@article {7752, title = {Risk-adjusted operative delivery rates and maternal-neonatal outcomes as measures of quality assessment in obstetric care: a multicenter prospective study.}, journal = {BMC Pregnancy Childbirth}, volume = {15}, year = {2015}, month = {2015}, pages = {20}, abstract = {

BACKGROUND: Although the evaluation of caesarean delivery rates has been suggested as one of the most important indicators of quality in obstetrics, it has been criticized because of its controversial ability to capture maternal and neonatal outcomes. In an "ideal" process of labor and delivery auditing, both caesarean (CD) and assisted vaginal delivery (AVD) rates should be considered because both of them may be associated with an increased risk of complications. The aim of our study was to evaluate maternal and neonatal outcomes according to the outlier status for case-mix adjusted CD and AVD rates in the same obstetric population.

METHODS: Standardized data on 15,189 deliveries from 11 centers were prospectively collected. Multiple logistic regression was used to estimate the risk-adjusted probability of a woman in each center having an AVD or a CD. Centers were classified as "above", "below", or "within" the expected rates by considering the observed-to-expected rates and the 95\% confidence interval around the ratio. Adjusted maternal and neonatal outcomes were compared among the three groupings.

RESULTS: Centers classified as "above" or "below" the expected CD rates had, in both cases, higher adjusted incidence of composite maternal (2.97\%, 4.69\%, 3.90\% for "within", "above" and "below", respectively; p = 0.000) and neonatal complications (3.85\%, 9.66\%, 6.29\% for "within", "above" and "below", respectively; p = 0.000) than centers "within" CD expected rates. Centers with AVD rates above and below the expected showed poorer and better composite maternal (3.96\%, 4.61\%, 2.97\% for "within", "above" and "below", respectively; p = 0.000) and neonatal (6.52\%, 9.77\%, 3.52\% for "within", "above" and "below", respectively; p = 0.000) outcomes respectively than centers with "within" AVD rates.

CONCLUSIONS: Both risk-adjusted CD and AVD delivery rates should be considered to assess the level of obstetric care. In this context, both higher and lower-than-expected rates of CD and "above" AVD rates are significantly associated with increased risk of complications, whereas the "below" status for AVD showed a "protective" effect on maternal and neonatal outcomes.

}, issn = {1471-2393}, doi = {10.1186/s12884-015-0450-2}, author = {Maso, Gianpaolo and Monasta, Lorenzo and Piccoli, Monica and Ronfani, Luca and Montico, Marcella and De Seta, Francesco and Parolin, Sara and Businelli, Caterina and Travan, Laura and Alberico, Salvatore} } @article {3525, title = {Diabetes in pregnancy: timing and mode of delivery.}, journal = {Curr Diab Rep}, volume = {14}, year = {2014}, month = {2014 Jul}, pages = {506}, abstract = {

Diabetes in pregnancy represents a risk condition for adverse maternal and feto-neonatal outcomes and many of these complications might occur during labor and delivery. In this context, the obstetrician managing women with pre-existing and gestational diabetes should consider (1) how these conditions might affect labor and delivery outcomes; (2) what are the current recommendations on management; and (3) which other factors should be considered to decide about the timing and mode of delivery. The analysis of the studies considered in this review leads to the conclusion that the decision to deliver should be primarily intended to reduce the risk of stillbirth, macrosomia, and shoulder dystocia. In this context, this review provides useful information for managing specific subgroups of diabetic women that may present overlapping risk factors, such as women with insulin-requiring diabetes and/or obesity and/or prenatal suspicion of macrosomic fetus. To date, the lack of definitive evidences and the complexity of the problem suggest that the "appropriate" clinical management should be customized according with the clinical condition, the type and mode of intervention, its consequences on outcomes, and considering the woman{\textquoteright}s consent and informed decisions.

}, keywords = {Delivery, Obstetric, Diabetes Mellitus, Diabetes, Gestational, Female, Humans, Pregnancy, Pregnancy Complications}, issn = {1539-0829}, doi = {10.1007/s11892-014-0506-0}, author = {Maso, Gianpaolo and Piccoli, Monica and Parolin, Sara and Restaino, Stefano and Alberico, Salvatore} } @article {3591, title = {The implications of diagnosis of small for gestational age fetuses using European and South Asian growth charts: an outcome-based comparative study.}, journal = {ScientificWorldJournal}, volume = {2014}, year = {2014}, month = {2014}, pages = {474809}, abstract = {

The antenatal condition of small for gestational age (SGA) is significantly associated with perinatal morbidity and mortality and it is known that there are significant differences in birth weight and fetal size among different populations. The aim of our study was to assess the impact on outcomes of the diagnosis of SGA according to Bangladeshi and European antenatal growth charts in Sri Lankan population. The estimated fetal weight before delivery was retrospectively reviewed according to Bangladeshi and European growth references. Three groups were identified: Group 1-SGA according to Bangladeshi growth chart; Group 2-SGA according to European growth chart but not having SGA according to Bangladeshi growth chart; Group 3-No SGA according to both charts. There was a difference in prevalence of SGA between Bangladeshi and European growth charts: 12.7\% and 51.7\%, respectively. There were statistically significant higher rates in emergency cesarean section, fetal distress in labour, and intrauterine death (P < 0.001) in Group 1 compared with Group, 2 and 3. No differences of outcomes occurred between Groups 2 and 3. Our study demonstrated that only cases diagnosed as SGA according to population-based growth charts are at risk of adverse outcome. The use of inappropriate prenatal growth charts might lead to misdiagnosis and potential unnecessary interventions.

}, keywords = {Asian Continental Ancestry Group, Bangladesh, Birth Weight, Europe, European Continental Ancestry Group, Female, Fetal Growth Retardation, Growth Charts, Humans, Infant, Newborn, Infant, Small for Gestational Age, Pregnancy, Prognosis, Sri Lanka}, issn = {1537-744X}, doi = {10.1155/2014/474809}, author = {Maso, Gianpaolo and Jayawardane, Mathota A M M and Alberico, Salvatore and Piccoli, Monica and Senanayake, Hemantha M} } @article {1946, title = {The clinical interpretation and significance of electronic fetal heart rate patterns 2 h before delivery: an institutional observational study.}, journal = {Arch Gynecol Obstet}, volume = {286}, year = {2012}, month = {2012 Nov}, pages = {1153-9}, abstract = {

PURPOSE: To evaluate the clinical significance of intrapartum fetal heart rate (FHR) monitoring in low-risk pregnancies according to guidelines and specific patterns.

METHODS: An obstetrician, blinded to neonatal outcome, retrospectively reviewed 198 low-risk cases that underwent continuous electronic fetal monitoring (EFM) during the last 2 h before delivery. The tracings were interpreted as normal, suspicious or pathological, according to specific guidelines of EFM and by grouping the different FHR patterns considering baseline, variability, presence of decelerations and bradycardia. The EFM groups and the different FHR-subgroups were associated with neonatal acid base status at birth, as well as the short-term neonatal composite outcome. Comparisons between groups were performed with Kruskal-Wallis test. Differences among categorical variables were evaluated using Fisher{\textquoteright}s exact test. Significance was set at p < 0.05 level.

RESULTS: Significant differences were found for mean pH values in the three EFM groups, with a significant trend from "normal" [pH 7.25, 95 \% confidence interval (CI) 7.28-7.32] to "pathological" tracings (pH 7.20, 95 \% CI 7.17-7.13). Also the rates of adverse composite neonatal outcome were statistically different between the two groups (p < 0.005). Among the different FHR patterns, tracings with atypical variable decelerations and severe bradycardia were more frequently associated with adverse neonatal composite outcome (11.1 and 26.7 \%, respectively). However, statistically significant differences were only observed between the subgroups with normal tracings and bradycardia.

CONCLUSIONS: In low-risk pregnancies, there is a significant association between neonatal outcome and EFM classification. However, within abnormal tracings, neonatal outcome might differ according to specific FHR pattern.

}, keywords = {Acidosis, Bradycardia, Female, Fetal Blood, Fetal Monitoring, Heart Rate, Fetal, Humans, Hydrogen-Ion Concentration, Infant, Newborn, Labor, Obstetric, Predictive Value of Tests, Pregnancy, Pregnancy Outcome, Retrospective Studies, Single-Blind Method, Statistics, Nonparametric, Time Factors}, issn = {1432-0711}, doi = {10.1007/s00404-012-2446-8}, author = {Maso, Gianpaolo and Businelli, Caterina and Piccoli, Monica and Montico, Marcella and De Seta, Francesco and Sartore, Andrea and Alberico, Salvatore} }