Successful pregnancy outcome depends on a co-coordinated series of events in development designed to attain normal placental function. The critical importance of placental vascular development is appreciated when a wide range of pregnancy complications including preterm labour (PTL), preterm premature rupture of the membranes (PPROM), pre-eclampsia (PE), fetal growth restriction (FGR), fetal demise (FD), and abruptio placenta (ABR) are all associated with restricted maternal and/or fetal blood flow, and secondary pathological lesions in the placental parenchyma. Other developmental defects of the placenta, such as its site (placenta praevia), extent of myometrial invasion (placenta accreta) or cord insertion (vasa praevia), may have major detrimental maternal and/or fetal effects if unrecognized during the antenatal period. In January 1999 we commenced a “Placenta Clinic” within the Fetal Medicine Unit at Mount Sinai Hospital (Toronto, Canada). Our rationale was that the early identification of many of these problems may, by facilitating appropriate multidisciplinary care and an elective delivery plan, reduce the attendant risks of maternal and perinatal morbidity and/or mortality due to placental malfunction.

Tara, a 24 year-old woman of Sri Lankan ancestry, was diagnosed with borderline chronic hypertension just 4 months before her first pregnancy. While she experienced a healthy childhood and normal pubertal development, by age 22 years her body mass index (BMI) was 29 kg/m2. The first pregnancy was complicated by chronic hypertension and superimposed preeclampsia (PET), necessitating Caesarian delivery at 33 weeks gestation. In her third pregnancy she was diagnosed with gestational diabetes mellitus (DM), and delivered a 4100 g macrosomic infant boy by Caesarian section. By age 42 years, Tara was started on oral medications for Type 2 DM and hypertriglyceridaemia; 9 years later she suffered a small lacunar stroke, leaving her with moderate left-sided weakness of the arm and leg. Her own mother had experienced “high blood sugars” during pregnancy, was overweight, and died at age 54 years from the complications of high blood pressure.

Obstetric cholestasis (OC) is defined as pruritus of onset in pregnancy in association with abnormal liver function in the absence of any other identifiable liver pathology which resolves on delivery. It may be associated with adverse obstetric outcome and significant maternal morbidity. The significance of the disease has only recently been appreciated, and our understanding of its pathophysiology is in its infancy. This article will describe our current knowledge of the disease and critically review the interventions proposed to improve obstetric outcome and maternal morbidity.

Antiphospholipid antibodies (aPLs) are a diverse group of autoantibodies with specificity for phospholipid surfaces. Antiphospholipid antibodies may be found in individuals with a clinical history of thrombotic events or in women suffering severe pregnancy complications typically involving fetal compromise or demise. The association is known as the antiphospholipid syndrome (APS).