Impact of clinical audits on cesarean section rate in a Spanish hospital: Analysis of 6 year data according to the Robson classification.

OBJECTIVES: The aim of this study is to analyze the impact of the introduction of an internal clinical audit on the cesarean section (CS) rate, evaluated according to the Robson Ten Group Classification System (TGCS), and to identify the main contributors to the overall CS rate in order to plan further interventions. STUDY DESIGN: In 2014, an internal clinic audit committee was established in our center. Modifications of clinical management protocols were also implemented. A retrospective review of clinical records was conducted and pre-audit (2011-2014) results were compared against audit (2015-2018) results. Patients were clustered according to the Robson TGCS and the analyzed outcomes were CS rate and maternal and neonatal results. RESULTS: Between January 2011 and December 2018, 12,766 women gave birth at our institution among which 2,281 CS were analyzed. After the establishment of the clinical audit, the overall CS rate decreased from 20.27% to 14.82 % (p < 0.01). The major contribution to the overall CS rate in both periods were made by Group 2a (nulliparous with a single cephalic pregnancy at term who underwent labor induction: 4.86 % of all cases), followed by Group 5 (patients with a previous C-section: 3.26 %) and Group 1 (nulliparous with a single cephalic pregnancy at term with spontaneous labor: 2.39 %), representing 59.6 % of all CS. The group that showed the greatest reduction to the overall Cs rate was Group 2 (5.77 % vs 3.96 %, OR 1.48 (p < 0.01). No differences in perinatal and maternal results were found between preaudit and audit group. CONCLUSION: Audit, feedback, and modification of clinical management protocols may be effective in changing clinical practice and reducing CS rates without worsening maternal and neonatal morbimortality. Robson TGCS allowed us to identify which groups had the greatest impact on CS rate in order to establish new strategies that may lead us to optimize the use of this intervention. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy.

Prenatal screening and diagnosis of genetic abnormalities: SEGO, SEQCML, AEDP consensus recommendations.

In this paper, the scientific societies SEGO, SEQCML and AEDP provide a series of consensus-based recommendations for prenatal screening and diagnosis of genetic abnormalities. A set of evaluation indicators are also proposed as a means to improve the quality of the biochemical, ultrasound, and genetic processes involved in prenatal screening and diagnosis of genetic anomalies. Some recommendations are also proposed in relation to invasive prenatal diagnostic procedures, more specifically regarding sample collection and genetic testing. The purpose of this proposal is to unify performance criteria and quality indicators at national level, with audits performed on a regular basis. It is strongly recommended that a national prenatal screening strategy be established and provided with the resources necessary to evaluate the performance of quality indicators and diagnostic procedures under the supervision of health authorities. Protocols should be revised on a regular basis to consider the incorporation of new cost-effective technologies.

Fetal intracranial hemorrhage. Prenatal diagnosis and postnatal outcomes.

OBJECTIVE: To present our experience with 14 cases of fetal intracranial hemorrhage (ICH). METHODS: Cases of fetal ICH detected in our institution between 2005 and 2016 by ultrasonography. Maternal characteristics, ultrasound and MRI findings, and postnatal outcome were noted. RESULTS: Twelve cases (86.7%) were identified during a third trimester routine scan at a median gestational age of 30.6 weeks. The ICH was classified as Grade 2 in two cases, Grade 3 in three cases, and Grade 4 in nine cases. Nine cases were bilateral and five were unilateral (four left/one right). The 11 MRI available confirmed grade and location and, in six cases (54.5%), added new findings. There were six terminations of pregnancy, one intrauterine fetal death and seven babies born alive. These were followed up for 28 months (range 3-96). Some grade of neurologic impairment was observed in five children (71.4%, one Grade 3/four Grade 4), mainly mild to moderate motor sequelae. CONCLUSION: Diagnosis of fetal ICH is amenable to antenatal US. Most of the cases identified are of high grade and usually detected during the third trimester. MRI is a valuable complementary tool in evaluating ICH. Conversely to that previously reported, postnatal survival is high but it entails the risk of adverse neurologic outcome in most neonates.

Brainstem-vermis and brainstem-tentorium angles: 3D ultrasound study of the intra- and inter-observer agreement.

OBJECTIVE: The brainstem-vermis angle (BVA) and the brainstem-tentorium angle (BTA) have been proposed to quantify vermian and tentorial alterations associated to fetal posterior fossa malformations. Our objective is to evaluate the intra- and inter-observer agreement for the measurement of these angles during the prenatal ultrasound scan. METHODS: Fifteen 3 D sets from fetuses with posterior fossa pathology were processed by multiplanar navigation. Four experts in prenatal ultrasound measured the BVA and the BTA on a mid-sagittal view of the fetal brain, following the criteria described by Volpe. Observer 1 did also repeated measurements following both the criteria by Volpe and Ghi. The intraclass correlation coefficient (ICC) was used to test consistency and absolute agreement for intra- and inter-observer measurements. The concordance is poor when ICC <0.40 and excellent when ICC >0.75. RESULTS: Consistency ICC for measurements between the 4 observers was 0.74 (95% CI: 0.54-0.89) for the BVA and 0.55 (95% CI: 0.29-0.78) for the BTA. Absolute agreement ICC was 0.67 (BVA) and 0.45 (BTA). The intra-observer study showed a significantly greater angle with the criteria by Ghi (mean 52.1°, 95% CI: 49.5-54.8) than with the criteria by Volpe (mean 37.4°, 95% CI: 33.1-41.6). CONCLUSIONS: A more precise methodology for the measurement of these angles should be described.

Intracranial translucency at 11-13 weeks of gestation: prospective evaluation and reproducibility of measurements.

OBJECTIVE: This paper aimed to determine the feasibility of identification and measurement reproducibility of intracranial translucency (IT) in our population. METHODS: This is a prospective study in which five accredited operators attempted to identify and measure the IT during first-trimester sonographic screening for aneuploidy in 990 fetuses. The presence or absence of spina bifida was determined at the time of the second-trimester scan or after birth. Measurement reproducibility was assessed through intraclass correlation coefficient (ICC) on a subgroup of 150 fetuses. RESULTS: Identification and measurement of the IT were possible in 961 (97%) cases. The mean IT anteroposterior diameter was 1.8 mm (SD ± 0.37; range 0.8-3.1), and the size increased linearly with advancing gestation (IT = 0.74 + 0.02 × crown-rump length; r(2) = 0.15, p < 0.0001). The only fetus with spina bifida in this series presented with absent IT. Intra-observer and inter-observer ICCs were 0.79 and 0.75, respectively (95% confidence intervals 0.72-0.84 and 0.67-0.81, respectively; both p < 0.001). CONCLUSIONS: The IT increases linearly with increasing crown-rump length and seems to be of value in the first-trimester detection of spina bifida. It is easy to identify and measure and shows excellent intra-observer and inter-observer reproducibility measurements.

¿Cuál es tu diagnóstico? Caso iconográfico número 12 / What is your diagnosis? Illustrated case number 12

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Feasibility of 3-dimensional sonographic examination of the fetal secondary palate during the second-trimester anatomy scan.

OBJECTIVES: To determine the feasibility of obtaining adequate 3-dimensional (3D) data sets to examine the fetal secondary palate during the second-trimester anatomy scan. METHODS: During a 3-month period, 3D data sets of the fetal secondary palate were obtained from consecutive women undergoing routine second-trimester scans. Only structurally normal singleton fetuses with a normal upper lip on 2-dimensional (2D) sonography were included. Three-dimensional data sets were obtained using a mechanical transducer with a 45° sweep and the same settings as for the standard 2D scan, ideally when the fetus was facing the transducer, with mild extension of the head, and the ultrasound beams projecting caudally to cranially to avoid shadowing from the primary palate or mandible. No additional scanning time was allocated for examination of the palate. Acquired 3D data sets were analyzed offline using dedicated software, and the secondary palate was assessed using the "flipped face" technique. RESULTS: Ninety-seven women met entry criteria and underwent second-trimester scans at a median gestational age of 22 completed weeks (range, 18-23 weeks). In 13 (13.4%) cases, it was not possible to obtain a midsagittal view of the face for capturing 3D volume data sets due to fetal position. Additional factors limiting visualization were shadowing from the primary palate in fetuses with flexion of the head in 30 (30.9%) cases, interposition of, or shadowing from, fetal arms or legs in 11 (11.3%), inability to reproduce a true midsagittal plane in 8 (8.2%), and poor image quality in 1 (1%). Therefore, it was only possible to assess the secondary palate in 34 (35.1%) cases. CONCLUSIONS: It is not feasible to obtain adequate 3D data sets for offline analysis of the fetal secondary palate in almost two-thirds of second-trimester fetuses during the routine scan. However, suboptimal visualization is primarily due to factors related to fetal position rather than equipment or image quality. This finding suggests that a dedicated scan, during which adequate time can be devoted to obtaining a satisfactory position in which the fetal face can be evaluated, may be warranted in high-risk cases.

Antenatally diagnosed renal duplex anomalies: sonographic features and long-term postnatal outcome.

OBJECTIVES: The purpose of this study was to assess the diagnostic accuracy and infant outcomes of antenatally detected renal duplex anomalies. METHODS: An observational longitudinal study of cases of renal duplex anomalies diagnosed on prenatal sonography was conducted. Information on the prenatal sonographic findings, antenatal course, and perinatal outcome was obtained by reviewing the sonography reports and delivery records. Postnatal follow-up, including neonatal and infant evaluations, was obtained from hospital records. RESULTS: During a 7-year period, a total of 24 cases of renal duplex anomalies were identified prenatally. Three cases were excluded from subsequent analysis because of termination of pregnancy after the diagnosis of a severe brain abnormality, loss to follow-up, and an inability to confirm the prenatal diagnosis on neonatal renal sonography. Among the 21 confirmed cases, the presence of two separate renal pelvises was the most common prenatal sonographic feature (n = 15 [71%]), followed by dilatation of a single moiety with a dilated ipsilateral ureter or ureterocele (n = 6 [29%]). In 43% of cases, the renal duplex anomalies had no adverse associations, but in 48%, they were complicated by a urinary tract infection, and 48% of the infants required a surgical procedure during early childhood. CONCLUSIONS: Renal duplex anomalies can be accurately diagnosed by prenatal sonography even when there is minimal dilatation of the renal pelvis. Antenatal diagnosis allows planning of postnatal care, which may prevent urinary tract infections and renal function impairment. The natural history of antenatally diagnosed duplex anomalies seems to be overall benign, with urinary tract infections and the need for surgery being the most common complications in affected infants.

First-trimester assessment of the nasal bones using the retronasal triangle view: a 3-dimensional sonographic study.

OBJECTIVE: The purpose of this study was to evaluate a new sonographic technique for identifying the nasal bones using the retronasal triangle view, ie, the coronal plane at which the palate and frontal processes of the maxilla are simultaneously visualized. METHODS: Three-dimensional (3D) volumes were acquired from women undergoing first-trimester sonographic screening for aneuploidy by 2 accredited operators. Those data sets in which the fetal face was clearly identified were selected for offline analysis by 2 other observers who were unaware of the sonographic or clinical findings. The nasal bones were classified as both present, only 1 present (right or left), or absent according to the presence or absence of 2 small paired echogenic linear structures at the upper tip of the retronasal triangle as determined by 3D navigation in the coronal plane and compared to those findings obtained by 3D navigation in the sagittal plane. Additional 3D data sets involving a subset of 4 first-trimester fetuses with trisomy 21 and absent nasal bones were also analyzed retrospectively and included randomly in the study group. RESULTS: A total of 110 3D data sets were analyzed, of which 86% were obtained transabdominally and 14% transvaginally. The quality of nasal bone identification was classified subjectively by the observers as good in 67% of cases, fair in 29%, and poor in 4%. The nasal bones were classified as at least 1 present in 106 of the cases (96%) and absent in 4 (4%), with complete agreement between observers in both the sagittal and coronal planes (κ = 1). Discrimination between the right and left nasal bones was possible in 89% and 93% for observer A and in 96% and 96% for observer B by assessing the sagittal and coronal views, respectively (right nasal bone: κ = 0.90 [95% confidence interval (CI), 0.79-1]; left nasal bone: κ = 0.85 [95% CI, 0.60-0.99]). The nasal bones were not identified at the level of the retronasal triangle view in any of the fetuses with trisomy 21 and absent nasal bones. CONCLUSIONS: This study shows that the nasal bones can be confidently identified as paired echogenic structures located at the upper tip of the retronasal triangle. This coronal view of the fetal face offers the possibility of screening for the presence or absence of the nasal bones in the first trimester, especially when the standard midsagittal views of the fetal face are suboptimal because of fetal or maternal factors. Because both nasal bones can be evaluated simultaneously in the coronal plane, the retronasal triangle view may be advantageous over the conventional midsagittal view assessment, in which only 1 of the 2 nasal bones is evaluated.