Association of glucose metabolism and blood pressure during pregnancy with subsequent maternal blood pressure.

The goal of this study was to examine associations of measures of maternal glucose metabolism and blood pressure during pregnancy with blood pressure at follow-up in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) cohort. The HAPO Follow-Up Study included 4747 women who had a 75-g oral glucose tolerance test (OGTT) at ~28 weeks' gestation. Of these, 4572 women who did not have chronic hypertension during their pregnancy or other excluding factors, had blood pressure evaluation 10-14 years after the birth of their HAPO child. Primary outcomes were systolic blood pressure (SBP), diastolic blood pressure (DBP), and hypertension (SBP ≥ 140 and/or DBP ≥ 90 or treatment for hypertension) at follow-up. Blood pressure during pregnancy was associated with all blood pressure outcomes at follow-up independent of glucose and insulin sensitivity during pregnancy. The sum of glucose z-scores was associated with blood pressure outcomes at follow-up but associations were attenuated in models that included pregnancy blood pressure measures. Associations with SBP were significant in adjusted models, while associations with DBP and hypertension were not. Insulin sensitivity during pregnancy was associated with all blood pressure outcomes at follow-up, and although attenuated after adjustments, remained statistically significant (hypertension OR 0.79, 95%CI 0.68-0.92; SBP beta -0.91, 95% CI -1.34 to -0.49; DBP beta -0.50, 95% CI -0.81 to -0.19). In conclusion, maternal glucose values at the pregnancy OGTT were not independently associated with maternal blood pressure outcomes 10-14 years postpartum; however, insulin sensitivity during pregnancy was associated independently of blood pressure, BMI, and other covariates measured during pregnancy.

Exploring the needs, concerns and knowledge of women diagnosed with gestational diabetes: A qualitative study.

OBJECTIVE: to explore the concerns, needs and knowledge of women diagnosed with Gestational Diabetes Mellitus (GDM). DESIGN: a qualitative study of women with GDM or a history of GDM. METHODS: nineteen women who were both pregnant and recently diagnosed with GDM or post- natal with a recent history of GDM were recruited from outpatient diabetes care clinics. This qualitative study utilised focus groups. Participants were asked a series of open-ended questions to explore (1) current knowledge of GDM; (2) anxiety when diagnosed with GDM, and whether this changed overtime; (3) understanding and managing GDM and (4) the future impact of GDM. The data were analysed using a conventional content analysis approach. FINDINGS: women experienced a steep learning curve when initially diagnosed and eventually became skilled at managing their disease effectively. The use of insulin was associated with fear and guilt. Diet advice was sometimes complex and not culturally appropriate. Women appeared not to be fully aware of the short or long-term consequences of a diagnosis of GDM. CONCLUSIONS: midwives and other Health Care Professionals need to be cognisant of the impact of a diagnosis of GDM and give individual and culturally appropriate advice (especially with regards to diet). High quality, evidence based information resources need to be made available to this group of women. Future health risks and lifestyle changes need to be discussed at diagnosis to ensure women have the opportunity to improve their health.

Women with pre-gestational diabetes have a higher risk of stillbirth at all gestations after 32 weeks.

AIM: To explore the additional risk of stillbirths and to quantify that risk according to gestational age among women with diabetes. METHODS: Data on pregnancies ending in 2007 and 2008 in women with pre-gestational diabetes in three English regional audits were identified. A prospective audit collected data on all pregnancies delivering between June 2010 and May 2011 in one region and in 13 other units across England. The data on all singleton pregnancies from these two cohorts were combined. Comparisons were made to all births in England and Wales for the same time period using data from the Office for National Statistics. RESULTS: In the cohort of women with pre-gestational diabetes there were a total of 2085 singleton pregnancies, of which 29 resulted in a stillbirth (overall stillbirth rate 13.9 per 1000, 95% CI 9.7-19.9, relative risk compared with all pregnancies in England and Wales 2.73, 95% CI 2.61-2.84). The relative risk of stillbirth between 32 and 34 weeks' gestation was 4.95 (95% CI 4.24-5.78), 3.77 (95% CI 3.42-4.16) at 35 to 36 weeks, 5.75 (95% CI 5.43-6.09) for deliveries at 37 or 38 weeks and 7.34 (95% CI 6.52-8.25) for those born at 39 weeks or more. CONCLUSION: Women with diabetes have a significantly higher risk of stillbirth at all gestations after 32 weeks and this additional risk is not just confined to pregnancies at 37 weeks or more.

Post-natal assessment of gestational diabetes: fasting glucose or full glucose tolerance test?

AIMS: To determine the performance of a fasting glucose sample compared with a full oral glucose tolerance test for the detection of glucose abnormalities in a diverse ethnic population after gestational diabetes. METHODS: Oral glucose tolerance test results for women attending post-natal testing over a 10-year (2003-2013) period at St Mary's Hospital, Manchester, UK were reviewed. Demographic data were also extracted from the hospital maternity database. RESULTS: The average attendance for a post-natal oral glucose tolerance test was approximately 45% over the study period. The prevalence of diabetes was 4.8% (30/629), with a higher rate in women of Asian ethnicity compared with other groups (6.6% vs. 3.5%). The sensitivity for a fasting plasma glucose of ≥ 6.1 mmol/l was 90% (95% CI 74.4-96.5%) for the detection of diabetes and 61% (49.1-71.5%) for the detection of diabetes and/or impaired glucose tolerance, with specificities of 91% (88.8-93.3%) and 93% (91.0-95.2%), respectively. The positive and negative likelihood ratios for diabetes and impaired glucose tolerance were 10.4 (7.8-13.8), 0.11 (0.03-0.32) and 9.2 (6.4-13.3), 0.42 (0.31-0.56), respectively. A fasting plasma glucose threshold of 5.6 mmol/l improved the sensitivity for impaired glucose tolerance (from 61% to 77%), but made no difference to the sensitivity for diabetes. CONCLUSIONS: The current study has demonstrated that detection of diabetes after gestational diabetes, in an ethnically diverse population using a fasting plasma glucose only, was approximately 90%. Compliance with post-natal screening might improve if women attended for a fasting plasma glucose only; this strategy would identify approximately 90% of cases of diabetes and 40% of cases of impaired glucose tolerance.

Body composition and bone status of children born to mothers with type 1 diabetes mellitus.

BACKGROUND: Altered growth, body composition and abnormalities of skeletal mineralisation have been reported in offspring of mothers with type 1 and type 2 diabetes mellitus. AIMS: The authors hypothesised that children born to mothers with type 1 diabetes mellitus (CDM) would be taller, have higher body mass index (BMI), greater fat mass, thicker diaphyseal bone cortices and reduced trabecular bone mineral density (BMD), as compared to those born to non-diabetic mothers. METHODS: Anthropometric, body composition and bone parameters were assessed using dual-energy x-ray absorptiometry (DXA) and peripheral quantitative CT in 67 white Caucasian CDM (35 boys; age 5-18 years) and in 246 (121 boys) age-matched controls. RESULTS: CDM were taller (p<0.0001), heavier (p<0.0001) and had higher BMI (p=0.02), and had 32% more total body fat mass and 7.5% more total body lean mass than controls. At the total body and lumbar spine (L1-L4) sites, CDM had significantly higher bone area and bone mineral content compared with controls. However, areal BMD at both these sites and lumbar spine bone mineral apparent density were not significantly different in the two groups, indicating that CDM have bigger bones compared with controls but their mineral content per unit area or volume is not substantially different. The distal radial trabecular and total volumetric BMD in CDM was not demonstrably different from controls. At the mid-radius, both periosteal (2.4%; p=0.03) and endosteal circumferences (5.7%; p=0.02) were bigger in CDM compared with controls. CONCLUSION: The authors speculate that the intrauterine diabetic environment is associated with an increase in linear growth, adiposity and larger bone dimensions during childhood and adolescence.

A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study.

OBJECTIVES: To examine and compare the medium-term results of hysterectomy and uterine artery embolisation (UAE) as a treatment for symptomatic uterine fibroids with regard to safety, efficacy, special issues in the UAE group, cost-effectiveness, and women's own perspectives on the treatments. DESIGN: Data were collected locally from patients' hospital records and also from patients themselves by postal questionnaire. Questionnaire data included free-text comments and this qualitative material was analysed using constant comparison. A two-stage probabilistic decision model was designed to estimate UK NHS costs and health outcomes in terms of quality-adjusted life-years (QALYs). SETTING: Eighteen NHS hospital trusts, 17 in England and one in Scotland. PARTICIPANTS: Eligible women (972 UAE, 762 hysterectomies) who had received treatment specifically for symptomatic fibroids were identified. INTERVENTIONS: The UAE patients were treated by experienced interventional radiologists and all received their index UAE prior to the end of 2002, ensuring a minimum 2-year follow-up. The average length of follow-up was 8.6 years for the hysterectomy cohort and 4.6 years for the UAE cohort. MAIN OUTCOME MEASURES: Primary outcome measures were complication rates to assess the comparative safety of the two interventions. Secondary outcome measures related to treatment efficacy including resolution of symptoms and patient-reported satisfaction with treatment. Further efficacy outcome measures obtained in the UAE group included fibroid/uterine size shrinkage and further treatments required for unresolved fibroid symptoms. Data were also gathered on pregnancies post-UAE. RESULTS: Data were available for 1108 women (649 UAE and 459 hysterectomy). Fewer complications were experienced by women in the UAE cohort compared to the hysterectomy cohort: hysterectomy n = 120 (26.1%), UAE n = 114 (17.6%), adjusted odds ratio 0.48 [95% confidence interval (CI) 0.26 to 0.89]. When only the severe/major complications were considered, this odds ratio was reduced to 0.25 (95% CI 0.13 to 0.48). Expected general side-effects of UAE occurred in 32.7% of the UAE cohort, of which 8.9% also experienced complications. Obesity and medical co-morbidity predisposed women to complications, whereas prophylactic antibiotics appeared to protect against both complications and the expected side-effects of UAE. More women in the hysterectomy cohort reported relief from fibroid symptoms (89% versus 80% UAE, p less than 0.0001) and feeling better (81% versus 74% UAE, p less than 0.0001), but only 70% (compared with 86% UAE, p = 0.007) would recommend their treatment to a friend. In the UAE cohort, 18.3% of the women went on to receive one or more further fibroid treatments including hysterectomy (11.2%). After adjusting for differential time of follow-up, the UAE women had up to a 23% (95% CI 19 to 27%) likelihood of requiring further treatment. The free-text data indicated that many women, in both cohorts, felt that their treatment had been a complete success. In the UAE cohort there were several areas where expectations were apparently high and outcome had not fulfilled their expectations. Disappointment was expressed mainly about continuation or return of symptoms or failure to become pregnant. Many continued to have remaining questions about their treatment. The economic analysis indicated that UAE is less expensive than hysterectomy even after further treatments for unresolved or recurrent symptoms are taken into account, with little difference in QALYs between the two treatments. Younger women are exposed to the risk of recurrent fibroids and subsequent additional procedures over a longer period and consequently UAE may no longer be cost-effective. CONCLUSIONS: The study results suggest that both UAE and hysterectomy are safe. No unexpected problems were detected following UAE after a long follow-up period (average 5 years). Complications are less common for UAE than hysterectomy. The cost-effectiveness analysis favours embolisation even after taking account of complications, expected side-effects associated with the procedure and subsequent re-treatments for women with a preference for uterus preservation. It is important to improve the management of expectations following UAE, particularly regarding fertility. The data suggested that fertility and miscarriage rate are consistent with those of age-matched women with fibroids. UAE is an effective treatment for some women with fibroids and our trial supports the National Institute for Health and Clinical Excellence guidance that it should be made available as one of the options for treatment, with a possible reduction in the need for hysterectomy as the first-line treatment. Further research is needed into which women will be treated most successfully by UAE, the best method of achieving effective embolisation, advice for women who desire future fertility, the role of prophylactic antibiotics in UAE, and the effects of HRT use after UAE on recurrence of fibroid symptoms.

The North West Diabetic Pregnancy Audit: a practical system for multi-centre diabetic pregnancy audit.

AIMS: Improving care for women with pre-gestational diabetic pregnancy is a core objective of the St Vincent Declaration and the Diabetes National Service Framework. The aim was to develop a practicable collaborative audit methodology for pre-gestational diabetic pregnancy. METHODS: In 1999, care professionals in the north-west of England agreed standards and a simple monthly data collection system. Annual reports are compiled to summarize compliance with the standards. Each hospital receives an individualized report comprising tables and funnel plots that allow between-hospital comparisons. RESULTS: Data on pre-gestational diabetic pregnancies are collated from 30 maternity units. Funnel plots and tables presented in the annual reports highlight any large differences between hospitals in booking and outcome measures for diabetic pregnancies. CONCLUSIONS: The annual audit reports allow the assessment of current management and outcomes for diabetic pregnancies at a regional and local level. These reports help to identify areas where diabetic pregnancy care requires further attention.

A UK multicentre retrospective cohort study comparing hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids (HOPEFUL study): main results on medium-term safety and efficacy.

OBJECTIVES: Comparison of medium-term safety and efficacy of hysterectomy and uterine artery embolisation (UAE) for symptomatic uterine fibroids. DESIGN: Multicentre retrospective cohort. SETTING: 18 UK NHS hospital trusts. PARTICIPANTS: Four hundred and fifty nine women who had hysterectomy within a national audit during 12 months from October 1994 (VALUE study) (average follow up of 8.6 years) and 649 women receiving UAE from 1996 to 2002 (average follow up of 4.6 years). METHODS: Clinical data from existing hospital records and patient completed postal questionnaires. MAIN OUTCOME MEASURES: Complication rates, side effects of embolisation, satisfaction with treatment, relief from symptoms and requirement for further fibroid treatment. RESULTS: Fewer complications were experienced by women receiving UAE (19 versus 26% hysterectomy, P = 0.001), the adjusted odds ratio for UAE versus hysterectomy was 0.48 (95% CI 0.26-0.89). One-third of women undergoing UAE experienced anticipated general side effects associated with the procedure. More women in the hysterectomy cohort reported relief from fibroid symptoms (95 versus 85%, P < 0.0001) and feeling better (96 versus 84%, P < 0.0001), but only 85% would recommend the treatment to a friend compared with 91% in the UAE arm (P = 0.007). There was a 23% (95% CI 19-27%) chance of requiring further treatment for fibroids after UAE. Twenty-seven women who had had UAE reported 37 pregnancies after treatment resulting in 19 live births. CONCLUSIONS: UAE results in fewer complications than hysterectomy. Side effects after embolisation should be anticipated, and almost one-quarter of women having UAE were likely to require further treatment for fibroid symptoms. Both treatments appear to be safe and effective over the medium term, and the choice of treatment may be a matter of personal preference for each individual woman.

Uterine artery embolisation or hysterectomy for the treatment of symptomatic uterine fibroids: a cost-utility analysis of the HOPEFUL study.

OBJECTIVES: To evaluate the relative cost-effectiveness of uterine artery embolisation (UAE) and hysterectomy in women with symptomatic uterine fibroids from the perspective of the UK NHS. DESIGN: Cost-utility analysis. SETTING: Eighteen UK NHS hospital trusts. POPULATION OR SAMPLE Women who underwent UAE (n= 649; average follow up of 8.6 years) or hysterectomy (n= 459; average follow up of 4.6 years) for the treatments of symptomatic fibroids. METHODS: A probabilistic decision model was carried out based on data from a large comparative cohort and the literature. The two interventions were evaluated over the time horizon from the initial procedure to menopause. Extensive sensitivity analysis was carried out to test model assumptions and parameter uncertainties. MAIN OUTCOME MEASURES: Costs of procedures and complications and quality of life expressed as quality-adjusted life years (QALYs). RESULTS: Overall, UAE was associated with lower mean cost (2536 pounds sterling versus 3282 pounds sterling) and a small reduction in quality of life (8.203 versus 8.241 QALYs) when compared with hysterectomy. However, when the quality of life associated with the conservation of the uterus was incorporated in the model, UAE was shown to be the dominant strategy--lower costs and greater QALYs. CONCLUSIONS: UAE is a less expensive option to the health service compared with hysterectomy, even when the costs of repeat procedures and associated complications are factored in. The quality of life implications in the short term are also predicted to favour UAE; however, this advantage may be eroded over time as women undergo additional procedures to deal with recurrent fibroids. Given the hysterectomy is the current standard treatment for symptomatic fibroids, offering women UAE as an alternative treatment for fibroids is likely to be highly cost-effective for those women who prefer uterus-conserving treatment.

Self-reported bladder function five years post-hysterectomy.

We have examined the contribution of hysterectomy, compared with less invasive surgery, for dysfunctional uterine bleeding (DUB) on the prevalence of bladder problems five years after surgery. We report a prospective cohort study of over 25,000 women treated for benign cause menorrhagia by three types of surgery - transcervical endometrial resection/ablation and hysterectomy with or without bilateral oophorectomy. Postal questionnaires were sent five years after surgery investigating satisfaction with surgery and bladder function. When adjusted for confounders the odds of severe urinary incontinence (OR = 1.59, CI 95%, 1.35 - 1.87), urinary frequency (1.23 (1.04 - 1.45)), and nocturia (1.19, (1.03 - 1.38)) - were increased for women who had a hysterectomy compared with endometrial ablation. Hysterectomy with bilateral oophorectomy was not as strongly associated with severe bladder problems. Women who had the LAVH were most likely to report severe urinary incontinence (2.02, CI 95% 1.32 - 3.07), but not severe frequency or nocturia.

Intrauterine programming of urinary calcium and magnesium excretion in children born to mothers with insulin dependent diabetes mellitus.

BACKGROUND: Offspring of diabetic rats have reduced urinary calcium and magnesium excretion compared with offspring of controls; these differences persist up to 16 weeks after birth, a time equivalent to young adulthood in humans. OBJECTIVES: To test the hypothesis that urinary calcium and magnesium excretion would be lower in children born to mothers with insulin dependent diabetes mellitus (ChMIDDM) than those born to non-diabetic mothers. METHODS: Concentrations of calcium, magnesium, sodium, and creatinine were measured in first void spot urine samples collected from 45 (28 male; median age 9.6 years) ChMIDDM and 127 (58 male; median age 11.3 years) controls. Analysis of covariance was used to test for differences in urinary calcium to creatinine ratios (UCa/Cr), magnesium to creatinine ratios (UMg/Cr), and log sodium to creatinine ratios (logUNa/Cr) between controls and ChMIDDM after allowing for the effects of sex and age. RESULTS: UCa/Cr (difference -0.10, 95% confidence interval (CI) -0.19 to -0.01; p = 0.03) and UMg/Cr (difference -0.15, 95% CI -0.22 to -0.08; p<0.0001) were lower in ChMIDDM than controls. However, logUNa/Cr did not differ between ChMIDDM and controls (difference -0.14, 95% CI -0.33 to 0.05; p = 0.1). The daily estimated intake of magnesium, sodium, and protein were significantly higher and that of calcium non-significantly higher in ChMIDDM than controls. In ChMIDDM, UCa/Cr and UMg/Cr were not related to diabetic control of mothers. CONCLUSIONS: Results of this study provide the first evidence that in humans, as in rats, there is modification of renal Ca and Mg handling in ChMIDDM, which persists well into childhood.

Screening for gestational diabetes mellitus.

The term 'gestational diabetes mellitus' is unsatisfactory as it refers to a heterogeneous group of women, including those with minimal abnormality of carbohydrate metabolism and those with undiagnosed type II diabetes. However, perinatal morbidity is increased even in the group of women who have only impaired glucose tolerance; the mothers are at increased risk of subsequent development of diabetes, and there may also be long-term implications for the offspring. Current research is aiming to define the blood glucose levels at which risks increase so that clinical management can be appropriately directed. When available, the criteria required to justify population screening in pregnancy should be satisfied. The glucose challenge and fasting glucose tests are the leading contenders as appropriate screening tests to determine who should have the diagnostic glucose tolerance test. However, until this is reviewed, the widely used scheme of risk factors as a screening method should continue, as it detects at least 50% of women with gestational diabetes.

Readmission to hospital 5 years after hysterectomy or endometrial resection in a national cohort study.

OBJECTIVES: To investigate the readmission experience of a large national prospective cohort of women up to 5 years after undergoing either transcervical resection of the endometrium (TCRE) or hysterectomy to assess reasons for readmission and whether TCRE can be viewed as a definitive substitute for hysterectomy. DESIGN AND PARTICIPANTS: Data are from the VALUE/MISTLETOE prospective national cohort studies of hysterectomy and TCRE respectively. 5294 women who underwent hysterectomy for dysfunctional uterine bleeding in 1994/5 and 4032 women who underwent TCRE in 1993/4 and who responded to postal questionnaires were included. Surgeons gathered operative details. Women completed postal follow up questionnaires at 3 and 5 years after surgery asking about readmission to hospital and reasons for readmission. Adjusted proportional hazard ratios were calculated for likelihood of readmission in each category comparing types of surgery. RESULTS: 41.7% of women undergoing hysterectomy and 44.6% of women undergoing TCRE experienced one or more readmissions to hospital overall within 5 years (adjusted hazard ratio for all readmissions (AHR) 0.87 (95% confidence interval (CI) 0.80 to 0.95)). 12.6% of hysterectomy patients and 30.3% of TCRE patients were readmitted for gynaecological reasons (AHR 0.40 (95% CI 0.33 to 0.48)). Rates of readmission for gynaecological reasons were similar up to 6 months but were markedly reduced for hysterectomy compared with TCRE patients towards the end of the follow up period (AHR for readmission at 3-5 years 0.28 (95% CI 0.20 to 0.39)). CONCLUSIONS: There are differences in the pattern of readmission to hospital after hysterectomy and TCRE for dysfunctional uterine bleeding. Women undergoing a hysterectomy are less likely to be readmitted to hospital up to 5 years after their operation overall, and are significantly less likely to be readmitted for reasons related to their operation, particularly for gynaecological reasons. Hysterectomy appears to be a more definitive operation. The different options for surgery for dysfunctional uterine bleeding are not interchangeable; they represent different patterns of care. Information should be available to women and practitioners to inform choices between these options.

The Diabetes and Pre-eclampsia Intervention Trial.

OBJECTIVE: Rates of pre-eclampsia in women with type 1 diabetes are two to four times higher than in normal pregnancies. Diabetes is associated with antioxidant depletion and increased free radical production, and an increasing body of evidence suggests that oxidative stress and endothelial cell activation may be relevant to disease pathogenesis in pre-eclampsia. The Diabetes and Pre-eclampsia Intervention Trial (DAPIT) aims to establish if pregnant women with type 1 diabetes supplemented with vitamins C and E have lower rates of pre-eclampsia and endothelial activation compared with placebo treatment. METHODS: DAPIT is a randomised multicentre double-blind placebo-controlled trial that will recruit 756 pregnant women with type 1 diabetes from 20 metabolic-antenatal clinics in the UK over 4 years. Women are randomised to daily vitamin C (1000 mg) and vitamin E (400 IU) or placebo at 8-22 weeks of gestation until delivery. Maternal venous blood is obtained at randomisation, 26 and 34 weeks, for markers of endothelial activation and oxidative stress and to assess glycaemic control. The primary outcome of DAPIT is pre-eclampsia. Secondary outcomes include endothelial activation (PAI-1/PAI-2) and birthweight centile.

Severe complications of hysterectomy: the VALUE study.

OBJECTIVES: To model the determinants of serious operative and post-operative complications of hysterectomy and their potential risk factors. DESIGN: A prospective cohort of women undergoing hysterectomies for benign indications in 1994/1995, with a six-week postsurgery follow up. POPULATION AND SETTING: A total of 37,512 women from 276 NHS and 145 private hospitals in England, Wales and Northern Ireland, originally recruited to compare the outcomes of endometrial destruction with those of hysterectomy. METHODS: Gynaecologists reported hysterectomies for non-malignant indications carried out during a 12-month period beginning in October 1994 and follow up data were obtained at outpatient follow up six weeks postsurgery. Odds ratios of severe complications by indication and method, adjusting for measured intrinsic risk factors, were calculated. MAIN OUTCOME MEASURES: Severe operative and post-operative complications. RESULTS: Severe operative complications occurred in 3%. The risk decreased with age and increased with greater parity and history of serious illness. Women with symptomatic fibroids (4.4%, 95% CI 3.9-4.9) experienced more complications than women with dysfunctional uterine bleeding (3.6%, 3.2-3.8), adjusted odds ratio (OR) = 1.3 (95% CI 1.1-1.6). Laparoscopic procedures (6.1%) doubled the risk of operative complications of abdominal hysterectomy (3.6%) (adjusted OR = 1.9, 1.5-2.5). Post-operative complications occurred in around 1% of women, with a slight decrease with increasing age, and the strongest risk factor was a history of operative complications. Relative to dysfunctional uterine bleeding (1.0%), a higher risk for fibroids (1.2%) persisted after adjustments (RR = 1.5, 1.1-2.0). Both vaginal (1.2%) and laparoscopic (1.7%) techniques had significantly higher adjusted risks than abdominal operations (0.9%), RR = 1.4 (1.0-1.9) and RR = 1.6 (1.0-2.7). There were no operative deaths; 14 women died within the six-week postsurgery (a crude mortality rate of 3.8/1000, 2.5-6.4). CONCLUSIONS: Hysterectomy is a common, routine surgery with comparatively rare serious complications. However, younger women, women with more vascular pelvis, who undergo hysterectomy, especially laparoscopically assisted vaginal surgery for symptomatic fibroids, are at most risk of experiencing severe complications both operatively and post-operatively. Therefore, a less invasive alternative treatment for symptomatic fibroids could particularly benefit this group of women, while less invasive treatments for dysfunctional uterine bleeding, such as various methods of endometrial ablations or resections, would need to meet the current low levels of clinical complications in order to replace hysterectomy.

Grandmultiparae in a modern setting.

OBJECTIVE: To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among women who had previously delivered five or more times (grandmultiparous) with that of age-matched control women who had previously delivered two or three times (multiparous). DESIGN: A matched cohort study. SETTING: An inner city university maternity hospital in the United Kingdom. SAMPLE: Three hundred and ninety-seven grandmultiparous women were compared with three hundred and ninety-seven age-matched multiparous women. METHODS: Data on the subjects were obtained from a computerised maternity information system (SMMIS). Characteristics and complications occurring in the two groups were compared. Data validation was performed with a 10% randomised sample of the casenotes in both groups. Nineteen relevant data fields were abstracted and compared with the matched SMMIS record. Results The overall incidence of intrapartum complications for grandmultiparous women was 16% compared with 18% in the control multiparous women (odds ratio 0.9, 95% CI 0.6-1.3). Grand multiparity was associated with a significantly higher body mass index at booking (P < 0.01) and the last antenatal clinic (P < 0.05), an increased incidence of antenatal anaemia (22% vs 16%, odds ratio 1.8, 95% CI 1.2-2.8) and a decreased incidence of elective caesarean section (6% vs 11%, odds ratio 0.5, 95% CI 0.3-0.9). Agreement was greater than 95% in all the data fields reviewed except three. In the 14 categorical variables reviewed the Cohen's kappa results were in excess of 0.6. CONCLUSION: This study suggests that in a developed country with satisfactory health care conditions, grandmultiparity should not be considered dangerous,and risk assessment should be based on past and present history and not simply on the basis of parity.

The VALUE national hysterectomy study: description of the patients and their surgery.

OBJECTIVES: To describe hysterectomies practised in 1994 and 1995: the patients, their surgery and short term outcomes. DESIGN: One of two large cohorts, with prospective follow up, recruited to compare the outcomes of endometrial destruction with those of hysterectomy. SETTING: England, Wales and Northern Ireland. POPULATION: All women who had hysterectomies for non-malignant indications carried out during a 12-month period. METHODS: Gynaecologists in NHS and independent hospitals were asked to report cases. Follow up data were obtained at outpatient follow up approximately six weeks post-surgery. MAIN OUTCOME MEASURES: Indication for surgery, method of hysterectomy, ovarian status post-surgery, surgical complications. RESULTS: 37,298 cases were reported which is estimated to reflect about 45% of hysterectomies performed during the period studied. The median age was 45 years, and the most common indication for surgery was dysfunctional uterine bleeding (46%). Most hysterectomies were carried out by consultants (55%). The proportions of women having abdominal, vaginal or laparoscopically-assisted hysterectomy were 67%, 30% and 3%, respectively. Forty-three percent of women had no ovaries conserved after surgery. The median length of stay was five days. The overall operative complication rate was 3.5%, and highest for the laparoscopic techniques. The overall post-operative complication rate was 9%. One percent of these was regarded as severe, with the highest rate for severe in the laparoscopic group (2%). There were no operative deaths; 14 deaths were reported within the six-week post-operative period: a crude mortality rate soon after surgery of 0.38 per thousand (95% CI 0.25-0.64). CONCLUSIONS: This large study describes women who undergo hysterectomy in the UK, and presents results on early complications associated with the surgery. Operative complications occurred in one in 30 women, and post-operative complications in at least one in 10. Laparoscopic techniques tend to be associated with higher complication rates than other methods.