Premature birth is associated with substantial excess childhood mortality and morbidity and therefore represents an important public health problem worldwide. In the United Kingdom and other industrialised countries it is now the commonest cause of infant mortality. This review will outline the most recently available data for the incidence of premature birth at local, regional, national and international level, and compare them to previously published figures. Any variation in these incidences will be considered along with factors likely to account for these differences. Problems with data collection and analysis will also be discussed.

It is only in the last decade that increasing recognition has been given to the impact of childbirth on the physical and psychological wellbeing of a woman. The fall in maternal mortality coupled with a rise in female life expectancy (80 years in the UK) have served to focus attention on quality of life. Childbirth has been implicated as a major aetiological factor in pelvic floor and perineal trauma.

Vascular and Interventional Radiology, more succinctly known as Interventional Radiology (IR), is the subspecialty of Medical Imaging or Radiology that deals with diagnosis and treatment using minimally invasive procedures under imaging guidance. Initially, fluoroscopy was the only imaging modality available, but ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are also currently being used for guidance. One of the basic skills used by interventional radiologists is the Seldinger technique: the introduction of a needle into a body cavity or lumen allowing passage of a wire guide, which in turn facilitates the insertion of a tube or catheter. Many IR procedures have supplanted more invasive surgical techniques, with the resultant benefits of lower morbidity and mortality, shorter hospital stays and recovery times, and lower costs. Traditionally, obstetricians and interventional radiologists seldom interacted with one another, but their collaboration in patient care and research is increasing as obstetricians realise the value of IR, and as the myriad techniques and tools in the interventionalist's armamentarium expand and evolve.

Prevention programmes against Rh alloimmunization are now so widespread as to be universal in the developed world. Accordingly, there has been a dramatic decline in the incidence of fetal anaemia secondary to this cause, along with relative growth in the importance of alloimmunization due to other antibodies, particularly Kell. Antibodies to the Kell group of antigens, in particular K1, can cause profound fetal anaemia leading to hydrops and fetal demise unless appropriate and timely intervention is undertaken.

Skeletal anomalies occur with a frequency of around 1:500 and can present a diagnostic challenge when detected prenatally. Increasingly more sophisticated imaging such as MRI or CT may elucidate features more easily interpreted by postnatal radiologists. The aetiology of these anomalies is varied and includes aneuploidy, genetic syndromes, skeletal dysplasias, teratogens, disruption and maternal disease, making a multidisciplinary approach to the diagnosis essential. The estimated prevalence of skeletal dysplasias varies from 2–3/10,000 to 4–7/10,000 and diagnosis may require biochemical, cytogenetic, molecular genetic or haematological investigation. Clinical genetic input is often required as the family history or parental examination may yield valuable clues to the diagnosis. This review will briefly describe the normal embryology and sonographic appearances of fetal limb development and go on to suggest a systematic approach to the diagnosis of fetal skeletal dysplasias.

During gametogenesis in mammals, half of the parental chromosomes segregate to each gamete. Upon fertilization of two haploid gametes, the diploid number is restored (Figure 1A). Nondisjunction, malsegregation of the chromosomes during gametogenesis, can give rise to chromosomally unbalanced offspring (trisomies and monosomies) (Figure 1B). Genomic imprinting is an epigenetic phenomenon in which the activity of a gene is reversibly modified depending on the parent of origin. This leads to unequal, monoallelic expression of the maternal and paternal alleles of a diploid locus (Figure 1C). Thus, the normal state of an imprinted locus is an “imbalance”, not of chromosomes, but of the functional genetic content.

The ultrasound diagnosis of myelomeningocele has been greatly improved by the recognition of associated abnormalities in the fetal skull and brain, potentially leading to an increased number of cases detected during pregnancy. Unfortunately, the counselling of potential parents about the natural history and prognosis of myelomeningocele is frequently based on extrapolations from data in which the diagnosis was made following delivery. Moreover, much of this information predates recent advances in paediatric care. In 1981, Leonard stated “as most children (with myelomeningocele) will grow to be productive, participating adults, then perhaps we should consider myelomeningocele a new disease”1. It is, therefore, appropriate to review recent outcome data for children with myelomeningocele, emphasising those studies where the diagnosis was made before delivery. This review will concentrate on issues of particular concern to the perinatal obstetrician, such as the reliability of sonographic diagnosis, the frequency of karyotypic anomalies, the likely longterm infant outcome and the most appropriate mode of delivery.

Gestational diabetes (GDM) is defined as “carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.” The definition is applicable regardless of whether insulin is used for treatment or the condition persists after pregnancy. It does not exclude the possibility that unrecognized glucose intolerance may have antedated the pregnancy”. GDM complicates 3–15% of all pregnancies and is a major cause of perinatal morbidity and mortality, as well as maternal long term morbidity. Of all types of diabetes, gestational diabetes (GDM) accounts for approximately 90–95% of all cases of diabetes in pregnancy.

In medicine, in general and fetal medicine in particular, the conceptual development and emerging application of a new diagnostic modality is fuelled firstly by a general recognition of the increasing relative importance of a particular clinical problem and then by critical examination of the body of scientific observation, often disparate in origin, that provides the key insights into the pathophysiology, manifestation and natural history of the disease process. So it is with the evolution of the fetal biophysical profile score. In general terms, until the 1950's the major goal of obstetric care was the prevention of maternal mortality and morbidity. As the result of a host of clinical advances including improved anaesthesia and surgical techniques and availability of blood and blood products, antibiotics and specific other drugs (oxytocin, anticonvulsants, antihypertensives, insulin etc.) maternal mortality declined to the low rates of the present day. Consequently, the focus of obstetric care shifted to the recognition and prevention of death or damage affecting the other patient in the obstetric dyad: the fetus. The first methods for evaluation of antepartum fetal health care were based on measurements of biochemical variables in the maternal compartment (e.g. oestriol, placental lactogen, alkaline phosphatase and oxytocinase).

The true measure of success or failure of perinatal care is not merely neonatal survival, but survival with good health and well-being into childhood and beyond. Quantifying this measure is important for all babies, particularly for those born prematurely. The risks are highest for those with a birthweight less than 1 kg (extremely low birthweight) and/or at less than 26 weeks gestation. There is continuing concern about the burden of illness and disability amongst survivors in this vulnerable group. However, we must not forget that all preterm infants are at increased risk of disability later in childhood and that the same is true for babies born at term who are sick enough to require neonatal intensive care.

One of the most important stages of pregnancy is the activation of uterine contractions that result in the expulsion of the fetus. The timely onset of labour is clearly important for a healthy start to life but incomplete understanding of the precise mechanisms regulating labour onset have prohibited the development of effective and safe treatments for preterm labour. This review explores the activation of the myometrium at labour onset, focussing on mechanisms of uterine contractility, including those proteins that play an important role in smooth muscle contractility. The review primarily focuses on human work but in the absence of human data describes animal studies. A broad overview of myometrial contraction mechanisms is provided before discussing more detailed aspects and identifying areas where uncertainty remains. Also discussed is the recent application of ‘omics’ based approaches to parturition research, which has facilitated an increase in the understanding of myometrial activation.

Prenatal care reduces the impact of illicit drug use on perinatal outcomes. Women who misuse substances are often excluded from mainstream society and, on becoming pregnant, feel guilty about their drug misuse and the potential effects this could have on their unborn baby. These women are vulnerable in many ways and agencies must ensure that they are not excluded from antenatal care. The latest enquiry into maternal deaths published in the UK (CEMACH report) highlights how women with socially complex lives who died were far less likely to have sought antenatal care early in pregnancy or to remain in regular contact with maternity services. Of the women who died from any cause, 11% had problems with substance abuse of whom 60% were registered addicts. Gaps in communication between agencies was highlighted as a particular problem.

The intrapartum management of the twin pregnancy has remained a controversial and challenging issue in obstetrics. Development of a management plan for delivery of a twin gestation necessitates consideration of multiple factors including fetal presentations, gestational age, estimated fetal weights, the presence of maternal or fetal complications, and the experience of the attending obstetrician, anaesthetic staff and neonatologists. In twin gestations in which a trial of labour is possible, the major factor determining the intrapartum course is the relative presentations of twin A and twin B on admission to the delivery suite.

For several decades, visual analysis of the antepartum fetal heart rate tracing has been a primary mode of fetal surveillance despite lack of proof from randomized trials that its use leads to a reduction in perinatal mortality in high risk pregnancies. A meta-analysis of these trials offered the same conclusion. The trials were performed in the early 1980's with fetal monitors with poor signal to noise ratios and poorer testing schemes in comparison to today. Therefore the results may no longer be pertinent, however, it is unlikely that these trials will be repeated because of present medico-legal constraints. Nonetheless, the use of non-stress testing alone is an accepted mode of fetal surveillance because of associated low fetal death rates within 1 week of a normal test; 1.9 to 3.2/1000 patients tested. The expense associated with this low fetal death rate is a low positive predictive value of 25% to 50%. Interrelated with this inefficiency, is the considerable inter- and intra-observer variation in the interpretation of antepartum fetal heart rate tracings. Variation in the interpretation of antepartum fetal heart rate tracings continues to exist despite the increase in experience and knowledge of fetal heart rate monitoring and improvement in fetal heart rate monitors. The end result is a form of fetal surveillance that is of questionable value and inefficient, requiring frequent back up testing to clarify fetal condition.

The incidence of preterm birth in developed countries has steadily increased over the past two decades and now approaches 12.5% of all live births in the U.S. This is due, in part, to our incomplete understanding of the pathways that maintain uterine quiescence throughout pregnancy, as well as those that promote increased uterine contractility and cervical ripening leading to labour. It is clear that uterine quiescence throughout most of pregnancy is maintained by progesterone acting through its nuclear receptor (PR). Furthermore, there is increasing evidence that both preterm and term labour are associated with activation of inflammatory response pathways in the pregnant uterus and cervix. In this article, we will consider the factors that induce the inflammatory response leading to term and preterm labour. We also will review findings to support the novel concept that the maintenance of uterine quiescence vs. induction of uterine contractility is exquisitely controlled by the cross-repressive effect of progesterone/PR and inflammatory transcription factors, such as nuclear factor κB (NF-κB).

Alcohol was discovered soon after the development of waterproof pots to store and transport water and fruit. Liquids produced by spontaneous fermentation of grains, sugars and fruits were found to enhance pleasure. During the middle ages alchemists discovered that distillation increased this power and thought they had found the elixir of life. Since then almost every culture has used alcohol. Each society has introduced its own restrictions on the availability, exports, imports and consumption of alcoholic beverages within its religious and political structure. Generally, drinking levels which interfere with self-control or result in individual, familial or societal harm are disapproved by all cultures.

A large number of studies show that low birth weight is associated with cardiovascular disease and its risk factors including raised blood pressure, glucose intolerance and the metabolic syndrome. These findings have formed the basis for the ‘fetal origins hypothesis’. This suggests that the operation of adverse influences during intrauterine life leads to permanent alterations in fetal structure and physiology which predispose to adult disease. The process is known as developmental plasticity or programming and is strongly supported by studies in experimental animals. Ongoing research is providing important insights in to the underlying mechanisms. It is likely that adverse environmental factors during pregnancy are important, and that these include suboptimal nutrition of the mother. The long-term programming effects may be transduced by alterations in the set-point of key hormonal axes, especially the hypothalamic-pituitary-adrenal axis, and recent evidence suggests that epigenetic modification of gene expression may be a key factor. Importantly, this has the potential to produce transgenerational effects.

The hypothesis has not remained unchallenged and a wide variety of criticisms have been put forward. These include accusations that the associations are weak and overestimated due to publication bias, that there are many inconsistencies between studies, that the associations are confounded by lifestyle factors, and that there has been inappropriate adjustment for adult size. Finally many studies report that the findings in singletons do not seem to be replicated in twins. While many of these issues have been resolved, some continue to form the basis of a lively dialogue and ongoing research. Nevertheless the research findings have important implications for clinical obstetric practice and maternal-fetal medicine.

The prevalence of neural tube defects (NTD) in Europe is around 9 per 10,000 births making it one of the most frequent congential anomalies affecting the central nervous system. NTD encompass all anomalies that are secondary to failure of closure of the neural tube. In this review, we will first summarize the embryology and some epidemiologic aspects related to NTDs. The review focuses on myelomeningocele (MMC), which is the most common distal closure defect. We will describe the secondary pathologic changes in the central and peripheral nervous system that appear later on in pregnancy and contribute to the condition's morbidity. The postnatal impact of MMC mainly depends on the upper level of the lesion. In Europe, the vast majority of parents with a fetus with prenatally diagnosed NTDs, including MMC, opt for termination of pregnancy, as they are apparently perceived as very debilitating conditions. Animal experiments have shown that prenatal surgery can reverse this sequence. This paved the way for clinical fetal surgery resulting in an apparent improvement in outcome. The results of a recent randomized trial confirmed better outcomes after fetal repair compared to postnatal repair; with follow up for 30 months. This should prompt fetal medicine specialists to reconsider their position towards this condition as well as its prenatal repair. The fetal surgery centre in Leuven did not have a clinical programme for fetal NTD repair until the publication of the MOMS trial. In order to offer this procedure safely and effectively, we allied to a high volume centre willing to share its expertise and assist us in the first procedures. Given the maternal side effects of current open fetal surgical techniques, we have intensified our research programmes to explore minimally invasive alternatives. Below we will describe how we are implementing this.