Women- and clinician- important outcomes and priorities regarding vasa praevia : An international qualitative study to inform development of a core outcome set

Background Many studies have reported interventions for women with vasa praevia to improve perinatal outcomes. However, which outcomes are important for women remains unclear. Aim To explore what outcomes are important for women with lived experience of vasa praevia and why, in order to inform the development of a core outcome set for studies on vasa praevia. Methods An international qualitative study was conducted with women and clinicians. Semi-structured interviews were audio-recorded, transcribed, and analysed taking an inductive approach. Findings Eighteen women and six clinicians (four obstetricians, two midwives) from the United States, United Kingdom, Canada, and Australia were interviewed. Participants identified 47 patient-important outcomes and experience measures, which were grouped under five themes: baby’s survival and health, mother’s physical health, mother’s mental and emotional health, quality of health care delivery, and resource use and cost. While survival of the baby without short- and long-term morbidity remained the main priority, other important considerations included the physical, mental, social and financial wellbeing of families, future access to antenatal screening and diagnosis, information on management options and consequences, continuity of care, clear and effective communication, peer support and the appreciation of individual variations to risk tolerance, values and resource availability. Conclusion We have identified patient-important outcomes and experience measures that have been directly fed into the development of a core outcome set on vasa previa. Incorporating these considerations into both clinical practice and future research studies has the potential to improve outcomes and experiences for women with vasa praevia

Long-term persistence of large dugong groups in a conservation hotspot around Hawar Island, Kingdom of Bahrain

1.Predictable aggregations of large marine mammals are valuable conservation targets, but aggregated populations can also be exposed to site-level threats. 2.The globally vulnerable Dugong dugon has a wide distribution but is found in large numbers mainly in Australia and the Arabian Gulf. Though Australian dugong populations are well studied, much less is known of the dugongs in the Arabian Gulf. 3.The spatial and temporal persistence of dugongs around Bahrain, with a focus on large dugong groups (>50 dugongs), was determined using an occupancy modelling framework supported by historical records, structured interviews, citizen science network reports, and small-scale boat and unmanned aerial vehicle surveys. 4.Historical records and current distributional studies confirmed that large dugong groups have been reliably sighted around Hawar Island (Bahrain) since at least 1986, forming large, clumped groups that persist almost year round. The largest recorded so far in the world, these fluid groups (maximum of ~700 dugongs) account for ~60% of the dugongs found in Bahrain and ~12% of all dugongs in the Arabian Gulf. 5.The delineated occupancy core area of large dugong groups (~145 km2) straddles the Bahrain–Qatar border, reflecting the transboundary nature of these groups. 6.Careful management of human-induced stressors (in particular, fishing, boating, and coastal development) combined with regular monitoring of Hawar Island's large dugong groups and their seagrass habitat is critical to safeguard this globally important population. 7.The effectiveness of any conservation management is predicated on strengthening cooperation among all range states in the Arabian Gulf. A key recommendation of this study is to establish a regional network of marine protected areas encompassing core aggregation sites for dugongs, particularly the Hawar Islands in Bahrain, the north-western waters of Qatar, Marawah Island in the United Arab Emirates in addition to the shallow waters between Saudi Arabia, Qatar, and United Arab Emirates

Core outcome set for studies on pregnant women with vasa previa (COVasP) : A study protocol

Introduction: Vasa previa is a condition where fetal blood vessels run unprotected in the membranes, outside the umbilical cord, and cross the internal opening of the cervix. During rupture of membranes, these vessels can rupture and put the baby at serious risk of severe blood loss and death. Numerous studies are being conducted to improve diagnostic modalities and establish clear management plans to improve pregnancy outcomes. However, the lack of a standardised set of outcomes for studies on vasa previa makes it difficult to compare study findings and draw meaningful conclusions. Through this project, we will be developing a core outcome set for studies on pregnant women with vasa previa (COVasP). Methods and analysis: The development of COVasP will involve five steps. The first will be a systematic review, in which we will generate a long list of outcomes based on published studies in pregnancies complicated with vasa previa. The second will involve in-depth interviews with current and former patients, their family members and healthcare providers who care for these patients. This will be followed by a two-round Delphi survey, which will aim to narrow down the long list of outcomes into those considered important by four groups of ‘stakeholders’: (1) patients, family members and patient advocates/representatives, (2) healthcare providers, (3) researchers, epidemiologists and methodologists and (4) other stakeholders directly or indirectly involved in the management of these pregnancies such as administrators, guideline developers and policymakers. The fourth step will involve a face-to-face consensus meeting using a nominal group approach to establish a finalised core outcome set. The final step will involve measuring and defining the identified outcomes using a combination of systematic reviews and Delphi surveys

Identifying conservation priorities for a widespread dugong population in the Red Sea: Megaherbivore grazing patterns inform management planning

Extensive home ranges of marine megafauna present a challenge for systematic conservation planning because they exceed spatial scales of conventional management. For elusive species like dugongs, their management is additionally hampered by a paucity of basic distributional information across much of their range. The Red Sea is home to a wide-spread, globally important but data-poor population of dugongs. We surveyed the north-eastern Red Sea in the waters of NEOM, Kingdom of Saudi Arabia, to locate feeding sites and determine priority areas for dugong conservation. We conducted large-scale in-water surveys of dugong feeding trails across 27 seagrass meadows that span 0.7 degree of latitude and recorded nine seagrass species and 13 dugong feeding sites. Spread over ∼4‚061 km2 of nearshore and offshore waters, many of these sites clustered around five main core feeding areas. Dugong feeding trails were mostly recorded at sites dominated by the fast-growing pioneer seagrasses Halodule uninervis, Halophila ovalis and/or H. stipulacea. Multispecific meadows with pioneer seagrasses tended to be sheltered and shallow, reflecting a similar spatial pattern to the identified dugong feeding sites. Often close to hotels and fishing harbours, these high-use dugong areas are subject to high boat traffic, fishing, and coastal development which places considerable pressures on this vulnerable mammal and its seagrass habitat. The rapidly accelerating coastal development in the northern Red Sea directly threatens the future of its dugong population. Although our sampling focuses on feeding signs in early successional seagrasses, the results are valuable to spatial conservation planning as they will trigger overdue conservation interventions for a globally threatened species in a data-poor area. Urgent dugong conservation management actions in the northern Red Sea should focus on shallow waters sheltered by coastal lagoons, bays and the lee of large islands

Values and preferences towards the use of prophylactic low-molecular-weight heparin during pregnancy : a convergent mixed-methods secondary analysis of data from the decision analysis in shared decision making for thromboprophylaxis during pregnancy (DASH-TOP) study

Altres ajuts: BH received a doctoral award from the Canadian Institutes for Health Research (Grant number: GSD - 152327). RD holds a Canada Research Chair in Maternal Health (CRC-2021\u201300337).Background: Venous thromboembolism (VTE) in pregnancy is a major cause of maternal morbidity and mortality, and the use of preventive low-molecular-weight heparin (LMWH) can be challenging. Clinical guidelines recommend eliciting pregnant individuals' preferences towards the use of daily injections of LMWH and discussing the best option through a shared decision-making (SDM) approach. Our aim was to identify individuals' preferences concerning each of the main clinical outcomes, and categorize attributes influencing the use of LMWH during pregnancy. Methods: Design: Convergent mixed-methods. Participants: Pregnant women or those planning a pregnancy with VTE recurrence risk. Intervention: A SDM intervention about thromboprophylaxis with LMWH in pregnancy. Analysis: Quantitatively, we report preference scores assigned to each of the health states. Qualitatively, we categorized preference attributes using Burke's pentad of motives framework: act (what needs to be done), scene (patient's context), agent (perspectives and influence of people involved in the decision), agency (aspects of the medication), and purpose (patient's goals). We use mixed-method convergent analysis to report findings using side-by-side comparison of concordance/discordance. Results: We comprehensively determined preferences for using LMWH by pregnant individuals at risk of VTE: through value elicitation exercises we found that the least valued health state was to experience a pulmonary embolism (PE), followed by major obstetrical bleeding (MOB), deep vein thrombosis (DVT), and using daily injections of LMWH (valued as closest to a 'healthy pregnancy'); through interviews we found that: previous experiences, access to care (scene) and shared decision-making (agent) affected preferences. LMWH's benefits were noted, but substantial drawbacks were described (agency). For participants, the main goal of using LMWH was avoiding any risks in pregnancy (purpose). Side-by-side comparisons revealed concordance and discordance between health states and motives. Conclusions: Mixed-methods provide a nuanced understanding of LMWH preferences, by quantifying health states preferences and exploring attributes qualitatively. Incorporating both methods may improve patient-centered care around preference-sensitive decisions in thromboprophylaxis during pregnancy

Vasa previa in singleton pregnancies: Diagnosis and clinical management based on an international expert consensus

There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies. (s): To systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions (FGD) and a Delphi technique. A four-round FGD and a three-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected based on their publication record on vasa previa. First, we convened an FGD panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A three-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa that the experts were asked to rate on a 5-point Likert scale (from strongly disagree = 1 to strongly agree = 5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of 3 or less were deemed to have had no consensus and excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and non-consensus statements were then aggregated. Sixty-eight international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on five continents and have contributed to over 80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, 91% for the first, second, and third rounds, respectively, and 71% completed all three rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including: 1) While there is no agreement on a distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2 cm distance; 2) All pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; 3) When a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at around 32 weeks to rule out vasa previa; 4) Outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; 5)Asymptomatic patients with vasa previa should be delivered by scheduled cesarean between 35- and 37-weeks of gestation; and 6) There was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa. Through FGD and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines. [Abstract copyright: Copyright © 2024. Published by Elsevier Inc.

Vasa Previa in Singleton Pregnancies: Diagnosis and Clinical Management Based on an International Expert Consensus

Background: There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies. // Objective: (s): To systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions (FGD) and a Delphi technique. // Study Design: A four-round FGD and a three-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected based on their publication record on vasa previa. First, we convened an FGD panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A three-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa that the experts were asked to rate on a 5-point Likert scale (from strongly disagree = 1 to strongly agree = 5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of 3 or less were deemed to have had no consensus and excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and non-consensus statements were then aggregated. // Results: Sixty-eight international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on five continents and have contributed to over 80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, 91% for the first, second, and third rounds, respectively, and 71% completed all three rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including: 1) While there is no agreement on a distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2 cm distance; 2) All pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; 3) When a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at around 32 weeks to rule out vasa previa; 4) Outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; 5)Asymptomatic patients with vasa previa should be delivered by scheduled cesarean between 35- and 37-weeks of gestation; and 6) There was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa. // Conclusions: Through FGD and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines

Association between maternal mRNA covid-19 vaccination in early pregnancy and major congenital anomalies in offspring: population based cohort study with sibling matched analysis

Objective: To examine the association between maternal mRNA covid-19 vaccination during the first trimester of pregnancy and the prevalence of major congenital anomalies in offspring. Design: Population based cohort study with sibling matched analysis. Setting: Multiple health administrative databases, linked and analysed at ICES, an independent, non-profit research institute that collects and analyses healthcare and demographic data, Ontario, Canada, from 16 October 2021 to 1 May 2023. Population: 174 296 singleton live births >20 weeks' gestation with an expected birth date between 16 October 2021 and 1 May 2023: 34 181 (20%) born to mothers who received one or two doses of an mRNA covid-19 vaccine in the first trimester and 34 951 (20%) born to mothers who did not receive a vaccine before or during pregnancy. The sibling matched analysis included 13 312 infants exposed to a covid-19 vaccine in the first trimester and 15 089 matched older siblings with the same mother, with an expected birth date after 16 October 2016 and no reported in utero exposure to a covid-19 vaccine. Main outcome measures: Major congenital anomalies, overall and grouped by specific organ systems, diagnosed within 28 days of birth. Results: Major congenital anomalies were present in 832 (24.3 per 1000 live births) infants exposed to an mRNA covid-19 vaccine in the first trimester compared with 927 (26.5 per 1000 live births) infants not exposed to a vaccine, resulting in an adjusted prevalence ratio of 0.89 (95% confidence interval (CI) 0.79 to 1.01). Major congenital anomalies were present in 283 (21.3 per 1000 live births) and 343 (22.7 per 1000 live births) infants exposed to an mRNA covid-19 vaccine in the first trimester and their older siblings not exposed to a vaccine, respectively (adjusted prevalence ratio 0.91, 95% CI 0.77 to 1.07). First trimester vaccination was not associated with an increase in major congenital anomalies grouped by specific organ system in the primary or sibling matched analyses. Results were similar across a range of subgroup and sensitivity analyses. Conclusions: In this large population based cohort study and sibling matched analysis, mRNA covid-19 vaccination during the first trimester of pregnancy was not associated with an increase in major congenital anomalies in offspring, overall or grouped by organ system.Canadian Institutes of Health ResearchVoRSUNY DownstateEpidemiology and BiostatisticsN/