Research Questionnaire

As part of our goal to increase awareness of vasa previa amongst the medical community worldwide, the IVPF participates in studies which yield important information about vasa previa.

You have been affected by vasa previa and understand, better than anyone else, the devastating impact of the loss of a much awaited and beloved otherwise healthy child to vasa previa. Our goal is to prevent more babies being lost to this terrible complication of pregnancy. This can only be achieved by raising awareness of the different ways the condition presents, of associated risk factors, diagnostic modalities, treatment and outcomes.

However, to achieve this goal, we need your help.  If you have not already done so, please help us by filling in the following questionnaire about your experience with vasa previa.

Your name will be kept confidential and will not be used in any study. We are counting on you to help us reduce the incidence of these preventable deaths.

Thank you for all of your help.

Victoria Goldstein
IVPF Research Committee
Research@vasaprevia.com

QUESTIONNAIRE:
1.	What was your age at time of your vasa previa pregnancy?
2.	Was this your first pregnancy?	Yes   No
3.	If not your first pregnancy, how many other pregnancies have you had before your vasa previa pregnancy?
4.	Were your other pregnancies vaginal or cesarean deliveries?	---Please select an answer--- a--Vaginal b--Cesearan c--One or more Vaginal and one or more Cesearean
5.	Were you diagnosed with a low lying placenta or another placental abnormality at any time during your pregnancy?  If so, did it correct itself?	---Please select an answer--- a--Yes b--Yes and it corrected itself c--No
6.	Did you bleed at any time during your pregnancy?	Yes   No
7.	If you did bleed, when did it occur?
8.	Did you undergo in-vitro fertilization (IVF)?	Yes   No
9.	Were you hospitalized during your pregnancy?	Yes at weeks gestation   No
10.	How was your vasa previa diagnosed?	---Please select an answer--- a--Ultrasound b--A test for fetal blood was performed when I bled c--Not Diagnosed
11.	Did your baby survive?	Yes   No
12.	What were the Apgars?
13.	Was a neonatal transfusion performed?	Yes   No
14.	Was your delivery vaginal or cesarean?	---Please select an answer--- a--Vaginal Delivery b--Cesarean Delivery
15.	Was amniocentesis performed for lung  maturity prior to delivery?	Yes   No
16.	Were steroids given?	Yes   No
17.	What was the gestational age at delivery?
18.	Reason for delivery:	---Please select an answer--- a--Elective, Diagnosed b--Elective, Not Diagnosed c--Emergency, Bleeding d--Emergency, Abnormal Fetal Heart Tracing e--Preterm Labor f--Other, fill in #27 g--I don't know
19.	Are you a smoker?	Yes   No
20.	Pathology:	---Please select an answer--- a--Velamentous Cord Insertion (VCI) b--Bi-lobed Placenta c--Succenturiate Lobed Placenta d--VCI AND Ruptured Vessels e--Bi-lobed or Succenturiate AND Ruptured Vessels f--VCI AND Bi-lobed or Succenturiate AND Ruptured Vessels g--Unknown h--I don't know
21.	Do you have pictures of the placenta or sonographic (ultrasound) reports?	---Please select an answer--- a--Yes, I have pictures of the placenta b--Yes, I have my ultrasound scan c--Yes, I have both placenta pictures and ultrasound scan d--No, I have neither pictures or scan
22.	Did you have a previous D&C before your vasa previa pregnancy?	Yes   No
23.	Full name of your vasa previa child: (first, middle, last)
24.	Child's Birthdate: (MM/ DD / YYYY)
25.	Mother's name:  (first, last)
26.	Father's name:   (first, last)
27.	Your email address:
28.	Additional Information:   (optional)