Monica Piccoli

Aetiology of preterm labour: bacterial vaginosis

Bacterial vaginosis (BV) is a common condition characterised by a polymicrobial disorder, with an overgrowth of several anaerobic or facultative bacteria and with a reduction or absence of lactobacillus colonisation. The prevalence of BV ranges from 4 to 64%, depending on the racial, geographic and clinical characteristics of the study population. In asymptomatic women, the prevalence varies from 12 to 25%, and similar percentages are observed in pregnant women. Although BV is associated with several adverse outcomes, such as upper genital tract infections, pelvic inflammatory disease, endometritis, preterm birth and low birthweight, many basic questions regarding the pathogenesis of BV remain unanswered. Mucosal immune system activation may represent a critical determinant of adverse consequences associated with BV. An unequal risk for BV acquisition and\or recurrence could derive from different mucosal immune host abilities and\or capability of invading microbes to produce factors that inactivate the local immune response. BV is associated with a two‐fold increased risk of preterm birth, with the greatest risk when BV is present before 16 weeks of gestation (odds ratio = 7.55). This may indicate a critical period during early gestation when BV‐related organisms can gain access to the upper genital tract and set the stage for spontaneous preterm labour later in gestation. The results of treatment trials for pregnant women with BV have been heterogeneous, with anywhere from an 80% reduction to a two‐fold increase in preterm birth among women who received treatment. For this reason, in current clinical practice significant controversy surrounds determining not only who and when to screen but also who and how to treat. Recent evidence shows that individual genetic backgrounds can affect chemokine production. This is an interesting area for future research and could lead to trials of treatment only for women genetically predisposed to preterm birth.

First-trimester intrauterine hematoma and outcome of pregnancy.

OBJECTIVE: To evaluate the outcome of pregnancies complicated by first-trimester intrauterine hematoma. METHODS: An analysis was performed on 248 cases. The pregnancy outcome was correlated with hematoma volume, gestational age (weeks), and maternal age (years). RESULTS: One hundred eighty-two cases were eligible for the study. Clinical complications occurred in 38.5% of the cases (adverse outcome group). Spontaneous abortion (14.3%), fetal growth restriction (7.7%), and preterm delivery (6.6%) were the most frequent clinical conditions observed. Considering the hematoma variables in adverse and favorable outcome groups, we found a significant difference only for gestational age at diagnosis. The median gestational age was significantly lower (P < .02) in the adverse outcome group (7.27, I and III quartiles 6.22–8.78) than in the favorable outcome cases (8.62, I and III quartiles 6.70–9.98). Among clinical conditions, the median gestational age was significantly lower (P = .02) in pregnancies complicated by spontaneous abortion (6.60, I and III quartiles 5.95–8.36) than in cases not ending in a miscarriage (8.50, I and III quartiles 6.70–9.91). The overall risk of adverse outcome was 2.4 times higher when the hematoma was diagnosed before 9 weeks (odds ratio 2.37, 95% confidence interval 1.20–4.70). In particular, intrauterine hematoma observed before 9 weeks significantly increases the risk of spontaneous abortion (odds ratio 14.79, 95% confidence interval 1.95–112.09) CONCLUSION: Intrauterine hematoma can affect the outcome of pregnancy. The risk of spontaneous abortion is related to gestational age and is significantly increased if diagnosed before 9 weeks. LEVEL OF EVIDENCE: III

The Application of the Ten Group Classification System (TGCS) in Caesarean Delivery Case Mix Adjustment. A Multicenter Prospective Study

Background Caesarean delivery (CD) rates are commonly used as an indicator of quality in obstetric care and risk adjustment evaluation is recommended to assess inter-institutional variations. The aim of this study was to evaluate whether the Ten Group classification system (TGCS) can be used in case-mix adjustment. Methods Standardized data on 15,255 deliveries from 11 different regional centers were prospectively collected. Crude Risk Ratios of CDs were calculated for each center. Two multiple logistic regression models were herein considered by using: Model 1- maternal (age, Body Mass Index), obstetric variables (gestational age, fetal presentation, single or multiple, previous scar, parity, neonatal birth weight) and presence of risk factors; Model 2- TGCS either with or without maternal characteristics and presence of risk factors. Receiver Operating Characteristic (ROC) curves of the multivariate logistic regression analyses were used to assess the diagnostic accuracy of each model. The null hypothesis that Areas under ROC Curve (AUC) were not different from each other was verified with a Chi Square test and post hoc pairwise comparisons by using a Bonferroni correction. Results Crude evaluation of CD rates showed all centers had significantly higher Risk Ratios than the referent. Both multiple logistic regression models reduced these variations. However the two methods ranked institutions differently: model 1 and model 2 (adjusted for TGCS) identified respectively nine and eight centers with significantly higher CD rates than the referent with slightly different AUCs (0.8758 and 0.8929 respectively). In the adjusted model for TGCS and maternal characteristics/presence of risk factors, three centers had CD rates similar to the referent with the best AUC (0.9024). Conclusions The TGCS might be considered as a reliable variable to adjust CD rates. The addition of maternal characteristics and risk factors to TGCS substantially increase the predictive discrimination of the risk adjusted model.

Diabetes in Pregnancy: Timing and Mode of Delivery

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’s consent and informed decisions.

Interinstitutional variation of caesarean delivery rates according to indications in selected obstetric populations: a prospective multicenter study.

The aim of the study was to identify which groups of women contribute to interinstitutional variation of caesarean delivery (CD) rates and which are the reasons for this variation. In this regard, 15,726 deliveries from 11 regional centers were evaluated using the 10-group classification system. Standardized indications for CD in each group were used. Spearmans correlation coefficient was used to calculate (1) relationship between institutional CD rates and relative sizes/CD rates in each of the ten groups/centers; (2) correlation between institutional CD rates and indications for CD in each of the ten groups/centers. Overall CD rates correlated with both CD rates in spontaneous and induced labouring nulliparous women with a single cephalic pregnancy at term (P = 0.005). Variation of CD rates was also dependent on relative size and CD rates in multiparous women with previous CD, single cephalic pregnancy at term (P < 0.001). As for the indications, “cardiotocographic anomalies” and “failure to progress” in the group of nulliparous women in spontaneous labour and “one previous CD” in multiparous women previous CD correlated significantly with institutional CD rates (P = 0.021, P = 0.005, and P < 0.001, resp.). These results supported the conclusion that only selected indications in specific obstetric groups accounted for interinstitutional variation of CD rates.

The Implications of Diagnosis of Small for Gestational Age Fetuses Using European and South Asian Growth Charts: An Outcome-Based Comparative Study

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.

OC238: The clinical significance of Persistence of Right Umbilical Vein

would have been detected. An alternative cut-off value of 35 U/ml would have resulted in a detection rate of 33%. Conclusions: Transvaginal ultrasonography can effectively detect intra-ovarian cancer and tumours of borderline malignancy in women with a family history of the disease. The level of serum CA125 can be used to select women for ultrasonography, but the detection rate for early cancers would be reduced.

OC017: Clinical significance of subchorionic haematoma in the first trimester of pregnancy

the pattern of serum hCG levels in early normal pregnancy, and also the correlation between low serum progesterone levels and spontaneous resolution of pregnancy. The diagnostic dilemma is how to predict which PUL are early ectopic pregnancies. There is no role for single serum hCG measurement in the management of PUL. Based on serum hCG > 1000 U/L, only 30% of ectopic pregnancies would be detected. In clinical terms, if one relied on the discriminatory zone alone, 6 laparoscopies would be performed in order to detect one ectopic pregnancies. Current hormonal criteria including initial serum progesterone < 20 nmol/L and an increasing serum hCG > 66% over 48 hours (hr) are very reliable in predicting pregnancy viability, but not its location. This question of establishing the location of a PUL was further investigated using subjective assessment of serum hCG and progesterone levels at defined times by gynaecologists of varying experience. It was found that experience per se did not play any role in the classification of PUL based on serum hormone evaluation and in this series only 25%–60% of ectopic pregnancies were detected. Interobserver agreement is almost perfect (Kappa 0.87) in the classification of non-EP, i.e. failing PUL and viable IUP. Conversely, the interobserver agreement in the classification of EP is only fair (Kappa 0.49). The development of new methods to establish pregnancy location has been investigated extensively in our unit. Using the hCG ratio (hCG 48 hr/hCG 0 hr), the detection of EP is improved to 75%. This figure has been improved significantly with the use of logistic regression analysis. This utilises the hCG ratio alone and is found not only to predict viability, but most importantly locate the pregnancy. The sensitivity and specificity of the model for the detection of ectopic pregnancies were 91.7% and 84.2% respectively.

Risk-adjusted operative delivery rates and maternal-neonatal outcomes as measures of quality assessment in obstetric care: a multicenter prospective study.

BackgroundAlthough 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.MethodsStandardized 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.ResultsCenters 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.ConclusionsBoth 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.

OP12.14: Screening for congenital heart disease (CHD) at 20–24 weeks: a five-year experience

Objectives: To examine the features of major congenital heart disease (CHD) diagnosed by early fetal echocardiography in chromosomally normal fetuses. Methods: During a five-year period, 24 major CHD were detected in pregnant women undergoing fetal echocardiography at 11 to 14 weeks because of high risk for CHD, and in whom aneuploidy had been ruled out. Transvaginal ultrasound was the preferred approach and colour and pulsed Doppler examination were always used. Whenever a normal early scan was found, a further fetal echocardiography at 20–22 weeks was performed. Reliability was assessed by postnatal follow-up or autopsy in the case of termination of pregnancy or perinatal death. Results: The 24 major CHD detected were the following: hypoplastic left heart syndrome (n = 7), atrioventricular septal defect (n = 6), tetralogy of Fallot (n = 4), transposition of the great arteries (n = 3), hypoplastic right heart syndrome (n = 3) and a ventricular diverticle + VSD. The main indication for study was the finding of increased NT ≥ 99th centile in 16 cases (67%), while a suspicion of anomaly in the 11–14 weeks’ screening scan accounted for seven cases (29%) and an isolated reverse flow in the ductus venosus for the last one (4%). The median gestational age at diagnosis was 13 weeks, with just two cases diagnosed at 12 weeks and none at 11 weeks. The median NT was 5.6 (range, 3.3–11.7) mm. We were able to affirm normality in the remaining normal cases, with neither false positive or negative results for major defects. Two further clinically asymptomatic minor defects were detected postnatally: a small VSD and an aortic insufficiency. Conclusions: Early fetal echocardiography is very accurate beyond the 12th week of gestation, thus should be offered in high-risk populations. The finding of an increased NT is the strongest predictor of CHD at this time of pregnancy.