Glomerulonephritis (GN) may be manifest clinically in several ways. It may be asymptomatic and associated with only minor urinary dipstick abnormalities, GN may present with one of the classic renal nephritic or nephrotic syndromes, or may be associated with progressive chronic kidney disease with hypertension and the gradual development of uraemia, or it may present with fulminating life threatening illness with severe acute kidney injury. The development of GN may indicate a primary renal limited disease, or may be secondary in association with systemic diseases such as systemic lupus erythematosus (SLE), myeloma, infections or diabetes. Although immunological abnormalities underlie the development of many forms of GN, precise pathogenic mechanisms remain unclear and diagnostic labels may simply reflect a description of the glomerular histological changes observed (Table 1).

Fetal bradycardia may herald fetal demise. This article highlights arrhythmic fetal bradycardia rather than bradycardia caused by perinatal distress. We briefly examine the embryonic conduction system's development and physiology and we review the classification, aetiology, evaluation, and approach to fetal bradycardia. Our aim is to provide the clinician with practical information about fetal bradycardia that enlightens causative conditions and aids management.

Thyrotoxicosis affects approximately 1:500 women of reproductive age. Untreated or poorly controlled thyrotoxicosis in pregnancy is associated with significant maternal and perinatal morbidity. Recognition and diagnosis of new onset thyrotoxicosis in pregnancy can be challenging as many of the symptoms can be misattributed to physiological adaptation of normal pregnancy. Women with hyperemesis gravidarum (HG) often have biochemical, but not clinical evidence of thyrotoxicosis, which does not need treatment with anti-thyroid drugs (ATDs). For women with clinical thyrotoxicosis, uncertainty regarding the risks of teratogenicity due to ATDs has led to new guideline recommendations for their use in pregnancy. Women with autoimmune diseases such as type I diabetes and who have thyroid peroxidase antibodies (TPOAb) are at an increased risk of developing postpartum thyroiditis, which can result in permanent hypothyroidism. This review summarises the management of thyrotoxicosis in pregnancy and highlights controversial areas for which conclusive evidence is still lacking.

Traditionally, the maternal mortality ratio has been used as a measure of the quality of maternity care and review of individual cases of maternal death has provided information for professional learning in order to improve patient care. In the United Kingdom, this process of multidisciplinary review has been carried out for over 50 years in the form of the Confidential Enquiry into Maternal Deaths (CEMD). The Confidential Enquiry is well respected internationally and has been used as a model for confidential enquiries in other countries, such as South Africa.

Significant advances in the field of regenerative medicine have intensified the search for novel sources of stem cells with potential for therapy. Although embryonic and adult tissues can be used for the isolation of pluripotent stem cells, significant limitations including ethical concerns, complexity of isolation/culture and tumorigenicity have hindered translation of laboratory findings to clinical practice.

Placenta praevia describes a placenta which partially or completely lies within the lower segment of the uterus. It is a major cause of antepartum haemorrhage and when it obstructs the internal os prevents safe vaginal delivery of the fetus.

Chronic fetal growth restriction is associated with both increased perinatal mortality and impaired neurodevelopment. Although it is a much more important cause of fetal neurological damage than intrapartum birth asphyxia, it is more difficult to treat, since the main intervention, timed delivery, carries its own risks. Since it is associated with a range of circulatory changes, which may also cause fetal damage, understanding these may improve management. In this article we review these fetal circulatory changes and assess their significance for predicting perinatal and long term neurodevelopmental outcome. We describe the Doppler assessment techniques, their clinical role in prediction of adverse outcome and the pathogenesis of brain injury in the preterm growth restricted fetus.

The diagnosis of twin pregnancy whilst causing delight for many of the parents and families involved is a source of concern and worry for their obstetric caregivers. This review will not deal with the myriad complications of twin pregnancies but will concentrate on two for which Doppler ultrasound has been often discussed; placental insufficiency and the problems of shared placental circulations in monochorionic twins.

Although antenatal care was widely introduced in the Western world only in the 20th century, it is now universally accepted and advocated as beneficial and advisable for all pregnant women and hence consumes a considerable amount of accommodation, equipment, professional time and costs to the women themselves. Resource use is rarely measured routinely but must vary enormously because of differences in the amount and intensity of care proposed, and in its uptake, in different geographical settings. However, even when resource use is at the lower end of the spectrum, antenatal care should be audited so that the needs of women and their babies can be best addressed.

Fetal growth restriction (FGR) as a consequence of uteroplacental insufficiency is an important contributor to perinatal death, neonatal morbidity and long-term health problems. Progressive uteroplacental dysfunction leads to placental respiratory failure and fetal hypoxaemia, which triggers compensatory fetal haemodynamic changes including blood flow redistribution towards essential fetal organs (brain, heart and adrenal glands) at the expense of the other body systems. The duration of the compensatory phase is variable, sometimes lasting weeks, and appears not to have deleterious short-term consequences. With further disease progression, the compensatory mechanisms reach their limit and myocardial dysfunction occurs. Once the disease enters this decompensatory phase, the fetus is at high risk of multisystem organ failure and in-utero demise. There is no effective in-utero therapeutic intervention. The main aim of management is to deliver the baby when the risks of antenatal demise and irreversible end-organ dysfunction associated with further prolongation of the pregnancy are greater than the risks from delivery.

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.

In the Netherlands, approximately 30% of all women of reproductive age smoke, compared with 36% of men.

Cigarette smoking is associated in women with a dose-related reduction in fecundity and fertility and in men with a reduction in semen quality. Smoking has a negative effect on pregnancy: increased rates of antepartum bleeding and placenta praevia have been described. Smoking is also associated with increases in the rates of spontaneous abortion, low birth weight and perinatal death. Some tobacco-related perinatal deaths are due to an increased risk of serious malformation. Children of mothers who smoke are admitted twice as often to hospital for pulmonary problems. However, studies on maternal smoking and childhood cancer have proved inconclusive.

Women with severe pre-eclampsia (PE) commonly require delivery by Caesarean section (CS). Whilst the choice of anaesthetic technique in this group of women has been controversial for a number of years, clinical experience has demonstrated the relative safety and value of well-managed incremental epidural anaesthesia. Several studies attest to the benefits of epidural analgesia in labour and epidural anaesthesia for CS. It is now widely recognised that epidurals provide relatively smooth control of blood pressure, maintain or improve utero-placental perfusion, optimising fetal outcome, and eliminate the airway and haemodynamic problems associated with general anaesthesia. Thus, epidural anaesthesia is the current technique of choice amongst most obstetric anaesthetists for CS in severe PE. Good inter-disciplinary communication between anaesthetic and obstetric staff should allow the need for CS to be anticipated early, and the epidural catheter inserted and topped-up in good time. However, in the case of urgent CS where it is not considered appropriate to wait the time required to produce effective epidural blockade, the choice of technique lies between spinal and general anaesthesia.

Pre-labour premature rupture of membranes (PPROM) is defined as rupture of membranes more than 1 hour prior to the onset of labour at <37 weeks gestation. PPROM occurs in approximately 3% of pregnancies and is responsible for a third of all preterm births. Once membranes are ruptured prolonging the pregnancy has no maternal physical advantage but fetal morbidity and mortality are improved daily at early gestations: 19% of those infants born <25 weeks develop cerebral palsy (CP) and 28% have severe motor disability. Those infants born extremely pre term (<28 weeks) cost the public sector £75835 (95% CI £27906–145508) per live birth not to mention the emotional cost to the family. To prolong gestation is therefore the suggested goal: however how and why might we delay birth in those at risk?

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.

Reduced fetal movement (RFM) is commonly defined as any reduction in maternal perception of fetal activity. Perceived fetal activity may be movement of limbs, trunk or head movement, but excludes fetal hiccoughs (as this is involuntary movement). The perception of fetal movement by an expectant mother is the first, and ongoing, non-sonographic indicator of fetal viability. The “normal” pattern of fetal movements varies from pregnancy to pregnancy, and often does not become established until 28 weeks’ gestation. Many babies have particularly active periods of the day, usually corresponding to periods of maternal rest and inactivity (which may in itself reflect increased maternal awareness of fetal movement). A variable percentage of sonographically observed fetal movements are perceived by prospective mothers (commonly 30–40%, although some studies report rates as high as 80%).

Improved diagnosis and corrective cardiac surgery has led to an increasing number of women with congenital heart diseases reaching reproductive age. Pregnancy places considerable strain on the heart and circulation, requiring marked cardiorespiratory adaptation. Today, with the exception of the Eisenmenger syndrome, there is no increased mortality associated with pregnancy in congenital heart disease. In contrast, there is still considerable morbidity, due to congestive heart failure, thromboembolic complications and disturbances of rhythm.

Reproductive failure is relatively common in humans compared with other mammalian species that have been studied. In young couples that are trying to conceive, the fecundity rate, (probability of achieving a clinically recognised pregnancy within a monthly cycle) is about 25%. The major cause of implantation failure in humans after both in vivo and in vitro fertilisation is now thought to be the high incidence of chromosomal abnormality.

There is little doubt that congenital abnormalities cause significant stresses to the affected children, their parents and the whole family. Such stresses can be physical, psychological, social and financial. To society, the cost of looking after these affected individuals properly can be substantial. In the absence of prenatal screening, birth defects affect approximately 2–4% of newborns, although there are significant variations between populations.