Endometrial assessment procedures: an audit of current practice in Scotland

The objective was to determine, in relation to endometrial assessment procedures, the extent to which the current practice of gynaecologists in Scotland (as assessed both by questionnaire survey of clinicians and review of hospital records) accords with recommendations in recent evidence-based guidelines. All 132 consultant gynaecologists in Scotland were surveyed and 123 (93%) responded. In addition, the case records of 1199 consecutive women undergoing endometrial assessment procedures in 12 representative hospitals were reviewed. Over two thirds of consultants agreed that endometrial assessment procedures are seldom indicated in women aged under 40 years and over 80% agreed that when such procedures are indicated, outpatient endometrial biopsy represents the method of choice. However, the review of case records showed that 23% of the women who underwent endometrial assessment were aged under 40 years and only 44% of the procedures undertaken were out-patient endometrial biopsies. We conclude that some Scottish women may be undergoing endometrial assessment procedures unnecessarily and that, in some centres, traditional dilatation and curettage is being replaced by hysteroscopy under general anaesthetic in theatre although there is no evidence that this procedure provides more clinically useful information than out-patient endometrial biopsy.

Fertility and pregnancy in inflammatory bowel disease

OBJECTIVE

A retrospective study of women with inflammatory bowel disease, aged 16-45 years during the 20-year period 1967-1986, was carried out in North East Scotland.

METHOD

Five-hundred and three women were identified: 15 patients had died from unrelated causes and 22 had emigrated, but 409 of the remaining 466 patients (88%) replied to the study questionnaire.

RESULTS

Women with ulcerative colitis and Crohn's disease had normal fertility when compared with the general population of north east Scotland. However, unresolved infertility problems were more frequent in women who had undergone surgery for inflammatory bowel disease compared with those who had not (12% vs. 5% for Crohn's disease; 25% vs. 7% for ulcerative colitis). Disease relapse rates did not increase in pregnancy.

CONCLUSIONS

Overall, at conception women with active disease were as likely to have a normal full-term pregnancy as those in remission. However, spontaneous abortion occurred in five (36%) pregnancies of women who had undergone previous surgery for Crohn's disease and had evidence of recurrent disease. Three of these pregnancies were associated with active disease.

How effective is patient-controlled analgesia? A randomized comparison of two protocols for pain relief during oocyte recovery

Although the conventional method of pain relief during outpatient oocyte recovery involves physician-administered drugs, patient-controlled analgesia (PCA) offers an alternative technique with the potential to give women more control over peroperative analgesia. We conducted a prospective randomized study to compare the effect of fentanyl administered either through a PCA delivery system or by a physician. Thirty-nine women were randomized to PCA during egg collection while 42 were allocated to receive intermittent doses administered by a physician. Pain was evaluated by means of a 100 mm linear analogue scale. The mean (SD) pain score in the PCA group was 38.5 (19.8) while in the other group it was 46.1 (21.3) (P = 0.1). In the PCA group, 64% of women felt very satisfied with their analgesia as compared with 57% in the non-PCA group (P = 0.6). Among the PCA users, 39% of demands were successful. Significantly more fentanyl (97.5 microg) was used in the PCA group than in the other group (84.6 microg) (P = 0.03). Though intraoperative PCA with fentanyl is an effective alternative to physician-administered techniques, many women still feel the need for more analgesia during the procedure.

The costs of treating miscarriage: a comparison of medical and surgical management

OBJECTIVES

To estimate and compare the costs of surgical and medical treatment of miscarriage to the National Health Service.

DESIGN

A patient-centred, partially randomised trial.

SETTING

A teaching hospital in Scotland.

PARTICIPANTS

Four hundred and thirty-seven women with a proven first trimester miscarriage.

MAIN OUTCOME MEASURES

The cost per patient of surgical and medical management of miscarriage plus the extra cost per patient of introducing medical management of miscarriage under three different scenarios are calculated.

RESULTS

The average cost of surgical treatment was Pounds 397 compared with Pounds 347 for medical treatment. Sensitivity analysis showed that the extra cost of introducing the medical management of miscarriage ranged from a cost saving of Pounds 71 per patient to an additional cost of Pounds 47 per patient.

CONCLUSIONS

Our analysis showed that it may be possible to generate cost savings by introducing medical methods in the management of early miscarriage. However, the savings assume that costs associated with theatre use can be fully realised.

Factors that affect outcome of in-vitro fertilisation treatment

BACKGROUND

The effectiveness of in-vitro fertilisation (IVF) treatment depends both on the overall success rate in the treating clinic and on the characteristics of the couple seeking treatment. Since 1991, the Human Fertilisation and Embryology Authority (HFEA) has been collecting information on all IVF cycles carried out in the UK. This database has been analysed to identify the factors that affect the outcome of treatment.

METHODS

All IVF treatment cycles and outcomes registered between August, 1991, and April, 1994, were identified (52507). Cycles that involved gamete or embryo donation, frozen embryo transfer, or micromanipulation and unstimulated cycles were excluded. Thus, 36961 cycles (70% of those registered) were included in the analysis. The main outcome measure was liverbirth rate per cycle started. The relation between age and outcome was investigated by fitting of different fractional polynomials of age with logistic regression models. All other factors were analysed by logistic regression with age included in the model.

FINDINGS

The overall livebirth rate per cycle of treatment was 13.9%. The highest livebirth rates were in the age-group 25-30 years; younger women had lower rates and there was a sharp decline in older women. At all ages over 30, use of donor eggs was associated with a significantly higher livebirth rate than use of the woman's own eggs, but there was also a downward trend in success rate with age (p = 0.04). After adjustment for age, there was a significant decrease in livebirth rate with increasing duration of infertility from 1 to 12 years (p < 0.001). The medical indication for treatment had no significant effect on the outcome. Previous pregnancy and livebirth significantly increased treatment success. The possibility of success decreased with each IVF treatment cycle.

INTERPRETATION

We were able to identify by logistic regression the factors that significantly affect the outcome of IVF treatment, and to measure the magnitude of that effect. These factors should be taken into account in assessment of IVF results. After allowance for background clinic success rates, these factors can be used to predict outcome in individual cases.

Emergency contraception: a survey of women's knowledge and attitudes

OBJECTIVES

To assess women's knowledge and attitudes in relation to emergency contraception and to identify ways in which these might be improved.

DESIGN

Postal survey: questionnaire seeking level of knowledge of emergency contraception, and attitudes to use, publicity and availability.

POPULATION

A stratified random sample of 2000 Grampian women aged 18 to 47. Women were identified through the Community Health Index.

RESULTS

Most women (94%) were aware of emergency contraception and identified an appropriate source. Fewer (39%) knew the correct timing for its use. These figures were generally higher among younger, single women. The popular media represented the commonest source of information, and GPs and Family Planning Clinics were cited rarely. Increased advertising was considered desirable by 71% (mainly older women); only 36% (mainly younger, single women) considered over-the-counter availability desirable. Reasons for these responses and factors influencing them were explored.

CONCLUSIONS

Knowledge of emergency contraception is greatest among those most likely to use it, but deficient mainly in relation to the correct timing for its use and to intrauterine methods. Publicity should concentrate on the timing of its use. The popular media are an important publicity vehicle, but health professionals appear to be under-used. Many women hold opinions on advertising and over-the-counter availability of emergency contraception which will have to be considered if deregulation proceeds.

A randomised comparison of oral and vaginal misoprostol for cervical priming before suction termination of pregnancy

OBJECTIVE

To assess the effectiveness and acceptability of oral misoprostol, self-administered 12 h before surgery, as a cervical priming agent prior to day case suction termination of pregnancy.

DESIGN

Randomised trial comparing oral misoprostol with the local standard regimen of vaginal misoprostol.

SUBJECTS

Sixty consecutive women scheduled for day case suction termination in one gynaecology unit.

INTERVENTIONS

Cervical priming with misoprostol 400 mg orally, 12 h prior to surgery or 800 mg vaginally, two to four hours prior to surgery.

MAIN OUTCOME MEASURES

Basal cervical dilatation, cumulative force required to dilate the cervix to 9 mm, operative blood loss and side effects (nausea, vomiting, diarrhoea, abdominal pain and vaginal bleeding).

RESULTS

There were no significant differences between the oral and vaginal treatment groups in relation to basal dilatation, cumulative force to achieve 9 mm dilatation or gastrointestinal side effects. However, those in the oral group experienced more severe pain and heavier pre-operative bleeding. Two patients in the oral group experienced incomplete abortion at home after taking misoprostol and a further patient required early admission because of heavy bleeding.

CONCLUSIONS

Because of the unpredictability of action of oral misoprostol, with incomplete abortion or heavy bleeding occurring prior to admission in three patients, we cannot recommend the dosage schedule evaluated here for routine clinical use.

A population based survey of women's experience of the menopause

OBJECTIVES

To describe the prevalence of, and degree of distress caused by, 15 symptoms commonly attributed to the menopause among a random sample of women aged 45 to 54, selected from the total population of a geographically defined area.

DESIGN

Postal questionnaire survey.

SETTING

Grampian Health Board area.

PARTICIPANTS

Eight thousand women, aged 45 to 54, randomly selected from the Grampian Community Health Index.

MAIN OUTCOME MEASURES

Self-reported symptoms, including depression, and use of hormone replacement therapy (HRT) among women of differing menopausal status.

RESULTS

The response rate was 78%; 57% of respondents had experienced one or more of the 15 symptoms listed, but only 22% had found such symptoms a problem. Women's experience of classic vasomotor and atrophic symptoms varied according to menopausal status but experience of general somatic and psychological symptoms did not. Users of HRT and women whose menopause was iatrogenic found more symptoms a problem.

CONCLUSIONS

Symptoms attributed to the menopause are common among women in the age group studied but often are not perceived as a problem. Among nonusers of HRT, only vasomotor and atrophic symptoms vary with menopausal status. Other somatic and psychological symptoms experienced by middle-aged women cannot be regarded as part of the same "menopausal syndrome'.

Selective transmission of human immunodeficiency virus type 1 variants to SCID mice reconstituted with human peripheral blood monoclonal cells

The relative infectiousness of laboratory and primary human immunodeficiency virus type 1 (HIV-1) variants was evaluated in in vitro cell cultures of peripheral blood mononuclear cells or MT-2 cells and in Hu-PBL-SCID mice. HIV(MN) and syncytium-inducing primary isolates were preferentially transmitted to cells in tissue culture. HIV(Ba-L) and non-syncytium-inducing (NSI) primary isolates were more infectious in Hu-PBL-SCID mice. Phylogenetic analysis of env sequences derived from the primary isolates, from the cell cultures, and from five Hu-PBL-SCID mice was performed by using methods designed for resolving differences among closely related sequence pairs. This analysis demonstrated preferential transmission of an evolutionarily related subset of NSI variants to Hu-PBL-SCID mice. The pattern of selective transmission of a restricted range of NSI variants that is observed in the clinical setting is maintained in Hu-PBL-SCID mice and not in tissue culture systems. The Hu-PBL-SCID mouse model system, when used with appropriate phylogenetic analysis methodologies, will be useful for identifying and characterizing the more infectious HIV-1 variants that should be targeted for vaccine development.

Sequence heterogeneity of Nef transcripts in HIV-1-infected subjects at different stages of disease

Nef transcripts were analyzed from peripheral blood mononuclear cells of 10 HIV-1-infected subjects with 9-822 CD4+ lymphocytes/cu mm, including 4 individuals with a probable common source infection. There was no relationship between the phylogenetic position of the various nef sequences and the disease state of the person from whom they were derived. The nef open reading frame was disrupted in all three clones from only 1 subject. Functional analyses of a representative clone from each of the remaining 9 subjects showed that all nef alleles were capable of CD4 cell surface down-regulation, but only three nef alleles suppressed the induction of IL-2 transcription.

The effects of steroidal and non-steroidal ovarian hormones on pituitary responsiveness to gonadotrophin surge-attenuating factor

Primary pituitary cultures from adult female rats were used to investigate the effects of steroidal (oestradiol and progesterone) and non-steroidal (inhibin, follistatin) ovarian hormones on the suppressive actions of the ovarian factor gonadotrophin surge-attenuating factor (GnSAF) in the control of gonadotrophin secretion. The source of GnSAF was a chromatographic preparation from follicular fluid containing four distinct protein bands as resolved on SDS-PAGE. Oestradiol and progesterone added alone had no effect on gonadotrophin secretion but had a wide range of effects on the suppression of both LH and FSH secretion caused by the non-steroidal factors. Oestradiol, progesterone and oestradiol+progesterone enhanced the suppressive actions of GnSAF on GnRH-induced LH secretion (causing 19.3 +/- 5.2% (P < 0.05), 41.9 +/- 3.4% (P < 0.001) and 32.2 +/- 5.3% (P < 0.001) greater suppression than GnSAF alone). Progesterone and oestradiol+progesterone completely abolished the suppression of basal FSH secretion caused by inhibin (causing 157.1 +/- 22.2%, P < 0.001, and 160.9 +/- 11.3%, P < 0.001, stimulation compared with inhibin alone). Separately the steroids had no effect on the suppression of gonadotrophin secretion caused by follistatin. However, in combination, oestradiol+progesterone potentiated the suppressive actions of follistatin on GnRH-induced LH secretion causing 29.9 +/- 5.3% (P < 0.05) greater suppression than follistatin alone. In combination, high-dose follistatin and GnSAF caused 31.1 +/- 6.5% (P < 0.01) greater suppression than GnSAF alone. Thus in combination high-dose follistatin and GnSAF have additive effects on the suppression of GnRH-induced LH secretion. Recombinant human inhibin and GnSAF added in combination had little further effect compared with either alone suggesting that they may have a similar mechanism of action at the pituitary level. These results demonstrate that while FSH secretion in vitro is mainly controlled by inhibin and follistatin, LH secretion is affected by the presence of a whole range of factors. We have demonstrated that oestradiol and progesterone potentiate the suppressive actions of GnSAF in vitro. These data are compatible with the suggestion that in the late follicular phase it is falling levels of GnSAF that allow positive feedback of the steroids on the pituitary to elicit the LH surge, rather than increases in the stimulatory effects of the ovarian steroids overcoming GnSAF. The actions of GnSAF on the pituitary may be modulated by follistatin but it is unlikely that inhibin has any modulatory effects on the GnSAF-induced suppression of LH secretion.

A comparison of 600 and 200 mg mifepristone prior to second trimester abortion with the prostaglandin misoprostol

OBJECTIVE

To compare the use of 600 and 200 mg mifepristone prior to second trimester termination of pregnancy with the prostaglandin misoprostol.

DESIGN

A randomised study.

SETTING

A Scottish teaching hospital.

PARTICIPANTS

Seventy women undergoing legal induced abortion between 13 and 20 weeks of gestation.

INTERVENTION

Administration of either 600 or 200 mg mifepristone 36 to 48 hours prior to prostaglandin.

MAIN OUTCOME MEASURE

Induction-abortion interval.

RESULTS

The geometric mean induction abortion interval was 6.9 (95% CI 5.8-8.4) h and 6.9 (95% CI 5.8-8.2) h in the 600 and 200 mg groups, respectively (no significant difference). The median dose of misoprostol was 1600 micrograms (three doses) in each group. Analgesic requirements and prostaglandin-related side effects were similar between groups. Overall, 11.4% of women required surgical evacuation of the uterus as a result of retained placenta.

CONCLUSIONS

The dose of mifepristone used in second trimester abortion can be reduced from 600 to 200 mg.

Role of progesterone and nonsteroidal ovarian factors in regulating gonadotropin-releasing hormone self-priming in vitro

We investigated the effects of gonadotropin surge-attenuating factor (GnSAF), inhibin, and follistatin on GnRH self-priming and its augmentation by progesterone. Two GnRH challenges, 60 min apart, were administered to rat pituitary monolayers after 90-min exposure to medium alone (control), progesterone, GnSAF, inhibin, or follistatin. Inhibin-stripped follicular fluid from superovulated women was used as a source of GnSAF bioactivity. Under control conditions, the greater response to the second GnRH challenge (peak 2, 9.2 +/- 2.1; peak 1, 4.4 +/- 0.9 ng LH/mL; P < 0.01) demonstrated GnRH self-priming. None of the treatments significantly altered the first LH peak. Progesterone markedly increased GnRH self-priming (peak 2, 12.6 +/- 2.5 ng LH/mL; P < 0.01). However, GnSAF and RU486 significantly reduced GnRH self-priming (peak 2, 4.6 +/- 0.9 and 5.6 +/- 1.6 ng LH/mL, respectively; P < 0.01). The augmentation of self-priming induced by progesterone was completely abolished by coincubation with either GnSAF or RU486 (peak 2, 7.5 +/- 1.6 and 4.3 +/- 0.9 ng LH/mL, respectively; P < 0.01). Neither inhibin nor follistatin had any effect on GnRH self-priming or its augmentation by progesterone. The actions of RU486 in the presence and absence of progesterone demonstrate a nonprogestagenic effect of RU486 on the gonadotropes. In conclusion, the suppression of GnRH self-priming, with or without progesterone augmentation, supports the hypothesis that GnSAF acts by maintaining the pituitary in an unprimed state of reduced responsiveness to GnRH.

Contractile responses to sumatriptan in isolated bovine pulmonary artery rings: relationship to tone and cyclic nucleotide levels

We examined responses to the 5-hydroxytryptamine 1D (5-HT1D)-receptor agonist sumatriptan in bovine pulmonary artery rings (2-3 mm ID). The effects of agonist-induced tone and agents that alter intracellular cyclic AMP [cyclic AMP]i or [cyclic GMP]i on responses to sumatriptan were investigated. At resting tension, responses to sumatriptan were slight or not evident. In the presence of tone induced by U46619, responses to sumatriptan (1 nM-30 mM) were greatly potentiated, as were responses to the alpha2-adrenoceptor agonist UK14304. Responses to the alpha 1-adrenoceptor agonist phenylephrine (PE) were potentiated only slightly. In the presence of U46619, addition of the adenylyl cyclase activator, forskolin (1 nM-0.1 microM or isoprenaline (ISO 1 microM) induced relaxations and increases in [cyclic AMP]i and resulted in further potentiation of the contractile response to sumatriptan. Addition of 0.1 microM sodium nitroprusside (SNP) inhibited sumatriptan-induced contractions. Whereas sumatriptan alone did not significantly affect [cyclic AMP]i, in the presence of U46619 it decreased [cyclic AMP]i. This effect of sumatriptan was further enhanced in the presence of forskolin. Sumatriptan increased [cyclic GMP]i. Using a nitric oxide (NO) synthase inhibitor and vessels denuded of endothelium, we showed that the increased [cyclic GMP]i in response to sumatriptan was endothelium-dependent and mediated by NO. This increase in [cyclic GMP]i was not observed in the presence of U46619. By measuring cyclic AMP and cyclic GMP phosphodiesterase (PDE) levels, we demonstrated that the point of "cross-talk" between cyclic nucleotides may not be at the level of total PDE activity. These results highlight the important role of [cyclic AMP], [cyclic GMP]i, and endothelium function in the control of 5-HT1D receptor-mediated vasoconstriction, which is dependent on a decrease in [cyclic AMP]i in the absence of an increase in [cyclic GMP]i.

Cryopreservation of human oocytes and fertilization by two techniques: in-vitro fertilization and intracytoplasmic sperm injection

Human oocyte cryopreservation results in poor survival and subsequent fertilization rates. It has been suggested that freeze-thaw-induced changes in the zona pellucida may impair sperm penetration or attachment. The aim of this study was to compare fertilization and cleavage rates in cryopreserved oocytes inseminated by conventional in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). A total of 220 oocytes, obtained from volunteers who had undergone ovarian stimulation, were cryopreserved using a slow freeze-rapid thaw protocol with 1.5 M propanediol as the cryoprotectant. Surviving oocytes (n = 74, 34.4%) were randomly allocated for fertilization by conventional IVF (group 1) or ICSI (group 2) using cryopreserved spermatozoa from a single donor of proven fertility. Fertilization was achieved in five (13.5%) of the oocytes in group 1 and 17 (45.9%) in group 2 (P < 0.005), with only one oocyte in group 1 exhibiting normal fertilization as opposed to 16 (43.2%) in group 2 (P < 0.001). Similarly, one oocyte fertilized by IVF cleaved, while all fertilized with ICSI cleaved (P < 0.001). We conclude that although the survival of oocytes is poor following cryopreservation, fertilization and cleavage rates can be enhanced significantly using ICSI. These data also suggest that the method of cryopreservation used in this study affected the zona pellucida, such that normal sperm attachment or penetration was impaired.

Infertility-epidemiology, aetiology and effective management

Current epidemiological evidence suggests that 15% of couples will experience infertility and in half this number the problem will remain unresolved. Background prevalence rates now appear to be reasonably stable, but there is evidence of an increase in the rate of referrals for medical help. Rates of secondary infertility are higher in the population than represented by clinic referrals. The distribution of the main diagnostic groups is as follows: Male 25%; Ovulation 25%; Tubal 20%; Unexplained 25%; and Endometriosis 5%. Effective management in the male includes donor insemination and assisted reproduction (including intra-cytoplasmic sperm injection). Drugs are ineffective for idiopathic oligozoospermia, while the role of varicocele ligation is uncertain, but marginal at best. Ovulation problems can be treated with a high degree of success, except in cases of clomiphene resistant polycystic ovarian disease. However there are continuing concerns over multiple pregnancy rates and future research is needed to clarify the additional risks, if any, of ovarian carcinoma. Surgical correction of tubal abnormalities should be left to specialised units, where audit indicates that the results can match those achieved by assisted reproduction. There is no evidence that the medical (drug) management of endometriosis improves fertility, although surgery for moderate and severe disease can still be considered. However the results should be compared with those achieved by assisted reproduction. Superovulation and intra-uterine insemination appears to be an effective treatment for certain cases of mild male factor infertility, mild endometriosis and unexplained infertility and can be considered, where the duration of infertility is more than four years. A pregnancy rate of around 10% per cycle can be anticipated, but there is a significant risk of multiple pregnancy. The evidence is that IVF (and GIFT) has achieved significantly improved results in recent years, with fecundity rates of 20% per cycle being a reasonable target in women under 40 years.

Current attitudes towards egg donation among men and women

Recent widespread concern has led to legislation in the UK preventing the use of fetal ovarian tissue for the treatment of infertile women. This questionnaire-based study aimed to assess the attitudes of both fertile and infertile men and women as well as egg donors and recipients towards the use of donated eggs for treatment, diagnosis and research. Fertile individuals were significantly less aware of egg donation but the majority in both the fertile and the infertile groups approved the use of eggs for research (89 and 95% of women and 88 and 92% of men respectively) and treatment (similar percentages). However, fetal sources of oocytes were acceptable to only 15% of women in the fertile, 21% in the infertile, 35% in the recipient and 19% in the donor groups. Cadaveric sources of oocytes were slightly more acceptable (28% fertile, 28% infertile, 50% recipient and 42% donors). Both these sources of oocytes were slightly more acceptable to men. Education had little influence on attitudes, although men and women of tertiary education level said they would be less likely to have gamete donation themselves. Thus there would appear to be widespread approval for the use of donor eggs in research and treatment but not if the source of eggs is fetal or cadaveric.

Induction of abortion with mifepristone (RU 486) and oral or vaginal misoprostol

BACKGROUND

Medical termination of pregnancy can be successfully performed with a combination of mifepristone (RU 486) and a prostaglandin analogue. We conducted a prospective, randomized trial to compare oral with vaginal administration of the prostaglandin E1 analogue misoprostol for first-trimester abortion in women treated initially with mifepristone.

METHODS

The study population consisted of 270 women seeking abortion within 63 days after the onset of amenorrhea. The dose of mifepristone was 600 mg, and the dose of misoprostol was 800 micrograms. The study had two primary end points: expulsion of the conceptus without the need for a surgical procedure, and abortion within four hours after the administration of misoprostol.

RESULTS

Expulsion of the conceptus without the need for a surgical procedure occurred in 95 percent of the women who received misoprostol vaginally and in 87 percent of those who received it orally (P = 0.03). The rate of continued pregnancy was 7 percent with the oral regimen and 1 percent with the vaginal regimen (P = 0.01). Ninety-three percent of the women receiving misoprostol vaginally had abortions within four hours, as compared with only 78 percent of the women receiving the drug orally (P < 0.001). Vomiting and diarrhea were reported more frequently by the women who received oral misoprostol than by those who received vaginal misoprostol (P = 0.04 and P = 0.002, respectively).

CONCLUSIONS

After the administration of mifepristone, vaginal administration of misoprostol is more effective and better tolerated than oral administration for the induction of first-trimester abortion.

Postnatal maternal morbidity: extent, causes, prevention and treatment

OBJECTIVE

To describe the prevalence and causes of postnatal maternal morbidity.

DESIGN

Questionnaire survey of postnatal patients. Further data extracted from SMR1 returns, case records and the Aberdeen Maternity and Neonatal Databank.

SETTING

Postnatal care in a teaching maternity hospital, midwife delivery hospital, general practitioner maternity units and in the community.

SUBJECTS

Twenty percent random sample of deliveries (1249 women) surveyed one week, eight weeks and 12 to 18 months after delivery.

MAIN OUTCOME MEASURES

Incidence of self reported maternal morbidity, treatment received, readmission rates and causes for readmission.

RESULTS

Of mothers in the sample 85% (99% CI 82-88%) reported at least one health problem in hospital, rising to 87% (84-90%) of those at home; 76% (71-81%) reported at least one health problem after eight weeks post-delivery.

CONCLUSIONS

Maternal morbidity is extensive and under-recognised after delivery. Measures to reduce and alleviate it must be sought.

Nef and LTR sequence variation from sequentially derived human immunodeficiency virus type 1 isolates

Variation in HIV-1 nef and LTR DNA sequences was assessed longitudinally during disease progression in four HIV-1-infected subjects. Point mutations were found among quasispecies obtained at a single time point in each individual, with increasing diversity with disease progression in two of three patients for whom sufficient data were available for analysis. Deletions and rearrangements were more common in late than early stages of disease. Continued sequence evolution in HIV-1 quasispecies with nef deletions along with coexistence of nef-bearing quasispecies suggest that nef-deleted quasispecies are capable of replication in vivo, possibly complemented by quasispecies lacking such deletions and/or by adaptation to a specialized niche within the 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.