Clinical Review

Recent developments in obstetrics

BMJ 2003; 327 doi: http://dx.doi.org/10.1136/bmj.327.7415.604 (Published 11 September 2003) Cite this as: BMJ 2003;327:604
  1. Andrew H Shennan, professor of obstetrics1
  1. Guy's, King's, and St Thomas's School of Medicine, St Thomas's Hospital, London SE1 7EH

    Introduction

    Two of the most challenging areas in antenatal care are prematurity and pre-eclampsia. Between them they affect one in 10 of all pregnant women, and their prevalence is static. Until recently management options have been limited. Improved understanding of the basic pathophysiology is changing this.

    Sources and selection

    This article describes those advances that have made an impact on the management of prematurity and pre-eclampsia. Another major concern in obstetrics is the rising number of interventions, particularly caesarean sections, without obvious benefit to mother or baby. Recent research has highlighted several simple but effective strategies that could help influence this trend. These include management of previous caesarean sections and breech presentation and more appropriate use of fetal monitoring and epidurals in labour; knowledge of these will be valuable to any clinician who comes into contact with pregnant women. The articles selected are from relevant searches in English from Pubmed and the Cochrane Collaboration, as well as the author's own experience through research and reviewing.

    Pre-eclampsia

    The current structure of antenatal care developed around detecting pre-eclampsia. The detection of hypertension and proteinuria, the defining signs of this syndrome, is the key aim of frequent surveillance in pregnancy. Pre-eclampsia occurs in about 3% of pregnant women and results in around 100 000 maternal deaths per year worldwide. The fetus is also affected, directly through placental insufficiency and indirectly through iatrogenic delivery; this accounts for 25% of all infants with a very low birth weight (< 1500 g). The onset and course of pre-eclampsia are unpredictable, and it therefore results in enormous use of health resources. Accurate prediction and targeted preventive measures would have enormous benefit.

    Prediction

    Many biochemical substances, principally of placental and endothelial origin, increase in pre-eclampsia. However, their predictive value to detect susceptible women before clinical presentation is poor. As the disorder originates in the …

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