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 ‡2500 ml or transfused ‡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.

The relationships between markers of pregnancy planning and prepregnancy 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 prepregnancy 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.Keywords Anomaly, pre-pregnancy, type 1 diabetes.Please cite this paper as: Pearson D, Kernaghan D, Lee R, Penney G on behalf of the Scottish Diabetes in Pregnancy Study Group. The relationship between pre-pregnancy care and early pregnancy loss, major congenital anomaly or perinatal death in type I diabetes mellitus. BJOG 2007;114:104-107. IntroductionDiabetes is the most common pre-existing medical condition in pregnancy, and although there are international and national guidelines for management, 1 outcomes remain significantly worse than for the nondiabetic population. 2-4 Some adverse outcomes, such as miscarriage and major congenital anomaly, are related to glycaemic control before and during early pregnancy. 4 At present, there is no standardised definition of pre-pregnancy care that is agreed by clinicians and research teams. A recent report from the Confidential Enquiries into Maternal and Child Health (CEMACH) described a preconception care service for women with diabetes as 'a multidisciplinary service which aims to provide information about diabetes and pregnancy, assess for and treat diabetes complications, review drug medication and work together with women to achieve optimal glycaemic control before pregnancy'. Such care would include a range of interventions such as reviewing and optimising blood glucose control, initiating folic acid and treating related medical conditions. In this study, we describe relationships between various markers of pregnancy planning and pre-pregnancy care in the context of type I diabetes. We suggest a definition of prepregnancy care for research and audit, which could be extended to type II diabetes, where outcomes are equally unfavourable. 3 MethodsThe publication of national guidelines for diabetic pregnancy in Scotland (SIGN 9 and SIGN 55) prompted national audits of pregnancy management and outcomes. During two national audit periods, 5 information was collected on all pregnancies in Scotland in women with pre-gestational type I diabetes mellitus. Women were registered at antenatal booking or at the first contact during pregnancy with a healthcare professional. A proforma was completed at the end of each pregnancy by a local carer by detailed case note review. In addition to the collection of information about outcomes, the proforma was designed to clarify the extent of pregnancy planning and the ...

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