The experience of vasa praevia for Australian midwives: A qualitative study

© 2018 Australian College of Midwives Background: Vasa praevia can cause stillbirth or early neonatal death if it is not diagnosed antenatally and managed appropriately. Experiencing undiagnosed vasa praevia during labour is challenging and traumatic for women and their care providers. Little is known about the experiences of midwives who care for these women. Aim: To investigate the experience of Australian midwives caring for women with undiagnosed vasa praevia during labour and birth. Methods: A qualitative descriptive study was conducted with midwives in Australia who had cared for at least one woman with vasa praevia during 2010–2016. Semi-structured in-depth telephone interviews were conducted and analysed using thematic analysis. Findings: Twelve of the 20 midwives interviewed were involved in a neonatal death and/or near-miss due to vasa praevia. There was one over-arching theme, which described the ‘devastating and dreadful experience’ for the midwives. This had two inter-related categories of feeling the personal impacts and addressing the professional processes. Feeling scared, shocked, and guilty described how the experience took its toll on the midwives personally. The professional processes included working in organised chaos; feeling for the parents; finding communication to be hard; and, doing their best to save the baby. Discussion: Caring for women who experienced ruptured vasa praevia had a profound impact on the emotional and professional well-being of midwives even when the baby survived. Conclusion: Ruptured vasa praevia was recognised as a traumatic experience that warrants serious considerations from maternity care providers, managers and policy makers. Midwives should be supported and adequately prepared to cope with traumatic events

Congenital tumors: imaging when life just begins

BACKGROUND: The technical developments of imaging methods over the last 2 decades are changing our knowledge of perinatal oncology. Fetal ultrasound is usually the first imaging method used and thus constitutes the reference prenatal study, but MRI seems to be an excellent complementary method for evaluating the fetus. The widespread use of both techniques has increased the diagnosis rates of congenital tumors. During pregnancy and after birth, an accurate knowledge of the possibilities and limits of the different imaging techniques available would improve the information obtainable, thus helping the medical team to make the most appropriate decisions about therapy and to inform the family about the prognosis. CONCLUSION: In this review article, we describe the main congenital neoplasms, their prognosis and their imaging characteristics with the different pre- and postnatal imaging methods available

Liquid biopsies come of age: towards implementation of circulating tumour DNA

Improvements in genomic and molecular methods are expanding the range of potential applications for circulating tumour DNA (ctDNA), both in a research setting and as a ‘liquid biopsy’ for cancer management. Proof-of-principle studies have demonstrated the translational potential of ctDNA for prognostication, molecular profiling and monitoring. The field is now in an exciting transitional period in which ctDNA analysis is beginning to be applied clinically, although there is still much to learn about the biology of cell-free DNA. This is an opportune time to appraise potential approaches to ctDNA analysis, and to consider their applications in personalized oncology and in cancer research.We would like to acknowledge the support of The University of Cambridge, Cancer Research UK (grant numbers A11906, A20240, A15601) (to N.R., J.D.B.), the European Research Council under the European Union's Seventh Framework Programme (FP/2007-2013)/ERC Grant Agreement n. 337905 (to N.R.), the Cambridge Experimental Cancer Medicine Centre, and Hutchison Whampoa Limited (to N.R.), AstraZeneca (to R.B., S.P.), the Cambridge Experimental Cancer Medicine Centre (ECMC) (to R.B., S.P.), and NIHR Biomedical Research Centre (BRC) (to R.B., S.P.). J.G.C. acknowledges clinical fellowship support from SEOM

Providing quality care for women with vasa praevia: Challenges and barriers faced by Australian midwives

© 2018 Elsevier Ltd Objective: To explore the barriers to providing quality maternity care for women with vasa praevia as identified by Australian midwives. Design: A qualitative descriptive study using semi-structured in-depth telephone interviews. Setting: Australian maternity system. Methods: Midwives were recruited from across Australia. Interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis. Participants: Twenty midwives from five Australian states practising in 15 different public or private hospitals who had cared for at least one woman with vasa praevia during 2010–2016 were interviewed. More than half of the participants held senior positions. Twelve were involved in a neonatal death or ‘near-miss’ due to vasa praevia. Findings: Two categories and five themes were identified in relation to barriers to the provision of quality care. Practitioner-level barriers included two themes: identifying lack of midwifery education and lack of knowledge. System-level barriers included lack of a local policy to guide practice, limited information for women, and paucity of research about vasa praevia. Conclusion: Midwives experienced a number of barriers in caring for women with vasa praevia. Offering more comprehensive pre-registration and continuing professional education to midwives, developing local protocols, and providing clear written information for women may improve the provision of quality care. Implications for practice: Midwives have a critical role in caring for and supporting women with vasa praevia. Improving midwives’ knowledge with contemporary evidence and clinical guidelines could enable them to deliver safer maternity care and improve a women's journey through this potentially catastrophic condition

A survey of opinion and practice regarding prenatal diagnosis of vasa previa among obstetricians from Australia and New Zealand

© 2018 International Federation of Gynecology and Obstetrics Objectives: To define current obstetric opinion and clinical practice regarding the prenatal diagnosis of vasa previa in Australia and New Zealand. Methods: A population-based cross-sectional survey of Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists was conducted from April to May, 2016. Descriptive analysis was used to define factors influencing opinion and practice regarding definition of vasa previa, attributable risk factors, and the value of screening. Results: Overall, 453 respondents were included in the study. Two-thirds (304/453; 67.1%) defined vasa previa as exposed fetal vessel(s) running over or within 2 cm of the internal os. A higher proportion of ultrasound specialists (30/65; 46.2%) preferred a broader definition as compared with generalists (115/388; 29.6%; P<0.001). Overall, Fellows were supportive (342/430; 79.5%) of both reporting ultrasound-based risk factors at the 20-week anomaly scan and targeted screening (298/430; 69.3%). Only 77/453 (17.0%) respondents recognized all five “known” risk factors for vasa previa. Conclusions: There was a lack of consensus regarding the definition and diagnosis process for vasa previa. There was also a knowledge gap in risk factors for vasa previa that would inform a targeted screening policy. Nevertheless, support for targeted screening was strong from obstetricians who responded

Increased nuchal translucency with normal karyotype

Increased fetal nuchal translucency (NT) thickness between 11 and 14 weeks’ gestation is a common phenotypic expression of chromosomal abnormalities, including trisomy 21. However, even in the absence of aneuploidy, nuchal thickening is clinically relevant because it is associated with an increase in adverse perinatal Outcome caused by a variety of fetal malformations, dysplasias, deformations, dysruptions, and genetic syndromes. Once the presence of aneuploidy is ruled Out, the risk of perinatal Outcome close not statistically increase until the nuchal translucency measurement reaches 3.5 min or more (&gt; 99th percentile). This increase in risk Occurs in an exponential fashion as the NT measurement increases. However, if the fetus survives until midgestation, and if a targeted ultrasound at 20 to 22 weeks fails to reveal any abnormalities, the risk of an adverse perinatal outcome and postriatal developmental delay is not statistically increased. (c) 2005 Elsevier Inc. All rights reserved

First-trimester ultrasound features associated with subsequent miscarriage: A prospective study

Background: First-trimester miscarriage is common, with women increasingly offered an ultrasound scan early in the first trimester to assess the status of their pregnancy. Ultrasound is uniquely situated to significantly impact the clinical management of these women. Aims: This study aims to determine whether there were any differences in the early ultrasound appearances of pregnancies that continued to be viable or resulted in miscarriage before 12 weeks gestation. Materials and Methods: This was a prospective cohort study including ultrasound measurements: mean sac diameter (MSD), yolk sac diameter (YSD), crown-rump length (CRL), fetal heart rate (FHR), trophoblast thickness, trophoblast volume (TTV) and mean uterine artery pulsatility index (meanUAPI). Regression models were fitted for each parameter and Z-scores compared between cohorts that progressed or miscarried after the scan but before 12 weeks gestation. Logistic regression analysis was used to create a prediction model for miscarriage prior to 12 weeks gestation based on the standardised ultrasound measurements recorded during the early first-trimester scan. Results: Comparison of Z-Scores for meanUAPI, TTV, FHR and MSD demonstrated significant variation between the two groups. The proposed logistic regression model resulted in an area under the receiver operator curve of 0.81. At a false-positive rate of 30%, the model resulted in a sensitivity of 76% (95% CI 64–89%). Conclusion: The combination of FHR, meanUAPI, TTV in a prediction model for miscarriage may prove to be of value for ongoing pregnancy management in the first trimester. © 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologist

Uterine artery pulsatility index assessment at <11 weeks' gestation: A prospective study

Objective: Mean uterine artery pulsatility index (meanUAPI) is commonly measured at 11–13+6 weeks to predict adverse pregnancy outcomes including hypertensive disorders and small-for-gestational age. The aims of this study were to establish a population-specific reference range for meanUAPI at <11 weeks, to determine if an abnormal meanUAPI at <11 weeks was associated with adverse pregnancy outcome, and to assess changes in meanUAPI between <11 weeks and 11–13+6 weeks. Methods: A prospective cohort was examined at <11 weeks and at 11–13+6 weeks to develop reference ranges for meanUAPI. Based on these regression models, meanUAPI Z-scores were compared between outcome groups using a two-sample t test. Longitudinal changes in the meanUAPI between <11 and 11–13+6 weeks were assessed by two-way mixed ANOVA. Results: Prior to 11 weeks, there was no significant difference in meanUAPI between normal (n = 622) and adverse (n = 80) outcomes (mean [95% CI]: 2.62 [2.57–2.67] and 2.67 [2.50–2.84], respectively; p = 0.807). At 11–13+6 weeks, meanUAPI was significantly higher in the adverse (n = 66) compared with the normal (n = 535) outcome group (mean [95% CI]: 1.87 [1.70–2.03] and 1.67 [1.63–1.72], respectively; p = 0.040). There was a statistically significant decrease (p < 0.0001) in meanUAPI between the two time points. Conclusion: MeanUAPI measured at <11 weeks’ gestation does not appear to be a useful marker for the prediction of placental-related adverse pregnancy outcomes, supporting an argument for the prediction of risk at 11–13+6 weeks’ gestation. s, there was no significant difference in meanUAPI between normal (n

First‐trimester ultrasound features associated with subsequent miscarriage: A prospective study

Background: First-trimester miscarriage is common, with women increasingly offered an ultrasound scan early in the first trimester to assess the status of their pregnancy. Ultrasound is uniquely situated to significantly impact the clinical management of these women. Aims: This study aims to determine whether there were any differences in the early ultrasound appearances of pregnancies that continued to be viable or resulted in miscarriage before 12 weeks gestation. Materials and Methods: This was a prospective cohort study including ultrasound measurements: mean sac diameter (MSD), yolk sac diameter (YSD), crown-rump length (CRL), fetal heart rate (FHR), trophoblast thickness, trophoblast volume (TTV) and mean uterine artery pulsatility index (meanUAPI). Regression models were fitted for each parameter and Z-scores compared between cohorts that progressed or miscarried after the scan but before 12 weeks gestation. Logistic regression analysis was used to create a prediction model for miscarriage prior to 12 weeks gestation based on the standardised ultrasound measurements recorded during the early first-trimester scan. Results: Comparison of Z-Scores for meanUAPI, TTV, FHR and MSD demonstrated significant variation between the two groups. The proposed logistic regression model resulted in an area under the receiver operator curve of 0.81. At a false-positive rate of 30%, the model resulted in a sensitivity of 76% (95% CI 64–89%). Conclusion: The combination of FHR, meanUAPI, TTV in a prediction model for miscarriage may prove to be of value for ongoing pregnancy management in the first trimester. © 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologist