Objective To estimate the shape and magnitude of associations between maternal Hb levels in the first and third trimesters of pregnancy, and pregnancy outcomes in a high-income setting. Design Prospective cohort studies Setting Two population based pregnancy cohorts from the UK Population The Avon Longitudinal Study of Parents and Children(ALSPAC) and Pregnancy Outcome Prediction Study(POPS). Methods We used multivariable logistic regression models to examine the relationship between Hb and pregnancy outcomes, adjusting for maternal age, ethnicity, BMI, smoking status and parity. Main Outcome Measures Preterm labour, low birth weight, small for gestational age(SGA), pre-eclampsia(PET), and gestational diabetes mellitus(GDM). Results There was no strong evidence of associations between a higher Hb (1g/dL) in the first trimester and preterm birth (1.07: 95% CI 0.96,1.21), low birth weight(1.09: 0.96, 1.24) and SGA (1.05; 0.96, 1.14). Higher Hb in the third trimester was associated with preterm birth (1.43:1.28,1.61), low birth weight(1.68: 1.48,1.90) and SGA (1.41:1.30, 1.53). Higher Hb in the first and third trimesters were associated with PET in ALSPAC(1st trimester- 1.38:1.07,1.76, 3rd trimester- 1.57: 1.28,1.94) but not in POPS(1st trimester- 1.10: 0.92, 1.30, 3rd trimester- 1.10: 0.92, 1.31). In ALSPAC(1st trimester- 1.37:0.96,1.95, 3rd trimester- 1.35:0.97,1.78) and POPS(1st trimester- 0.94:0.77, 1.17, 3rd trimester- 0.85: 0.69, 1.01), there were no associations with GDM. Conclusion Higher maternal Hb, in late pregnancy, may indicate a suboptimal increase in blood volume and therefore, women at risk of adverse pregnancy outcomes. Further research is required to investigate if this association is causal, and to identify underlying mechanisms.

Objective To explore and characterise maternity healthcare professionals’ (MHCPs) experience and practice of informed decision-making (IDM), to inform policy, research and practice development. Design Qualitative focus group study. Setting Online with MHCPs from a single maternity unit in the Southwest of England. Population MHCPs who give information relating to clinical procedures and pregnancy care and are directly involved in decision-making conversations purposively sampled from a single National Health Service (NHS) Trust. Data collection: A semi-structured topic guide was used. Data Analysis: Reflexive thematic analysis . Results Twenty-four participants attended seven focus groups. Two themes were developed: contextualising decision-making and controversies in current decision-making. Contextual factors that influenced decision-making practices included lack of time, and challenges faced in intrapartum care. MHCPs reported variation in how they approach decision-making conversations and asked for more training on how to consistently achieve IDM. There were communication challenges with women/birthing people who do not speak English. Three controversies were explored in the controversies theme: the role of prior clinical experience, the validity of informed consent when women/birthing people were in pain and during emergencies, and instances where women/birthing people declined medical advice. Conclusions We found that MHCPs are committed to IDM but need better support to deliver it consistently. Structured processes including core information sets, communication skills training and the decision support aids may help to standardise the information and better support IDM.

Background: The success of coronary artery bypass grafting surgery (CABG) is dependent on long-term graft patency, which is negatively related to early wall thickening. Avoiding high-pressure distension testing for leaks and preserving the surrounding pedicle of fat and adventitia during vein harvesting may reduce wall thickening. Methods: A single-centre, factorial randomised controlled trial was carried out to compare the impact of testing for leaks under high versus low pressure and harvesting the vein with versus without the pedicle in patients undergoing CABG. The primary outcomes were graft wall thickness, as indicator of medial-intimal hyperplasia, and lumen diameter assessed using intravascular ultrasound after 12 months. Results: 96 eligible participants were recruited. With conventional harvest, low-pressure testing tended to yield a thinner vessel wall compared to high-pressure (mean difference MD (low minus high) -0.059mm, 95%CI -0.12, +0.0039, p=0.066). With high pressure testing, veins harvested with the pedicle fat tended to have a thinner vessel wall than those harvested conventionally (MD (pedicle minus conventional) -0.057mm, 95%CI -0.12, +0.0037, p=0.066, test for interaction p=0.07). Lumen diameter was similar across groups (harvest comparison p=0.81; pressure comparison p=0.24). Low pressure testing was associated with fewer hospital admissions in the 12 months following surgery (p=0.0008). Harvesting the vein with the pedicle fat was associated with more complications during the index admission (p=0.0041). Conclusions: Conventional saphenous vein graft preparation with low pressure distension and harvesting the vein with a surrounding pedicle yielded similar graft wall thickness after 12 months, but low pressure was associated with fewer adverse events.