The established technique of investigating peripheral arteries by continuous-wave Doppler ultrasound was first applied to obstetrics by FitzGerald and Drumm in 1977. Since that time, each year has seen an increasing number of reports regarding obstetric Doppler, but assessment of its true value in pregnancy management, by large prospective randomized trials, is still awaited. Continuous-wave Doppler ultrasound is a relatively simple and inexpensive technique, ideal for screening the uterine and umbilical arterial circulations without the necessity for concurrent ultrasound imaging. However, difficulties in interpretation and analysis of the displayed Doppler-shifted frequencies, as well as the limited number of reports on the performance characteristics of Doppler ultrasound instruments, may well have contributed to the slowness with which the technique has been taken up for study. Continuous-wave Doppler systems designed for obstetric use have recently become available and the Vasoflo-3 (Oxford Sonicaid, Chichester, Sussex) has a microprocessor which makes the instrument very versatile. I shall review the technique of continuous-wave Doppler ultrasound measurement in obstetrics, with particular reference to measurement variation, in the light of our experience with the Vasoflo-3 (Figure 1). I shall then briefly summarize a few of the reports which have used continuous-wave Doppler ultrasound in obstetrics.

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.

Third stage practice, including the timing of cord clamping and its impact on neonatal health, has been comprehensively reviewed previously by Downey and Bewley, and this opinion will focus on the evidence about neonatal transition which has been published since. Many professional organisations and experts recommend at least a 30-second delay before clamping the umbilical cord, especially after preterm births.

The World Health Organisation (WHO) has estimated that 1500 women die every day from preventable complications of pregnancy and childbirth. While barriers to accessing healthcare are undoubtedly multi-factorial, studies have repeatedly shown that providing skilled healthcare workers can result in untold benefits for women and babies in developing countries. The phenomenon of preventable maternal and fetal morbidity and mortality is not limited to the developing world. The Confidential Enquiries into Maternal Deaths (CEMD) and Stillbirths and Infant Deaths (CESDI) in the UK have repeatedly identified substandard care as a major contributor to maternal and neonatal mortality. In 2008 The King's Fund published Safe Births: Everybody's business, an independent enquiry into the safety of maternity services in England. This recommended that simulation-based training to assess clinical, communication and team skills should be available to all maternity staff, and that training should form a core activity. Many hospitals in the UK have been running in-house courses for staff for over a decade with measurable improvements in neonatal outcomes. The value of these training schemes is recognised and rewarded through reduced insurance premiums for participating hospital trusts as part of clinical negligence schemes. Gaining competence in managing obstetric emergencies presents particular challenges for trainees. Most emergencies are, thankfully, uncommon but some constitute life-threatening events where management naturally falls to the most experienced available clinician. The skills required are often particular to emergencies and therefore novel to trainees. Utilising emergencies as training opportunities is further complicated by the presence of a conscious patient.

Musculoskeletal complaints are a common source of antenatal and peripartum morbidity, yet are frequently dismissed by healthcare professionals. Although increasing pelvic laxity is thought to be physiological as pregnancy advances, a number of women develop pain and disability out of proportion to the degree of joint distension. The term ‘symphysis pubis dysfunction’ is one of the many used to describe the constellation of typical symptoms and signs. (Table 1) The first formal documentation of the condition is accredited to Snelling in 1870. “The affection appears to consist of a relaxation of the pelvic articulations, becoming apparent suddenly after parturition, or gradually during pregnancy; and permitting of a degree of mobility of the pelvic bones which effectively hinders locomotion, and gives rise to the most peculiar, distressing and alarming sensations.” Although dated his description still provides a succinct description of the condition.

Cystic Fibrosis (CF) is the most common life-shortening recessive genetic disease in the UK. Far from being a condition managed exclusively by paediatricians with sufferers dying in early childhood, CF is now a condition in which adults outnumber children with the condition, and the death of a child in a paediatric centre is rare. As increasing numbers of young people grow up relatively healthy it is unsurprising they begin to ask about relationships, sex, fertility and the possibility of having a child. This paper briefly describes the genetics, pathophysiology and clinical features of CF with an emphasis on how it pertains to female reproduction. The management of women with CF considering having a baby including contraception, preparation for pregnancy, the pregnancy itself, delivery and the post natal period will be discussed. Contraindications to pregnancy, method of termination, and pregnancy after transplantation will also be considered. Much of the detailed management is given in the European Guidelines for the Management of Pregnancy in Women with CF on which this paper is based.

Investigation of fetal cardiac function remains a challenging task. Although the response of the heart to changes in load is well-known in animal models and the adult human, the developmental changes in fetal cardiac response remain poorly characterised. However, quantitative evaluation of cardiovascular function is important to predict the clinical course and to manage the fetus optimally. To date, the routine evaluation of fetal cardio vascular function has relied largely on Doppler echocardiography which enables an estimate of haemodynamics; newer modalities such as measurement of myocardial velocities are employed less routinely. Fetal magnetic resonance imaging still lacks the resolution necessary to contribute significantly to morphological or functional assessment of the fetal cardiovascular system.

The ability to obtain fetal material that could be used for prenatal genetic diagnosis without requirement for an invasive test was a watershed moment in antenatal care. Cell-free fetal DNA (cffDNA) was identified in the maternal plasma by Lo and colleagues in 19971 and despite being technically challenging, non-invasive tests for fetal sex determination, fetal rhesus D (RHD) genotyping, some single gene disorders and the major aneuploidies are now being offered in clinical practice throughout the world2 . Progress continues at pace and recent developments in next generation sequencing (NGS) are driving significant advances in research and in the clinical application of non-invasive prenatal testing (NIPT) and diagnosis (NIPD) (Table 1).

In monozygotic twin pregnancies embryonic splitting within three days of fertilisation, which occurs in approximately one-third of cases, results in two separate fetuses with independent placental circulations. Splitting after the third day of fertilisation is associated with vascular communications between the placentae; when cleavage is delayed beyond day 12 the fetuses are conjoint. In some monochorionic twin pregnancies imbalance in the net flow of blood across the placental vascular communications from one fetus (the donor) to the other (the recipient) results in twin to twin transfusion syndrome (TTS).

Delivery of an infant via an abdominal and uterine incision has a very long history. It is impossible to discover when the first such operation was performed, but it is known to have been practised in ancient Roman, Hindu and Egyptian civilisations. Usually it was performed on a recently dead mother in the hope of saving the infant, but there is also some evidence that in ancient times it may occasionally have been attempted on living mothers. In more recent centuries, there are several reports of caesarean sections being performed on living patients in Europe from 1500 onwards. The date of the first successful operation is uncertain, but there is no doubt that mortality of both mothers and infants was very high. In the British Isles, out of 131 caesarean sections performed between 1737 and 1878, only 23 mothers survived. The high maternal mortality was not surprising considering that there was no anaesthesia nor effective control of infection, and the uterine incision was not closed.

Caesarean section (CS) is one of the most common major operations performed around the world, yet operative rates vary considerably. This review will address the variation in caesarean section rates worldwide and changes in these rates over time. In addition we shall try to assess possible explanations for the differences and whether such differences are reflected in outcome.

The puerperium is a time of substantial maternal risk. Within recent years, crude maternal mortality rates of 8.9/100,000 total births have been reported from England and Wales and of 6.6/100,000 from Sweden. Maternal deaths are considerably more likely to follow delivery than to precede it (Table 1). The risks associated with caesarean section are particularly noteworthy: death rates have been reported to be as much as 12 times greater than those following vaginal delivery.

The management of congenital diaphragmatic hernia (CDH) in the newborn infant has changed radically since the first successful outcomes were reported 60 years ago. Then it seemed a surgical problem with a surgical solution – do an operation, remove the intestines and solid viscera from the thoracic cavity, repair the defect and allow the lung to expand. CDH in that era was regarded as the quintessential neonatal surgical emergency. The expectation was that urgent surgery would result in improvement in lung function and oxygenation. That approach persisted up to the 1980s when it was realized that the problem was far more complex and involved both an abnormal pulmonary vascular bed as well as pulmonary hypoplasia. The use of systemically delivered pulmonary vasodilator therapy, principally tolazoline, became a focus of interest in the 1980s with small case reports and case series suggesting improved survival. In the 1990s, based on studies that showed worsening thoracic compliance and gas exchange following surgical repair, deferred surgery and pre-operative stabilization became the standard of care. At the same time extracorporeal membrane oxygenation (ECMO) was increasingly used either as part of pre-operative stabilization or as a rescue therapy after repair. Other centres chose to use high frequency oscillatory ventilation (HFOV). Despite all these innovations the survival in live born infants with CDH did not improve to more than 50% in large series published from high volume centres. However, in the past 10 years there has been an appreciable improvement in survival to the extent that many centres are now reporting survival rates of greater than 80%. Probably the biggest impact on this improvement has been the recognition of the role that ventilation induced lung injury plays in mortality and the need for ECMO rescue. This has ushered in an era of a lung protective or “gentle ventilation” strategy which has been widely adopted as a standard approach. While there have been these radical changes in postnatal management attempts have been made to improve outcome with prenatal interventions, starting with prenatal repair, which was abandoned because of preterm labour. More recently there has been increasing experience in the use of balloon occlusion of the trachea as a prenatal intervention strategy with patients being selected based on prenatal predictors of poor outcome. This approach can only be justified if those predictors can be validated and the outcomes (death or serious long term morbidity) can be shown to be better than those currently achievable, namely 80% survival in high volume CDH centres rather than the 50–60% survival frequently quoted in historical papers.

Risk is defined as the probability of an untoward event. In fetal medicine this event is one or more of the outcomes listed in Table 1. The aim of antenatal care is to predict these events and thereby, hopefully, to avoid them.

Autoimmune thrombocytopenia (ITP)

1) The risks to mother and fetus have previously been overstated.

2) There is no maternal test which will accurately determine fetal thrombocytopenia.

3) The only reliable test for fetal thrombocytopenia is cordocentesis – this carries a higher morbidity than that of fetal intracerebral haemorrhage from ITP.

4) Contrary to received wisdom, there is no evidence that, even for the most severely thrombocytopenic infant, abdominal delivery protects against intracranial haemorrhage.

5) Management therefore involves keeping the maternal platelet count above 50 × 1091 and choosing the route of delivery on normal obstetric grounds.

Alloimmune thrombocytopenia

1) Alloimmune thrombocytopenia is commoner than hitherto believed (0.15% all neonates).

2) The fetal risks are considerable: intracranial haemorrhage occurs in 4% of cases antenatally and in 10% in labour. The risks are virtually confined to those with a platelet count of less than 30 × 109l−1.

3) Cordocentesis is justified for the ‘at risk’ fetus; fetal immunoglobulin or platelet therapy can be given.

4) When the fetal platelet count is below 50 × 109l−1, abdominal delivery should be planned.

5) A maternal screening test for neonatal alloimmune thrombocytopenia exists (lack of P1A1 antigen).

During nine months of pregnancy, a woman who smokes 20 cigarettes each day will inhale nicotine, tar and carbon monoxide more than 50 000 times. This smoke contains chemicals known to be mutagenic and carcinogenic and will interfere with the normal growth and development of her child. Recent studies have revealed disturbing long-term consequences for the offspring. This article reviews the constituents of cigarette smoke, the effects of tobacco usage on the pregnancy, child and placenta, and strategies by which smoking during pregnancies may be prevented.

Approximately 12%–27% of cerebrovascular disease in women of childbearing age is associated with pregnancy. The reported incidence of stroke in pregnancy ranges from 0.01%–0.05%. While these events are uncommon, they are often clinically devastating. The Center for Disease Control's (CDC) review of death certificates in all 50 states and the District of Columbia found that neurologic or neurovascular problems are one of the leading causes of mortality in pregnancy.

The sequelae of shoulder dystocia with persistent brachial plexus injury (BPI) are among the most serious of obstetrical complications. Shoulder dystocia with BPI generally places second or third in the list of the top causes of permanent birth-related neonatal injuries. Apart from the devastating medical and social consequences of lifelong impairment for the family, ensuing litigation with its allegations regarding poor care exacts a heavy toll on the medical profession.

Human milk contains a unique mixture of nutrients that meet all the nutritional requirements of the growing infant for the first few months of life. Furthermore, it provides bioactive, non-nutritional substances including anti-microbial and anti-inflammatory factors, growth factors, cytokines, hormones and digestive enzymes which confer protection from bacterial and viral infections, and may aid growth and development of the newborn.

Facial clefting is the commonest congenital malformation to affect the head and neck. There are worldwide variations in the incidence of cleft lip and/or palate (CL/P) and cleft palate (CP) but in general they occur in around 1 in 600–800 live births. The diagnosis of CL/P or CP may be missed on mid-trimester screening anomaly scans, as the appropriate facial views may not be required as a routine. In a recent survey of ultrasound departments and with reference to the mid-trimester screening scan, only 50% sought a view of the lips and 25% a view of the palate. Facial clefts may occur as part of a recognised genetic syndrome or chromosomal condition. Structural anomalies associated with such syndromes will prompt a detailed fetal assessment, with greater sensitivity of detection for CL/P and CP than where the defect is isolated. Under such circumstances however, the facial cleft may be less significant than the accompanying abnormalities. Treatment of facial clefts has improved over recent years, not only with advances in surgical care but also with the development of a multidisciplinary approach to ensure that continued care is provided from infancy through to adult life.