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Autoimmune diseases disproportionately affect women and have been linked to increased risk of maternal and perinatal mortality and morbidity. Our aim was to determine the prevalence of autoimmune disease among pregnant women and women of reproductive age (WRA), which is not well described.A population-based study was conducted using data from a survey of general practitioner (GP) encounters and state-wide hospital admissions in New South Wales (NSW). A list of 29 conditions and relevant diagnosis codes was used to identify autoimmune disease. Prevalence estimates and trends were calculated using population denominators for GP encounters for WRA in 2011-2015 and hospital admissions for WRA and pregnant women in 2013-2017.A total 31,065 GP encounters for WRA were identified and 607 (2.0%) reported an autoimmune disease, equivalent to 1.1 GP encounters per 10 WRA each year when extrapolating to NSW population figures. For WRA admitted to hospital, 2.6% had an autoimmune diagnosis recorded each year equivalent to a population prevalence of 0.5%. A total 477,243 births were identified, of which 4230 mothers (0.9%) had at least one autoimmune disease recorded during a 1-year pregnancy lookback period. Autoimmune disease prevalence among both pregnant women and WRA either attending GP or hospital increased, on average, 2-4% per year over the study period.A small, but potentially growing proportion of reproductive age and pregnant women have a diagnosed autoimmune disease, and this may impact their health outcomes.

Ionizing radiation should be considered an avoidable exposure although all pregnant women receive some radiation from their environment. The potential effect of ionizing radiation on the fetus is determined by the dose and the timing of the exposure with growing interest in the potential risks of transgenerational effects of radiation as an epigenetic phenomenon. High dosage exposure is very unlikely in routine situations such as occupational, diagnostic, or therapeutic exposures. Individual diagnostic radiation procedures (fetal dosage

In this clinical review we highlight aspects of the diagnosis and management of pulmonary embolism (PE) in pregnancy and post-partum and how this may impact on antenatal and postnatal management. Investigation for PE in pregnancy is challenging and includes appropriate patient selection and knowledge of the risks and benefits of pulmonary imaging modalities. The complete Society of Obstetric Medicine of Australia and New Zealand Position Statement on Pulmonary Embolism in Pregnancy and Post-Partum comprehensively reviews all aspects of diagnosis, investigation and management and is accessible at https://www.somanz.org/guidelines.asp. It includes a summary of all recommendations and a guide to developing a management plan for birth in women on anticoagulation.

This is a brief summary of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) evidence-based guideline for the management of nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum (HG). The full guideline and executive summary including auditable outcomes are freely available on the SOMANZ website [https://www.somanz.org/guidelines.asp]. The guideline includes a proposed SOMANZ definition of NVP and HG and evidence-based practical advice regarding the investigation and management of NVP, HG and associated conditions including thyroid dysfunction. A practical algorithm for assessment and management as well as an individual patient management plan and self-assessment tools are included.

The use of diagnostic imaging involving ionising radiation may be necessary in pregnancy and requires an assessment of the most appropriate and safest imaging modality which will provide the necessary information balanced with the potential risks to the mother and fetus. In most cases, this will involve a potential fetal radiation dose well below 50 mGy. At these doses, there is no risk of lethality, genetic damage/epigenetic change, teratogenicity, growth impairment or sterility. Older epidemiological data indicating a potential increased cancer risk have been contradicted by newer data and better understanding of the biology of low dose radiation. The linear no-threshold rule has been challenged by many and more realistic estimates of oncogenicity risk along with the potential risks of contrast agents are summarised in this review. Imaging in the pregnant population is increasing in both the number of examinations performed and the number of patients being imaged, with the greatest increase being computed tomography scans. Counselling and obtaining informed consent for imaging that involves radiation requires the clinician to communicate with the woman and her family a realistic estimate of the potential radiation dose to herself and her fetus, to describe and quantitate the risks of this estimated dose, to outline the benefits of the imaging procedure and to respond to any questions or concerns. As almost all diagnostic imaging involves doses below the 50 mGy threshold, clinically indicated investigations should not be withheld during pregnancy. All allied staff must also be well informed to ensure the patient receives a consistent message about the risks and benefits of the proposed test.

This guideline is an evidence based, practical clinical approach to the management of Hypertensive Disorders of Pregnancy. Since the previous SOMANZ guideline published in 2008, there has been significant international progress towards harmonisation of definitions in relation to both the diagnosis and management of preeclampsia and gestational hypertension. This reflects increasing knowledge of the pathophysiology of these conditions, as well as their clinical manifestations. In addition, the guideline includes the management of chronic hypertension in pregnancy, an approach to screening, advice regarding prevention of hypertensive disorders of pregnancy, and discussion of recurrence risks and long term risk to maternal health. The literature reviewed included the previous SOMANZ Hypertensive Disorders of Pregnancy guideline from 2008 and its reference list, plus all other published National and International Guidelines on this subject. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT), National Institute for Health and Care Excellence (NICE) Evidence Search, and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2007 and March, 2014.

SOMANZ (Society of Obstetric Medicine Australia and New Zealand) has written a guideline to provide evidence-based guidance for the investigation and care of women with sepsis in pregnancy or the postpartum period. The guideline is evidence-based and incorporates recent changes in the definition of sepsis. The etiology, investigation and treatment of bacterial, viral and non-infective causes of sepsis are discussed. Obstetric considerations relevant to anaesthetic and intensive care treatment in sepsis are also addressed. A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women have contributed to the development of the guidelines. This is an executive summary of the guidelines.

AIMS To investigate the effect of nausea and vomiting of pregnancy (NVP) on quality of life (QoL) and activities of daily living/socioeconomic function in a contemporary Australian setting. MATERIALS AND METHODS Observational, single centre prospective cohort study using validated survey instruments in pregnant women at 9-16 weeks gestation at a tertiary metropolitan women's hospital in Sydney, Australia. QoL measured by the Short-Form Health Survey (SF-12) was compared between those with and without NVP. NVP severity scores were correlated with QoL scores, work patterns and medication use. RESULTS Of 116 participants, 72% had NVP, with no baseline (including mental health) differences between women with or without NVP. As classified by modified Pregnancy-Unique-Quantified-Emesis (PUQE) survey, 42% had mild symptoms, 55% moderate and 1% severe. SF-12 Physical Component Summary (PCS) scores were significantly lower for those with NVP (P

Diagnostic imaging in pregnancy requires a detailed understanding of the risks and benefits of the imaging options. This will ensure the most appropriate and safest imaging modality is performed to provide maximal information for diagnosis and management. Counselling and obtaining informed consent for imaging that involves radiation requires the clinician to communicate with the woman and her family a realistic estimate of the potential radiation dose to herself and her fetus, to describe and quantitate the risks of this estimated dose, to outline the benefits of the imaging procedure and to respond to any questions or concerns. Although the “as low as reasonably achievable” (ALARA) should be applied, pregnant women should be imaged using the standard imaging protocols used for any other patients. If dose reduction strategies do not compromise image quality, then they should be used for all patients. The American College of Radiology particularly note that “It is best to create written protocols for all imaging of pregnant patients to avoid reactive, non-optimal protocol adjustments by physicians attempting to reduce radiation exposures.” All allied staff must also be well informed to ensure the patient receives a consistent message about the risks and benefits of the proposed test(s). In almost all diagnostic imaging,with or without contrast or nuclear isotopes, maternal and fetal risks are negligible and therefore the most sensitive and specific imaging should be performed at the most appropriate time whether during or after pregnancy. With adequate information and knowledge, the reflex “no radiation” approach to selection of diagnostic imaging modalities in pregnancy should be replaced with principle of ensuring that non-ionising radiation options are considered first, whether during or after pregnancy; but when X ray, CT, nuclear scan or PET are the most suitable modality; these should be applied with appropriate care and counselling.

The consultation is a sacred place for physicians and their patients. Whether in the office, clinic or at the bedside, the patients share their symptoms, their signs, their social situation, their family history, their emotional status, their relationships, their fears and their hopes. In exchange, we give them a management plan based on the best of our knowledge and experience. We liaise with relevant colleagues in a range of fields and instigate treatment that will be in their best interests. Well that’s how it used to be but the room is getting much more crowded. Now I’m also sharing the consultation space with the bloggers who had some or all of the patient’s symptoms, with alternative therapists who recognise and treat a range of conditions I’ve never heard of and the usual assortment of well meaning friends and relatives who all seem to know best. Let me present a typical but hypothetical example. I was recently asked to see a young woman referred for pre-pregnancy counselling. She had presented with fatigue and other non-specific symptoms persisting for many months postpartum and saw an alternative medical practitioner who diagnosed ‘‘adrenal fatigue’’. A number of predominantly endocrine tests were performed, and repeated several times, all of which to my eyes looked perfectly normal. She was prescribed highdose cortisol, high-dose triiodothyronine (T3), dihydroepiandrostenodione (DHEAS) sublingually, and metformin. Her symptoms improved but not completely and her secondary amenorrhoea continued. Her husband just wanted ‘‘the woman he knew before’’ back. Further research reveals she is being treated for ‘‘Wilson’s syndrome’’ (as opposed to Wilson’s disease which is all to do with copper!): a mix of various common and non-specific symptoms associated with low body temperature and impaired conversion of thyroxine (T4) to triiodothyronine (T3), despite normal thyroid function tests. 1 Like most sufferers her diagnosis has been missed because mainstream practitioners don’t understand how the body works and all tests are normal. The American Thyroid Association described the diagnostic criteria for Wilson’s syndrome as imprecise and non-specific, and found a lack of any scientific evidence supporting this syndrome. 2 How do I investigate a woman already on therapies that may mask

We hope you were all pleased with your first issue of Obstetric Medicine: the Medicine of Pregnancy, and that you share with us a feeling that the launch of the journal represents an important milestone in the development of our small specialty. It was fitting that the journal was launched at the 4th Scientific meeting of the International Society of Obstetric Medicine in Washington DC. It is our aim to apply for the journal to be on Medline by the time of the next Scientific meeting, which will take place in Melbourne, Australia in October 2010. The HighWire website for Obstetric Medicine is also now live… take a look at www.obmed.rsmjournals.com and bookmark it; all subscribers to the journal will have free access to the site. This is your journal and we welcome your feedback. You will find a feedback tab on the website or, if you prefer, you can email the editorial office or one of the editors directly.

Many aspects of hypertension care outside pregnancy may be applied in pregnancy, but little information is available on which to base decision-making. It would seem reasonable to continue previous dietary salt restriction and physical activity in women with pre-existing (and controlled) hypertension, encourage a heart-healthy diet in all women with a hypertension disorder of pregnancy, and take patient preference into account when deciding on place of care. Although bed rest has become a key part of obstetric practice and for care of women with a hypertension disorder of pregnancy, in particular, the evidence is lacking to support this practice. This may also increase thromboembolic risk. Antihypertensive treatment is strongly advised for women with severe hypertension. The most common agents are parenteral labetalol, hydralazine, or oral nifedipine capsules. Clinicians should familiarise themselves with multiple agents. Until the role of antihypertensive treatment for non-severe hypertension in pregnancy is clarified by ongoing research, clinicians should explicitly state an individual patient's blood pressure goal, which could reasonably be anywhere between 130/80 and 155/105 mmHg. Labetalol and methyldopa are used most commonly. Breastfeeding should be encouraged. Many risk factors for hypertension (e.g. obesity), as well as hospitalisation and pre-eclampsia, all increase the thromboembolic risk for pregnant women, and care providers should consider thromboprophylaxis in the appropriate setting. Finally, anaesthetists play a critical role in the management of women with a hypertension disorder of pregnancy, and should be involved earlier rather than later in the course of their care.

This is the Executive Summary of updated guidelines developed by the Society of Obstetric Medicine of Australia and New Zealand for the management of hypertensive diseases of pregnancy. They address a number of challenging areas including the definition of severe hypertension, the use of automated blood pressure monitors, the definition of non-proteinuric pre-eclampsia and measuring proteinuria. Controversial management issues are addressed such as the treatment of severe hypertension and other significant manifestations of pre-eclampsia, the role of expectant management in pre-eclampsia remote from term, thromboprophylaxis, appropriate fluid therapy, the role of prophylactic magnesium sulfate and anaesthetic issues for women with pre-eclampsia. The guidelines stress the need for experienced team management for women with pre-eclampsia and mandatory hospital protocols for treatment of hypertension and eclampsia. New areas addressed in the guidelines include recommended protocols for maternal and fetal investigation of women with hypertension, preconception management for women at risk of pre-eclampsia, auditing outcomes in women with hypertensive diseases of pregnancy and long-term screening for women with previous pre-eclampsia.

Neurological disease presents a particular challenge to those providing obstetric care, to minimise maternal, foetal and neonatal morbidity. Women with pre-existing neurological disease should ideally be given a preconceptual assessment in order to optimise medical management. Headache is an extremely common problem both during and outside of pregnancy and requires a structured approach. Some conditions, such as eclampsia, are unique to pregnancy, whereas others, such as carpal tunnel syndrome, are seen much more frequently but not exclusively in pregnancy. The drug management of epilepsy in pregnancy represents a particular challenge, balancing the desire to limit foetal exposure on the one hand, with the need to maintain therapeutic benefit to the mother on the other. Assessment of all neurological conditions requires a sound knowledge of neuroanatomy and the physiology of pregnancy, with appropriate use of neuroimaging and neurophysiological testing. Management should involve a multidisciplinary team with specialist neurological input.

The majority of neurological diseases encountered in pregnant women are pre-existing conditions. The impact of such chronic diseases, e.g. epilepsy, may include an increase in maternal morbidity, an increase in fetal or neonatal morbidity and mortality and possibly more long-term consequences to the developing child. These consequences may reflect an effect of the disease itself or an effect of treatment. Some neurological conditions occur more frequently in pregnant women, e.g. compression mononeuro-pathies while others are unique to pregnancy, e.g. eclampsia. The following review discusses the most common neurological diseases with brief mention of rare but important disorders that may occur during pregnancy or the puerperium.

The use of anticonvulsant drugs in pregnancy presents unique challenges to clinicians and their patients. The need for control of maternal epilepsy must be balanced with the fetal and neonatal risks associated with anticonvulsant drugs. Anticonvulsant drugs may have potential effects on embryogenesis, neurological development, growth and subsequent paediatric progress. Drug selection and dose adjustment must be appropriate and based on a combination of known maternal and fetal risks as well as the clinical status of the patient. Overall, no one drug can be specifically recommended but monotherapy with most of the recognized first-line drugs will result in a satisfactory outcome. Polytherapy is associated with an increase in congenital malformations and should be avoided if possible. It is possible that newer second-line agents, for example, gabapentin, may be safer as add-on therapy. Neurological disorders such as migraine, and the less common conditions of myasthenia gravis and multiple sclerosis, may require the use of drugs which have not been well studied in pregnancy. Information is provided about the use of drugs to control symptoms and prevent disease progression in these disorders during pregnancy.

Cauda equina syndrome is rarely associated with pregnancy, with few cases reported in the literature. The majority of cases describe antenatal presentations, with only one case manifesting post-partum, three weeks after a normal vaginal delivery. We outline a case of cauda equina syndrome following caesarean section in a patient with known lumbar disc disease, and discuss the contribution of the mode of delivery and anaesthesia as precipitants of disc herniation causing cauda equina compression. We conclude that vigilance, particularly in the post-partum setting, be attributed towards the neurological surveillance of women with known disc disease.

Complex pregnancy is a game of pass the parcel. In every case report we receive, the authors remind us of the need for multidisciplinary care. Frequently, when the music stops, it is the neonatologist who is left ‘holding the baby’. It was not long ago that neonatal clinicians faced a neonatal death almost weekly in level 3 units. A close colleague was recently relating that in one week he attended five babies that died. I remember as a registrar I would prepare the monthly perinatal morbidity/mortality meeting and there would be several deaths and dozens of major morbidities.

We are writing this in the week after the London 2012 Olympics. Even the most cynical of Brits were forced to join in the infectious and friendly atmosphere that impressed all visitors to a city not normally known for its welcoming and helpful inhabitants. The unifying power of sport that the world witnessed was impressive. Similarly the coming together of so many clinicians with a shared passion for the care of pregnant women with medical problems ensured that ISOM 2012 felt like a global family reunion. Thank you so much to the speakers and all those who attended and made it such a stimulating and educational meeting.

The disastrous events in Chernobyl in 1986 heightened awareness in the community of the hazards of radiation in our everyday lives. The pregnant woman and her fetus are considered to be particularly vulnerable to the adverse effects of radiation and the use of diagnostic radiography in obstetric practice has been substantially curtailed because of the fear of iatrogenic injury and the availability of safe alternatives such as ultrasound. However, in certain situations, diagnostic radiography is a necessary and unavoidable part of the management of the pregnant patient and it is necessary to balance the benefits of such procedures with an accurate assessment of the risk. Additional sources of radiation such as background or occupational exposure may contribute to the risk in an individual woman and the importance of these must also be considered as part of the total exposure. The amount of radiation can be expressed in two ways: 1. X-ray or gamma radiation exposure through air (Roentgens) or 2. radiation dose absorbed by the body, in this case the fetus (rads).

Gestational diabetes mellitus (GDM) is associated with a marked increase in the long-term risk of type 2 diabetes and adverse pregnancy outcomes. Engaging in vigorous recreational physical activity prior to and during pregnancy significantly reduces the risk of developing GDM. In contrast, evidence of a therapeutic effect from participation in a structured exercise training regimen, although promising, is limited and requires further more substantial investigation. This paper briefly reviews the pathophysiology of GDM, the evidence related to physical activity participation and exercise regimen intervention on GDM, and the clinical considerations required for prescribing exercise.

Internal medicine and its subspecialties will become an even more integral part of the care of pregnant patients as the obstetric population ages and has an increase in comorbid conditions, such as diabetes, heart disease, hypertension and obesity. In the United States, there are 62 million women of childbearing age, most of whom will have given birth by the age of 44, translating to 4 million births annually. Over 25% of these women will enter pregnancy with a chronic medical condition, and nearly half will be overweight or obese, further increasing risk. The metabolic syndrome has been associated with hypertension, preeclampsia and increased risk for thromboembolic disease. A recent review of maternal morbidity during obstetric hospitalizations in the US has shown a 26% increase in overall medical complications, and an even higher rate for pulmonary embolism, respiratory and renal failure. Complications rise with increase in age and with caesarean delivery, and this was especially true for pulmonary embolism and acute respiratory distress syndrome, but all of the increase cannot be accounted for by age or mode of delivery. There is little doubt that internal medicine will need to step up and fill the void that exists in treating this complex patient group. Obstetric medicine specialists must act as mediators between women with complex medical illnesses and their obstetrical care team.

News of unusual or interesting cases spread throughout the hospital or clinic like a virus. Everyone wants to hear about the patient with the rare syndrome or unheard of side-effect. Such cases engender fear, excitement and trepidation in the treating team and the patient. Often such a case will generate the suggestion from a consultant to junior doctor: ‘You should write this up’. And yet the humble case report is considered a lowly ranked publication. Single case reports are rarely cited and do not contribute to the Impact Factor for the publishing journal. They are given the lowest level of evidence rating and many journals have abandoned publishing case reports.

The journal celebrates its first birthday this month. It has been well received and we would like to thank all those of you who have written, re-written, reviewed, re-reviewed and edited the many submissions we have received. If you have ideas for topics that you would like to appear as review articles please do contact one of the editorial board. We are also keen to receive any general feedback about the journal.

Obstetric medicine emerged as a specialty to address an important gap in care. When pregnant women had medical problems beyond the scope of obstetricians, but physicians trained in internal medicine did not yet have the expertise to be comfortable providing care, patients were often orphaned by the health-care system. Training programmes and national and international curricula were developed to train obstetric internists, and obstetric medicine societies led worldwide efforts in education and collaboration. Despite progress in clinical care, teaching and research in obstetric medicine, an important fragmentation of care still exists.

Comprehensive care of the pregnant woman involves a number of health professionals with a significant input from the woman and her family. The family physician, midwife and/or obstetrician may provide antenatal care through a variety of settings from hospital-based outpatient clinics or private surgeries to community centres or even the home. When pregnancy is complicated by a medical condition, either de novo or pre-existing, the number of interested parties may multiply exponentially. Who should be providing this additional care remains controversial. The history of obstetric medicine as practiced by physicians or internists is relatively brief. Many physicians are forced to care for pregnant patients as an extension of their care of adults, but without any specific training or expertise. Often this is accompanied by a high level of anxiety as the physician may be inexperienced in, or not familiar with, aspects of normal pregnancy, let alone abnormal pregnancy. In the case of pre-existing conditions, how is the underlying disease going to influence the pregnancy; is the current therapy suitable in pregnancy; and how is the pregnancy likely to effect the maternal condition? What about delivery, breastfeeding, the effects of poor sleep and postnatal mood disturbance? From this dilemma has evolved the role of the obstetric physician, a subspecialty dedicated to the prepregnancy, antenatal and postnatal care of women with medical disorders of pregnancy. Not surprisingly, as a new subspecialty evolves there may be new borders to be established. In the past, the obstetrician-gynaecologist was responsible for all aspects of obstetric care from diagnosing and managing infertility to resuscitating the neonate after a difficult delivery for shoulder dystocia. With improving knowledge and technology a number of subspecialties have evolved, including assisted conception, fetomaternal medicine, fetal surgery and perinatology. In many units, high-risk midwives play an active role in the monitoring, counselling and management of pregnant women with medical disorders. In addition, the general anaesthetist has been replaced by the obstetric anaesthetist, the intensivist and the neonatal anaesthetist. Each of these subspecialists may form part of a multidisciplinary team caring for a woman with a medical complication in pregnancy. So, to whom does obstetric medicine belong? The correct answer must be whoever has the expertise, experience and ability to work in a multidisciplinary team to provide the most appropriate care for that particular woman. This may involve a number of health professionals, the only prerequisite being that a model of care is established taking into account local resources and abilities. What is clear is that optimal care requires a continual updating of knowledge and skills. As we are all aware, it is very difficult to keep up to date in all fields of medicine. Given its complexities, we need to acknowledge the potential contribution of all of the specialists with an interest in the medical disorders of pregnancy. There is no place for ego or isolationism when caring for this special population of patients, and every reason to cooperate and learn from each other. In Obstetric Medicine: the Medicine of Pregnancy, we hope to stimulate and satisfy the interests of all those clinicians working with women with medical complications of pregnancy. In this issue we review the fascinating and unique physiology of calcium in pregnancy and lactation, highlighting the important role of parathyroid hormone-related protein (PTHrP) in this complex system. In contrast, mitral valve disease is an old disease revisited in the context of current practice. We examine two very different aspects of liver disease in pregnancy. Individual case reports remain an important mechanism for highlighting the diversity and difficulties of practice in the area of obstetric medicine, and the importance of multidisciplinary input and advice. We look forward to original contributions from all those committed to improving the care of women with medical disorders in pregnancy.

It is with a sense of pride and hope that we welcome you to the inaugural edition of Obstetric Medicine: the Medicine of Pregnancy. The editors-in-chief and the editorial board represent physicians from across the globe who have dedicated their careers to improving care for pregnant women with medical illness. A special thanks must go to Professor Michael de Swiet and Dr Richard V Lee, our UK and USA grandfathers of Obstetric Medicine, who have served as mentors to each of us. This new journal would not exist were it not for Richard Lee who had the vision and determination and has been the driving force behind its development. To him we are extremely grateful. Despite a vast improvement in maternal mortality from obstetric causes (haemorrhage, infection, preeclampsia/eclampsia) in the developed nations, there has been little change in the rates of maternal mortality from medical illness. Cardiac disease and thromboembolism continue to be the leading causes of indirect and direct maternal mortality respectively. Sadly, in developing nations maternal mortality rates are similar to those that existed in the UK and USA in the 1950s. The improvement in the safety of obstetric services in our richest nations has not translated to similar outcomes worldwide. Additionally, HIV/AIDS continues to ravage mothers and babies in the developing world. Dr Lewis’s review in this first edition of Obstetric Medicine lends heart-wrenching clarity to this issue. Those who practise in the area of obstetric medicine are well aware of the variety of professionals involved in the care of pregnant women. Michael de Swiet, highlights that ‘huge advances have been made in reducing maternal mortality from traditional obstetric causes. It is now time to pay more attention to the medical problems of pregnancy. Although the situation will be improved by training more physicians (internists) in the medical problems of pregnancy, there will never be enough of these physicians to provide all the medical care that is needed. Those responsible for the obstetric care of pregnant women (midwives, general practitioners and obstetricians) must be more aware of (and receive training in) the significance of medical conditions; both to treat sick pregnant women with a medical problem and to recognise when they should be referred to a physician’. Improving outcomes for pregnant women with medical illness must start prior to pregnancy. Emphasis on the need for prepregnancy counselling and adequate contraception will be found throughout the issues of Obstetric Medicine. Women with diabetes, obesity, hypertension, heart disease, epilepsy, thromboembolism, autoimmune disorders and psychiatric illness will benefit from prepregnancy interventions. ‘To be effective, the knowledge of obstetric medicine of all doctors caring for medical problems in women of childbearing age must be improved.’ Great strides have been made in teaching, which include the development of fellowships and an international curriculum in obstetric medicine that will be discussed in future editions of Obstetric Medicine. This first issue includes all the abstracts from the ISOM meeting in Washington, as well as those from the joint ISSHP/ISOM sessions. For this reason space for review articles is limited but there are many seminal reviews

BACKGROUND: Hepatic ischemia associated with coarctation of the aorta has not previously been reported in an adult; pregnancy increases the pressure gradient across a coarctation. CASE: A young woman with known coarctation of the aorta developed severe hepatic ischemia in pregnancy. A pregnancy-induced increase in the mean pressure gradient across the coarctation, from 18 mm Hg before pregnancy to 40 mm Hg in the third trimester, predisposed to critical hepatic hypoperfusion in the setting of dehydration. CONCLUSION: This case documents an association between coarctation of the aorta and hepatic ischemia, precipitated by pregnancy and dehydration in combination. It emphasizes the need in the assessment of patients with liver disease in pregnancy to consider not only traditional pregnancy-related conditions such as acute fatty liver and the hemolysis, elevated liver enzymes, low platelets syndrome, in which delivery may be necessary as a clinical emergency, but also those in which the circulatory and metabolic demands of pregnancy may precipitate liver injury.

Background: The use of X-rays, computed tomography scanning and nuclear medicine imaging in the pregnant woman is a source of great anxiety for the patient, her family and the treating doctor. Methods: A literature review of appropriate databases, articles and relevant institutional protocols was performed. Data was sought regarding any adverse effects of diagnostic radiation in pregnancy, fetal absorbed dose of diagnostic radiation and how the timing of exposure and form of administration might influence these effects. Results: The estimated radiation dose for a fetus from background sources as well as medical imaging was identified. Most diagnostic radiation procedures will lead to a fetal absorbed dose of less than 1 mGy for imaging beyond the abdomen/pelvis and less than 10 mGy for direct or nuclear medicine imaging. Potential adverse outcomes related to radiation exposure during pregnancy include teratogenicity, genetic damage, intrauterine death and increased risk of malignancy. The only adverse effect statistically proven at the dose levels associated with diagnostic radiation procedures is a very small increase in childhood malignancy, with an estimated increase of one additional cancer death per 1700 10 mGy exposures. The important exception was the risk to the fetal thyroid from radioiodine exposure after 12 weeks’ gestation. Conclusion: In practice, diagnostic radiography during pregnancy not involving direct abdominal/pelvic high dosage, is not associated with any significant adverse events. Counselling of pregnant women who require diagnostic radiographic procedures as well as those inadvertently exposed should be based on the available human data with an emphasis on the minimal impact of such procedures.

We are all constantly exposed to guidelines: writing them, reviewing them and hopefully following their recommendations. However, we are also all aware that many of these guidelines are based on inadequate or ever-changing evidence. Many guidelines appear to be written by lawyers with so many exceptions or options that the advice becomes virtually useless. The process of guideline development is now well established and is designed to reflect uncertainty where it exists. The grading of evidence and the acceptance of minority or non-unanimous points of view better reflects the reality of clinical decision-making but makes implementation of such guidelines problematic. The enormous task of collating, reviewing, and distilling the evidence in an area such as obstetric medicine is daunting. For historical reasons we have tended to approach these tasks regionally. For example, there are guidelines for recommended weight gain in pregnancy from the USA1 but in the UK the National Institute for Health and Clinical Excellence (NICE) Guidelines provide no formal recommendation on what constitutes appropriate weight gain during pregnancy.2 Currently, many countries are grappling with the recommendations from the International Association of Diabetes Pregnancy Study Groups (IADPSG) regarding the diagnosis and classification of hyperglycaemia in pregnancy.3 In this case, a complex and time-consuming formal process has led to recommendations which then need to be implemented in each country. The argument for International Guidelines in Obstetric Medicine is obvious: harness global expertise to produce a uniform guideline and if necessary amend with local protocols that reflect any minor regional differences. In this edition of Obstetric Medicine, Linda Barbour presents a review of the Institute of Medicine (IOM) weight gain in pregnancy guidelines from the point of view of both mother and baby. Our research articles this month are on the related topics of gestational diabetes and weight. We also have a review on the common subject of antihypertensive therapy in pregnancy and this is complemented by a journal watch addressing a new analysis of angiotensin-converting enzyme inhibitors and their effects in early pregnancy. This edition of Obstetric Medicine will be published just prior to the Sixth International Scientific Meeting of ISOM (the International Society of Obstetric Medicine) to be held in Oxford on 7–8 July 2012.4 This promises to be an informative and stimulating meeting. It also offers the opportunity to meet with colleagues in the field of obstetric medicine and discover what guidelines they have already developed. We should also take the time to consider subjects which might be suitable for an international guideline. As an organization, ISOM can play a role in helping us share knowledge and experience along with other useful information.

This year will see the fourth anniversary of the launch of the journal Obstetric Medicine. Many thanks to all those who completed the reader’s survey. This has reassured us that most of you find the journal useful and believe that it fills what was previously a gap. We will be using the results of this survey to appeal the decision not to include Obstetric Medicine in MEDLINE. We know that all of you will feel more comfortable writing, reviewing and commissioning copy for the journal once it is listed in MEDLINE. However, the long-term success of the journal also depends on securing enough institutional subscriptions to ensure financial viability. All members of ISOM, MOMS, NASOM and SOMANZ receive the journal at a substantially subsidized cost and we do not wish to change this. We feel it is and should remain an important benefit of membership of these societies. However, we would really appreciate your help in approaching your own institution’s library. Please consider completing a library recommendation form at http://www. rsmpress.com/librarians/recommend.php. Subscription information can also be found at www.obmed.rsmjournals.com. Obstetric Medicine, along with other RSM journals, is available online on the newly released RSM H2O platform hosted by the world’s leading electronic content provider, HighWire, which offers instant access to full text, where available, with links to references and cited articles. Your Librarian would benefit from

In this September issue of Obstetric Medicine, we congratulate our co-editor Professor Karen Rosene-Montella on her appointment as Chairman of our Editorial Board. Karen has been an integral member of our editing team since the conception and launch of Obstetric Medicine: The Medicine of Pregnancy. As incoming Chairman she replaces the indefatigable Professor Richard Lee. Dick's vision, determination and enthusiasm, in association with our publishers the Royal Society of Medicine, has allowed us to produce a truly international journal representing this specialized field of medicine. We are very grateful for his efforts and look forward to his contributions as Emeritus Editor-in-Chief.

In March this year the Eighth Report of the Confidential Enquiries into Maternal Deaths in the UK was published.1 These enquiries began in 1952 and, as well as providing a breakdown of the causes of deaths in pregnancy and the puerperium, have highlighted areas of substandard care and listed recommendations to improve the care received by pregnant and puerperal women. The maternal death enquiries have influenced maternity health-care policy in the UK as well as stimulated the development of local and national evidence-based guidelines. Other nations look to the UK Maternal Death Enquiries to learn lessons and many of the recommendations are relevant for other developed countries.

If you perform a search of the terms ‘hypertophic cardiomyopathy’ and ‘pregnancy’ in Medline after 1996, 88 articles are identified. These include articles about fetal cardiomyopathy, especially as related to maternal diabetes. There are also a number of publications of maternal hypertrophic obstructive cardiomyopathy (HOCM) from various centres including literature reviews. But in addition, there are two brief case reports about ‘bad outcomes’ in women with HOCM. In fact, it is these articles that are most instructive for a variety of reasons.

As increasing numbers of women of child-bearing age enter pregnancy with chronic medical conditions and an increasing number are overweight or obese, the role of obstetric medicine expands as well. The challenge to safely prepare these women for pregnancy, care for them during pregnancy and develop plans for their long-term care will be enormous. We must be able to develop a workforce across disciplines to answer this need. In the latest UK Confidential Enquiries into Maternal Deaths,1 in which the individual deaths were reviewed in detail, ‘the assessors were struck by the number of health care professionals who appeared to fail to be able to identify and manage common medical conditions or potential emergencies outside their immediate area of expertise’. In this edition of the journal, we are pleased to publish ‘Validation of a Canadian Curriculum in Obstetric Medicine’. This is an instrument specific to Canadian Residency training that has had country-wide validation. In addition, there have been contributions from the North American and the International Society of Obstetric Medicine's work on an international curriculum, spearheaded by our UK editor-in-chief, Professor Catherine Nelson-Piercy, and by Professor Raymond Powrie of the USA.

Health and disease are expensive for any government. Deciding which drugs and therapies to fund, which services to invest in, which to expand and develop, and which should be cut, is something that is not within our immediate control. Maternity care is viewed as essential, but the extra investment required to provide holistic and specialist care for those women with medical, psychiatric or social problems in pregnancy is not. Certainly in the UK the focus is on safe and senior staffing of the labour wards, and not on the development of services for women with medical problems in pregnancy.