Retrospective study 2005-2015 of all cases of fetal death occurred at 6523 gestational weeks, in Friusli Venezia Giulia, Italy

Background: Intrauterine fetal death (IUFD) is a tragic event and, despite efforts to reduce rates, its incidence remains difficult to reduce. The objective of the present study was to examine the etiological factors that contribute to the main causes and conditions associated with IUFD, over an 11-year period in a region of North-East Italy (Friuli Venezia Giulia) for which reliable data in available. Methods: Retrospective analysis of all 278 IUFD cases occurred between 2005 and 2015 in pregnancies with gestational age 65 23 weeks. Results: The incidence of IUFD was 2.8\u2030 live births. Of these, 30% were small for gestational age (SGA), with immigrant women being significantly over-represented. The share of SGA reached 35% in cases in which a maternal of fetal pathological condition was present, and dropped to 28% in the absence of associated pathology. In 78 pregnancies (28%) no pathology was recorded that could justify IUFD. Of all IUFDs, 11% occurred during labor, and 72% occurred at a gestational age above 30 weeks. Conclusion: The percentage of IUFD cases for which no possible cause can be identified is quite high. Only the adoption of evidence-based diagnostic protocols, with integrated immunologic, genetic and pathologic examinations, can help reduce this diagnostic gap, contributing to the prevention of future IUFDs

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

Receiver Operating Characteristic (ROC) curves for the multivariate logistic regression models.

<p>Footnotes: Model 1: Adjusted for maternal characteristics, pregnancy related variables and risk category. Model 2a: Adjusted for ten-groups. Model 2b: Adjusted for ten-groups, maternal characteristics and risk category.</p

The 10-group classification.

<p>CD, caesarean delivery.</p

Mode of delivery (vaginal vs. caesarean) according to maternal characteristics, obstetric variables and 10-Group classification.

<p>Data are expressed in number, percentage and crude Risk Ratios – 95% confidence interval (bivariate analysis).</p><p>RR, risk ratios; CI, confidence interval; BMI, body mass index; CD, caesarean delivery; ceph, cephalic; Nlp, nulliparous; Mlp, multiparous; spont, spontaneous; ind, induced; lab; labor; wks, weeks.</p>*<p>No past caesarean delivery.</p><p>p<0.05 is considered statistically significant.</p

Inter-institutional crude and adjusted Risk Ratios (RR, 95% Confidence Interval) for caesarean risk-adjustment models.

<p>Center A is considered as the referent.</p><p>RR, risk ratios; CI, confidence interval.</p><p>Model 1: Adjusted for maternal characteristics, pregnancy related variables and risk category.</p><p>Model 2a: Adjusted for ten-groups.</p><p>Model 2b: Adjusted for ten-groups, maternal characteristics and risk category.</p>*<p>p<0.05 is considered statistically significant.</p

Inter-institutional caesarean delivery rates: data are presented as percentages (number of caesarean deliveries/total number of deliveries.

<p>The dot line represents the average of overall caesarean delivery rates.</p

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. Spearman’s 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 bothCD rates in spontaneous and induced labouring nulliparous women with a single cephalic pregnancy at term( = 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 ( < 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 ( = 0.021, = 0.005, and < 0.001, resp.).These results supported the conclusion that only selected indications in specific obstetric groups accounted for interinstitutional variation of CD rates