%0 Journal Article %J BMC Pregnancy Childbirth %D 2015 %T Risk-adjusted operative delivery rates and maternal-neonatal outcomes as measures of quality assessment in obstetric care: a multicenter prospective study. %A Maso, Gianpaolo %A Monasta, Lorenzo %A Piccoli, Monica %A Ronfani, Luca %A Montico, Marcella %A De Seta, Francesco %A Parolin, Sara %A Businelli, Caterina %A Travan, Laura %A Alberico, Salvatore %X

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.

%B BMC Pregnancy Childbirth %V 15 %P 20 %8 2015 %G eng %1 http://www.ncbi.nlm.nih.gov/pubmed/25751768?dopt=Abstract %R 10.1186/s12884-015-0450-2 %0 Journal Article %J BMC Pregnancy Childbirth %D 2014 %T The role of gestational diabetes, pre-pregnancy body mass index and gestational weight gain on the risk of newborn macrosomia: results from a prospective multicentre study. %A Alberico, Salvatore %A Montico, Marcella %A Barresi, Valentina %A Monasta, Lorenzo %A Businelli, Caterina %A Soini, Valentina %A Erenbourg, Anna %A Ronfani, Luca %A Maso, Gianpaolo %K Adolescent %K Adult %K Birth Weight %K Body Height %K Body Mass Index %K Diabetes, Gestational %K Female %K Fetal Macrosomia %K Gestational Age %K Humans %K Infant, Newborn %K Italy %K Middle Aged %K Obesity %K Pregnancy %K Pregnancy in Diabetics %K Prospective Studies %K Risk Factors %K Weight Gain %K Young Adult %X

BACKGROUND: It is crucial to identify in large population samples the most important determinants of excessive fetal growth. The aim of the study was to evaluate the independent role of pre-pregnancy body mass index (BMI), gestational weight gain and gestational diabetes on the risk of macrosomia.

METHODS: A prospective study collected data on mode of delivery and maternal/neonatal outcomes in eleven Hospitals in Italy. Multiple pregnancies and preterm deliveries were excluded. The sample included 14109 women with complete records. Associations between exposure variables and newborn macrosomia were analyzed using Pearson's chi squared test. Multiple logistic regression models were built to assess the independent association between potential predictors and macrosomia.

RESULTS: Maternal obesity (adjusted OR 1.7, 95% CI 1.4-2.2), excessive gestational weight gain (adjusted OR 1.9, 95% CI 1.6-2.2) and diabetes (adjusted OR 2.1, 95% CI 1.5-3.0 for gestational; adjusted OR 3.0, 95% CI 1.2-7.6 for pre-gestational) resulted to be independent predictors of macrosomia, when adjusted for other recognized risk factors. Since no significant interaction was found between pre-gestational BMI and gestational weight gain, excessive weight gain should be considered an independent risk factor for macrosomia. In the sub-group of women affected by gestational or pre-gestational diabetes, pre-gestational BMI was not significantly associated to macrosomia, while excessive pregnancy weight gain, maternal height and gestational age at delivery were significantly associated. In this sub-population, pregnancy weight gain less than recommended was not significantly associated to a reduction in macrosomia.

CONCLUSIONS: Our findings indicate that maternal obesity, gestational weight gain excess and diabetes should be considered as independent risk factors for newborn macrosomia. To adequately evaluate the clinical evolution of pregnancy all three variables need to be carefully assessed and monitored.

%B BMC Pregnancy Childbirth %V 14 %P 23 %8 2014 %G eng %1 http://www.ncbi.nlm.nih.gov/pubmed/24428895?dopt=Abstract %R 10.1186/1471-2393-14-23 %0 Journal Article %J Arch Gynecol Obstet %D 2012 %T The clinical interpretation and significance of electronic fetal heart rate patterns 2 h before delivery: an institutional observational study. %A Maso, Gianpaolo %A Businelli, Caterina %A Piccoli, Monica %A Montico, Marcella %A De Seta, Francesco %A Sartore, Andrea %A Alberico, Salvatore %K Acidosis %K Bradycardia %K Female %K Fetal Blood %K Fetal Monitoring %K Heart Rate, Fetal %K Humans %K Hydrogen-Ion Concentration %K Infant, Newborn %K Labor, Obstetric %K Predictive Value of Tests %K Pregnancy %K Pregnancy Outcome %K Retrospective Studies %K Single-Blind Method %K Statistics, Nonparametric %K Time Factors %X

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'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.

%B Arch Gynecol Obstet %V 286 %P 1153-9 %8 2012 Nov %G eng %N 5 %1 http://www.ncbi.nlm.nih.gov/pubmed/22791414?dopt=Abstract %R 10.1007/s00404-012-2446-8