Obesity is the modern health epidemic of Western society. The World Health Organisation estimated in the year 2000 that as many as 300 million people worldwide are clinically obese. European countries are now following the worrying trends set by our American neighbours with as many as 30% of adults now classified as overweight and obese (Table 1). In the recent British Women's Heart and Health Study over 4000 women from 23 towns in England, Scotland and Wales were surveyed to establish the prevalence of cardiovascular risk factors. Over one quarter of the participants were obese (Body mass index (BMI)>30 kg/m2) with the mean BMI of the sample being 27.7 kg/m2 (SD 5.2). One fifth of the women were inactive (participated in less than one episode of moderate activity per week) and two fifths of women did not eat a portion of fresh fruit at least daily. In Sweden, 5600 individuals were surveyed to assess the trends for lifestyle changes between the periods 1986 and 1994. The prevalence of obesity (BMI>30 kg/m2) increased from 6.1% to 9.8% and overweight (BMI 25–29.9 kg/m2) from 19.6%–29.1% in women over this time period. In support of this the proportion of leisure time physical inactivity increased from 19.4% to 26.7%. Perhaps of more concern is the alarming increase in the prevalence of obesity in children. Data from a nationally representative sample of 2630 English children showed that the frequency of overweight (>85th centile) ranged from 22% at age 6 years to 31% at age 15 years and that of obesity (>95th centile) ranged from 10% at age 6 years to 17% at age 15 years. Obesity rates also vary in different ethnic groups with Afro-Caribbean and Pakistani girls living in the UK being more likely to be obese than the general population (OR 2.74 (95%CI 1.74–4.31), OR 1.71 (95%CI 1.06–2.76) respectively. A recent study has suggested that these concerning statistics may not be totally attributable to poor diet but also to a decline in total energy expenditure. For example, at age three the median time spent in sedentary behaviour was 79% of monitored hours and 76% by age five. In general these children spent only 20–25 minutes per day in moderate to vigorous physical activity. The most severe consequences of these observations is the fact that type 2 diabetes, once virtually unheard of in adolescence, now accounts for as many as half of all new diagnoses of diabetes in some populations in North America.

In the 1960s caesarean section accounted for approximately 3% of births in many nations of the Western world. By the mid-1980's, however, this rate was beginning to increase and concern was not only being expressed at the rising numbers of babies being delivered abdominally but also at the four-fold difference in national rates, from 5% of births in Czechoslovakia to 18% of births in the United States. This difference, it was argued, could not be explained either by variability in the characteristics of women living in these various countries, nor in their fetuses. The increased use of caesarean section at this time was attributed to a lowering of the threshold at which the operation was being used to manage dystocia (delayed progress in labour), breech presentation, fetal distress and the delivery of small or pre-term infants. The large difference between caesarean rates in North America and some European countries was felt to be due to differences in the management of dystocia and of women who had previous caesarean deliveries.

Successful pregnancy outcome depends on a co-coordinated series of events in development designed to attain normal placental function. The critical importance of placental vascular development is appreciated when a wide range of pregnancy complications including preterm labour (PTL), preterm premature rupture of the membranes (PPROM), pre-eclampsia (PE), fetal growth restriction (FGR), fetal demise (FD), and abruptio placenta (ABR) are all associated with restricted maternal and/or fetal blood flow, and secondary pathological lesions in the placental parenchyma. Other developmental defects of the placenta, such as its site (placenta praevia), extent of myometrial invasion (placenta accreta) or cord insertion (vasa praevia), may have major detrimental maternal and/or fetal effects if unrecognized during the antenatal period. In January 1999 we commenced a “Placenta Clinic” within the Fetal Medicine Unit at Mount Sinai Hospital (Toronto, Canada). Our rationale was that the early identification of many of these problems may, by facilitating appropriate multidisciplinary care and an elective delivery plan, reduce the attendant risks of maternal and perinatal morbidity and/or mortality due to placental malfunction.

Since the discovery that major histocompatibility complex (MHC) proteins provide a barrier to tissue transplantation between individuals it has been a paradox that, during pregnancy, the mother is able to retain a fetus that expresses MHC antigens from the father without rejection. The nature of this materno-fetal tolerance is not well understood and may involve multiple mechanisms. However since a major mechanism of histo-incompatible tissue rejection involves T lymphocytes, it seems plausible that controlling T cell responses is likely to be important. Recently, there has been considerable research activity focusing on the role of a sub-set of CD4+ T cells that express the interleukin-2 receptor chain CD25+. These CD4+CD25+ cells are termed regulatory T cells (Treg) based on their ability to prevent autoimmune tissue damage. In this review we discuss recent evidence that may link Treg to materno-fetal tolerance during pregnancy.

Twenty-five years have passed since the first “test tube baby” was born in 1978. Since then, more than 1 million children have been born world-wide. Today, they represent 2% of all new-borns in some countries, such as Sweden. After conventional in vitro fertilisation (IVF) was established, the cryopreservation technique developed and the first baby produced implementing this technique was born in 1984. The cryopreservation technique is firmly established in most IVF programmes at present. The introduction of intracytoplasmic sperm injection (ICSI) in 1992 has given many men the opportunity to father children, hitherto an impossibility.

Preterm delivery occurs in less than 10% of pregnancies but accounts for more than 70% of all neonatal deaths. Approximately one third of preterm deliveries are associated with preterm prelabour amniorrhexis. In those with infection, labour frequently ensues and survival depends on gestational age at amniorrhexis. In those without infection the pregnancy continues and death is then dependent on the development of pulmonary hypoplasia (PH).

Gestational diabetes (GDM) has an estimated incidence of 3–10%, depending upon geography and ethnic origin; it is considered by many to be a major health concern for the mother and fetus. Dietary modification and pharmacological therapy are the principal means employed to control maternal hyperglycemia. The two main pharmacological options for GDM management are administration of insulin or the use of oral hypoglycaemic and anti-hyperglycaemic drugs. Although controversy continues regarding the need for hypoglycaemic agents in all GDM women, approximately 30–60% do require pharmacological therapy in order to maintain targeted levels of glycaemic control.

Tara, a 24 year-old woman of Sri Lankan ancestry, was diagnosed with borderline chronic hypertension just 4 months before her first pregnancy. While she experienced a healthy childhood and normal pubertal development, by age 22 years her body mass index (BMI) was 29 kg/m2. The first pregnancy was complicated by chronic hypertension and superimposed preeclampsia (PET), necessitating Caesarian delivery at 33 weeks gestation. In her third pregnancy she was diagnosed with gestational diabetes mellitus (DM), and delivered a 4100 g macrosomic infant boy by Caesarian section. By age 42 years, Tara was started on oral medications for Type 2 DM and hypertriglyceridaemia; 9 years later she suffered a small lacunar stroke, leaving her with moderate left-sided weakness of the arm and leg. Her own mother had experienced “high blood sugars” during pregnancy, was overweight, and died at age 54 years from the complications of high blood pressure.

The adverse effects of alcohol on the developing human have been known since historical times but were not introduced into the medical literature before the late 1960's when French doctors reported that alcohol abuse during pregnancy might cause serious damage to the unborn child. Independently, the same observations were made in the United States, and in 1973 the term fetal alcohol syndrome (FAS) was introduced. Since then, FAS has been recognized in most industrialized and developmental countries where alcohol is widely used. Because of the magnitude of the problem, “The Committee to Study Fetal Alcohol Syndrome” in 1996 published a comprehensive report on the present state of diagnosis, epidemiology, prevention, and treatment of the disorder. The report recognised that only recently, during the last 20 years, have we become aware of the profound impact of substance abuse on individuals, their families, and society. Of all current substance abuse, alcohol is undoubtedly the most serious problem, both when considering the frequency of the disorder, and alcohol's power to injure the embryo and fetus.

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.

Vascular and Interventional Radiology, more succinctly known as Interventional Radiology (IR), is the subspecialty of Medical Imaging or Radiology that deals with diagnosis and treatment using minimally invasive procedures under imaging guidance. Initially, fluoroscopy was the only imaging modality available, but ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are also currently being used for guidance. One of the basic skills used by interventional radiologists is the Seldinger technique: the introduction of a needle into a body cavity or lumen allowing passage of a wire guide, which in turn facilitates the insertion of a tube or catheter. Many IR procedures have supplanted more invasive surgical techniques, with the resultant benefits of lower morbidity and mortality, shorter hospital stays and recovery times, and lower costs. Traditionally, obstetricians and interventional radiologists seldom interacted with one another, but their collaboration in patient care and research is increasing as obstetricians realise the value of IR, and as the myriad techniques and tools in the interventionalist's armamentarium expand and evolve.

Ultrasound has been used in cardiac diagnosis since the 1960s. The original modality used was M-mode, which recorded the movement of heart structures relative to a single line of sound passed through the heart and was displayed as a paper tracing. During the 1970s, a two-dimensional image became possible, but it was a static image, which had limited value for cardiac evaluation. However, by the end of the 1970s, advances in ultrasound equipment allowed the heart to be displayed in real-time. This technology was applied initially in the adult and subsequently in the child. Echocardiography proved particularly suitable for children, partly because it is non-invasive and repeatable, but also because most heart disease in children is due to malformation of anatomical structure, which ultrasound can ideally display. At the same time, obstetric ultrasound was progressing rapidly and descriptions of the appearances of malformations in most fetal systems began to be published by the end of the 1970s. It was not until real-time equipment became generally available in obstetrics that the fetal heart could be satisfactorily evaluated. This led to descriptions by several authors of normal fetal cardiac anatomy as seen echocardiographically in 1980. The appearances of the echocardiogram in different forms of congenital heart disease (CHD) in children were published in the late 1970's, setting the stage for diagnosis in fetal life. As a result, by the mid-1980's, most major forms of CHD had been detected prenatally.

In the United States alone, more than one million women of childbearing age suffer from epilepsy. New cases are diagnosed at a rate of 20–30 per 100,000 young women per year. Therefore, it is not surprising that epilepsy is the most common neurological disorder among pregnant women, complicating between 3 and 6 of every 1000 pregnancies.

Isolated case reports of the prenatal detection of urinary tract malformations first appeared in the literature in the late 1970s and by the mid 1980s prenatal diagnosis had already become a firmly established feature of paediatric urological practice throughout the developed world. The rapid development of prenatal diagnosis of urinary tract malformations can be attributed to the relatively high incidence of congenital anomalies within this system and the fact that the common anomalies are usually associated with dilatation or cystic pathology which is readily visualised by ultrasound. Although many aspects of prenatal diagnosis have been clarified by studies undertaken over the last twenty years some important questions have yet to be fully resolved – for example the long term natural history of asymptomatic uropathies such as pelvi ureteric obstruction and the benefit (if any) of prenatal diagnosis in reducing long term burden of chronic renal failure associated with posterior urethral valves.

The maintenance of the structural integrity of the fetal membranes is critical for successful progression of pregnancy. At term rupture of the fetal membranes (ROM) does not occur until the onset of labour-associated contractions in 90–95% of deliveries. This is often referred to as ‘spontaneous’ ROM, but since ‘spontaneous’ is also employed clinically to distinguish ‘natural’ from ‘artificial’ rupture, ‘labour-associated’ ROM (LROM) may be a more appropriate terminology. In the remaining 5–10% of term deliveries the membranes rupture prior to the onset of clinically apparent contractions. This has been referred to as ‘premature’ ROM, but it is less ambiguously defined as ‘pre-labour’ ROM (PROM). In direct contrast to the situation at term, PROM precedes 30–40% of preterm deliveries. If iatrogenic deliveries are excluded, PROM precedes 50% of preterm births, and represents the major cause of preterm birth. There is therefore great interest in the mechanisms underlying membrane rupture whether PROM or LROM.

Antiphospholipid antibodies (aPLs) are a diverse group of autoantibodies with specificity for phospholipid surfaces. Antiphospholipid antibodies may be found in individuals with a clinical history of thrombotic events or in women suffering severe pregnancy complications typically involving fetal compromise or demise. The association is known as the antiphospholipid syndrome (APS).