Rapid and constant progress in prenatal diagnosis has made screening and diagnosis for fetal aneuploidy available in the first and early second trimester. However, relatively late diagnosis of severe fetal conditions has also increased due to better performance of routine second trimester ultrasound examination together with a systematic approach to fetal evaluation and determination of prognostic factors with increasing gestation. Such situations include fetal infections, brain abnormalities, and several osteochondrodysplasias. Prognostic uncertainty is often weighed against ethical and legal issues in the decision making process, leading to either early termination of a potentially normal fetus or a late termination of a fetus more severely affected with better definition of overall prognosis. Our aim is to review the current literature with regard to technique and potential complications of late terminations of pregnancy.

In the modern Health Service frequent inspection has become commonplace. These inspections are often viewed with a degree of suspicion by clinicians and none has fallen into greater disrepute than the visits conducted for the Clinical Negligence Scheme for Trusts, CNST. These visits are often seen as a ‘Tick box’ exercise, more important to the finances of the Trust than the care of patients. Fortunately as with many other generalisations this is incorrect. Although one can always disagree with individual standards examined during this inspection the fundamental principles that these standards are based upon are often suggested by medical colleges and are founded on sound risk management theory.

The management of children with cleft lip and palate presents many challenges but also many rewards. Our involvement with these children and their families often begins before birth and can extend into late adulthood. Affected individuals present a multiplicity of problems and effective management involves a wide range of specialists.

In 1999, the US Food and Nutrition Board revised the Adequate Intake (AI) for calcium in pregnancy and recommended 1000 mg/day for adult pregnant women and 1300 mg/day for adolescent women (<19 years). Our interest, from the perspective of an international health organization, was to assess if pregnant women globally meet those requirements. This is particularly important because, among the various biological functions of calcium, the potential protective effect of adequate calcium intake in pregnancy on the risk of pre-eclampsia may have major public health implications, pre-eclampsia being one of the most important causes of maternal and perinatal mortality world-wide. Therefore, we conducted a systematic review of studies, published from 1991 to 2004, that assessed calcium dietary intake in pregnant women. In addition, we conducted a multicentre survey of calcium dietary intake during pregnancy among nulliparous women attending antenatal care in developing countries. This survey was conducted before starting a large calcium supplementation multicentre trial: the WHO Calcium Supplementation Trial in Low Calcium Intake Women for the Prevention of Pre-eclampsia. This article presents the results of the systematic review and of the multicentre survey.

Congenital diaphragmatic hernia (CDH) is a major life-threatening cause of respiratory failure in the newborn. Regions of the diaphragm failing to form during embryogenesis characterize the developmental anomaly. Normally, the diaphragm develops to form a continuous sheet that completely separates the thoracic and abdominal cavities prior to the major period of internal organ growth. However, in the instance of CDH, a significant proportion of the diaphragmatic musculature (typically the left dorsolateral region) is absent. Consequently, the developing viscera can invade the thoracic cavity, occupying space normally reserved for the growing lungs. As a result, newborns with CDH (∼1:2500 births) suffer from a combination of pulmonary hypoplasia, pulmonary hypertension and surfactant deficiency. Treatment strategies include nitric oxide administration, high frequency oscillatory ventilation, extracorporeal membrane oxygenation, exogenous surfactant administration and surgical repair of the diaphragm. Despite these advances in neonatal intensive care, mortality and morbidity remains high.

Parvoviruses are widespread in nature, with a diversity of virus types affecting many animal species, usually in a species-specific manner. Some members of the parvovirus family give rise to asymptomatic infections but others are highly pathogenic, causing disease not only in adults but also in the young, the newborn and in the fetus. Parvoviruses of animals have for long been regarded as agents of reproductive failure and parvovirus B19 was recognised as a cause of fetal loss in humans in the 1980s. Moreover, following the control of congenital rubella by pre-pubertal and child vaccination, parvovirus B19 infection has emerged as probably the leading cause of viral embryopathy. This review will focus on the laboratory diagnosis of parvovirus B19 infection following exposure in pregnancy. The indications for testing maternal and fetal samples and the interpretation of test results will be discussed and a section is included on clinical management of the infection in pregnancy. The obstetric outcome in pregnant women who seroconvert will be reviewed.

The combined spinal epidural (CSE) as an anaesthetic technique for providing analgesia for labour and anaesthesia for operative delivery has gained in popularity over the last ten years. Essentially the CSE consists of identification of the epidural space and insertion of an epidural catheter plus the initial intentional placement of an intrathecal dose of opioid, local anaesthetic or both, all as a single procedure. Theoretically the technique combines the advantages of the speed of onset and the reliability of block achieved by subarachnoid anaesthesia with the flexibility provided by the presence of an epidural catheter and avoids their individual disadvantages. The complications that may be encountered are those attributable to subarachnoid and epidural anaesthesia individually but some are unique to the CSE technique. The CSE technique is also applicable to other situations in obstetrics where a block is initiated by subarachnoid anaesthesia and its continuation is facilitated by the presence of an epidural catheter, either to maintain anaesthesia for prolonged procedures or for post operative pain control. The CSE's popularity has been ensured by the fact that it has allowed rapid onset analgesia with minimal motor blockade to be provided routinely for mothers in labour.

Reports in the 1970's by Snyder and others of opioid receptors in the brain and the substantia gelatinosa of the spinal cord triggered a search for endogenous opioid ligands (β-endorphin and the encephalin peptides) which might modify pain transmission. It was not long after that morphine was administered into the human epidural space for pain control, including obstetric patients.

Schmorl is generally credited with being the first to report finding fetal cells in maternal blood. In 1893 he identified trophoblasts in the pulmonary circulation of women who had died of eclampsia. Years later, in 1969, Walnowska identified Y chromosomes in lymphocytes isolated from the blood of pregnant women carrying male fetuses and this was repeated by Herzenberg in 1979 in white blood cells recognised as fetal by their surface HLA-A2 expression. Other sporadic reports followed but not until the 1990's did investigation into harvesting fetal cells from maternal blood begin in earnest. The aim of this article is to review the progress made in isolating and analysing these cells for the purposes of prenatal diagnosis.

In October 2000, Hannah et al published a randomised controlled trial comparing perinatal and maternal outcome between planned vaginal and planned caesarean deliveries of term breech pregnancies. The study was closed after an interim analysis, showing a reduced perinatal morbidity and mortality with planned caesarean section. The result was not unexpected, although a trial like this had been called for over many years to resolve the issue. Many cohort- and case-control studies, and two small randomised studies had been performed since 1959, when Wright reported a reduced perinatal mortality and morbidity with CS. A few large registry studies had shown a better perinatal outcome with caesarean delivery, whereas smaller studies often showed no statistically significant difference in outcome, often with the conclusion that vaginal delivery (VD) is safe.

Venous thromboembolism (VTE) is a leading cause of maternal mortality in the western developed world. VTE may present as deep vein thrombosis (DVT) or pulmonary embolism (PE) but if untreated can result in fatal PE. Although fatal PE is clearly the most significant consequence of VTE in pregnancy, DVT also often leads to morbidity related to the development of post-thrombotic syndrome (PTS). Pregnancy is an independent risk factor for VTE and the risk of VTE is 4–10 fold higher in pregnant women than in non-pregnant women of similar age. The puerperium represents a time of even higher risk. It is clear that many additional high-risk situations in pregnancy lower the threshold for thrombosis and warrant measures to prevent VTE and its complications. Risk factors for pregnancy-related VTE may be inherited or acquired. Acquired risk factors may be specifically related to the pregnancy or may have developed prior to pregnancy. Well-documented risk factors for pregnancy-related VTE include delivery by Caesarean section, previous VTE, and inherited or acquired thrombophilia. Other risk factors that have been identified include obesity, multiparity, multiple gestation, pre-eclampsia and medical conditions, such as sickle cell disease, that predispose to VTE. Our ability to diagnose VTE overall is poor as presenting signs and symptoms are extremely varied and unreliable. This is further complicated in pregnancy where signs and symptoms suggestive of VTE are common and invasive testing is more complicated. It is essential that physicians be vigilant in monitoring patients for the development of VTE and maintain a low threshold for considering thromboprophylaxis. Guidelines have recently been published by several medical societies to help with these difficult decisions. In this review the risk factors for the development of VTE in pregnancy will be discussed and guidelines for risk assessment presented. Management of patients who develop VTE in pregnancy is also outlined.

The renowned British obstetrician Smellie is credited with the first medical description of an obstetric brachial plexus palsy. In his 1768 treatise on midwifery, he reported a case of transient bilateral arm paralysis in a newborn after difficult labour with a face presentation. In 1861, Duchenne coined the term “obstetric palsy of the brachial plexus” after analyzing 4 infants with paralysis of identical muscles in the arm and shoulder. In 1875, Erb concluded in his thesis on adult brachial plexus injuries that associated palsies of the deltoid, biceps, and subscapularis are derived from a radicular lesion at the level of C5 and C6 rather than isolated peripheral nerve lesions. In the same year, Klumpke described lesions of C8 and thoracic nerve T1 in birth palsy and associated the Horner sign with lower trunk lesions of the brachial plexus. Perhaps the most famous case of brachial plexus palsy was that of Prince William of Germany, who subsequently became Kaiser Wilhelm II in 1888. Apparently, William was in breech presentation and manipulated by several physicians and a midwife during delivery. Three days after delivery, the midwife noticed that William's left arm was slack. For the rest of his life, William's withered left arm was concealed from the public by careful posing for photographs.

The optimal mode of breech delivery has been one of the major controversies in Obstetrics, until the Term Breech Trial was published in 2000. This multi-centre randomised trial showed that planned Caesarean breech delivery is safer than planned vaginal breech delivery, resulting in a significant reduction in perinatal death and serious neonatal morbidity by two-thirds. Since then there was a rapid and significant worldwide changes in the clinical management of breech presentation at term towards planned Caesarean section (CS). Although the Term Breech Trial is a well-designed and conducted study, it is not without criticism. Firstly, among the perinatal deaths reported in the study, some were unrelated to the mode of delivery such as antenatal stillbirths. If such perinatal losses were excluded from analysis, the difference in perinatal death might not have reach statistical significance. Secondly, some intrapartum deaths occurred during intermittent fetal heart monitoring. It is plausible that these could have been prevented if continuous monitoring had had carried out. Furthermore, although neonatal morbidity after vaginal breech delivery is higher, whether these morbidities have significant long term developmental or neurological effect is still controversial. In fact in the follow-up study of babies from the Term Breech trial at the age of 2 years, no statistically significant difference in neurodevelopmental delay or death rate was found in children between the treatment groups. Finally, the cost for the preventing 1 perinatal death or serious fetal morbidity requires an additional performance of 14 CSs. This figure rises to 39 CSs among developing countries. Elective CS is not only associated with an increase in short-term maternal morbidity, but also long term complications including risk of scar rupture in subsequent pregnancies, placenta praevia, abnormal adherent placentation, and of unexplained antenatal stillbirth. The medical cost for managing these long term complications could be substantial.

Affecting 7–10% of pregnancies, pre-eclampsia is, in fact, the most common glomerular disease worldwide. It remains a leading cause of fetal growth restriction, premature birth, as well as infant and maternal morbidity and mortality. Epidemiological studies have identified numerous risk factors for the development of pre-eclampsia including a positive family history, race, nulliparity, advanced maternal age and the presence of pre-existing co morbidities such as kidney disease, hypertension or diabetes mellitus. The incidence of pre-eclampsia has increased by an alarming 40% over the past decade, likely due to the number of women delaying pregnancy and/or becoming pregnant despite the presence of other comorbid conditions.

Reference to people suffering bouts of severe headache with associated vomiting and visual aura may be found in texts that date back 5000 years but the first clear description of migraine as a distinct clinical entity was provided by Aretaeus of Cappadocia in the second century AD. Today, at least 80% of women experience headaches in adult life and in approximately a quarter of these cases the pain is recurrent and incapacitating. When each episode of headache lasts between 4 and 72 hours and is accompanied by nausea, vomiting, photophobia or phonophobia, the symptoms fulfil the International Headache Society's current definition of the syndrome called migraine, detailed in Table 1.

Apart from the measurement of blood pressure, dipstick analysis of urine for protein is the most commonly performed antenatal screening test. The presence of proteinuria is seen as a possible indication of many complications in pregnancy, from urinary tract infection to chronic renal disease and it remains central to the diagnosis of pre-eclampsia in a hypertensive pregnancy. It has both diagnostic and prognostic implications when it is found though the optimal methods for detection and quantification in primary and secondary care remain controversial.

Das, S., Muhasseb, M.K. and Loughney, A.D. (2005) Migraine in pregnancy. Fetal and Maternal Medicine Review 16, 179–193.

An error in the spelling of the name of the second author of the above article was inadvertently introduced during the production stage. The correct spelling should be Mehasseb, M.K.

We apologise to Dr Mehasseb and to the readers for this mistake.