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Objective: To describe the incidence, risk factors, management and outcomes of amniotic-fluid embolism (AFE) over time., Design: A population-based cohort and nested case-control study using the UK Obstetric Surveillance System (UKOSS)., Setting: All UK hospitals with obstetrician-led maternity units., Population: All women diagnosed with AFE in the UK between February 2005 and January 2014 (n = 120) and 3839 control women., Methods: Prospective case and control identification through UKOSS monthly mailing., Main Outcome Measures: Amniotic-fluid embolism, maternal death or permanent neurological injury., Results: The total and fatal incidence of AFE, estimated as 1.7 and 0.3 per 100 000, respectively, showed no significant temporal trend over the study period and there was no notable temporal change in risk factors for AFE. Twenty-three women died (case fatality 19%) and seven (7%) of the surviving women had permanent neurological injury. Women who died or had permanent neurological injury were more likely to present with cardiac arrest (83% versus 33%, P < 0.001), be from ethnic-minority groups (adjusted odds ratio [OR] 2.85, 95% confidence interval [95% CI] 1.02-8.00), have had a hysterectomy (unadjusted OR 2.49, 95% CI 1.02-6.06), had a shorter time interval between the AFE event and when the hysterectomy was performed (median interval 77 minutes versus 248 minutes, P = 0.0315), and were less likely to receive cryoprecipitate (unadjusted OR 0.30, 95% CI 0.11-0.80)., Conclusion: There is no evidence of a temporal change in the incidence of or risk factors for AFE. Further investigation is needed to establish whether earlier treatments can reverse the cascade of deterioration leading to severe outcomes., (© 2015 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Objectives: To audit interval from decision to delivery in urgent caesarean section to determine whether the current standard of 30 minutes is achievable routinely; to determine whether delay leads to an excess of admissions to special care., Design: Three audit cycles over four years followed by a continuous audit over 32 months., Setting: Large district general hospital delivering 5500 women each year., Participants: All women delivered by urgent caesarean section for abnormal fetal heart rate patterns, cord prolapse, failed instrumental delivery, or suspected placental abruption., Main Outcome Measures: Proportion of women delivered within 30 and 40 minutes of decision. Admission rates to special care by length of interval between decision and delivery., Results: In the continuous audit 478 of 721 (66.3%) women were delivered in 30 minutes and 637 (88.3%) within 40 minutes; 29 (4.0%) were undelivered at 50 minutes. If the woman was taken to theatre in 10 minutes, 409 of 500 (81.8%) were delivered in 30 minutes and 495 (97%) in 40 minutes. There was no significant difference in the proportion of babies born at 36 weeks or later who were admitted to special care, when analysed by interval from decision to delivery. 36/449 (8%) babies with an interval from decision to delivery of less than 30 minutes were admitted to special care and 3/23 (13%) with an interval of more than 50 minutes were admitted., Conclusions: The current recommendations for the interval between decision and delivery are not being achieved in routine practice. Failure to meet the recommendations does not seem to increase neonatal morbidity.

Objectives: To describe the characteristics, management and outcomes of women giving birth at advanced maternal age (≥48 years).Design: Population-based cohort study using the UK Obstetric Surveillance System (UKOSS).Setting: All UK hospitals with obstetrician-led maternity units.Population: Women delivering at advanced maternal age (≥48 years) in the UK between July 2013 and June 2014 (n = 233) and 454 comparison women.Methods: Cohort and comparison group identification through the UKOSS monthly mailing.Main Outcome Measures: Pregnancy complications.Results: Older women were more likely than comparison women to be overweight (33% versus 23%, P = 0.0011) or obese (23% versus 19%, P = 0.0318), nulliparous (53% versus 44%, P = 0.0299), have pre-existing medical conditions (44% versus 28%, P < 0.0001), a multiple pregnancy (18% versus 2%, P < 0.0001), and conceived following assisted conception (78% versus 4%, P < 0.0001). Older women appeared more likely than comparison women to have pregnancy complications including gestational hypertensive disorders, gestational diabetes, postpartum haemorrhage, caesarean delivery, iatrogenic and spontaneous preterm delivery on univariable analysis and after adjustment for demographic and medical factors. However, adjustment for multiple pregnancy or use of assisted conception attenuated most effects, with significant associations remaining only with gestational diabetes (adjusted odds ratio [aOR] 4.81, 95% CI 1.93-12.00), caesarean delivery (aOR 2.78, 95% CI 1.44-5.37) and admission to an intensive care unit (aOR 33.53, 95% CI 2.73-412.24).Conclusions: Women giving birth at advanced maternal age have higher risks of a range of pregnancy complications. Many of the increased risks appear to be explained by multiple pregnancy or use of assisted conception.Tweetable Abstract: The pregnancy complications in women giving birth aged 48 or over are mostly explained by multiple pregnancy. [ABSTRACT FROM AUTHOR]

Objective: To describe the incidence, risk factors, management and outcomes of amniotic-fluid embolism (AFE) over time.Design: A population-based cohort and nested case-control study using the UK Obstetric Surveillance System (UKOSS).Setting: All UK hospitals with obstetrician-led maternity units.Population: All women diagnosed with AFE in the UK between February 2005 and January 2014 (n = 120) and 3839 control women.Methods: Prospective case and control identification through UKOSS monthly mailing.Main Outcome Measures: Amniotic-fluid embolism, maternal death or permanent neurological injury.Results: The total and fatal incidence of AFE, estimated as 1.7 and 0.3 per 100 000, respectively, showed no significant temporal trend over the study period and there was no notable temporal change in risk factors for AFE. Twenty-three women died (case fatality 19%) and seven (7%) of the surviving women had permanent neurological injury. Women who died or had permanent neurological injury were more likely to present with cardiac arrest (83% versus 33%, P < 0.001), be from ethnic-minority groups (adjusted odds ratio [OR] 2.85, 95% confidence interval [95% CI] 1.02-8.00), have had a hysterectomy (unadjusted OR 2.49, 95% CI 1.02-6.06), had a shorter time interval between the AFE event and when the hysterectomy was performed (median interval 77 minutes versus 248 minutes, P = 0.0315), and were less likely to receive cryoprecipitate (unadjusted OR 0.30, 95% CI 0.11-0.80).Conclusion: There is no evidence of a temporal change in the incidence of or risk factors for AFE. Further investigation is needed to establish whether earlier treatments can reverse the cascade of deterioration leading to severe outcomes. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Acosta C, Bhattacharya S, Tuffnell D, Kurinczuk J, Knight M. Maternal sepsis: a Scottish population-based case-control study. BJOG 2012;119:474-483. Objective To describe the risk of maternal sepsis associated with obesity and other understudied risk factors such as operative vaginal delivery. Design Population-based, case-control study. Setting North NHS region of Scotland. Population All cases of pregnant, intrapartum and postpartum women with International Classification of Disease-9 codes for sepsis or severe sepsis recorded in the Aberdeen Maternal and Neonatal Databank (AMND) from 1986 to 2009. Four controls per case selected from the AMND were frequency matched on year-of-delivery. Methods Cases and controls were compared; significant variables from univariable regression were adjusted in a multivariable logistic regression model. Main outcome measures Dependent variables were uncomplicated sepsis or severe ('near-miss') sepsis. Independent variables were demographic, medical and clinical delivery characteristics. Unadjusted and adjusted odds ratios (OR) with 95% confidence intervals (95% CI) are reported. Results Controlling for mode of delivery and demographic and clinical factors, obese women had twice the odds of uncomplicated sepsis (OR 2.12; 95% CI 1.14-3.89) compared with women of normal weight. Age <25 years (OR 5.15; 95% CI 2.43-10.90) and operative vaginal delivery (OR 2.20; 95% CI 1.02-4.87) were also significant predictors of sepsis. Known risk factors for maternal sepsis were also significant in this study (OR for uncomplicated and severe sepsis respectively): multiparty (OR 6.29, 12.04), anaemia (OR 3.43, 18.49), labour induction (OR 3.92 severe only), caesarean section (OR 3.23, 13.35), and preterm birth (OR 2.46 uncomplicated only). Conclusions Obesity, operative vaginal delivery and age <25 years are significant risk factors for sepsis and should be considered in clinical obstetric care. [ABSTRACT FROM AUTHOR]

Presents letters to the editor concerning medical issues. Thoughts on a social contract for the practice of medicine; Delivery by Caesarean section; Take home naloxone for opiate addicts; Use of lactulose to prevent urinary tract infections; Others.