RESUMEN
BACKGROUND: The aim of the study was to investigate whether the angle of progression (AoP), as measured by transperineal ultrasound, was predictive of both the time remaining in labor and vaginal delivery. METHODS: This was a prospective observational cohort study involving 270 low-risk women with singleton pregnancies at term. The AoP, measured at the end of the first stage of labor, was used as a predictive variable of time remaining in labor and mode of delivery. The Kaplan Meier and Cox algorithms were used to evaluate the time elapsed between AoP measurement and delivery as a function of AoP. Instead, logistic regression was used to calculate the adjusted probability of vaginal delivery as a function of AoP. RESULTS: Of the 270 women enrolled, 15 (5.6%) delivered by cesarean section and 33 (12.1%) by vacuum or forceps. The AoP, stratified by quartiles, was a significant predictor of the time remaining in labor, even after adjustment for possible confounders (Body Mass Index [BMI], oxytocin administration and parity). The mean±SD second stage of labor length for each AoP quartile was 134±25, 126±18, 96±33 and 58±23 minutes (P value<0.001, ANOVA). The mean±SD probability of a vaginal delivery expressed as a function of the AoP quartile (adjusted for BMI) was 51.5±0.16%, 81.5±0.10%, 97.0±0.16% and 99.3±0.004% at the AoP of the 1st, 2nd, 3rd and 4th quartiles, respectively, (P value<0.001 ANOVA). CONCLUSIONS: The AoP was directly associated with the time remaining in labor and was predictive of a successful vaginal delivery; however, the impact on clinical practice seems low.
Asunto(s)
Cesárea/estadística & datos numéricos , Parto Obstétrico/métodos , Trabajo de Parto/fisiología , Ultrasonografía Prenatal/métodos , Adulto , Estudios de Cohortes , Parto Obstétrico/estadística & datos numéricos , Femenino , Humanos , Estimación de Kaplan-Meier , Primer Periodo del Trabajo de Parto/fisiología , Segundo Periodo del Trabajo de Parto/fisiología , Modelos Logísticos , Embarazo , Estudios Prospectivos , Extracción Obstétrica por Aspiración/estadística & datos numéricosRESUMEN
BACKGROUND: The rate of cesarean delivery is currently increasing all over Europe. In Italy it reaches 38% of all child births. Therefore, it is important to identify the clinical and organizational variables that determine the appropriateness of elective cesarean delivery. With this aim we chose the technology of clinical audit, a process that promotes improvement in clinical practice through systematic review of clinical care in relation with explicit standards derived from scientific literature. METHODS: This is a prospective audit: in the period March 2014-July 2014 we analyzed the medical records of 150 women who underwent elective cesarean delivery at Gynecological and Obstetrical University Hospital Sant'Anna, Turin. We collected data related to five quality criteria derived from scientific literature. Each criterion was stratified by indicators and matched with respective standards of adequate care. Criteria and indicators are: 1) cesarean section (CS) rate in twin pregnancies with both cephalic fetal presentation (stratified by dichorionic diamniotic and monochorionic diamniotic); 2) CS rates in preterm births (stratified by gestational age ≤32, ≤34 and ≤37 week); 3) CS rates on maternal request due to tokophobia in patients who received a psychological support during pregnancy; 4) repeated CS rates; 5) multidisciplinary evaluation of the indication to CS for non-obstetric reasons (orthopedic, ophthalmologic, psychiatric and neurological). The rate of CSs found in each criterion was compared with the respective standard in literature. The value obtained for each indicator was tested for statistical significance (CI 95%). We considered performing indicators whose final rate was found to be better or equal to the reference standard. RESULTS: The majority of the indicators result to be performant. CS rate for previous CS was 84% (73/86), far more frequent than the standard of optimal care fixed at ≤30% (P<0.05). Repeated CSs were analyzed in steps IV and V of audit because of the high gap between observed and adequate scores, the significant potential of improvement and the high incidence of the event, as they account for the 20% of average cesarean deliveries in our unit in the period of the study. Thus, we implemented a plan of improvement that consisted on introduction in clinical practice of the cervical ripening balloon for women who desire a trial of labor after CS (TOLAC), congress sessions and training to clinicians, information and counselling to pregnant woman with a previous cesarean. The impact of the implemented measures of correction applied for two years was evaluated with a re-audit on 40 patients, from May to April 2016. The cesarean birth after cesarean (CBAC) rate observed after the re-audit was 62% (32/50), significantly lower compared to the previous 80% P<0.01. Thus, the established plan of improvement induces a reduction in CBAC rate of 24%. CONCLUSIONS: Clinical audit is a powerful instrument that can improve standards of care. In our Unit, clinical audit on elective cesarean leads to the identification of an excess in repeated cesareans and a significant reduction of them. However, to realize an effective improvement we are planning furthers audits.
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Cesárea/estadística & datos numéricos , Auditoría Clínica/métodos , Parto Obstétrico/métodos , Obstetricia/métodos , Femenino , Edad Gestacional , Humanos , Italia , Embarazo , Resultado del Embarazo , Nacimiento Prematuro/epidemiología , Estudios ProspectivosRESUMEN
BACKGROUND: To evaluate whether sonographic (US) diagnosis of the fetal spine position could increase the success rate of manual rotation of the fetal occiput (MRFO) in second-stage arrest in persistent occiput posterior position (OPP). METHODS: In this randomized controlled parallel single-center trial, 58 nulliparous in second-stage arrest of labor with fetus in cephalic presentation and OPP diagnosed by US were randomly assigned to group A where the fetal spine position was not known by the operator or to group B where the operator knew it. The main outcome was the success of MRFO in the two groups. Secondary outcomes were perineal injuries, blood loss, duration of expulsive period, and neonatal APGAR at 5 minutes. RESULTS: A priori knowledge of the spine position improves the success of the MRFO (41.4% group A versus 82.8% group B, p value < 0.001), the percentage of spontaneous deliveries (27.6% group A versus 69% group B, p value = 0.01), and maternal outcome (intact perineum and blood loss). No differences were detected on the neonatal side. CONCLUSIONS: MRFO is a safe and useful procedure that should be performed in second-stage arrest in OPP. A better performance was observed when supported by the US knowledge of the spine position. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:472-476, 2017.
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Parto Obstétrico , Presentación en Trabajo de Parto , Columna Vertebral/anatomía & histología , Columna Vertebral/embriología , Ultrasonografía Prenatal/métodos , Versión Fetal/métodos , Adulto , Femenino , Humanos , Embarazo , Reproducibilidad de los Resultados , RotaciónRESUMEN
The relationship between Helicobacter pylori infection and extragastric disease is well established. This study prospectively investigated whether maternal H. pylori seropositivity, detected during the first half of pregnancy, could be associated with the development of the major pregnancy-related pathological conditions during the late second or third trimester in a general population. Our hypothesis was that H. pylori infection might negatively influence pregnancy development and outcome. A total of 2820 consecutive pregnant women were recruited before 20 weeks' gestation, from October 2008 to August 2010, and blood samples were collected from each subject. IgG antibodies against H. pylori were assayed in maternal serum by a commercial immunoassay. Logistic regression analyses were performed to assess any association between H. pylori seropositivity and adverse pregnancy outcomes. Gestational diabetes mellitus (GDM) was the most common maternal complication (5.7%) and the only pregnancy-related disorder with a significantly higher rate of H. pylori-positive women (41.3%) compared with subjects who did not develop the disease (27.7%; P < 0.001; OR = 1.829, 95% CI = 1.320-2.533). The difference observed remained statistically significant after adjusting for potential confounding variables. The presence of antibodies against H. pylori antigens in maternal serum was independently associated with the development of GDM. These findings suggest that H. pylori eradication might play a role in the prevention of gestational diabetes mellitus.
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Anticuerpos Antibacterianos/sangre , Diabetes Gestacional/sangre , Infecciones por Helicobacter/sangre , Helicobacter pylori , Inmunoglobulina G/sangre , Complicaciones Infecciosas del Embarazo/sangre , Tercer Trimestre del Embarazo/sangre , Adulto , Femenino , Estudios de Seguimiento , Humanos , Embarazo , Segundo Trimestre del Embarazo/sangre , Estudios ProspectivosRESUMEN
Preeclampsia, affecting 5-8% of pregnancies, is the main cause of fetal-maternal mortality and morbidity. The differential diagnosis with chronic kidney disease (CKD) is a challenge owing to the overlapping clinical features. No biomarker has been found to discriminate between the two conditions. Here, we tested whether maternal serum levels of placental growth factor (PlGF) and soluble FMS-like tyrosine kinase-1 (sFlt-1), markers of preeclampsia, could be used to discriminate between 34 patients with preeclampsia, 23 patients with CKD during pregnancy, and 38 healthy pregnant women. Serum levels of PlGF and sFlt-1 were determined during the third trimester by commercially available immunoassays. In preeclampsia, sFlt-1 levels were significantly increased in comparison with that in CKD and in the control women. Serum levels of PlGF in preeclampsia were significantly decreased relative to both controls and patients with CKD. The sFlt-1 to PlGF ratio was significantly increased in preeclampsia (median 436) compared with controls (median 9.4) and CKD (median 4.0). No differences were found between controls and patients with CKD. Thus, our study suggests that it is possible to discriminate between preeclampsia and CKD during pregnancy by determining maternal serum levels of sFlt-1 and PlGF and their ratio.
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Preeclampsia/diagnóstico , Proteínas Gestacionales/sangre , Insuficiencia Renal Crónica/diagnóstico , Receptor 1 de Factores de Crecimiento Endotelial Vascular/sangre , Adulto , Biomarcadores/sangre , Estudios de Casos y Controles , Diagnóstico Diferencial , Femenino , Humanos , Factor de Crecimiento Placentario , Preeclampsia/sangre , Embarazo , Tercer Trimestre del Embarazo/sangre , Insuficiencia Renal Crónica/sangre , Sensibilidad y EspecificidadRESUMEN
AIM: To better understand the pathogenic role of Helicobacter pylori (H. pylori) in pre-eclampsia (PE), and whether it is associated or not with fetal growth retardation (FGR). METHODS: Maternal blood samples were collected from 62 consecutive pregnant women with a diagnosis of PE and/or FGR, and from 49 women with uneventful pregnancies (controls). Serum samples were evaluated by immunoblot assay for presence of specific antibodies against H. pylori antigens [virulence: cytotoxin-associated antigen A (CagA); ureases; heat shock protein B; flagellin A; persistence: vacuolating cytotoxin A (VacA)]. Maternal complete blood count and liver enzymes levels were assessed at delivery by an automated analyzer. RESULTS: A significantly higher percentage of H. pylori seropositive women were found among PE cases (85.7%) compared to controls (42.9%, P < 0.001). There were no differences between pregnancies complicated by FGR without maternal hypertension (46.2%) and controls. Importantly, persistent and virulent infections (VacA/CagA seropositive patients, intermediate leukocyte blood count and aspartate aminotransferase levels) were exclusively associated with pre-eclampsia complicated by FGR, while virulent but acute infections (CagA positive/VacA negative patients, highest leukocyte blood count and aspartate aminotransferase levels) specifically correlated with PE without FGR. CONCLUSION: Our data strongly indicate that persistent and virulent H. pylori infections cause or contribute to PE complicated by FGR, but not to PE without feto-placental compromise.