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We sought to audit the documentation of shoulder dystocia in our institution and re-audit following the introduction of a structured proforma. All cases of shoulder dystocia were identified and studied retrospectively from January 1st2005 to December 31st2006. A standardized proforma was introduced and cases of shoulder dystocia were prospectively identified over a 6 month period in 2008. The incidence of shouder dystocia was 0.79% in the initial study and 1.36% in the subsequent audit. Documentation improved with the introduction of the proforma. There was also a significant improvement in neonatal APGARs in the re-audit (35% vs 11.5% APGARs

We sought to determine subsequent pregnancy outcomes in a cohort of women with a history of unexplained recurrent miscarriage (RM) who were not receiving medical treatment.This was a prospective cohort study, of women with a history of three unexplained consecutive first trimester losses, who were recruited and followed in their subsequent pregnancy. Control patients were healthy pregnant patients with no previous adverse perinatal outcome.A total of 42 patients with a history of unexplained RM were recruited to the study. About nine (21.4%) experienced a further first trimester miscarriage, one case of ectopic and one case of partial molar pregnancy. About 74% (23/31) of the RM cohort had a vaginal delivery. There was one case of severe pre-eclampsia. The RM group delivered at a mean gestational age of 38 + 2 weeks and with a mean birthweight of 3.23 kg. None of the neonates were under the 10th centile for gestational age. Overall, there was no significant difference in pregnancy outcomes between the two cohorts.Our study confirms the reassuring prognosis for achieving a live birth in the unexplained RM population with a very low incidence of adverse events with the majority delivering appropriately grown fetuses at term.

Objective This study was designed to evaluate platelet aggregation in pregnant women with a history of unexplained recurrent miscarriage (RM) and to compare platelet function in such patients who go on to have either another subsequent miscarriage or a successful pregnancy. Study design A prospective longitudinal study was performed to evaluate platelet function in a cohort of patients with a history of unexplained RM. Platelet reactivity testing was performed at 4–7 weeks gestation, to compare platelet aggregation between those with a subsequent miscarriage and those who had successful live birth outcomes. Platelet aggregation was calculated using a modified assay of light transmission aggregometry with multiple agonists at different concentrations. Results In a cohort of 39 patients with a history of RM, 30 had a successful pregnancy outcome while nine had a subsequent miscarriage again. Women with subsequent miscarriage had reduced platelet aggregation in response to adenosine diphosphate ( P value 0.0012) and thrombin receptor activating peptide ( P value 0.0334) when compared to those with successful pregnancies. Women with subsequent miscarriages also had a trend towards reduced platelet aggregation in response to epinephrine ( P value 0.0568). Conclusion Patients with a background history of unexplained RM demonstrate reduced platelet function if they have a subsequent miscarriage compared to those who go on to have a successful pregnancy.

Neural tube defects (NTDs) are complex congenital anomalies. Spina bifida and anencephaly which arise from failure of closure of the neural tube during embryogenesis are the most common forms of NTDs. While anencephaly is a letal malformation, spina bifida is a common birth defect in which patients can suffer from a multitude of potential medical and surgical morbidities and increased risk of mortality throughout their life. The incidence and prevalence of NTDs varies in different parts of the world [1]. This is attributable to many factors including; geographic region, maternal age, obesity, ethnicity and socioeconomic status of the parents. However a declining trend has been seen in many countries. This in part may be explained by the availability of prenatal diagnosis, folic acid supplementation recommendations, folic acid food fortification initiatives and selective termination. Prevention of NTDs presents a complex problem as the underlying aetiologies of NTDs are an interplay of genetic, environmental and nutritional factors. Folate deficiency explains approximately 72% of NTDs cases and this chapter will primarily address the role of folic acid supplementation for the prevention of NTDs [2]. However, it is necessary to briefly review the metabolism of folate to understand how these prevention strategies were developed.

SGA was defined by a BW 10% are at increased risk of adverse perinatal outcome and should therefore be considered high risk pregnancies.

Objective To evaluate platelet aggregation in patients with a history of recurrent miscarriage (RM) during a subsequent successful pregnancy and compare them to healthy pregnant controls. Study design A prospective longitudinal study was performed to compare platelet function in 30 patients with a history of three consecutive unexplained first trimester pregnancy losses and 30 healthy age-matched pregnant controls. Exclusion criteria included the use of anti-platelet medications such as aspirin and medical conditions that can affect platelet function. Light transmission aggregometry was used to assay platelet agonists at different times and concentrations to create dose-response curves. Results In contrast, to the increased platelet aggregation response seen in healthy controls, platelet reactivity in patients with RM peaked at 12–14 weeks gestation, highlighted by the increased aggregation response to epinephrine (p = 0.0008) and collagen (p Conclusion Patients with a history of recurrent miscarriage have significantly different platelet function when compared to healthy controls, in particular during the first trimester. Knowledge of which patients have impaired platelet function may allow for more targeted therapy in the setting of recurrent miscarriage.

Abnormalities of platelet function have been implicated in a number of obstetric complications and anti platelet therapy is used to prevent certain conditions. Research of platelet function in pregnancy has yielded conflicting results. We sought to critically evaluate platelet reactivity in pregnancy using an assay which allowed several agonists of varying concentrations to be assessed concurrently and aimed to clarify platelet reactivity in normal pregnancy. A prospective longitudinal study was performed throughout uncomplicated singleton pregnancies with patients recruited prior to 15 weeks’ gestation. They were controlled for a number of factors known to affect platelet reactivity. Blood samples were obtained in each trimester (n = 36). Thirty non-pregnant healthy female volunteers also had a platelet assay performed. A modification of standard light transmission aggregometry was used to assess platelet reactivity, with light absorbance measured following addition of 5 different agonists at sub-maximal concentrations. Dose-response curves were plotted and the Ec50 was calculated for each agonist. Platelet reactivity, as demonstrated by the Ec50, was significantly reduced in the 1st and 2nd trimester of pregnancy compared to the non pregnant state particularly with respect to collagen, (p = 0.002). Within the pregnancy cohort the platelet reactivity increased as the pregnancy progressed, most evident in response to arachidonic acid (AA) (p = 0.033). This study demonstrates that platelet reactivity is altered in pregnancy, highlighted by the significant reduction in reactivity seen in the 1st trimester. This information will be critically important for designing and interpreting interventions to prevent obstetric complications, such as preeclampsia.

The recommended mode of delivery for the fetus with an abdominal wall defect is controversial, with no evidence to support caesarean delivery other than for routine obstetric indications. We sought to review mode of delivery in cases of prenatally diagnosed gastrochisis in our centre. This was a retrospective cohort study of prenatally diagnosed fetal gastroschisis cases in the Rotunda Hospital over a fourteen year period. Cases were identified from the Fetal Assessment Unit database. We identified 35 cases fetal gastroschisis cases during the study period. The average age of mothers was 22.5 years. The median gestation at delivery was 35 + 4 with an average birthweight of 1.97 kg. An elective caesarean section was performed in 13.3% (n = 4) cases. Vaginal delivery was the intended mode of delivery for the remaining cases (n = 26) however 54% resulted in an emergency caesarean delivery with nonreassuring CTG cited as the most common indication (64%, 9/14). Of these, 50% (7/14) were performed outside of normal working hours. Although the numbers in our cohort are relatively small, we found a significantly high rate of caearean delivery in young women with pregnancies complicated by gastroschisis. The high proportion of cases with nonreassuring fetal testing during labour resulted in a higher than expected number of emergency deliveries which were performed outside normal working hours. Our findings suggest that re-evaluation of the optimal mode of delivery in this cohort may be warranted.

Aim We sought to determine subsequent pregnancy outcomes in a cohort of women with a history of unexplained recurrent miscarriage (RM) as compared to healthy pregnancy controls. Study design This was a prospective cohort study of women attending a dedicated RM clinic in the Rotunda Hospital in 2011. Inclusion criteria included women with a history of three consecutive first trimester losses that were unexplained in the past, no medical intervention and singleton pregnancies only. The inclusion criteria for the healthy controls included no history of stillbirth, intrauterine growth restriction, preeclampsia or preterm labour. Results Of the 42 women with RM recruited to the study nine (23%) experienced further first trimester miscarriages, one molar and one ectopic pregnancy. The remaining RM cohort with ongoing pregnancies (n = 31) were compared to healthy controls (n = 31) matched for age and BMI. The only statistical difference between the two groups was the earlier mean gestational delivery of the RM group (38 + 2 vs 39 + 4 weeks, p = 0.004) attributed to earlier induction due to their past history. Otherwise there was no significant difference with respect to pregnancy complications, delivery and neonatal outcomes. All of RM patients achieved successful term deliveries with a 74% vaginal delivery rate and a mean birthweight of 3.23 kg. Conclusion This study re-iterates the reassuring prognosis for women with a history of unexplained RM who undergo supportive care at a dedicated clinic. The majority delivered appropriately grown fetuses at term which was comparable to healthy controls.

During the recent epidemic of Parvovirus infection, three complicated pregnancies were managed in the Rotunda Hospital. The fetuses were significantly affected in all three cases, presenting with ultrasonographic findings consistent with severe anaemia; all required intra-uterine fetal transfusions. Case 1: The first case involved a 30 year old multip who presented at 20 weeks with severe fetal hydrops and a history of Parvovirus exposure. Severe fetal thrombocytopenia was noted at the time of cordocentesis. Repeated intrauterine transfusions were required however fetal cardiac function deteriorated further which resulted in fetal demise. Case 2: The second cases involved a 32 year old multip with confirmed Parvovirus infection who was referred with severe fetal hydrops. Severe thrombocytopenia was again noted however a successful fetal transfusion was performed. Unfortunately the mother subsequently developed Ballantyne (Mirror) syndrome which resolved with expectant management. Case 3: The final case involved a 28 year old multip with a dichorionic twin pair both of which were severely anaemic with similar haematocrit levels at cordocentesis. Both twins received the same treatment course however different outcomes were encountered. This case series demonstrates the various complications that add further challenging features to the management of pregnancies affected by Parvovirus infection.

It is essential to counsel patients about all options following the prenatal diagnosis of fetal aneuploidy (FA). We sought to ascertain the prenatal course and pregnancy outcomes in those with a prenatal diagnosis of fetal aneuploidy and were managed expectantly. Prenatally diagnosed cases of FA were identified from the anomaly register between 2005 and 2011. The indication for diagnostic testing, the ultrasound findings and subsequent pregnancy outcomes were analysed. There were 212 cases of prenatally diagnosed FA registered on the database during the study time period. There were 84 (39%) cases of expectant management. The indication for invasive testing included; markers at fetal anatomical survey (n = 49); cystic hygroma (n = 21); high risk FTS (n = 11) and maternal request (n = 3). Second trimester ultrasound abnormalities detected included; Multiple abnormalities 36%, cardiovascular 19%, central nervous system 19%, cystic hygroma 9% and others 17%. Cases of Trisomy 18 and 13 were more likely to be managed expectantly than T21, OR 0.14 (95% CI 0.08–0.25 p This study provides much needed data about the expectant management of affected pregnancies. Important information includes the high rate of IUD and preterm delivery. We found that patients in our cohort were more likely to continue the pregnancy with a lethal diagnoses of T13 and 18 compared to T21.

Platelet function in pregnancies complicated by intra-uterine growth restriction (IUGR) is not well understood. We sought to evaluate platelet function in response to multiple concentrations of multiple agonists in pregnancies complicated by IUGR using a novel platelet function assay. Cases of intrauterine growth restricted singleton pregnancies were recruited following ultrasound diagnosis between 24–40 weeks gestation (estimated fetal weight th centile for gestational age) in a tertiary referral centre. A modification of standard light transmission aggregometry was used to assess platelet reactivity. Several agonists were assessed at incremental concentrations to characterise the response to multiple receptors. The findings were compared to healthy controls matched for gestational age with normal fetal weight. A total of 24 pregnancies complicated with IUGR and 36 healthy controls were recruited. Platelet reactivity in response to the agonists Arachidonic acid, Adenosine-diphosphate, Epinephrine and Thrombin-receptor activating protein was significantly reduced in the IUGR cohort. There was a nonsignificant trend to decreased reactivity in response to collagen (Table 1). In pregnancies complicated by IUGR there is a significant decrease in platelet function compared to healthy pregnant controls. This may reveal valuable insights into the patho-physiology of the disease, and may represent an inadequate growth factor response in IUGR. Further evaluation of the role of platelets may and aid in the development of future interventions for IUGR.

Platelet function has not been well characterised in pregnancy. We used a modification of light transmission aggregometry to prospectively assess SPA in normal and complicated pregnancies. The study was powered (80%) to detect a 6% change in platelet aggregation across the time-points and an 8% change for PET or IUGR. In 50 patients with normal pregnancy, platelet function was assessed in the three trimesters and post-natally. In 35 patients with pre-eclampsia (PET) and 18 patients with intra-uterine growth restriction (IUGR) platelet function was assessed in the third trimester. Comparisons between platelet function assays in the four time points of normal pregnancy were made using a mixed effects model with study participant as a random-effect, allowing for possible correlations between the repeated assessments. ANOVA was used to compare these assessments with the PET and IUGR groups. The results are presented as Bonferroni adjusted p-values. SPA increased significantly between the 1st and 2nd trimester (7% increase, p-value=0.0001); the 3rd trimester (9% increase, p-value=0.0020) and the post-natal assessment (15% increase, p-value=0.0002) in normal pregnancy. In contrast there was no increase in the platelet aggregation profile of patients with either PET or IUGR. We demonstrate for the first time a significant incremental increase in SPA with advancing gestational age in normal pregnancy. In contrast this increase in platelet aggregation does not occur in the third trimester in platelets from patients with either PET or IUGR. These results suggest that sequential analysis of SPA may be a novel marker for at risk pregnancies.

Forty patients diagnosed with either pre-eclamspia or gestational hypertension were recruited. Inclusion criteria were singleton pregnancies between 24+0 and 39+6 with either pre-eclampsia or gestational hypertension as defined by ACOG criteria. Exclusion criteria included diabetes, clotting disorders, aspirin usage or BMI >30. Patients were in the third trimester of pregnancy and the values obtained were compared to patients (N=30) who were in the third trimester of uncomplicated ‘normal’ pregnancy. A 30ml whole blood sample was drawn according to a strict protocol to maintain platelet integrity. A platelet function assay was performed on each sample within 30 minutes of blood draw. A modification of standard light transmission aggregometry was used to assess platelet function, with light absorbance measured following addition of 5 different agonists at maximal and sub-maximal concentrations. Since platelets have multiple receptors it is necessary to study more than one receptor with the various agonists. The percentage aggregation response for each concentration of each agonist was calculated. Platelet reactivity differed significantly between the two groups of patients for each agonist. Platelet aggregation to arachidonic acid (p We have demonstrated a significant reduction in platelet reactivity in patients with both pre-eclampsia and gestational hypertension compared to patients with uncomplicated pregnancies in the third trimester. These data may be of value when designing interventions for prevention or treatment of pre-eclampsia.

Aim To identify the incidence of monochorionic monoamniotic (MCMA) twins over a 5 year period in a tertiary referral centre and to assess the perinatal outcome this group. Methods A retrospective search of ultrasound database of both electronic and paper records was performed from October 2006-October 2011. All pregnancies >12 weeks were included. Chorionicity was confirmed by histological review of placentae. Results 359 monochorionic pregnancies were identified, 6.4% (24) were MCMA. There were 2 TRAP sequences, 2 conjoined twin pairs, 2 MCMA pairs within triplet pregnancies, 2 twin pairs with congenital anomalies. 14/24 (61%) had USS evidence of cord entanglement. Excluding conjoined twins, TRAP and triplets, there were 18 simple MCMA pairs with a loss rate after 12 weeks of 14/36 (38%), excluding congenital anomalies this was 31%. Double demise was more common. After 20 weeks, there were 4/24 IUD (15%) and after 24 weeks there were no IUDs. Maternal age range was 17-34 years,( mean 27). The mean infant birthweight was 1824g. Length of stay in NICU ranged from 3-18 days ( mean 8.3). The only neonatal death was an infant with a prenatally diagnosed congenital anomaly. The mean gestational age at delivery was 32 weeks for the liveborn twin pairs, with a 100% caesarean section rate. Conclusion Perinatal mortality is mainly a consequence of conjoined twins, TRAP, congenital anomalies and miscarriage less than 20 weeks gestation. Perinatal survival in MCMA twins managed by close ultrasound surveillance and elective delivery at 32-34 weeks is high.

This study evaluated the predictive value of fetal head circumference (FHC) for difficult birth and assessed the correlation between FHC and neonatal head circumference (NHC). A prospectively collated database was analysed for maternal age, body mass index (BMI), fetal biometry, labour and neonatal outcomes. Delivery was considered complicated if achieved by emergency Caesarean section (EmCS) or operative vaginal delivery, while spontaneous vertex delivery was classified as ‘uncomplicated’. Delivery by elective CS was excluded. Data analysis was performed using SAS software. 583 nulliparous singleton term pregnancies were included for analysis. FHC was measured at a mean gestational age of 35.4 weeks. 43% (252) had an uncomplicated delivery. 57% (333) had a complicated delivery (EmCS =24.8% (145), forceps = 4.5% (26), vacuum = 25.9% (151), vacuum plus forceps = 1.5% (9)). A FHC of 34cm at 35 weeks9 gestational age was identified as the 90th centile. Sonographic measurement of FHC consistently underestimated NHC by 3.0cm (8.5%). Odds ratio (OR) for having a “difficult birth” if the FHC was greater than the 90% centile was 2.8 (95% CI 1.3-6.3). The OR increases further with increasing age (OR=1.5, 95% CI 1.3-1.8) and increasing BMI (OR 1.2, 95% CI 1.0-1.6). Despite underestimating NHC by an average of 8%, FHC greater than the 90 th centile in the late third trimester is a significant risk factor for difficult birth. Prospective interventional trials should now be considered to evaluate the role of late gestation ultrasound assessment of FHC as a predictive tool toward selecting optimal mode of delivery.

This study assessed if the NHC could be an indicator of complicated birth. Prospectively collated data from two tertiary referral medical centres were amalgamated and analysed for maternal age, body mass index (BMI), biometry, labour and neonatal outcomes. Delivery was considered complicated if achieved by emergency Caesarean section or operative vaginal delivery, while spontaneous vertex delivery was classified as ‘uncomplicated’. Data analysis was performed using SAS and SPSS software. A total of 4399 nulliparous singleton term pregnancies were included for analysis. 53.5% (2354) had an “uncomplicated birth”. 37cm was identified as the 90th centile for NHC. The odds ratio for having a “complicated birth” if the NHC was greater than the 90th centile was 2.9 (95% CI 2.1-4.0). This effect remained after adjusting for increasing maternal age (OR 2.6, 95% CI1.3 - 1.8) and increasing BMI (OR 1.3, 95% CI 1.04 -1.8). This large prospective cohort study demonstrates that NHC >90th centile is associated with an increased incidence of difficult birth. This raises the possibility of correlation of this measurement with determination of fetal head circumference in order to better predict those who may require operative vaginal delivery or indeed avoid attempted vaginal birth in the first place.

Aoife Murray, Naomi Burke, Karen Flood, Brian Cotter, Zara Fonseca-Kelly, Mark Hehir, Mark Dempsey, Louise Fay, Jennifer Catherine Donnelly, Patrick Dicker, Michael Geary, Dermot Kenny, Fergal Malone Royal College of Surgeons in Ireland, Obstetrics and Gynecology, Dublin 1, Ireland, Rotunda Hospital, Obstetrics and Gynecology, Dublin 1, Ireland, National Maternity Hospital, Obstetrics and Gynaecology, Dublin, Ireland, Royal College Of Surgeons in Ireland, Epidemiology and Public Health, Dublin, Ireland, Rotunda Hospital, Obstetrics and Gynaecology, Dublin, Ireland, Clinical Research Centre, Royal College of Surgeons in Ireland, Dublin 2, Ireland, Royal College of Surgeons in Ireland, Obstetrics and Gynaecology, Dublin, Ireland OBJECTIVE: To determine abnormalities in reactivity of platelets in cases of pre-eclampsia and gestational hypertension using a novel platelet function assay. STUDY DESIGN: Thirty patients diagnosed with either pre-eclamspia or gestational hypertension were recruited. Inclusion criteria were singleton pregnancies between 24 0 and 39 6 with either pre-eclampsia or gestational hypertension as defined by ACOG criteria. Exclusion criteria included diabetes, clotting disorders, aspirin usage or BMI 30. All patients were in the third trimester of pregnancy and the values obtained were compared to patients (N 30) who were in the third trimester of uncomplicated normal pregnancy not affected by either pre-eclamspia or gestational hypertension. A 30ml whole blood sample was drawn according to a strict protocol to maintain platelet integrity. A platelet function assay was performed on each sample within 30 minutes of blood draw. A modification of standard light transmission aggregometry was used to assess platelet function, with light absorbance measured following addition of 5 different agonists at maximal and sub-maximal concentrations. Since platelets have multiple receptors it is necessary to study more than one receptor with the various agonists. The percentage aggregation response for each concentration of each agonist was calculated. RESULTS: Platelet reactivity differed significantly between the two groups of patients for each agonist. Platelet aggregation to arachidonic acid (p 0.0042), epinephrine (p 0.00001) and collagen (p 0.00001) was less reactive in pre-eclamptic and gestational hypertension than in uncomplicated third trimester patients. This pattern of platelet aggregation was not repeated for the agonists TRAP and ADP. CONCLUSION: We have demonstrated a significant reduction in platelet reactivity in patients with both pre-eclampsia and gestational hypertension compared to patients with uncomplicated pregnancies in the third trimester. These data may be of value when designing interventions for prevention or treatment of pre-eclampsia. 740 Effect of postnatal angiotensin-converting enzyme inhibition on fetal vascular programming in a transgenic mouse model lacking endothelial nitric oxide synthase Arshag Kalanderian, Giuseppe Chiossi, Maged Costantine, Phyllis Orise, Gary D.V. Hankins, George R. Saade, Monica Longo The University of Texas Medical Branch, Obstetrics & Gynecology, Galveston, TX OBJECTIVE: Angiotensin converting-enzyme (ACE) inhibitors have been used in adults to prevent progression of hypertension and altered vascular remodeling. We have previously shown that heterozygous offspring developing in an adverse uterine environment lacking endothelial nitric oxide synthase (NOS3) have altered vascular function, and develop hypertension later in life. Our objective was to determine whether captopril, an ACE inhibitor, prevents the fetal programming of adult vascular function in this murine model. STUDY DESIGN: Homozygous NOS3 knockout (KO) and wild type (WT) mice were cross-bred to produce heterozygous offspring developing in a WT mother with a normal uterine environment (KOP) versus a KO mother lacking a functional NOS3 (KOM). Osmotic minipumps were placed in female offspring at 4 weeks of age to deliver captopril or vehicle at 0.25 l/hr for 4 weeks. At 14 weeks, the offspring were sacrificed, and carotid arteries were isolated for in vitro vascular reactivity studies. Contractile responses to phenylephrine (PE), in the presence and absence of the nitric oxide synthase inhibitor L-NAME, and angiotensin (ANG), as well as vasorelaxant responses to acetylcholine (Ach) and isoproterenol (ISO) were determined. ANOVA followed by Neuman-Keuls post hoc test were used for statistical analysis (significance: P 0.05). RESULTS: Contractile responses to PE were significantly increased in KOM offspring compared with KOP, and treatment with captopril corrected this response without any effect on responses in KOP (Figure A). The difference between KOM-CAP vs KOM was decreased by L-NAME, although the response in KOM remained higher. No significant differences were seen in response to ANG between the groups. Vasorelaxant responses to Ach (Figure B) and ISO were significantly improved in KOM treated with captopril compared to untreated KOM offspring (p 0.05). CONCLUSION: Treatment with an ACE inhibitor at a young age prevents the vascular dysfunction seen with fetal programming of adult hypertension. ACE inhibition may represent a potential strategy for postnatal prevention of adult hypertension. Poster Session V Academic Issues, Antepartum Fetal Assessment, Genetics, Hypertension, Medical-Surgical-Disease www.AJOG.org

Ireland continues to experience a high incidence of neural tube defects (NTD). Knowledge about the natural history of this condition is limited as pregnancy termination is practiced in most countries. We aimed to describe perinatal outcomes of pregnancies complicated by fetal NTDs in a setting in which pregnancy termination is not locally available. We conducted a retrospective cohort study over a 6-year period in a tertiary referral center in Dublin (2005–2010). Only singleton gestations with confirmed normal karyotype were included for analysis. During the study period 1742 women attended a specialist clinic to confirm and manage fetal abnormalities. NTDs accounted for 4.5% of consultations. We identified 78 consecutive cases of NTD; these comprised 29 meningomyeloceles (37%), 11 encephaloceles (14%) and 38 cases of anencephaly (49%). The majority of pregnancies affected by anencephaly were terminated (71%). Of the 11 cases of anencephaly in which expectant management was chosen, 7 (64%) infants were liveborn. Of the 39 non-lethal NTDs, 15 patients (38%) terminated their pregnancy. Of the 23 ongoing pregnancies with available outcome data, four fetuses with encephaloceles (19%) had an intrauterine fetal demise at a mean gestational age of 24+2 weeks. Of the 19 liveborn infants, 15 (79%) were delivered by caesarean section. There were 3 neonatal deaths (16%). 16 infants underwent meningomyelocele closure ± ventriculoperitoneal shunting. 14/16 (88%) were alive at follow-up (2 months to 6 years). The above natural history outcome data provides useful information for health professionals charged with prenatal counselling for NTD.