Birth weight and maternal glycated haemoglobin in pregnancies complicated by type 1 diabetes.

AIM: To re-examine the relationships between birth weight and maternal glycated haemoglobin (HbAlc) concentration at different time points in pregnancies complicated by pre-gestational type 1 diabetes. METHODS: A dataset was collected prospectively on all deliveries in Scotland to women with pre-gestational type 1 diabetes occurring during two 12 month periods (01/04/98 to 31/03/99 and 01/04/03 to 31/03/04). Relationships between standardised measures of birth weight and HbAlc at each time point were examined using correlation analysis. RESULTS: Standardised birth weights (Z scores) were calculated for 338 singleton live born infants. HbA1c concentrations were available for: 204 women (pre-pregnancy), 297 women (1st trimester), 314 women (2nd trimester) and 303 women (3rd trimester). Standardised birth weight showed a unimodal distribution shifted to the right relative to a reference population (Mean, +1.62 S.D). There was a significant negative correlation between pre-pregnancy HbAlc and birth weight (Spearman's Rho -0.138; p=0.049). CONCLUSIONS: Standardised birth weights of the infants of diabetic mothers are higher than those of a reference population. There is no simple relationship between maternal glycaemic control and birth weight, but the previously described paradoxical inverse relationship between pre-pregnancy glycaemic control and birth weight has been confirmed using a larger dataset.

The incidence, characteristics, and prognosis of patients whose infertility is unexplained.

Review of the case records of 500 consecutive couples attending one Scottish infertility clinic revealed a group of patients whose infertility remained unexplained after completion of a standard protocol of investigations. The incidence of this condition in the clinic population was 24%. Various patient characteristics were examined, and no differences from patients with a detectable, organic cause for their infertility were found. Life-table analysis was used to provide a prognostic guide for such couples. About 34% of those with primary infertility and 21% of those with secondary infertility will remain infertile after 9 years of attempting to conceive.

PIP: Review of the case records of 500 consecutive couples attending 1 Scottish infertility clinic revealed a group of patients whose infertility remained unexplained after completion of a standard protocal of investigations. The incidence of this condition in the clinic population was 24%. Various patient characteristics were examined, and no differences from patients with a detectable, organic cause for their infertility was found. Life table analysis was used to provide a prognostic guide for such couples. About 34% of those with primary infertility and 21% of those with secondary infertility will remain infertile after 9 years of attempts to conceive.

Survey of psychological health in women with infertility.

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 GHQ-12 responders, 32.5% had a GHQ-12 score of > or = 8/12 suggesting they were at risk of clinically significant psychological disturbance. There were no significant associations between GHQ-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.

Impact of a national audit project on gynaecologists in Scotland.

The objectives of the study were (a) to determine consultant gynaecologists' awareness of and views on a national audit project (the gynaecology audit project in Scotland) and (b) to measure changes in their reported practice in relation to 12 specific elements of care related to three audit topics (induced abortion, endometriosis, and vulvar carcinoma) for which recommendations for change had been made within the project. The study comprised a postal questionnaire survey of all 128 consultant gynaecologists in NHS practice in Scotland. The response rate was 90%. Of the respondents, 96% (109/113) recalled receiving feedback material from the audit project team and around 75% (range 66/89 to 84/105) had retained feedback reports for future reference. For the two more common clinical topics (induced abortion and endometriosis), over two thirds of the respondents indicated that they had been prompted to reconsider or change aspects of practice. Significant changes in reported practice, in line with project recommendations, were found for seven of the 12 specific elements of care examined. Thus, gynaecologists in Scotland showed a high level of awareness of and positive views towards a national audit project. Significant changes in reported practice, in accordance with circulated recommendations, were measurable in relation to several elements of clinical care.

Agreeing criteria for audit of the management of induced abortion: an approach by national consensus survey.

OBJECTIVE: To obtain a national consensus view of suggested criteria for good quality care in induced abortion to serve as a basis for standards for audit to assess current clinical practice. DESIGN: Postal, questionnaire survey assessing consensus agreement with criteria identified from a literature review and refined by an invited panel of four gynaecologists and the gynaecology audit project in Scotland (GAPS) committee. SETTING: Scotland. SUBJECTS: All 132 practising consultant gynaecologists. MAIN MEASURES: Overall level of agreement with each of 20 suggested audit criteria. RESULTS: 121 completed questionnaires were received (response rate 92%), of which 119 were returned in time for analysis; 107 came from consultants who practised abortion routinely and were included in the analysis. Nineteen of 20 suggested criteria were validated by an overall balance of agreement. The most strongly supported criterion (agreement score +93) was for ascertaining rhesus status of the woman and prophylaxis after abortion, if indicated. The only criterion to elicit a negative agreement score (-27) was that dilatation and evacuation is the best method of abortion at 12-15 weeks' gestation. The ranked and prioritised criteria resulting from this exercise are being used within a national audit project. CONCLUSIONS: A postal questionnaire survey among interested clinicians resulted in a good response rate and enabled the audit criteria to be validated and ranked more objectively and among more clinicians, than would have been possible by group discussion.

Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries.

The objective of the study described is to assess the feasibility and effectiveness of using a criterion-based clinical audit to measure and improve the quality of obstetric care at the district hospital level in developing countries. The focus is on the management of five life-threatening obstetric complications--hemorrhage, eclampsia, genital tract infection, obstructed labor and uterine rupture was audited using a "before and after" design. The five steps of the audit cycle were followed: establish criteria of good quality care; measure current practice (Review I); feedback findings and set targets; take action to change practice; and re-evaluate practice (Review II). Systematic literature review, panel discussions and pilot work led to the development of 31 audit criteria. Review I included 555 life-threatening complications occurring over 66 hospital-months; Review II included 342 complications over 42 hospital-months. Many common areas for improvement were identified across the four hospitals. Agreed mechanisms for achieving these improvements included clinical protocols, reviews of staffing, and training workshops. Some aspects of clinical monitoring, drug use and record keeping improved significantly between Reviews I and II. Criterion-based clinical audit in four typical district hospitals in Ghana and Jamaica is a feasible and acceptable method for quality assurance and appears to have improved the management of life-threatening obstetric complications.

Multicentre criterion based audit of the management of induced abortion in Scotland.

OBJECTIVES: To assess and improve the quality of care provided to women undergoing induced abortion. DESIGN: Two rounds of prospective, criterion based case note review audit. SETTING: Ten NHS gynaecology units throughout Scotland. SUBJECTS: 2004 patient episodes of abortion care identified consecutively during two rounds of audit. The first round comprised 967 cases and the second round 1037. INTERVENTIONS: Dissemination of results from the first round of audit and recommendations for change in the form of a written report and at postgraduate meetings in participating hospitals. MAIN OUTCOME MEASURES: Improvements in quality of care as assessed against 16 previously agreed criteria, both overall across the 10 study hospitals and within individual hospitals. RESULTS: Overall, four significant improvements occurred: increased availability of early medical abortion, decreased utilisation of surgical abortion at very early gestation, increased use of mifepristone priming before second trimester medical abortion, and increased provision of follow up. At the individual hospital level 42 of 150 elements of care studied were "close to optimal" at the time of the first round of audit, rising to 54 at the second round (NS). A total of 31 significant improvements in individual elements of care occurred, but 11 significant deteriorations also occurred (at the P < 0.05 level). CONCLUSIONS: The prospective multicentre audit proved feasible and achieved the aims of any form of audit in terms of identifying deficiencies and variations in care. The audit results prompted objective review of local abortion services in participating hospitals. At least for some elements of care in some hospitals significant improvements were detectable.

PIP: The objective was to assess and improve the quality of care provided to women undergoing induced abortion. Two rounds of prospective, criterion-based case note review audit were carried out in 10 National Health Service gynecology units throughout Scotland, and 2004 patient episodes of abortion care were identified. The first round comprised 967 cases and the second round 1037. Significant improvements occurred in quality of care as assessed against 16 previously agreed upon criteria across the 10 study hospitals and within individual hospitals. These included increased availability of early medical abortion, decreased utilization of surgical abortion at very early gestation, increased use of mifepristone priming before 2nd trimester medical abortion and increased provision of follow up. At the individual hospital level, 42 of 150 elements of care studied were close to optimal at the time of the first round of audit, rising to 54 at the second round. A total of 31 significant improvements in individual elements of care occurred, but 11 significant deteriorations also occurred at the p 0.05 level. At the time of the 2nd round of audit 4 significant overall improvements across the 10 hospitals were detected: the use of medical abortion for women at 9 weeks' gestation rose from 39 to 516 (7.6%) to 172 of 541 (31.8%) (p0.0001); the inappropriate use of surgical abortion in women at 7 weeks' gestation decreased from 68 of 85 (80.0%) to 56 of 98 (57.1%) (p=0.0017); the use of mifepristone cervical priming before midtrimester medical abortion increased from 15 of 64 women (23.4%) to 64 of 102 (62.7%) (p 0.0001); the recording of a follow up arrangement in the case notes increased from 52% to 69% of cases (p=0.037), and the advising of follow up within the recommended interval of two weeks after abortion also increased (from 5% to 32%; p=0.0645). There were no overall deteriorations in relation to any elements of care. The prospective multicentre audit proved feasible and achieved the aims of any form of audit in terms of identifying deficiencies and variations in care.

The relationship between pre-pregnancy care and early pregnancy loss, major congenital anomaly or perinatal death in type I diabetes mellitus.

The relationships between markers of pregnancy planning and pre-pregnancy care and adverse outcomes (early pregnancy loss, major congenital anomaly and perinatal death) were examined in 423 singleton pregnancies in women with pre-gestational type I diabetes mellitus. Pregnancy planning and markers of pre-pregnancy care were associated with reduced risks of adverse pregnancy outcomes. 'Documentation of achievement of an optimal haemoglobin A1c prior to discontinuation of contraception' was the marker associated with the lowest rate of adverse outcome (OR 0.2; 95% CI 0.06-0.67) and might serve as an appropriate definition of pre-pregnancy care for research and audit purposes.

Do panels vary when assessing intrapartum adverse events? The reproducibility of assessments by hospital risk management groups.

INTRODUCTION: A national audit project, Scotland-wide Learning from Intrapartum Critical Events (SLICE), included local assessment of quality of care in cases of perinatal death and neonatal encephalopathy due to intrapartum events. Concerns had been raised about interobserver variation in case assessment by different panels. We therefore studied the extent of agreement and disagreement between assessment panels, and examined the areas in which agreement and disagreement tended to occur. METHODS: 8 cases were randomly selected from all 42 cases identified during a 6-month period (1 January-1 July 2005). Each case was independently reviewed by three panels: the local hospital clinical risk-management group and two specially convened external panels. Panels assessed quality of care in three areas: admission assessment, recognition of incident, and method and timing of delivery. Predefined standards of care were provided for these three areas. Panels were also asked to assess the overall quality of care. RESULTS: For each area of care, agreement between the two external panels was lowest. The lowest levels of agreement between panels were seen in assessment of overall care (50% crude agreement between external panel 1 and the hospital (kappa = 0.24, AC(1) = 0.36); 29% crude agreement between external panels 1 and 2 (kappa = -0.11, AC(1) = 0.1); 47% crude agreement between external panel 2 and the hospital (kappa = 0.36, AC(1) = 0.46). The lowest level of agreement among all three panels was also in the assessment of overall care (crude agreement 48%; kappa = 0.16, AC(1) = 0.34). CONCLUSION: Moderate to substantial agreement among the three panels was achieved for the three areas in which explicit standards were provided. Therefore, a systematic approach to analysis of adverse events in perinatal care improves reproducibility.

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.

Preventing infective sequelae of abortion.

Pelvic infection complicates up to 12% of induced abortions and has an adverse effect on future reproductive outcome. The presence in the lower genital tract of Neisseria gonorrhoeae, Chlamydia trachomatis or the anaerobic organisms characterizing bacterial vaginosis is associated with an increased risk of post-abortion infective morbidity. Meta-analysis of randomized trials has shown that prophylaxis with antibiotics effective against either C. trachomatis or bacterial vaginosis reduces the risk of post-abortion infective morbidity by around a half. Other strategies which have been advocated for minimizing the risk of infective morbidity are screening for lower genital tract infections, with treatment of positive cases only, and a combined strategy where women are screened for sexually transmitted infections as well as receiving prophylaxis. These strategies provide the opportunity for appropriate follow-up and partner notification of those women found to have sexually transmitted infections. A multicentre study designed to determine the prevalence of genital tract infections among Scottish women seeking induced abortion, and to compare strategies of 'universal prophylaxis' and 'screen and treat' for minimizing infective morbidity in such women has been undertaken. A total of 1672 women were recruited. Prevalence rates of lower genital tract gonorrhoea, chlamydia and bacterial vaginosis were found to be similar to those reported in other UK studies. Women managed by the 'screen and treat' strategy (particularly those whose genital tract swabs were reported negative) had slightly higher rates of infective morbidity in the 8 weeks after abortion than those managed by 'prophylaxis'. Using currently available screening tests and genitourinary medicine services, 'prophylaxis' appears to be the more cost effective of the two strategies studied.

PIP: Reported rates of post-abortion pelvic inflammatory disease (PID) range from 5-29%. The risk of infection has been associated with the presence of Neisseria gonorrhoeae, Chlamydia trachomatis, and anaerobic organisms in the lower genital tract. The present study analyzed the prevalence of genital tract infections in 1672 women undergoing induced abortion at 3 centers in Scotland and evaluated the efficacy of two preventive interventions. Prevalence rates of lower genital tract gonorrhea, chlamydia, and bacterial vaginosis before abortion were similar to those identified in other UK studies. Women were randomly allocated to receive either prophylactic metronidazole (immediately before abortion) and doxycycline (for 7 days after abortion) or received antibiotics only if pre-abortion genital tract swabs were positive for any of the 3 infections. During the 8-week post-abortion follow-up period, women managed by the screen-and-treat protocol had slightly less favorable outcomes in terms of hospital readmissions, general practitioner consultations, antibiotic prescriptions, time off work, and limitations on domestic activities than women who received prophylactic treatment. Differences were statistically significant, however, only for women whose swabs were negative for all 3 infections. The rate of post-abortion PID/endometritis in this groups was 3% among women who received prophylactic antibiotics and 6% in those who were screened and not treated. These findings suggest that universal antibiotic prophylaxis may represent the most cost-effective approach to minimizing the risk of infective morbidity. Advocated for consideration is a third strategy involving prophylaxis at the time of abortion followed by screening for gonorrhea and chlamydia to ensure adequate follow-up of treatment results and partner notification.

Comparison between biochemical and histochemical assessments of peroxidase activity in rat mammary tumours.

The endogenous peroxidase content of 26 'hormone-dependent' and 16 'hormone-independent' rat mammary tumours was assessed by means of a biochemical (guaiacol) assay on tumour extracts and by means of a histochemical (diaminobenzidine) technique on frozen sections of the same tumours. By guaiacol assay, the hormone-dependent tumours had significantly higher peroxidase levels than the hormone-independent tumours. In contrast, by diaminobenzidine staining of the same tumours, peroxidase was detectable in 94% of hormone-independent tumours but in only 54% of hormone-dependent tumours. Moreover, there was no direct correlation between the results of biochemical and histochemical methods. At least in these rat mammary tumours, therefore, histochemical estimates of peroxidase activity based on the diaminobenzidine reaction do not seem to reflect the same tissue properties as biochemical estimates based on the guaiacol reaction after tissue disruption.

Induced abortion: an audit of reported current practice among consultant gynaecologists in Scotland.

OBJECTIVE: To obtain an overview of current abortion practice in Scotland for comparison with agreed criteria for good quality care based on literature review. DESIGN: Postal questionnaire survey. SUBJECTS: All 132 consultant gynaecologists practising in the NHS in Scotland. RESULTS: Response rate 92%. The survey revealed regional inequalities in the availability of services, particularly with regard to early medical abortion and second trimester procedures. It also revealed great individual variations in many areas of practice notably in screening for genital tract infection, the use of cervical predilatation, contraceptive provision, and follow up. Several aspects of practice compared poorly with the agreed criteria for good quality care. CONCLUSIONS: The postal questionnaire approach achieved a good response rate and has provided an informative overview of current practice on a national basis. Variations in the provision of services and in clinical practice, both among regions and among individual consultants, have been identified. Elements of abortion care in which great variations exist and in which current practice compares poorly with the agreed criteria have been highlighted as appropriate areas for the development of national guidelines and for educational initiatives. Such a questionnaire approach to assessing current practice can complement, and possibly replace, some aspects of casenote review audit.

PIP: A questionnaire was sent to all 132 consulting gynecologists in Scotland in September, 1992, to examine current abortion practices so researchers could compare abortion practices with criteria for good quality care. The response rate was 92%. Inequalities in the availability of abortion services existed among regions. For example, the maximum gestation at which abortion was available ranged from 12 weeks in region 13 to 24 weeks in regions 2 and 4. Yet, the Birth Control Trust and the Scottish Home and Health Department recommend that all Health Boards provide second trimester abortion. Further, early medical abortion was available on a very limited basis in 13 hospitals of 8 of the 13 Health Boards. 23 of 26 gynecology units had a centralized referral telephone system. Individual differences existed in terms of quality of care. For example, 29% took no special precautions to manage potential genital tract infection. Just 22% took genital swabs of all cases. 35% did of selected cases. 3% administered prophylactic antibiotics in all abortion cases. Just 39% would predilate the cervix in all patients, even though the risk of cervical damage is great in young and multiparous women. Just 49% would discuss and provide contraception as part of postabortion care. 28% did not suggest any follow-up. 14% did not advocate day case care when medically appropriate. Most gynecologists used medical abortion in the second trimester. Gynecologists at only 3 of the 26 gynecology units used mifepristone as a pretreatment to facilitate second trimester prostaglandin abortion. Even though quality of care criteria call for contraceptive provision and postabortion care and counseling, few gynecologists considered these aspects of care to be important. The questionnaire can complement, perhaps even replace, the casenote review audit to assess current abortion practice.

Histochemical assay of oestrogen receptor.

PIP: A histochemical approach is useful in overcoming some of the problems of conventional ER (estrogen receptor) assay techniques. It is also valuable in providing a more accurate prediction of response to endocrine therapy. However, there are some aspects of this technique which are still puzzling. Histochemical assays of estrogen binding have been found to correlate with results of conventional biochemical assays using triated-H-estradiol-17 beta with tissue cytosol. However, such technique involves the cutting of frozen sections of thickness 4 um; this would likely transect many cells and thus allow the leaching-out of the soluble ER protein into aqueous media. This leaching-out may be prevented by fixation of the tissue before or after the binding of estrogen or conjugate to the section; however, such method may also inactivate the receptor. Nonspecific binding may be problematic too, especially when high concentrations of estradiol or conjugates are used. Thus maintaining functional integrity and intracellular localization of the ER during histochemical processing remains a big problem with histochemical assays of estrogen receptors.^ieng

A national audit to monitor and promote the uptake of clinical guidelines on the management of diabetes in pregnancy.

Seeks to assess maternity care for women with Type 1 diabetes in relation to recommendations in a national clinical guideline using a criterion-based clinical audit. The audit covered all 22 consultant-led maternity units in Scotland, focusing on 268 completed pregnancies in women with Type 1 diabetes. Results are presented and discussed. Concludes that a national audit to monitor the impact of clinical guidelines proved feasible. Antenatal care is organised in line with guideline recommendations but there is lower provision of formal prepregnancy care. Pregnancy planning and periconceptual care fall short of recommendations but care during pregnancy is meticulous. Adverse pregnancy outcomes remain commoner than in non-diabetic pregnancies.

Histochemical detection of oestrogen receptors: a progress report.

Four albumin conjugates of oestradiol. Labelled with fluorescein or peroxidase to permit visualization under light or fluorescence microscopy, were synthesized. These were used to examine the feasibility of identifying oestrogen binding in frozen section by two published histochemical techniques. In a variety of experimental tissues and human breast cancers, binding of the oestrogen conjugates was demonstrable, but it appeared nonspecific (i.e., rarely displaceable by competitor) and unrelated to oestrogen receptor (RE) status of the tissue as determined biochemically by assay with dextran-coated charcoal. Investigation of the fate of the RE through the various steps of a histochemical assay, demonstrated major losses of RE from unfixed tissue or after tissue fixation. The RE also exhibited a 10-50-fold poorer affinity for the conjugates synthesized than for oestradiol-17 beta and, at the concentrations of conjugate routinely used in histochemical assays, it seems likely that considerable nonspecific binding takes place. These factors may combine to make it (1) difficult to implement such histochemical assays and (2) unlikely that the RE is being detected.

The management of carcinoma of the vulva: current opinion and current practice among consultant gynaecologists in Scotland.

A postal questionnaire survey of all 126 consultant gynaecologists in Scotland was undertaken in order to obtain an overview of current opinion and current practice in relation to the management of vulval carcinoma. The response rate was 95%. Fifteen suggested criteria for good quality care were validated by a balance of agreement among respondents. There was particularly strong agreement (> 90% of respondents) that vulval carcinoma should be managed by subspecialists rather than generalists, that en bloc radical vulvectomy is not always required, that patients should be informed of their diagnosis and that long-term follow-up is required. There was least agreement (< 50% of respondents) that groin lymphadenectomy may be omitted in selected cases and that follow-up need be at special multidiscipline clinics. An encouraging picture of current practice emerged. Very few consultants who do not profess to be oncology subspecialists would manage cases alone, few perform en bloc radical vulvectomy in all cases and few undertake deep pelvic lymphadenectomy. Most acknowledge the importance of psychosexual issues and all generally inform patients of the nature of their diagnosis. The postal questionnaire approach achieved a good response rate and has provided an informative overview of current opinion and practice on a national basis. This approach may be more valuable than case-note review audit in providing a meaningful picture of contemporary practice for uncommon conditions like vulval cancer.

The relationship between birth weight and maternal glycated haemoglobin (HbA1c) concentration in pregnancies complicated by Type 1 diabetes.

AIM: To examine the relationships between maternal HbA1c 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 HbA1c concentrations prior to conception and in each of the three trimesters of pregnancy, and birth weight. Relationships between standardized birth weight and HbA1c 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. HbA1c 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 HbA1c 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.