Learning from adverse clinical outcomes: major obstetric haemorrhage in Scotland, 2003-05.

OBJECTIVE: To describe a system for learning from cases of major obstetric haemorrhage. DESIGN: Prospective critical incident audit. SETTING: All consultant-led maternity units in Scotland, between 1 January 2003 and 31 December 2005. POPULATION: Women suffering from major obstetric haemorrhage (estimated blood loss > or = 2500 ml or transfused > or = 5 units of blood or received treatment for coagulopathy during the acute event). METHODS: Hospital clinical risk management teams reviewed local cases using a standard, national assessment pro forma. MAIN OUTCOME MEASURES: Standard of care provided and learning points identified. RESULTS: Rate of major haemorrhage was 3.7 (3.4-4.0) per 1000 births. Pro formas returned for 517 of 581 reported cases (89%); 41% were delivered by emergency caesarean section (compared with 15% of all Scottish births). Uterine atony was the most common cause (250 women, 48%); 32% had multiple causes. A consultant obstetrician gave hands-on care to 368 (71%) and a consultant anaesthetist to 262 (50%). Placenta praevia as a cause was independently associated with consultant presence. Central venous pressure monitoring was used in 164 (31%) women, and 108 (21%) women were admitted to intensive care. Parity, blood loss, and placenta praevia as a cause were independently associated with peripartum hysterectomy (performed in 62 women, 12%). Balloon tamponade and haemostatic uterine suturing were successful in 92 of 116 women (79%). Most cases were assessed as well managed, with 'major suboptimal' care identified in only 14 cases (3%). CONCLUSIONS: It is feasible to identify and assess cases of major obstetric haemorrhage prospectively on a national basis. Most women received appropriate care, but many learning points and action plans were identified.

An evaluation of the impact of a national health demonstration project on testing and management for Chlamydia trachomatis infections in two regions of Scotland.

OBJECTIVES: To compare clinical practice relating to testing for, and management of, genital Chlamydia trachomatis infection in the Lothian and Grampian regions of Scotland as part of an evaluation of a Government-funded health demonstration project in Lothian, Healthy Respect. STUDY DESIGN: Clinical audit against standards developed from a national clinical guideline. METHODS: Clinical practice relating to testing for, and management of, genital C. trachomatis infection was assessed against standards for good quality care developed from a national clinical guideline (Scottish Intercollegiate Guidelines Network Guideline 42). Audit methods comprised: postal survey of primary care clinicians; review of referral letters from primary to secondary care; and review of primary and secondary care patient case records. Findings from Lothian and Grampian were compared. RESULTS: Questionnaires were returned by 167 primary care clinicians in Lothian and 96 in Grampian. Clinicians in Lothian and Grampian gave similar responses relating to: testing of symptomatic patients (87 vs 88%); offer of testing for asymptomatic young patients (55 vs 55%); choice of antichlamydial agent (47 vs 42% azithromycin as first line); and follow-up strategies (50 vs 51% offer follow-up in primary care). Clinicians in Lothian were significantly more likely to participate in partner notification work (57 vs 44%; P=0.04) and to agree with statements reflecting 'perceived self-efficacy' in chlamydia-related care (57 vs 48%; P=0.006). Referral letters from primary to secondary care were reviewed for 31 women with genital symptoms in Lothian and 28 in Grampian. More women in Lothian were tested for chlamydia prior to referral (65 vs 39%; difference not significant). Review of primary care records for consultations in young people (145 in Lothian; 203 in Grampian) showed a higher level of chlamydia testing in Grampian (Lothian, 14%; Grampian, 34%; P<0.0001). However, review of secondary care records (n=39) showed a much higher level of testing in Lothian (Lothian, 75%; Grampian, 9%; P<0.0001). Review of secondary care records relating to proven chlamydia-positive women (n=159) suggested better care in Lothian in relation to ensuring antibiotic treatment (Lothian, 91%; Grampian, 74%; P=0.004), and use of the preferred antibiotic, azithromycin (Lothian, 78%; Grampian, 37%; P<0.0001). However, documented referral to a health adviser appeared to be better in Grampian (Lothian, 32%; Grampian, 48%; P=0.048). CONCLUSIONS: During the period of activity of the Healthy Respect demonstration project, few differences were detected between clinicians in Lothian and Grampian with regard to chlamydia-related practice. In both regions, clinicians appeared to be very aware of the need to test for chlamydia in patients with relevant symptoms, but were less likely to offer opportunistic testing to young patients without specific symptoms. These findings suggest that Healthy Respect in Lothian has had little impact on clinicians. However, these findings must be considered within the context of a broader evaluation, and it is noteworthy that the few significant differences that were detected tended to suggest better practice in Lothian.

Klippel-Trenaunay-Weber (KTW) syndrome: the use of in utero magnetic resonance imaging (MRI) in a prospective diagnosis.

The diagnosis of the Klippel-Trenaunay-Weber (KTW) syndrome is rarely made antenatally. We report the use of both ultrasound and in utero magnetic resonance imaging (MRI) in the prenatal diagnosis of this syndrome. This is the first report of the use of prenatal MRI in the diagnosis of this condition. There was concordance in the findings of both modalities, with limb hypertrophy, and multiple haemangiomata - both subcutaneous and internally - demonstrated with ultrasound and MRI. The patient elected to terminate the pregnancy because of associated oligohydramnios and a small fetal chest noted at 20 weeks. The postmortem examination confirmed the antenatal diagnosis.

Prenatal diagnosis and outcome in sacrococcygeal teratomas: a review of cases between 1992 and 1998.

A review of sacrococcygeal teratomas diagnosed in the antenatal period in the West Midlands region over a six year interval is reported. The aim of the study was to assess the contribution of ultrasound scanning to the management of cases and to determine the outcome of prenatally diagnosed sacrococcygeal teratomas. A retrospective review of 10 cases was performed to obtain pregnancy details, ultrasound scan data and outcome information. Two fetuses were electively aborted. Perinatal mortality was 62.5% in the remaining cases with all stillbirths and neonatal deaths occurring in babies delivered preterm (at or before 34 weeks' gestation). Marked increase in tumour size (mainly vascular/solid) was observed in five of the fetuses, which was often associated with local compression effects and the development of hydrops. Eight out of 10 cases were delivered vaginally, one following aspiration of the large cystic tumour. Three of the four neonates surviving to surgery underwent successful resection of their benign tumours. As well as guiding prognosis, serial ultrasound scans may also allow the mode of delivery to be planned more effectively. The importance of a multidisciplinary team approach to these difficult cases is emphasized.

Postgraduate journal club as a means of promoting evidence-based obstetrics and gynaecology.

We assessed the feasibility of a new educational programme to teach critical appraisal of the medical literature to postgraduate trainees. The new programme used a journal club format where selection of topics and articles was driven by clinical problems arising in day-to-day practice. Papers were appraised critically according to validated guidelines using computer software for appraisal, electronic storage and retrieval. Over the initial 4-month period the journal club produced 17 critically appraised topics, two of which were published in peer-reviewed journals. During the study, trainees' reading time improved from a median of 2.0 hours (range 1-5 hours) to 3.5 hours (range 2-8 hours) (P = 0.026) and their knowledge scores improved from a mean of 50.8 (SD 4.0) to 62.9 (SD 4.3) (P = 0.003). We conclude that a journal club supported by electronic means of critical appraisal and dissemination of appraised information can be used to encourage the practice of evidence-based medicine.