Changes in cesarean delivery in an Italian university hospital, 1982-1996: a comparison with the national trend.

BACKGROUND: The cesarean delivery rate in Italy rose dramatically from the mid-1970s to 1996, accounting for 22.4 percent of all deliveries in the last national survey. The aim of this study was to analyze the results of the clinical practice of a new staff in the Department of Obstetrics and Gynecology of a university hospital, with particular focus on the application of common protocols. The rates of cesarean sections and perinatal mortality were chosen as parameters for good clinical practice and were compared with national data. METHODS: A new staff assumed the obstetric management at the hospital in 1982. Standardized protocols were implemented for all major indications for cesarean delivery (repeat cesarean section, dystocia, breech presentation, fetal distress). RESULTS: The rate of cesarean deliveries decreased from 26.4 to 12 percent and remained stable during the past decade. Other operative modalities were used for approximately 1.5 percent of deliveries. The perinatal mortality decreased to 0.5 percent in 1994. To confirm whether or not staff followed common protocols, a review of three years (1994-1996) showed a fairly stable frequency of cesarean sections on different days and nights during the week, confirming the homogeneity of obstetric management. CONCLUSIONS: Our data showed that, irrespective of the local situation and of the risks of litigation, a significant reduction of cesarean sections can be achieved in a tertiary care center without detrimental effects on newborns, especially in a teaching hospital where residents are trained. Despite national trends suggesting the contrary, some women may choose to deliver in an obstetrics department with better care and fewer operative procedures than in hospitals with higher cesarean delivery rates.

[Report on obstetrical activity during the triennium 1985-1987. 4th Obstetrics and Gynecology Clinic, University of Milan, Institute of Biomedical Sciences, S. Gerardo Hospital, Monza]. / Rapporto sull'attività ostetrica del triennio 1985-87. IV Clinica Ostetrica e Ginecologica-Università degli Studi di Milano Istituto di Scienze Biomediche-Ospedale S. Gerardo-Monza.

The data of three years of activity (1985-1987) at the 4th Obstetrics and Gynecology Department of the University of Milan, S. Gerardo Hospital in Monza, for a total of 5595 deliveries and 5672 new-borns are reviewed. Each case of perinatal death has been evaluated for gestational age, weight, way of delivery and preexisting or pregnancy-induced maternal diseases, trying to single out the primary causes of death. In order to compare these data with the ones of the previous three years the results have been divided, following the gestational age, in two groups (less or more and equal than 28 weeks). Late perinatal death rate (including all the babies older than 24 weeks of gestational age, still-born or live-born and dead within the 28th day of life) has been 1.8%, compared to the 2.1% in the previous 3 years. Obstetrical procedures and neonatal outcomes are analyzed in depth. Puerperium was pathological in 8.9% of patients. Only 4.2% of women decided not to breast-fed their babies.

[Intrahepatic cholestasis in pregnancy: incidence, clinical course, complications]. / Colestasi intraepatica gravidica: incidenza, decorso, complicanze.

From January 1st, 1984 to December 31st, 1988 67 cases of cholestasis during pregnancy (frequency rate 0.7%) have been reviewed. In the 79% of the cases cholestasis arose after the 32nd week. Preterm deliveries were 19.5% and cesarean sections were 19.4%. Perinatal mortality was 30%. Pregnancy complicated by cholestasis is a high risk problem in obstetrics. An attempt to show a clinical management is exposed.

[Premature birth and perinatal mortality 1982-1988. I]. / Parto prematuro e mortalità perinatale 1982-88: Parte I.

The Authors analyzed the premature deliveries performed between 1982 and 1988 at the IV Clinica Ostetrica e Ginecologica of the University of Milan at the S. Gerardo Hospital, Monza, 1267 newborns out of 12507 were preterm. The rate was between 8.7 and 11.0% (average 9.8%). The early neonatal mortality is 10.6% (excluding malformed newborns, 8.3%), the late neonatal mortality is 12.7% (excluding malformed newborns, 9.8%). The early mortality is significantly lower starting from the 32nd week of pregnancy (35.4% vs 3.2%) and with a newborn's weight greater than 1500 grams (36.9 vs 3.2%). The early mortality is lower for females (8.4%) than for males (11.1%). In spite of other Authors, the early mortality is significantly higher than for AGA newborns (19.4 vs 7.9%). The causes of the early mortality are analyzed in detail.

Pre-induction cervical ripening with prostaglandin E2 gel: intracervical versus intravaginal route.

The aim of our study was to evaluate the best method for cervical ripening before a classical induction with amniotomy and oxytocin. One hundred term pregnant patients who presented an unfavorable cervix and an indication for the induction of labor were assigned randomly to either 0.5 mg prostaglandin (PG) E2 gel intracervically (N = 52) or 3 mg PGE2 gel intravaginally (N = 48). The intravaginal gel had a greater effect on cervical ripening according to a modification of the Bishop score than did intracervical gel, but it had a higher incidence of side effects.

Lupus nephropathy and pregnancy. A study of 26 pregnancies in patients with systemic lupus erythematosus and nephritis.

We describe 26 pregnancies in 19 patients with lupus nephritis. There were 4 spontaneous abortions, 2 therapeutic abortions, 4 stillbirths and 1 neonatal death. 10 deliveries were preterm and 2 fetuses were small for gestational age. 8 pregnancies were not accompanied by change of renal symptoms. Mild signs of renal involvement appeared during pregnancy in 4 patients. 6 patients showed an increase in proteinuria already present before pregnancy without renal function deterioration. A moderate worsening of renal function was observed in 3 patients. 4 patients, 3 of whom had an apparent onset of systemic lupus erythematosus during pregnancy, developed anuric acute renal failure after delivery or after late spontaneous abortion. 2 of them died from sepsis and disseminated intravascular coagulation while 2 had complete recovery of renal function. A high rate of complications was observed in patients not adequately treated during pregnancy. Renal biopsy before gestation was not predictive of the outcome of nephropathy during pregnancy, and change of histology in repeated biopsies was frequently observed.

Pharmacokinetics of furosemide in gestosis of pregnancy.

Furosemid 50 mg was administered orally and intravenously to twelve gestotic women for brief periods as a part of a randomized, multicentre clinical trial comparing the efficacy of bed rest and pharmacological treatment. The pharmacokinetic profile was investigated using a gas-liquid chromatographic technique. The plasma half-life after oral and intravenous administration was 115 +/- 37.1 and 71.8 +/- 26.3 min and plasma clearance was 153 +/- 48 and 152 +/- 23 ml/min, respectively (mean +/- SD). Comparative data from healthy pregnant women cannot be obtained for ethical reasons. The results show that gestosis has only a marginal if any effect on the kinetics of furosemide in comparison with published kinetic parameters in healthy volunteers, and patients with renal failure. The new-born babies where checked for side effects according to a protocol in use in a larger regional surveillance programme. No clinical side-effects were attributable to furosemide, but the small size of the group does not permit any definitive conclusions about this aspect.