The continuing fall in incidence of hypoxic-ischaemic encephalopathy in term infants

Objective To examine trends in incidence of hypoxic-ischaemic encephalopathy in term infants over a twenty-one year period.
Design A retrospective analysis of medical records of all term infants admitted to a neonatal unit with hypoxic-ischaemic encephalopathy during the years 1992–1996 (period C) and a comparison with data from the years 1976–1980 (period A) and 1984–1988 (period B) from the same unit (previously published ¹ ).
Setting A District Health Authority in Central England serving a population of about 450,000.
Sample All term infants admitted with clinical features of hypoxic-ischaemic encephalopathy.
Main outcome measures Incidence of three grades of hypoxic-ischaemic encephalopathy, disability and mortality.
Results In each five year period there were similar numbers of births. Over the time-span of this study the stillbirth rate and neonatal mortality rate has consistently fallen. The overall incidence of hypoxicischaemic encephalopathy in term infants was significantly lower (P < 0.001; OR 0.42 CI 0.29–0.59) in the present study period (C) compared with the earlier study period B (1.9 vs 4.6 per 1000 total live births). The fall in moderately and severely affected infants between the present and the first study period was significant (1.2 vs 2.6 per 1000 total live births,   P < 0.001  : OR 0.46 CI 0.29–0.72). The number of deaths and the incidence of cerebral palsy in survivors fell progressively over the 21 years spanned by this study.
Conclusion This study shows that the incidence of hypoxic-ischaemic encephalopathy and its sequelae in term infants has fallen significantly. The use of cardiotocography and caesarean section rates have risen but the relative contributions of changes in clinical practice are uncertain.     

Diabetes in pregnancy: a population-based study of incidence, referral for care, and perinatal mortality

During 1979 and 1980 in Washington State, 260 infants (live births plus fetal deaths greater than or equal to 20 weeks' gestation) were born to women with preexisting diabetes mellitus, the equivalent to a population-based incidence of 2.1 per 1000 total births. One quarter of these women had non-insulin-dependent diabetes prior to pregnancy. The perinatal mortality rate for all infants of diabetic mothers in this series was 108 per 1000, which was eight times the state perinatal mortality rate. Only 45% of births occurred in the five tertiary centers in the state, whereas 39% occurred in hospitals that had fewer than six deliveries per year complicated by overt diabetes. The mortality rate was slightly, but not significantly, lower among infants born in referral hospitals than among those born in primary-level hospitals. Congenital malformations accounted for 43% of the 28 perinatal deaths, and fetal losses between 20 and 27 weeks' gestation accounted for another 21%. During the 2-year study period there were only three cases in which antepartum care in nonspecialty centers may have contributed to a perinatal loss.     

Is intrapartum asphyxia preventable?

The contribution of intrapartum events to asphyxia-related mortality and morbidity and the degree to which it may be prevented are controversial. We examined trends in asphyxia-related mortality and morbidity in a single large regional perinatal centre. Between 1994 and 2005, the rate of asphyxia fell from 2.86/1000 births in 1994 to 0.91/1000 births in 2005 ( P < 0.001). Hypoxic-ischaemic encephalopathy of all grades fell from 2.41 to 0.77/1000 live births ( P < 0.001). This substantial and steady fall in the rate of asphyxia-related mortality and morbidity over a 12-year period suggests that a significant proportion of cases of intrapartum asphyxia may be preventable.     

Herpes simplex virus infection after vacuum-assisted vaginally delivered infants of asymptomatic mothers.

OBJECTIVE: To determine whether vacuum extraction technique is associated with an increased risk of herpes simplex virus (HSV) infection in infants born to asymptomatic mothers. PATIENTS AND METHODS: We reviewed the charts of all infants born at the Edith Wolfson Medical Center and admitted to the hospital's neonatal intensive care unit from January 1999 to June 2002 diagnosed with HSV infection. RESULTS: During the study period, 6953 infants were delivered at our institution and 11 infants had HSV infection. The prevalence of neonatal HSV infection was 1.6 per 1000 live births. In 699 infants, vacuum extraction was used for delivery. Five out of the 11 infants delivered vaginally by vacuum extraction developed HSV infection at the site of the vacuum extractor application. They were born to mothers who were asymptomatic at delivery and had no history of HSV genital infection. HSV type 2 was isolated from the vesicular fluid in all infected infants delivered by vacuum extraction, and none had central nervous system involvement. The prevalence of neonatal HSV infection in vacuum-assisted births was seven per 1000 live births as compared to 0.95 in 1000 in infants delivered vaginally or by cesarean section (p<0.0001). The relative risk of HSV infection in infants born in vacuum-assisted births was 7.45 (95% confidence interval (CI) 1.99 to 27.42, p=0.001). All patients were treated with intravenous acyclovir and no recurrences of HSV infection have been noticed at follow-up. CONCLUSIONS: Laceration of the fetal scalp by vacuum extraction technique may enhance the acquisition and the early appearance of cutaneous infection in infants exposed to HSV shedding in the genital tract of asymptomatic mothers, as the virus gains access through the lacerated scalp.     

Seizures in the Nigerian neonate: Perinatal factors

A prospective study of 55 infants with neonatal seizures admitted to the Special Care Baby Unit of the University of Benin Teaching Hospital over a 5.5-year period revealed that perinatal asphyxia and hypoglycemia were the principal aetiologic factors in about 71% of the cases. The most frequently encountered seizure types were unilateral clonic (51.5%). Generalized clonic and massive generalized myoclonic seizures were found in 14 (25.5%) and seven (12.7%) cases, respectively, and subtle seizures in three.The overall incidence was $\text{3.5}\text{1000}$ live births, with a preponderance of male infants in the seizure population, among whom preterm infants were significantly more common.The mortality, (34.5%) was closely related to the etiology. Since the associated adverse perinatal events are largely preventable, improved prenatal and perinatal health care delivery should lead to a decline in the frequency of neonatal seizures.     

Causes and consequences of recent increases in preterm birth among twins.

OBJECTIVE: To examine the causes and consequences of the recent increase in preterm birth among twins. METHODS: We studied all twin births among residents of the province of Nova Scotia, Canada, between 1988 and 1997. Rates of preterm birth, preterm labor induction, preterm cesarean, small-for-gestational age (SGA), respiratory distress syndrome (RDS), stillbirth, perinatal mortality, and infant mortality were compared between past and more recent years. Changes in perinatal mortality were examined using logistic regression to adjust for the effects of other determinants. RESULTS: The study included 2516 twin births (73 stillbirths and 2443 live births). The rate of preterm birth increased from 42.3% in 1988-1992 to 48.2% of twin live births in 1993-1997 (14% increase, P =.04). Twin live births born after preterm labor induction increased from 3.5% in 1988-1989 to 8.6% in 1996-1997 (P for trend =.007). Of live births between 34 and 36 weeks' gestation, the proportion born SGA decreased from 17.5% in 1988-1992 to 9.2% in 1993-1997 (P =.005). Over the same period, rates of prophylactic maternal steroid therapy increased substantially and rates of RDS declined. Perinatal mortality rates among pregnancies reaching 34 weeks decreased from 12.9 per 1000 total births in 1988-1992 to 4.2 per 1000 total births in 1993-1997 (P =.05). CONCLUSION: Increases in preterm labor induction appear to be responsible for the recent increase in preterm birth among twins. These changes have been accompanied by decreases in perinatal morbidity and mortality among twin pregnancies that reach 34 weeks' gestation.     

Neonatal sepsis of vertical transmission: an epidemiological study from the "Grupo de Hospitales Castrillo"

A prospective multicenter study was designed to assess the epidemiology of neonatal sepsis of vertical transmission in Spain. The study was carried out by the "Grupo de Hospitales Castrillo" that included the neonatal services of 19 tertiary care (reference) hospitals and 9 secondary care hospitals. Prospective data from infants with culture-proved neonatal sepsis, clinical sepsis and bacteremia were recorded for 1995 to 1997. In a total of 203,288 neonates, proven sepsis was diagnosed in 515 (rate of 2.5 per 1000 live births), clinical sepsis in 724 (rate of 3.6 per 1000 live births), and bacteremia of vertical transmission in 155 (rate of 0.76 per 1000 live births). Very low birth weight (VLBW) infants (< or = 1500 g) showed a significantly higher incidence of confirmed sepsis (26.5 per 1000 live births) and clinical sepsis (32.4 per 1000 live births) than infants weighing > 1500 g. Streptococcus agalactiae was the most frequent causative pathogen in cases of proven sepsis (51%) and bacteremia (33%), but Escherichia coli was the most frequently recovered organism in the VLBW group. The mortality rate of proven sepsis was significantly higher than that of clinical sepsis (8.7% versus 4.3%) (P < 0.01). In the VLBW cohort, there were no significant differences in the mortality rate between proven sepsis and clinical sepsis. In conclusion, clinical sepsis was the most frequent diagnosis, probably related to intrapartum chemoprophylaxis. Streptococcus agalactiae was the most frequent causative pathogen of culture-positive sepsis and bacteremia, whereas E. coli was the most significant in VLBW infants.     

Does training in obstetric emergencies improve neonatal outcome?

OBJECTIVES: To determine whether the introduction of Obstetrics Emergency Training in line with the recommendations of the Clinical Negligence Scheme for Trusts (CNST) was associated with a reduction in perinatal asphyxia and neonatal hypoxic-ischaemic encephalopathy (HIE). DESIGN: A retrospective cohort observational study. SETTING: A tertiary referral maternity unit in a teaching hospital. POPULATION: Term, cephalic presenting, singleton infants born at Southmead Hospital between 1998 and 2003 were identified; those born by elective Caesarean sections were excluded. METHOD: Five-minute Apgar scores were reviewed. Infants that developed HIE were prospectively identified throughout this period. The study compared the period 'pre-training' (1998-1999), with the period 'post-training' (2001-2003). MAIN OUTCOME MEASURES: Five-minute Apgar scores and HIE. RESULTS: Infants (19,460) were included. Infants born with 5-minute Apgar scores of 相似文献   

Infants born at the threshold of viability in relation to neonatal mortality: Colorado, 1991 to 2003

OBJECTIVE: To determine the contribution of infants born at the threshold of viability (defined as <750 g birth weight) and the role of regionalization of perinatal care on the neonatal mortality rate (NMR) in Colorado. STUDY DESIGN: We performed a retrospective cohort study, evaluating all live births in Colorado from 1991 to 2003, and comparing the periods 1991 to 1996 versus 1997 to 2003. RESULT: The overall unadjusted NMR of the two time periods was 4.3 and 4.4 per 1000 live births, respectively (P=0.42). The contribution of infants with birth weights<750 g to the overall NMR increased from 45.0 to 54.5% (P<0.01). The odds of death for infants<750 g increased between time periods (Odd ratio 1.3, 95% Confidence interval 1.11, 1.61). However, NMR decreased between time periods for all birth weight categories, until infants<600 g. With respect to regionalization, the number of infants<750 g born in a level III care center increased slightly between the two time periods (69.6 versus 73.3%; P=0.04); however, adjusted analysis showed no difference in the practice of regionalization between time periods. Regardless of time period, infants who weighed <750 g born in a level III center had 60% lower mortality risk when compared to <750 g infants born in a non-level III center (P<0.01; 95% CI 0.30, 0.52). CONCLUSION: Despite advances in neonatal medicine, the overall NMR in the state of Colorado remained unchanged between the time periods of 1991 to 1996 and 1997 to 2003. Infants at the threshold of viability continue to have a large impact on the Colorado NMR, making up a larger proportion of overall neonatal deaths. While the results demonstrate that the risk of mortality is significantly reduced for <750 g infants born in a level III center, the practice of regionalization has not changed between the two time periods. Improved efforts to standardize the referral practices to ensure delivery of <750 g infants in level III centers could potentially reduce the impact of these infants on the NMR. While the overall NMR in Colorado has not changed between the two time periods, the NMR for infants>600 g has significantly decreased, suggesting that the boundary delineating the threshold of viability needs reevaluation, as it may have been pushed lower than previously defined.     

The Egypt National Perinatal/Neonatal Mortality Study 2000.

OBJECTIVES: To estimate stillbirth, perinatal (PMR) and neonatal mortality rates (NMR) in Egypt and to assign main causes of death. STUDY DESIGN: Data were collected from a representative sample of women who gave birth from 17,521 households which were included in the Egypt Demographic and Health Survey (EDHS) 2000. Comparisons were made between three systems for classifying causes of death. RESULTS: The NMR was 25 per 1000 live births (17 early and eight late). Half the deaths occurred in the first two days of life. Neonatal causes of death were pre-maturity (39%), asphyxia (18%), infections (7%), congenital malformation (6%) and unclassified (29%). The PMR was 34 per 1000 births, mainly attributed to: asphyxia (44%) and prematurity (21%). The revised Wigglesworth classification agreed well with the physicians except the panel attributed more deaths to infections (20%). The WHO verbal autopsy algorithm left 48% of deaths unclassified. CONCLUSIONS: Infant mortality in Egypt is showing an epidemiological transition with a significant decrease in mortality, resulting in a disproportionate percentage of deaths in the first week of life. Infant mortality in Egypt declined 64% from 124 per 1000 between 1974 and 1978 to 44 per 1000 between 1995 and 1999, the decline being greatest among older infants; 55% of all infant deaths occurred during the neonatal period. The neonatal mortality rate in this study was estimated to be 25 per 1000 live births.     

Narrowing of sex differences in infant mortality in Massachusetts.

OBJECTIVES: To examine whether the improved survival of preterm infants has influenced the known male excess in infant mortality. STUDY DESIGN: We analyzed sex-specific infant mortality using linked birth and death certificates for all 619,811 live born infants in Massachusetts between 1989 and 1995. RESULTS: Between 1989 and 1995 the male excess in infant mortality decreased by 50%, from 1.6/1000 to 0.8/1000 live births (LB). This narrowing resulted primarily from a more rapid decline in neonatal mortality among male infants (1.5/1000 LB) than among female infants (0.9/1000 LB). The largest declines in the male excess in neonatal mortality occurred among very premature infants (GA < or = 30 weeks) and resulted primarily from a more rapid decrease in male deaths from respiratory distress syndrome. CONCLUSIONS: The narrowing of the sex difference in mortality between 1989 and 1995 suggests that newer treatments like antenatal steroids, and surfactants may have differentially benefited male infants.     

Time of birth and the risk of neonatal death

OBJECTIVE: To assess whether mortality is increased in the United States in infants born at night, we compared case-mix adjusted neonatal mortality for low- and high-risk infants born during the daytime (7 am to 6 pm), early night (7 pm to 12 am), and late night (1 am to 6 am). METHODS: California linked birth-death certificate data on 3,363,157 infants, weighing more than 500 g and born without lethal congenital anomalies in 1992-1999, were analyzed. Logistic regression, adjusting for birth weight, gender, prenatal care initiation, maternal hypertension, eclampsia, diabetes, and placental abruption/previa, was used to estimate the relationship between neonatal mortality and time of birth. RESULTS: The overall neonatal mortality was 2.08 deaths per 1,000 live births. Neonatal mortality was 1.88 for daytime births, increasing to 2.37 for early night and 2.31 for late night births. After adjusting for case mix, early night births had a 12% increase and late night births a 16% increase in the odds of neonatal death, an excess that accounts for 9.6% of all neonatal deaths. Mortality was increased for night births that were less than 1,500 g or more than 1,500 g, singletons or multiples, and those delivered vaginally or by cesarean. The increased risk was identified in hospitals that provide intermediate, community, and regional neonatal intensive care, but not in hospitals that provide primary care. CONCLUSION: Identifying the causal factors and reducing the increased burden of mortality for infants born at night should be a major priority for perinatal medicine.     

Umbilical artery blood gas parameters in neonates with early onset seizures who die

OBJECTIVE: To relate umbilical artery blood gas parameters to mortality among neonates with hypoxic-ischaemic encephalopathy related to early onset seizures. DESIGN: Population cohort study. SETTING: British Columbia Women's Hospital. POPULATION: Forty-seven infants at >or=32 weeks of gestation admitted to NICU with early onset seizures secondary to hypoxic-ischaemic encephalopathy with umbilical artery blood gases done at delivery. METHODS: Patients were divided into two groups: (1) Infants with neonatal seizures who survived, and (2) infants with neonatal seizures who died related to hypoxic-ischaemic encephalopathy complications. Comparison of umbilical artery pH, PO(2), PCO(2), base deficit was done between the two groups with Student's t tests. MAIN OUTCOME MEASURES: Umbilical artery pH, PO(2), PCO(2) and base deficit. RESULTS: The PO(2) was significantly higher in the group that expired (18.36 +/- 9.15 vs 12.33 +/- 7.51). There were no significant differences in any other blood gas parameters between the groups. CONCLUSION: Neither the umbilical artery pH nor base deficit is predictive of neonatal death in infants with hypoxic-ischaemic encephalopathy with seizures. The finding of a high PO(2) in neonates who died may indicate an inability of those infants to efficiently extract oxygen from blood.     

Social inequalities in preterm birth in Scotland 1980-2003: findings from an area-based measure of deprivation

Objective  The preterm birth rate in Scotland has been increasing in recent years. Although preterm birth rates show a social gradient, it is unclear how this gradient has been affected by the overall increase. We examined time trends in singleton live preterm birth rates in relation to area-based socio-economic indicators.
Design  Population-based retrospective cohort study.
Setting  Scotland.
Participants  All singleton live births delivered in Scottish hospitals between 1980 and 2003 ( n = 1 423 993).
Main outcome measures  Singleton live preterm birth rates in each deprivation quintile were derived. Subgroup analyses of those born moderately preterm (32–36 weeks), very preterm (28–31 weeks) and extremely preterm (24–27 weeks) were performed.
Results  The rate of singleton live preterm births increased from 49.7 per 1000 live births in the 5-year period 1980–84 to 56.1 per 1000 in the 4-year period 2000–03, a relative increase of 12.9%. A marked social gradient was apparent at all time periods: relative indices of inequality were 1.63 (95% CI 1.38–1.92) in 1980–84 and 1.55 (1.44–1.66) in 2000–03. Similar social gradients existed for all gestational age subgroups. Smoking status at first antenatal contact and increased obstetric intervention, possibly reflecting improvements in fetal monitoring and neonatal care, appeared to explain some but not all the social gradient.
Conclusions  Social inequalities in preterm birth were apparent in Scotland between 1980 and 2003. In addition to helping pregnant women to stop smoking, other means to reduce social inequalities are required.     

Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality

Objective To evaluate gestation-specific risks of stillbirth, neonatal and post-neonatal mortality.
Design Retrospective analysis of 171,527 notified births (1989–1991) and subsequent infant survival at one year, from community child health records.
Setting Notifications from maternity units in the North East Thames Region, London.
Main outcome measures The incidence of births, stillbirths, neonatal and post-neonatal deaths at each gestation after 28 completed weeks. Mortality rates per 1000 total or live births and per 1000 ongoing pregnancies at each gestation were calculated.
Results The rates of stillbirth at term (2.3 per 1000 total births) and post-term (1.9 per 1000 total births) were similar. When calculated per 1000 ongoing pregnancies, the rate of stillbirth increased six-fold from 0.35 per 1000 ongoing pregnancies at 37 weeks to 2.12 per 1000 ongoing pregnancies at 43 weeks of gestation. Neonatal and post-neonatal mortality rates fell significantly with advancing gestation, from 15 1.4 and 31.7 per 1000 live births at 28 weeks, to reach a nadir at 41 weeks of gestation (0.7 and 1.3 per 1000 live births, respectively), increasing thereafter in prolonged gestation to 1.6 and 2.1 per 1000 live births at 43 weeks of gestation. When calculated per 1000 ongoing pregnancies, the overall risk of pregnancy loss (stillbirth + infant mortality) increased eight-fold from 0.7 per 1000 ongoing pregnancies at 37 weeks to 5.8 per 1000 ongoing pregnancies at 43 weeks of gestation.
Conclusion The risks of prolonged gestation on pregnancy are better reflected by calculating fetal and infant losses per 1000 ongoing pregnancies. There is a significant increase in the risk of stillbirth, neonatal and post-neonatal mortality in prolonged pregnancy. This study provides accurate data on gestation-specific risks of pregnancy loss, enabling pregnant women and their carers to judge the appropriateness of obstetric intervention.     

Neonatal group B streptococcal disease: incidence, presentation, and mortality.

OBJECTIVES: To ascertain the incidence, and compare the clinical characteristics, laboratory parameters, and immediate mortality of neonates with early-onset (symptomatic and asymptomatic) and late-onset group B streptococcal (GBS) disease. METHODS: A chart review of 81 neonates with GBS disease (either blood and/or cerebrospinal fluid culture-proven) born between 1995 and 2002 admitted to two tertiary care perinatal centers in Toronto was conducted. Clinical characteristics were compared for (1) asymptomatic early-onset, symptomatic early-onset, and late-onset GBS disease and (2) survivors and non-survivors. RESULTS: The incidence of GBS disease was 1.13/1000 live births. One or more antepartum or intrapartum predisposing factors were recognized in 62% of cases. Early-onset was noted in 65 (80%) neonates (23 asymptomatic and 42 symptomatic). All full-term infants survived. The mortality was 6% and was confined to preterm neonates with early symptomatic disease who presented with shock and had thrombocytopenia. CONCLUSION: Antepartum or intrapartum known predisposing risk factors of GBS disease were lacking in one third of patients. Patients who died were preterm infants in the early symptomatic group.     

Neonatal outcomes and quality of care in level II perinatal centers supported by a children's hospital-medical school level III program.

OBJECTIVE: Eight Level II perinatal centers developed contracts with the children's hospital to provide consultative neonatal patient care, education, and administrative support. The purpose of the present study was to evaluate infant outcomes and quality of care during a 3-year period of the program, 1994 to 1996. STUDY DESIGN: Neonatal mortality rates were determined for the 18,703 live births. Quality of care was assessed for 30 infants who died at the Level II centers and 315 infants transferred to the children's hospital. RESULTS: The neonatal mortality rate was 2.2/1000 live births. Quality-of-care issues primarily involved 80 "drop-in" deliveries 相似文献   

The evolving national birth prevalence of Down syndrome in Taiwan. A study on the impact of second-trimester maternal serum screening

OBJECTIVES: The aim of the present study was to determine whether the liberal use of second-trimester maternal serum screening in Taiwan started in 1994 had a measurable impact on birth prevalence of infants with Down syndrome (DS) in the past decade. METHODS: We based our study on the databases of 'National Birth Defect Registration and Notification System', 'Amniocentesis in Pregnant Women', and 'Demographic Fact Book' in Taiwan. Collected data included total registered birth number, the registered number of stillbirths, the registered numbers of live births and of DS stillbirths affected with DS, amniocentesis rates each year in pregnant women aged 35 or more, and the age distribution of pregnant women in Taiwan. The live birth rate of and total birth rate of fetuses affected with DS, and the rates of live birth and stillbirth to total birth with DS, were analyzed year by year, in order to understand the change of birth rate of infants affected with DS between 1993 and 2001. Those with isolated cleft palate (ICP) were also analyzed as internal control variable. Confidence interval of live birth rate of infants with DS under Poisson distribution was calculated. Chi-square test for trend in binomial proportions was performed to see if there is an increasing (or decreasing) trend in the proportion of incidence of fetuses affected with DS. The difference was statistically significant if a p value was <0.05. RESULTS: A total of 1 331 616 deliveries were collected during the study period, including 840 cases of DS confirmed by karyotyping study. A marked decrease in the live birth rates of case with DS occurred in 1994-95, from 0.63 per 1000 births to 0.23 per 1000 births. There was a crossover from more live births with DS to more stillbirths with DS during 1994 to 1996 after the implementation of second-trimester maternal serum screening for DS in 1994. In 1993, 76.9% of births diagnosed with DS were born alive, compared to 32.5% in 2001 (p < 0.001). CONCLUSIONS: The policy of prenatal diagnosis program including amniocentesis for pregnant women aged 35 or more and the liberal application of maternal serum screening for DS in younger women was responsible for the marked decrease in the live births affected with DS in Taiwan from 1993 to 2001.     

Mortality of full-term infants during the first month of life in a tertiary care hospital.

OBJECTIVE: The neonatal mortality rate is disproportionately influenced by preterm infants and does not reflect the rate in full-term infants. Our objectives were to estimate the full-term neonatal mortality rate and to identify causes of death in full-term infants during the first month of life. STUDY DESIGN: A retrospective study of full-term infant deaths during a 6-year period from 2000 to 2005, in a tertiary medical center. RESULT: During the study period there were 44,703 full-term births and 31 deaths, representing a mortality rate of 0.69 per 1,000 live births. The main cause of death was congenital anomalies (64.5%), specifically cardiac anomalies. Other causes were chromosomal anomalies or syndromes (12.9%), labor complications (12.9%), infections (3.2%), congenital diseases (3.2%) and metabolic disorders (3.2%). CONCLUSION: The mortality rate of full-term infants may be lower than previous estimates. Efforts aimed at decreasing mortality among full-term infants should focus on prenatal diagnosis.     

Outcomes of pregnancies in women with type 1 diabetes in Scotland: a national population-based study

Objective To determine the outcomes of pregnancies in women with pre-existing, type 1 diabetes.
Design Prospective, population-based cohort.
Setting Scotland.
Population All 273 women with type 1 diabetes with a pregnancy ending (in miscarriage, abortion or delivery) during the 12 months (from April 1, 1998 to March 31, 1999).
Methods Pregnancies identified prospectively by clinicians in each hospital; outcome data collected from case records and from Scottish national data sets.
Main outcome measures Perinatal and infant mortality, congenital anomaly and birthweight.
Results Of the 273 pregnancies, 40 (14.7%) ended in miscarriage, 20 (7.3%) in abortion and 213 (78%) in delivery. Three deliveries were twin births, thus 216 babies were born. Stillbirth rate (4/216): 18.5 (95% CI 5.1–46.8) per 1000 total births; perinatal mortality rate (6/216): 27.8 (95% CI 10.2–59.4) per 1000 births. There were 13 verified congenital anomalies (in six abortions and seven live births), anomaly rate: 60 (95% CI 32–101) per 1000 total births. Among 208 singleton, live born infants, the mean birthweight was 3427 g. Standardised birthweight scores, relative to a reference population, showed a unimodal distribution, shifted to the right (mean, 1.57 SD).
Conclusions In an unselected population, adverse outcomes remain more common among the infants of mothers with type 1 diabetes than in the general population. The targets of the St Vincent Declaration of 1989 have not been met. Improvements may be gained by increases in provision of prepregnancy care and in the proportion of pregnancies that are planned. However, further research is needed to clarify the root causes of adverse outcomes in the pregnancies of women with diabetes.