After 12 years as Editor-in-Chief of Fetal and Maternal Medicine Review I have decided to step down, albeit I welcome the opportunity to stay on as an Associate Editor. The last 12 years have witnessed a lot of changes, not only in the field of Perinatal Medicine but also in medical publishing, with the near demise of the ‘paper-based’ journal. I have enjoyed working with Cambridge University Press who have embraced these changes and remained strong supporters of the ‘Review Journal’ concept. The quality of the papers published over this time has progressively improved and we have continued my initial vision of publishing not only clinical but scientific reviews in a range of topics related to Maternal and Fetal Medicine. I owe a huge debt of gratitude to all the Associate Editors who have contributed over the last 12 years; Karel Marsal (Lund, Sweden), Lucilla Poston (London, UK), Mark Kilby (Birmingham, UK), Tze Kin Lau (Hong Kong) and Jason Waugh (Newcastle, UK). However I would particularly like to thank John Kingdon (Toronto, Canada) and Carl Weiner (Kansas, USA) who have stayed the course and whose sage contributions have been outstanding. Most importantly I would like to acknowledge the assistance of Jean Birtles whose endless detective work and ‘polite reminders’ have made my job considerably easier. Jean is also stepping down as Editorial Assistant.

Hypoxia in pregnancy is rare, however the anatomical and physiological changes associated with pregnancy may exacerbate hypoxia and hypoxaemia arising from pathological processes.

In this review we seek to briefly outline the well recognised changes to the maternal airway and respiratory anatomy and physiology. We will discuss a hierarchical approach to the tests used in differential diagnoses, summarise the physical principles behind commonly used tests and identify pitfalls and considerations in their use in the obstetric population. Some of the more commonly seen pathological states that may cause hypoxia in pregnancy will be discussed.

Secondary postpartum haemorrhage is defined as any abnormal or excessive bleeding from the birth canal occurring between 24 hours and up to 12 weeks postpartum. The quantity of blood loss that constitutes secondary postpartum bleeding, unlike primary postpartum hemorrhage, is not clearly defined. Subjective estimation of the amount of blood loss constituting ‘haemorrhage’ accounts for at least some of the variation in reported incidence of secondary postpartum haemorrhage from 0.47% to 2%

It is well recognised that birth before 32 weeks of gestation is associated with substantial neonatal morbidity and mortality and these risks have been extensively reported. The focus of perinatal research for many years has therefore been very preterm and extremely preterm delivery, since the likelihood and severity of adverse neonatal outcomes are highest within this group. In contrast, until recently, more mature preterm infants have been understudied and indeed, almost ignored by researchers.

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.

The epidural route is currently the gold standard for labour analgesia, although it is not without serious consequences, especially when incorrect placement goes unrecognised. Intravascular, intrathecal and subdural placements have been reported to occur with incidences of 1 in 5000, 1 in 2900 and 1 in 4200 respectively. Until recent years there has not been a viable alternative to epidural analgesia.

Umbilical cord prolapse is the descent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of ruptured membranes. Cord prolapse is a rare obstetric complication, usually requiring immediate delivery of the fetus to reduce neonatal morbidity and mortality. Therefore staff caring for women in labour should train regularly to manage it appropriately, because team training has been demonstrated to improve outcomes.

Kielland's forceps have been in obstetric practice for over 80 years but their use causes a wide spectrum of reactions in obstetricians. Those that have been well tutored in their use argue that they are a very effective instrument to achieve vaginal delivery in the malpositioned fetus, avoiding the problems of full cervical dilation caesarean section, with low complications in their hands. These exponents of the instrument argue that the “art” of obstetrics is demonstrated in the use of Kielland's forceps. However, others claim that Kielland's forceps are dangerous with high complication rates and that they should be confined to the obstetric museum. This paper reviews the history of the instrument and its inventor, to consider evidence for its effectiveness and its safety, to briefly consider other methods for delivery of the malpositioned fetus at full cervical dilation and finally to complete the journey by considering the future with particular emphasis on training the new generation of obstetricians.

The prophylactic use of low-dose aspirin for prevention of preeclampsia has been an important research question in obstetrics for the last three decades. In 1979, Crandon and Isherwood observed that nulliparous women who had taken aspirin regularly during pregnancy were less likely to have preeclampsia than women who did not. In 1985, Beaufils et al published the first randomized trial suggesting that 150 mg aspirin and 300 mg dipyridamole daily from 3 months’ gestation onwards decreased the risk of preeclampsia, fetal growth restriction and stillbirth in high-risk women. Subsequently, more than 50 trials have been carried out throughout the world and a meta-analysis of these studies reported that the administration of low-dose aspirin in high-risk pregnancies is associated with a decrease in the rate of preeclampsia by approximately 10%. Consequently, several national professional bodies recommend that high-risk pregnancies should be treated with aspirin (50–150 mg daily).

Congenital malformations are common, occurring in around 1 in 40 pregnancies. Analysis of data from European population-based congenital anomaly registers reported a malformation rate of 29.3 per 1000 births. Eighty percent of these were in live births whereas 17% were observed in fetuses terminated after ultrasound diagnosis of fetal abnormality. The remainder were stillborn or fetal deaths in utero. Fetal autopsy is still regarded as the gold standard procedure for identification of fetal abnormalities but assessment of the fetus by a clinical geneticist or other specialist with expertise in dysmorphology may also be informative. When coupled with other investigations which are non-invasive or involve only sampling of blood or other body fluids, examination for external malformations and dysmorphic features may complement autopsy findings or provide important information as to the causation of fetal abnormalities when autopsy is not possible. This situation is now becoming more common as rates of fetal autopsy have dropped significantly in the UK in recent years.

“Clinical decisions and research programs ultimately depend on the reliable and valid measurement of adherence. Yet, 50 years of research in this field have not provided the data necessary to answer critical measurement questions.”.

Preeclampsia (PE) is a multisystem disorder of human pregnancy, affecting about 6% of all pregnancies worldwide, and is one of the leading causes of maternal and infant morbidity and mortality. Despite decades of research into the pathogenesis of this complex disease, the underlying mechanisms remain unclear. As a result, the options for prevention and management of PE are limited. In recent years, there has been a growing body of evidence suggesting that folate deficiency is associated with PE, and folic acid supplementation may reduce the risk of developing PE in certain populations. Folate contributes to cell division and growth, and folate metabolism is involved in a large number of physiological and pathophysiological processes in human development. Sufficient supply of folate is therefore particularly important during pregnancy. Nevertheless, the exact mechanisms of folic acid deficiency increasing the risk of developing PE are still unclear. This article reviews what is understood about the aetiology of PE and the relationship between folate metabolism and PE so as to enhance further discussions on the subject.

Acute appendicitis is the most common non-obstetric indication for surgical intervention in pregnancy, complicating 1/500 to 1/2000 deliveries. Due to the anatomical and physiological changes associated with pregnancy, appendicitis may present a diagnostic dilemma, leading to management delays and thus increasing the risk of appendiceal perforation. Many of the common presenting symptoms of appendicitis are common features of normal pregnancy including lower abdominal pain, nausea, vomiting and leukocytosis. Furthermore, the enlarging gravid uterus may displace the appendix to varying degrees thus altering the classic symptom pattern of appendicitis. The often nonspecific presentation in pregnancy may necessitate the utilization of diagnostic imaging to aid in accurate diagnosis. However, the perforated appendix is the most common surgical cause of fetal loss and the time required for any diagnostic aid must be weighed against the increasing risk of perforation caused by delay in surgical intervention.