The cardiovascular system undergoes remarkable adaptive changes in pregnancy. Through a complex network of interrelated pathways the physiological response to the conceptus ensures an adequate blood supply and oxygen gradient to meet the demands of the feto-placental unit whilst maintaining normal maternal blood pressure. This is achievable because the increase in maternal cardiac output and blood volume which characterise normal pregnancy occur with an associated and profound decrease in peripheral vascular resistance. Longitudinal studies using Doppler ultrasound and echocardiography indicate that the decline in peripheral vascular resistance occurs very early and data from the pregnant baboon and pregnant women suggest that this is the stimulus which activates the renin-angiotensin aldosterone axis and the resultant rise in plasma volume.

Gestational diabetes mellitus (GDM) is defined as ‘carbohydrate intolerance of variable severity with onset or first recognition during pregnancy’. GDM affects approximately 4–10% of all pregnancies in the United States. Pregnancies complicated by GDM have both short and long term effects on the developing fetus. Studies have shown that elevated levels of glycaemia are associated with increased perinatal mortality. O'Sullivan et al. in his original work, found a four-fold higher rate of perinatal mortality in untreated women with gestational diabetes when compared to women with a normal glucose tolerance test in the same time period. Pettit et al., when studying Pima Indians, found a direct association between a 2-hour, 75g glucose load result and perinatal mortality. Evaluation of recent studies concerning gestational diabetes revealed relatively high rates of stillbirth and perinatal mortality. Thus, it is clear that lack of a therapeutic regimen for these patients will result in increased fetal mortality.

Mid trimester miscarriage and premature birth remain a significant cause of perinatal morbidity and mortality presenting an important challenge in perinatal medicine. The place of cervical cerclage requires to be reconsidered and redefined. Insertion of a cervical suture may be useful when there is cervical weakness in a woman at risk of miscarriage or premature birth. Miscarriage is a preferable word to abortion and weakness is a preferable word to incompetence because of the sensitivities of the woman in this situation.

Early this century, the term cytomegalic inclusion disease (CID) was used to designate the cellular changes characterized by enlargement and typical intranuclear inclusions observed in tissues of fetuses and infants with a fatal illness. In 1957, Smith and Weller et al, identified the causative agent of CID, which was named cytomegalovirus (CMV) by Weller in 1960. By 1971, it was clear that congenital human CMV (HCMV) infection was an important health problem. Since then, many advances have been made in the diagnosis, therapy, and knowledge of the epidemiology of congenital HCMV infection. However, most of these improvements, particularly those concerning diagnostic technologies and development of antiviral drugs, have been the result of the powerful effort to reduce the devastating impact of HCMV infections in AIDS and transplanted patients. Indeed, it is disappointing to observe that in the year 2000 CID does still occur, that HCMV is still recognized as the leading cause of congenital infection and the leading infectious cause of mental retardation and deafness, and, most important, that no active prevention is available for seronegative women. Moreover, because of the limited possibilities of prophylaxis and treatment, and the misuse of the currently available serologic assays, the issue of whether the determination of HCMV antibody status for women of childbearing age is justified has become a matter of debate.

The incidence of premature delivery (at less than 37 completed weeks) has been stable at between 5–10% of deliveries over the past 20 years despite intensive research in this field. Preterm delivery is a major cause of perinatal morbidity and mortality. The identification of women at increased risk for this condition has traditionally been based on clinical history (e.g. previous premature birth or second-trimester miscarriage), digital evaluation of the cervix and the occurrence of uterine contractions.

This review will focus largely on the prostaglandins (PGs) in relation to term and preterm birth and highlight some of the newer concepts in this field including the pathways of maternal and fetal PG synthesis, metabolism and receptors. Data from studies in women or from experiments utilizing human gestational tissues will be combined with knowledge gained from animal experiments. An attempt will be made to provide a straightforward, updated view of the role of PGs in these processes. Potential therapeutic strategies for delaying preterm birth and prolonging pregnancy will also be discussed.

Congenital heart disease (CHD) is the commonest congenital malformation with an incidence of approximately 8 per 1000 live births. Half of the defects are severe. Cardiac anomalies at birth are 4 times more common than neural tube defects and 6.5 times more common than chromosomal abnormalities. Within a stillborn population the incidence is approximately 10 times that of live births. Congenital heart disease is responsible for approximately 40% of the perinatal and 60% of post neonatal deaths due to congenital anomalies. Despite screening of the infant population, 30% of cases of CHD are unsuspected or unconfirmed prior to death. Sadly, many of these missed lesions are correctable. However, the overall outlook for CHD is excellent since 85% of infants born with heart malformations will survive into adult life.

Emergency anaesthesia for the compromised fetus encompasses anaesthesia for both acute fetal distress and the chronically hypoxic fetus. Fetal distress, a poorly defined term, is still used by clinicians today. Parer and Livingston defined fetal distress as “progressive fetal asphyxia, that if not corrected or circumvented, will result in decompensation of the physiologic responses (primarily redistribution of blood flow to preserve oxygenation of vital organs) and cause permanent central nervous system and other organ damage or death.” More recently the term “non-reassuring fetal status” has been adopted as a better descriptor than fetal distress.

The uterine cervix is a remarkable structure, which plays an essential role in pregnancy. During the development of the conceptus within the uterus, the cervix usually remains firmly closed to ensure that the developing fetus attains an appropriate degree of maturity to permit extra-uterine survival. On the other hand, it prepares for labour and birth, by undergoing a process of effacement, whereby the substance of the cervix shortens and thins out. During labour, it must be stretched and dilated to a sufficient diameter, usually about 10cm at term, to allow the successful passage of the fetus through the birth canal.

Cerebral Palsy (CP) describes a group of permanent non progressive but often changing neurological impairement syndromes as assessed at 3 and 5 years of age. The term includes serious motor disorders including spastic diplegia (Little syndrome), hemiplegia and quadriplegia associated with neuropsychological seizures and cognitive impairment due to permanent damage to the immature brain. Fifty percent of CP cases are premature neonates and 25% are very severely premature. There is a significant correlation between CP and brain lesions in the neonatal period among which periventricular leukomalacia (PVL) is the most common.

Group B streptococcus (GBS), or Streptococcus agalactiae, has been a continuing focus of debate in the paediatric and obstetric worlds. The organism has emerged as the leading cause of early-onset neonatal sepsis. With an average of 20% of mothers being carriers for the organism (range from 15–40%), the following questions remain to be answered:

1 How best to screen for GBS and which protocol to use?

2 How best to counsel patients who are GBS carriers?

3 What is the cost effectiveness of the screening protocols?

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.

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.

Some babies are hypoxic at birth, yet suffer no ill effects, whilst others have a poor prognosis. To understand why this is so, we need to consider the factors that determine fetal oxygen supply and how the fetus copes with any decrease in oxygen delivery.

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.