Conjoined twins are a rare anomaly with a high rate of in-utero and perinatal mortality. They are physically joined in ventral, lateral or dorsal unions and may be detected early in prenatal care with ultrasound. The prognosis and ability to separate conjoined twins is specific to their anatomy. Extensive prenatal and postnatal evaluation with a combination of sonography, computed tomography, magnetic resonance imaging, echocardiography and fluoroscopy are used together in order to tailor a care plan for each patient. Conjoined twins are typically delivered as scheduled surgical deliveries,and may be managed postnatally with 1) non-operative management, 2) emergency separation, or 3) planned surgical separation.

Fetal surgery has evolved over the last three decades from an innovative and ambitious concept into an accepted reality. The metamorphosis from curiosity to sought-after therapy has been driven by the refinement of techniques used in open hysterotomy surgeries, advances in the available technology and instrumentation, expansion of the repertoire of minimally invasive image-guided percutaneous interventions, and the development of safe and effective fetoscopic surgical procedures. Serious complications associated with the early era fetal surgery procedures such as intraoperative fetal death, abruptio placentae and pulmonary edema have been largely eliminated, and extreme preterm delivery (<28 weeks) has been significantly reduced. Specialized anesthesia protocols and intraoperative management algorithms have led to improved fetal tolerance of these procedures, and advancements in neonatal intensive care have dramatically improved neonatal outcomes.

Postpartum hemorrhage (PPH) is the leading direct cause of maternal death in both industrialized and nonindustrialized nations, second only to preexisting conditions and indirect causes of maternal death.

Introduction

Eclampsia refers to the occurrence of one or more generalized convulsions and/or coma in the setting of pre-eclampsia and in the absence of other neurologic conditions. Pre-eclampsia is a multisystem disorder of pregnancy and the puerperium, complicating approximately 6–8% of all pregnancies (ACOG, 1996, 2002). Pre-eclampsia is characterized by new onset hypertension (sitting blood pressure ≥140/90), proteinuria (≥2+ in a random urine sample or ≥300 mg in a 24-h collection) with or without non-dependent edema after 20 weeks' gestation. Eclampsia was at one time thought to be the end result of pre-eclampsia, hence the nomenclature. It is now clear, however, that seizures are but one clinical manifestation of “severe” pre-eclampsia. Other manifestations include, among others, HELLP syndrome (Hemolysis, Elevated Liver enzymes and Low Platelets), disseminated intravascular coagulopathy (DIC), renal failure, hepatocellular damage, pancreatitis, congestive cardiac failure, pulmonary edema and fetal intrauterine growth restriction.

The pathophysiology of pre-eclampsia is poorly understood. It is a disease of human pregnancy; more precisely, it is a disease of the placenta since it is also described in pregnancies where there is trophoblast but no fetal tissue (complete molar pregnancies) (Goldstein and Berkowitz, 1994). The blueprint for the development of pre-eclampsia is laid down early in pregnancy. The pathologic hallmark of pre-eclampsia appears to be a failure of the second wave of trophoblast invasion from 8 to 18 weeks' gestation, a process that is responsible for destruction of the muscularis layer of the spiral arterioles and, as such, establishment of the definitive uteroplacental circulation (Brosens et al., 1972; Cross et al., 1994; Meekins et al., 1994).

Introduction

Pre-eclampsia complicates 5–8% of pregnancies and significantly contributes to maternal mortality in the United States (Berg et al., 2003; Chang et al., 2003), the United Kingdom (de Swiet, 2000; Scott and Owen, 1996), Europe (Hogberg et al., 1994; Schuitemaker et al., 1998) and, most notably, in developing nations (Bouvier-Colle et al., 2001). Pre-eclampsia is a disease unique to human pregnancy, with pathophysiologic effects which may compromise cardiovascular, renal, hematologic, neurologic, hepatic, and other organ systems. Early-onset pre-eclampsia is associated with greater morbidity (Murphy and Stirrat, 2000). The classification of hypertensive diseases and the pathophysiology of pre-eclampsia are comprehensively addressed in other sections of this book. The purpose of this chapter is to provide a practical guide to clinicians caring for patients with complications of pre-eclampsia.

Eclampsia

The incidence of eclampsia in the United Kingdom and the United States is approximately 5 per 10,000 births (Atrash et al., 1990; Douglas and Redman, 1994). However, at teaching hospitals in Africa, the eclampsia rate is reported around 50 per 10,000 deliveries (Adze et al., 2001; Majoko and Mujaji, 2001), likely an effect of home births and late medical care. Contemporary maternal mortality rates of eclampsia are under 2% in developed countries but are significantly higher in developing nations (Table 27.8). In the Dallas series of 245 eclamptics, one maternal death occurred, which was attributed to magnesium overdose (Cunningham et al., 1984).

Pre-eclampsia complicates 2–3% of primigravid pregnancies and 5–7% of nulliparous women. It is one of the leading causes of death and disability of mothers and babies. Over four million women will develop the disorder worldwide every year. This book, written by scientists and clinicians who are internationally recognized as experts in their respective fields, focuses on both the scientific basis of pre-eclampsia along with management.

The basic science section contains up-to-date reviews and theories focused on the most exciting research developments in pre-eclampsia. The clinical chapters provide a comprehensive review of the pertinent literature highlighting recent data and work that suggest new ideas or changes in current management. There is a section in each chapter (when appropriate) that deals with management on a practical level so that the clinician (residents/registrars/consultants) will be able to take away a formulated treatment plan that they can implement directly.

The book will be of interest to scientists and students interested in reproductive sciences as well as medical students, obstetricians and physicians with an interest in pre-eclampsia.