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Objective To assess the quality of perinatal autopsy. Design Review of all reports of post mortem examinations carried out following perinatal deaths from January 1994 to June 1994. Population Former Northern Region of England. Methods Assessment of post mortem reports concerning their content and interpretation, the assessment carried out by panel comprising a pathologist, obstetrician and paediatrician. Results Reports were available for all 104 cases where post mortem examinations had been undertaken, of which 53 (51%) met the minimum standards for such autopsies proposed by the Royal College of Pathologists. Interpretative comments were judged to be adequate in 51 (49%). Conclusions The quality of perinatal autopsies is frequently poor. Improvement requires increased awareness of the potential value of the autopsy, and more consultation between pathologists, obstetricians and paediatricians.

Objective To highlight the causes of perinatal mortality in the Faroe Islands where perimortality is high according to Nordic standards. Design Two systems were employed to classify perinatal deaths on the basis of clinico-pathological findings, one focusing on obstetrical factors and the other on fetal-neonatal factors. Setting Faroe Islands. Data from Iceland were used for comparison since the two communities have many similarities, including similar birthweight distributions. Subjects Birth and death certificates and medical and midwife files were recovered for 98 of the 102 officially recorded perinatal deaths in the Faroes during 1977–1986. Icelandic data for 1976–1985 were available in the literature. Results The perinatal mortality rate was 13.7 per 1000 births. Obstetric factors were classified as unexplained, congenital anomaly, antepartum haemorrhage, pre-eclampsia, mechanical causes, and maternal disorders and accounted for 43%, 18%, 15%, 11%, 6%, and 6% of the 98 cases, respectively. Fetal-neonatal factors were classified as antepartum asphyxia, congenital anomaly, intrapartum asphyxia, hyaline membrane disease, pulmonary immaturity, and other causes, and these factors accounted for 43%, 18%, 15%, 9%, 5%, and 8%, respectively. The excess perinatal mortality rate of 4.1 cases per 1000 births in the Faroes, relative to Iceland, could mainly be attributed to an excess of 2.9 cases per 1000 births in the group classified as unexplained, as defined according to the obstetrics classification. Conclusions No well defined cause was particularly common in the Faroes or could account for the excess perinatal mortality rate in the Faroes relative to Iceland.

Summary. The pregrmncy outcome of 16 971 women carrying 17 352 living fetuses after 16 weeks gestation was studied. As well as recording perinatal deaths, all losses before 28 weeks and up to one year after delivery were recorded to give a total perinatal wastage rate of 21.6 per 1000 fetuses alive at 16 weeks compared with a perinatal mortality rate (stillbirths plus early neonatal deaths) of 7.8 per 1000 births. All deaths were then classified according to pathological sub-groups. The concept of auditing perinatal care using perinatal mortality was then compared with that using total perinatal wastage.

Summary There were 66 974 births at the three largest Dublin maternity hospitals in the years 1980–1982. Data on numbers of spontaneous and elective births, birthweight and perinatal mortality were analysed by day of the week. Perinatal mortality rates were highest on Wednesdays and Saturdays. The rate on Sunday was close to average. The largest number of perinatal deaths per day occurred on Wednesdays and the smallest on Sundays. Significant variations in mortality rates and percentage low birthweight were found among the 19% of infants who were born electively, but not among those born after a spontaneous onset of labour. High-risk pregnancies, including many with intrauterine fetal death, were induced in large numbers from Tuesdays through Saturdays with a peak on Wednesdays. Low risk cases were induced mainly from Monday through Fridays with a peak on Fridays. The pattern of perinatal mortality through the week followed closely that of the risk status of pregnancies delivered electively. The results indicate that the pattern of perinatal mortality by day of the week of birth was determined by a highly organized weekly routine of selective elective delivery.

Summary. The perinatal mortality rate in all singleton births was 103 per 1000; 67% of all perinatal deaths were stillbirths and in 77% of stillbirths, intrauterine death had already occurred before admission to hospital. Nine per cent of live births but 40% of stillbirths and 50% of neonatal deaths were of low birthweight (≤2.5 kg). The principal obstetric causes of perinatal deaths were obstructed labour and its consequences, anaemia, antepartum haemorrhage, eclampsia and low fetal birthweight. Nearly half of all perinatal deaths were associated with complicated deliveries of which vaginal breech delivery was by far the most hazardous. Both the proportion of babies with low birthweight and the perinatal mortality rates rose dramatically and progressively with haematocrit 0.40. Of the biosocial factors influencing perinatal health, lack of antenatal care, residence outside Zaria, early teenage pregnancy and high parity exerted the most deleterious effect and literacy and antenatal care the most favourable effect on pregnancy outcome.

A survey of 335 perinatal deaths in the Wessex region revealed a perinatal mortality rate of 10.1 per 1000 total births. Lethal malformations accounted for 82 (24%) deaths. Of the 253 normally formed infants, 124 (49%) died during pregnancy and 33 (13%) in labour. More than 60% of the stillbirths weighed greater than 1500 g. Of the 96 postpartum deaths, half occurred within 24 h of delivery, mostly following complications of labour and circumstances suggesting hypoxia. The Aberdeen classification showed half of the mothers had pregnancy complications: other predisposing factors were identified in 10% of perinatal deaths. There were 185 neonatal deaths of which 150 occurred within 7 days and 35 within the next 3 weeks. Sixteen (46%) of the late neonatal deaths were due to a congenital abnormality; pregnancy or labour complications were present in six (32%) of the remaining 19 normally formed infants. Review of existing methods of antenatal supervision in particular, followed by the use of better monitoring systems for earlier detection of fetal distress and prompt action when indicated, together with improvement in neonatal care in the first 24 h after birth should further reduce the perinatal mortality.

In a series of 2434 patients with pre-eclampsia, the prevalence of fetal growth retardation was 8.7 per cent compared with 8.6 per cent in the total hospital population. The prevalence was increased in early-onset pre-eclampsia (18.2 per cent) (P less than 0.001) and reduced in late-onset pre-eclampsia (5.6 per cent) (P less than 0.001). In patients who later developed early-onset pre-eclampsia with fetal growth retardation, the prevalence of subnormal oestriol excretion was significantly increased (79.5 per cent) (P less than 0.001) as was the prevalence of hypoglycaemia (33.3 per cent) (P less than 0.001) suggesting that fetal growth retardation in these pregnancies preceded the clinical signs of pre-eclampsia. The prevalence of placental abruption (8.3 per cent) and the prevalence of perinatal deaths (28.7 per cent) were both significantly higher in pregnancies with early-onset pre-eclampsia and fetal growth retardation (P less than 0.001).

Summary. Adapting Sir Dugald Bairďs concept of primary obstetric causes of perinatal mortality, a revised clinico-pathological classification has been evolved to take account of new knowledge and developments, and to direct attention to potentially avoidable deaths and to where intensified efforts and investigation are needed. Categories highlighting the importance of intrauterine growth retardation, unexplained intrauterine death and spontaneous premature labour have been introduced, intrapartum hypoxia is separated from birth trauma, and infection again has its own category. Regular perinatal audit at one obstetric hospital, since 1979, has shown that the new system provides a workable and useful means for classifying not only perinatal deaths, but also late abortions, late neonatal deaths and perinatally related infant deaths. The rate of total perinatally related wastage, defined in this way, was almost twice that for perinatal mortality (22–8 compared with 11.9 per 1000 births). The former is advocated as a more realistic index for the audit of perinatal care. The revised and extended system is put forward as a contribution to the current debate on classifying and reporting such wastage, in the hope that it may be tested as a model for regional as well as hospital surveys.

Oocyte donation provides an option for achieving pregnancy in women lacking functioning gonads, or in whom IVF techniques have failed to harvest adequate oocytes, or those who do not wish to use their own gametes because of hereditary disease. In agonadal women, artificial menstrual cycles are required before proceeding to gamete donation. A fixed cyclical steroid replacement schedule of oestradiol (E2) valerate and progesterone (P4) pessaries was initially used, but the need for synchrony between donor and recipient cycles, and the narrow window for implantation limited the transfer of fresh embryos. Donor-recipient cycle asynchrony can be overcome by using frozen-thawed embryos, or by extending the follicular phase in the recipient to widen the transfer window. Twenty-two pregnancies have now been achieved by the Monash/Epworth group, resulting in the birth of 13 healthy infants. There were no statistically significant differences in pregnancy rates (per transfer) between transfers in natural cycles (14%, four pregnancies) and steroid replacement cycles (24%, 16 pregnancies). Five pregnancies (36%) were established in women treated with 2 mg of E2 daily 13-18 days before embryo transfer with P4 starting on the day of or the day following oocyte retrieval. E2 was continued for a median of 85 days (range 49-110) and P4 for a median of 86 days (range 49-133) after the supposed last menstrual period. All but one delivery was by caesarean section. There were no perinatal deaths and no ectopic pregnancies.

Summary Out of 180 patients who had a myomectomy at the Chelsea Hospital for Women between 1954 and 1962, 116 were followed for more than one year. One in four of these patients had a subsequent hysterectomy and about one in three conceived after surgery. Of the patients known to have conceived only three out of four carried pregnancies beyond 28 weeks. Myomectomy did not seem to alter the high incidence of abortions and perinatal deaths in patients found to have fibromyomata. Pregnancies occurring after myomectomy required close specialist supervision and often ended in Caesarean section.