 (pre‐pregnancy) and 192 (third trimester) cases. Standardized birth weight, relative to a reference population, showed a unimodal distribution, shifted to the right (mean, +1.57 sd). There was a significant negative correlation between pre‐pregnancy HbA_1c and birth weight (Spearman's R, −0.208; P = 0.016). There were no statistically significant correlations for other time points.Conclusions  Standardized birth weight scores of the infants of diabetic mothers are higher than those of a reference population. There is no simple relationship between maternal glycaemic status and birth weight, but there appears to be a paradoxical inverse relationship between pre‐pregnancy glycaemic control and standardized birth weight.

The aims of this study were to assess mental well-being in women undergoing investigation and initial management of infertility and to determine any specific factors, such as the duration or type of infertility, that might be associated with an increased risk of psychological morbidity. A postal survey was sent to 1080 women with infertility attending gynecology outpatient departments in 12 Scottish centres. The survey included the Twelve-Item General Health Questionnaire (GHQ-12) and three multi-item scales from the Short Form Health Survey Questionnaire (SF-36). The response rate was 47.4% (512/1080) of which 507 completed the GHQ-12. Of the 507 CHQ-12 responders, 32.5% had a CHQ-12 score of ≥ 8/12 suggesting they were at risk of clinically significant psychological disturbance. There were no Significant associations between CHQ-12 scores and duration of infertility, the presence of existing children, or the cause of infertility. GHQ-12 scores significantly increased with the number of clinic attendances and decreased as the patient's age increased. Responders scored significantly lower on all aspects of the selected SF-36 questions as compared to published population data, suggesting poorer mental health. These standardized psychological instruments suggest that approximately 32% of women in the early stages of infertility management may be at risk of developing clinically relevant mental health problems. Psychological aspects of infertility should be addressed as part of a more holistic approach to management of these patients.