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ObjectivesTwitter is the most frequently used social media platform by healthcare practitioners, at medical conferences. This study aimed to analyze Twitter conversations during the virtual International Gynecological Cancer Society 2020 conference to understand the interactions between Twitter users related to the conference.MethodsTweets using the hashtag ‘#IGCS2020’ were searched using the Twitter Search Application Programming Interface (API) during the period 10–13 September 2020. NodeXL Pro was used to retrieve data. The Clauset-Newman-Moore cluster algorithm clustered users into different groups or ‘clusters’ based on how users interacted.ResultsThere were 2009 registrants for the virtual IGCS 2020 conference. The total number of users within the network was 168, and there were 880 edges connecting users. Five types of edges were identified as follows: ‘replies to’ (n=18), ‘mentions’ (n=221), ‘mentions in retweets’ (n=375), retweets (n=198), and tweets (n=68). The most influential account was that of the IGCS account itself (@IGCSociety). The overall network shape resembled a community where distinct groups formed within the network. Our current analyses demonstrated that less than 10% of the total members interacted on Twitter.ConclusionThis study identified the most influential Twitter users within the ‘#IGCS2020’ community. he results also confirmed the community network shape of the #IGCS2020 hashtag and found that the most frequent co-related words were ‘ovarian’ and ‘cancer’ (n=39).

BackgroundVulvar cancer is a rare disease and despite broad adoption of sentinel lymph node mapping to assess groin metastases, inguino-femoral lymph node dissection still plays a role in the management of this disease. Inguino-femoral lymph node dissection is associated with high morbidity, and limited research exists to guide the best surgical approach.ObjectiveTo determine international practice patterns in key aspects of the inguino-femoral lymph node dissection technique and provide data to guide future research.MethodsA survey addressing six key domains of practice patterns in performing inguino-femoral lymph node dissection was distributed internationally to gynecologic oncology surgeons between April and October 2020. The survey was distributed using the British Gynecological Cancer Society, the Society of Gynecologic Oncology, authors' direct links, the UK Audit and Research in Gynecology Oncology group, and Twitter.ResultsA total of 259 responses were received from 18 countries. The majority (236/259, 91.1%) of respondents reported performing a modified oblique incision, routinely dissecting the superficial and deep inguino-femoral lymph nodes (137/185, 74.1%) with sparing of the saphenous vein (227/258, 88%). Most respondents did not routinely use compression dressings/underwear (169/252 (67.1%), used prophylactic antibiotics at the time of surgery only (167/257, 65%), and closed the skin with sutures (192 74.4%). Also, a drain is placed at the time of surgery by 243/259 (93.8%) surgeons, with most practitioners (144/243, 59.3%) waiting for drainage to be less than 30–50 mL in 24 hours before removal; most respondents (66.3%) routinely discharge patients with drain(s) in situ.ConclusionOur study showed that most surgeons perform a modified oblique incision, dissect the superficial and deep inguino-femoral lymph nodes, and spare the saphenous vein when performing groin lymphadenectomy. This survey has demonstrated significant variability in inguino-femoral lymph node dissection in cases of vulvar cancer among gynecologic oncology surgeons internationally.

Objective: The objective of this study was to assess the ability of the American College of Surgeons (ACS) NSQIP surgical risk calculator to accurately identify patients at increased risk of perioperative complication following surgery for gynaecological malignancy. Methods: A retrospective review of 142 patients who underwent major surgery under the gynae-oncology team between 06/08/2018-16/04/2019 at the University Hospital of Wales. Pre-operative factors combined with a procedure-specific code generated the predicted risk of 13 post-operative complications for each patient. Brier scores assessed calibration and receiver operated curves (AUC) evaluated the discriminative power of NSQIP. Results: Complications were experienced by 50/142 (35.2%) patients. The calculator displayed adequate calibration when used to predict serious complications (Brier = 0.070), readmission (Brier = 0.058), return to OR (Brier = 0.000) and UTI (Brier = 0.001). It had the greatest discriminative power when predicting the risk of serious complications (AUC = 0.672; 95% CI, 0.481-0.863). The calculator successfully identified a majority of patients who had a complication as being of ‘above average risk’ for all complications, apart from return to OR, based on their pre-operative factors. Discussion: NSQIP has previously been demonstrated to be a useful pre-operative tool for evaluating the risk of post-operative complications in colorectal surgery. This study suggests that in the setting of gynaeoncology surgery the calculator does not have adequate discriminative power to be an absolute predictor of all complications, however, it may be useful in identifying patients who are likely to develop serious complications and those at above average risk of complications.

Introduction/Background* Despite the informed consent process, patients’ understanding of potential post-operative complications is often limited, making it difficult to call the decision an informed one, so estimating the risk of postoperative complications is important for shared decision making and to help multidisciplinary teams plan postoperative care. Increased incidence of gynaecological cancers and operations, especially technically challenging minimally invasive surgery (MIS) in older, obese and patients with multiple comorbidities, requires accurate prediction of the likelihood of mortality and morbidity and patient involvement in joint decision making about the management. ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) risk calculator is a validated web-based tool based on 21 preoperative risk factors to predict 8 post-operative outcomes. The objective of our study was to explore the validity of ACS NSQIP in gynaeoncology for perioperative prediction of postoperative complications. Methodology A retrospective multicentre cohort study evaluated 1552 patients who underwent surgery at a tertiary oncology centre. Data collection undertaken through dedicated database. Data collated on 764 patients undergoing robotic, 248 laparoscopic and 540 open surgery for suspected or confirmed gynaecological malignancy. All missing data collated from patient notes. Following data lock with the actual post-op event/complication that occurred in this retrospective cohort, ACS NSQIP used to count predictive scores for each patient. Data analysis evaluating ACS-NSQIP validity and relevance in gynaecological oncology patients and its ability to predict postoperative complications performed. Result(s)* ACS-NSQIP was found to best predict mortality (AUC - 0.908), it was most accurate for prediction of complications as follows: discharge to rehabilitation (AUC-0.875), cardiac complications (AUC-0.854), sepsis (AUC-0.795), pneumonia (AUC-0.764), return to theatre (AUC-0.696), surgical site infection (AUC-0.686), VTE (AUC-0.676), readmission (AUC-0.669), renal failure (AUC-0.601). Poor result in the prediction of UTI (AUC-0.543) was noted. Conclusion* ACS-NSQIP risk calculator appears to predict major complications and post-operative mortality making it useful as an informed consent tool. Preliminary data suggests that further validation is required to fully evaluate if the risk scores may be used to inform patients pre-operatively of their risk of complications and is currently being undertaken.

In 1985, the International Gynecologic Cancer Society (IGCS) was established to enhance the care of women with gynecologic cancer worldwide through education, training, and public awareness. In 2020, the COVID-19 pandemic brought global travel to an abrupt halt and ushered in a new era of virtual

Introduction/Background The objective of this study was to examine the clinical utility of the American College of Surgeons (ACS) surgical risk calculator, developed as part of the National Surgical Quality Improvement Programme (NSQIP), in predicting perioperative morbidity in gynae-oncology patients, primarily, as a prediction model and secondly, as a tool to identify patients who are at increased risk of developing complications. Methodology A retrospective review of 142 patients who underwent major surgery under the gynae-oncology team between 06/08/2018–16/04/2019 at the University Hospital of Wales. Pre-operative factors combined with a procedure-specific code generated the predicted risk of 13 post-operative complications for each patient. Brier scores assessed calibration and receiver operated curves (AUC) evaluated the discriminative power of NSQIP. Results Complications were experienced by 35.2% (50/142) patients. The calculator displayed adequate calibration when used to predict serious complications (Brier = 0.070), readmission (Brier = 0.058), return to OR (Brier = 0.000) and UTI (Brier = 0.001). It had the greatest discriminative power when predicting the risk of serious complications (AUC = 0.672; 95% CI, 0.481–0.863). The calculator successfully identified a majority of patients who had a complication as being of ‘above average risk’ for all complications, apart from return to OR, based on their pre-operative factors. Conclusion NSQIP has previously been demonstrated to be a useful pre-operative tool for evaluating the risk of post-operative complications in colorectal surgery. This study suggests that in the setting of gynae-oncology surgery the calculator does not have adequate discriminative power to be an absolute predictor of all complications, however, it may be useful in identifying patients who are likely to develop serious complications and those at above average risk of complications. Disclosures Ines Murray – I can confirm that I have no conflict of interest with reference to this work. Kenneth Lim – I can confirm that I have no conflict of interest with reference to this work. Robert Howells – I can confirm that I have no conflict of interest with reference to this work. Rhidian Jones – I can confirm that I have no conflict of interest with reference to this work. Aarti Sharma – I can confirm that I have no conflict of interest with reference to this work. Sadie Jones - I can confirm that I have no conflict of interest with reference to this work.

Introduction Older patients undergoing cancer surgery are at increased risk of post-operative morbidity and mortality. Frailty is particularly prevalent in this patient cohort and is a major contributor to adverse outcomes. A survey was conducted to assess the confidence and knowledge of trainees in obstetrics and gynaecology (O&G) regarding identification and management of perioperative issues encountered in frail gynaecological oncology patients. Methods A web-based survey on the management of frail perioperative patients was disseminated to doctors-in-training (trainees) in O& G in the United Kingdom (UK) and Ireland. Results Of the 666 trainees who participated, 67% (n=425/666) reported inadequate training in the perioperative management of frail patients. Validated frailty assessment tools were used by only 9% (n=59/638) of trainees and less than 1% (n=4/613) were able to correctly identify the diagnostic features of frailty. Common misconceptions included the use of chronological age and gender in frailty assessments. The majority trainees (>75%) correctly answered a series of questions relating to mental capacity; however, only 6% (n=36/606) were able to correctly identify all three diagnostic features of delirium. 87% (n=495/571) of trainees supported closer collaboration with geriatricians and a multi-disciplinary approach. Conclusions O&G trainees reported inadequate training in the perioperative care of frail gynaecological oncology patients, and overwhelmingly favoured input from geriatricians. Routine use of validated frailty assessment tools may aid diagnosis of frailty in the perioperative setting. There is an unmet need for formal education in the management of frail surgical patients within the UK and Irish O&G curriculum.

IntroductionOlder patients undergoing cancer surgery are at increased risk of post-operative complications, prolonged hospital stay, and mortality. Identification of frailty can help predict patients at high risk of peri-operative complications and allow a collaborative, multidisciplinary team approach to their care. A survey was conducted to assess the confidence and knowledge of trainees in obstetrics and gynecology regarding identification and management of peri-operative issues encountered in frail gynecological oncology patients.MethodsA web-based survey was distributed via the Audit and Research in Gynaecological Oncology (ARGO) collaborative and UK Audit and Research Collaborative in Obstetrics and Gynaecology (UKARCOG) . The survey on the management of frail peri-operative patients was disseminated to doctors-in-training (trainees) working in obstetrics and gynecology in the United Kingdom (UK) and Ireland. Specialty (ST1–7), subspecialty, and general practice trainees, non-training grade doctors, and foundation year doctors currently working in obstetrics and gynecology were eligible. Consultants were excluded. Study data were collected using REDCAP software hosted at the University of Manchester. Responses were collected over a 6-week period between January and February 2020.ResultsOf the 666 trainees who participated, 67% (425/666) reported inadequate training in peri-operative management of frail patients. Validated frailty assessment tools were used by only 9% (59/638) of trainees and less than 1% (4/613) were able to correctly identify all the diagnostic features of frailty. Common misconceptions included the use of chronological age and gender in frailty assessments. The majority of trainees (76.5%, 448/586) correctly answered a series of questions relating to mental capacity; however, only 6% (36/606) were able to correctly identify all three diagnostic features of delirium. A total of 87% (495/571) of trainees supported closer collaboration with geriatricians and a multidisciplinary approach.ConclusionsObstetrics and gynecology trainees reported inadequate training in the peri-operative care of frail gynecological oncology patients, and overwhelmingly favored input from geriatricians. Routine use of validated frailty assessment tools may aid diagnosis of frailty in the peri-operative setting. There is an unmet need for formal education in the management of frail surgical patients within the UK and Irish obstetrics and gynecology curriculum.

In 2019, Dr Pedro T. Ramirez, Editor-in-Chief of IJGC, in partnership with the European Network of Young Gynecological Oncologists (ENYGO), European Society for Gynecological Oncology (ENYGO-ESGO) and the International Gynecologic Cancer Society (IGCS) launched a joint IJGC Editorial Fellowship. The

Purpose: Response rates to treatment of vulval intraepithelial neoplasia (VIN) with imiquimod and cidofovir are approximately 57% and 61%, respectively. Treatment is associated with significant side effects and, if ineffective, risk of malignant progression. Treatment response is not predicted by clinical factors. Identification of a biomarker that could predict response is an attractive prospect. This work investigated HPV DNA methylation as a potential predictive biomarker in this setting.Experimental Design: DNA from 167 cases of VIN 3 from the RT3 VIN clinical trial was assessed. HPV-positive cases were identified using Greiner PapilloCheck and HPV 16 type-specific PCR. HPV DNA methylation status was assessed in three viral regions: E2, L1/L2, and the promoter, using pyrosequencing.Results: Methylation of the HPV E2 region was associated with response to treatment. For cidofovir (n = 30), median E2 methylation was significantly higher in patients who responded (P ≤ 0.0001); E2 methylation >4% predicted response with 88.2% sensitivity and 84.6% specificity. For imiquimod (n = 33), median E2 methylation was lower in patients who responded to treatment (P = 0.03; not significant after Bonferroni correction); E2 methylation Conclusions: These data indicate that cidofovir and imiquimod may be effective in two biologically defined groups. HPV E2 DNA methylation demonstrated potential as a predictive biomarker for the treatment of VIN with cidofovir and may warrant investigation in a biomarker-guided clinical trial. Clin Cancer Res; 23(18); 5460–8. ©2017 AACR.

Introduction/Background Radical hysterectomy for cervical cancer may be performed using a minimally invasive approach or and open, abdominal surgical approach. A growing body of evidence provides conflicting evidence regarding survival outcomes between these two surgical approaches. This study contributes a retrospective review of 10 years of data from the South East Wales Gynaecology Oncology Centre. Methodology A retrospective review of all cases of radical hysterectomy (open and laparoscopic) carried out between January 2008 and December 2018. Data collected included patient age, BMI, performance status, surgical approach, pre and post op cancer stage, tumour size, length of stay in hospital, complications, recurrence rates and disease free survival. Data were analysed using SPSS software, statistical significance was set at P≤0.05. Results Two hundred and twenty-nine cases of radical hysterectomy were identified. One hundred and forty-one open, abdominal procedures and 88 minimally invasive procedures were carried out. Patient demographics and cancer stage were comparable between the two groups. Mean duration of follow up was 64 months. Nine out of 141 (6.4%) laparotomy cases developed a recurrence and 5/88 (5.7%) patients having had a laparoscopic procedure developed a recurrence. Conclusion This retrospective review demonstrates no significant difference in recurrence rates between patients having undergone open, abdominal radical hysterectomy compared to minimally invasive hysterectomy in our centre. Disclosure Nothing to disclose.

Background New university students are at particular risk of invasive meningococcal disease (IMD). Group W, a particularly aggressive strain, is increasing in prevalence and the high case-fatality rate is concerning. This age group has been offered the MenACWY vaccine since 2015. National uptake has been low, leaving students vulnerable to infection. Aims To investigate MenACWY uptake, knowledge of and attitudes towards vaccination among first-year students, with the aim of informing university vaccination policy and practice. Methods A mixed methods approach was used, involving a questionnaire (response rate = 4.4%, n=144) and follow-up interviews (n=13). Eligibility criteria were first year students, undergraduates and over the age of 18. Statistical tests, including multiple logistic regression, were carried out and interviews were analysed thematically. Results MenACWY uptake was 84%, with more socioeconomically disadvantaged students less likely to be vaccinated (aOR = 0.117, p=0.006). Most students thought vaccines were safe (95.1%) and important (97.2%). Students with above average knowledge were more likely to be vaccinated (OR=3.057, p=0.019). Students unaware that meningitis can be fatal were less likely to be vaccinated (aOR = 0.173, p=0.035). Vaccination views were positive and knowledge level was moderate to high. Reasons for vaccination include influence of authority figures and peers, to avoid disease and due to an inherent trust of vaccines. Reasons for non-vaccination included temporary illness, laziness, forgetfulness and difficulty with GP access. Opinions regarding the university’s vaccination campaign were positive, and in particular there was praise for the university’s awareness campaign. Issues raised by this study include difficulty in accessing GP services and the belief that the vaccine prevents any cause of meningitis. Conclusion High vaccine uptake is essential to protect students. Uptake was higher than at other universities in previous studies. These results highlight several areas requiring further study, including the association between uptake and socioeconomic group and understanding of post-vaccination risk of meningitis. This research has implications for vaccination policy at UK universities.

Introduction/Background Inguino-femoral lymph node dissection plays a crucial role in the management of vulval cancer. The procedure is associated with high complication rates including infection, lymphocysts and wound dehiscence. Several skin incision techniques exist and practice amongst gynaecology oncologists is variable. Little evidence exists to guide surgeons regarding optimal surgical approach. This study aimed to determine the difference in complication rates, node harvest and length of stay between patients undergoing the modified oblique and classical 9lazy S9 skin incision. Methodology A retrospective review of 4 years of data between 2014 and 2018 was carried out in the UHW, Cardiff. Data collected included age, BMI, incision, length of stay, complications, cancer stage, suture material, node count and recurrence of disease. Data were analysed using SPSS software and clinical significant was set as p≤0.05. Results Thirty-five cases of classical 9lazy S9 and 14 cases of modified oblique. More serious, grade 3/4 complications were significantly more common following classical 9Lazy S9 versus modified oblique (20/35, 57.1% vs. 2/14, 14.3%). Mean number of nodes harvested was significantly higher in the classical 9Lazy S9 group compared to the modified oblique (11.1 vs. 7 nodes). Mean hospital stay was significantly higher in patients undergoing classical 9Lazy S9 vs. Modified oblique (10.7 vs. 4.5 days). One case of groin node recurrence occurred and this patient was in the classical 9lazy S9 arm. Conclusion This study demonstrates significantly lower rates of overall and serious complications following modified oblique skin incision compared to classical 9Lazy S9. However, this would appear to be at the compromise of a reduced node count. This study was not designed to determine the clinical significance of node count and recurrence but this is also a subject upon which the literature is scarce. More research is required to determine optimal surgical incision in this challenging procedure. Disclosure Nothing to disclose

The Authors' reply We want to thank Dr Carvalho and colleagues for their letter[1][1] written in response to our article[2][2] in this journal. We read with interest the technique that Carvalho and colleagues describe in their letter for inguino-femoral lymph node dissection and their low

Summary Background Vulval intraepithelial neoplasia is a skin disorder affecting the vulva that, if left untreated, can become cancerous. Currently, the standard treatment for patients with vulval intraepithelial neoplasia is surgery, but this approach does not guarantee cure and can be disfiguring, causing physical and psychological problems, particularly in women of reproductive age. We aimed to assess the activity, safety, and feasibility of two topical treatments—cidofovir and imiquimod—as an alternative to surgery in female patients with vulval intraepithelial neoplasia. Methods We recruited female patients (age 16 years or older) from 32 centres to an open-label, randomised, phase 2 trial. Eligibility criteria were biopsy-proven vulval intraepithelial neoplasia grade 3 and at least one lesion that could be measured accurately. We randomly allocated patients to topical treatment with either 1% cidofovir (supplied as a gel in a 10 g tube, to last 6 weeks) or 5% imiquimod (one 250 mg sachet for every application), to be self-applied three times a week for a maximum of 24 weeks. Randomisation (1:1) was done by stratified minimisation via a central computerised system, with stratification by hospital, disease focality, and presentation stage. The primary endpoint was a histologically confirmed complete response at the post-treatment assessment visit 6 weeks after the end of treatment (a maximum of 30 weeks after treatment started). Analysis of the primary endpoint was by intention to treat. Secondary outcomes were toxic effects (to assess safety) and adherence to treatment (to assess feasibility). We present results after all patients had reached the primary endpoint assessment point at 6 weeks; 2-year follow-up of complete responders continues. This trial is registered with Current Controlled Trials, ISRCTN 34420460. Findings Between Oct 21, 2009, and Jan 11, 2013, 180 participants were enrolled to the study; 89 patients were randomly allocated cidofovir and 91 were assigned imiquimod. At the post-treatment assessment visit, a complete response had been achieved by 41 (46%; 90% CI 37·0–55·3) patients allocated cidofovir and by 42 (46%; 37·2–55·3) patients assigned imiquimod. After 6 weeks of treatment, 156 (87%) patients (78 in each group) had adhered to the treatment regimen. Five patients in the cidofovir group and seven in the imiquimod group either withdrew or were lost to follow-up before the first 6-week safety assessment. Adverse events of grade 3 or higher were reported in 31 (37%) of 84 patients allocated cidofovir and 39 (46%) of 84 patients assigned imiquimod; the most frequent grade 3 and 4 events were pain in the vulva, pruritus, fatigue, and headache. Interpretation Cidofovir and imiquimod were active, safe, and feasible for treatment of vulval intraepithelial neoplasia and warrant further investigation in a phase 3 setting. Both drugs are effective alternatives to surgery for female patients with vulval intraepithelial neoplasia after exclusion of occult invasive disease. Funding Cancer Research UK.

Pre-eclampsia is a common problem in pregnancy which can present at any time to any delivery suite. This article summarizes current best practice to enable the multidisciplinary team to deliver appropriate timely management to achieve best outcomes for both mother and baby.

To evaluate the impact of the Downstate Team-Building Initiative (DTBI), a model multicultural and interdisciplinary health care team-building program for health professions students.A total of 65 students representing seven health disciplines participated in DTBI's first three years (one cohort per year since implementation). During the 18-session curriculum, students self-evaluated their group's progress through Tuckman's four team-development stages (FORMING, STORMING, NORMING, PERFORMING) on an 11-point scale. Students completed matched pre- and postintervention program evaluations assessing five variables: interdisciplinary understanding, interdisciplinary attitudes, teamwork skills, multicultural skills, and team atmosphere. After participation, students completed narrative follow-up questionnaires investigating impact one and two years after program completion.Each year's team development curve followed a similar logarithmic trajectory. Cohort 1 remained in team development stage 3 (NORMING) while Cohorts 2 and 3 advanced into the final stage-PERFORMING. A total of 34 matched pre- and postintervention evaluations showed significant change in all major variables: Team atmosphere and group teamwork skills improved most (48% and 44%, respectively). Interdisciplinary understanding improved 42%. Individual multicultural skills (defined by ability to address racism, homophobia, and sexism) started at the highest baseline and improved the least (13%). Group multicultural skills improved 36%. Of 23 responses to the follow-up surveys, 22 (96%) stated DTBI was a meaningful educational experience applicable to their current clinical surroundings.DTBI successfully united students across health discipline, ethnicity, socioeconomic class, gender, and sexual orientation into functioning teams. The model represents an effective approach to teaching health care team building and demonstrates benefits in both preclinical and clinical years of training.

The initial presentation of macroprolactinoma with visual field impairment, especially in males, is well recognized. Successful treatment with dopamine agonist therapy is characterized by a reduction in hyperprolactinaemia and often rapid and progressive resolution of the visual impairment. A small proportion of patients may subsequently develop a secondary deterioration in both their visual fields and visual acuities despite normalization of prolactin levels and tumour shrinkage. When pituitary apoplexy can be excluded this may result from traction on the optic chiasm which is pulled down into the now partially empty sella. We report a series of seven patients in whom chiasmal traction is believed to be the cause of their secondary deterioration in visual acuity occurring after dopamine agonist therapy for macroprolactinoma. The clinical history of two patients both of whom had rapid resolution of field defect with bromocriptine therapy but subsequently developed a recurrence of their bitemporal hemianopia is detailed. In both patients MRI scanning showed not only tumour involution but also marked optic chiasm herniation into the pituitary fossa. Surgical treatment was considered too risky; but on reduction of bromocriptine dosage the field defect improved in both cases; there was a modest elevation of prolactin and a degree of tumour re-expansion. The latter is believed to have released tethering of the optic chiasm and/or its vascular supply and thus obviated the need for surgery. Regular monitoring of visual fields in patients with macroprolactinoma receiving medical treatment is therefore important. Early recognition of secondary field loss due to chiasmal herniation enables correction of the visual field loss by manipulation of the medical therapy.

The standard of obstetrics care by general practitioners in Bradford was assessed by reviewing the case records of all women who in 1988 were booked for delivery under their general practitioner but subsequently required transfer to consultant care. A total of 5885 women were delivered in Bradford during 1988. Of 1289 booked under their general practitioner, 637 required transfer to consultant care. In 259 cases transfer occurred during labour; only 37 of these women were visited by their general practitioner. Many of the problems that precipitated transfer were predictable and some were considered preventable: 263 of the women transferred were considered unsuitable for booking by general practitioners. The perinatal mortality among women booked under their general practitioner was 10.1/1000 and the stillbirth rate 7.8/1000. These figures are high and suggest a need for tighter controls over the qualifications and experience of doctors participating in a fully integrated system of obstetric care.