This first paper of the Lancet Series on ending preventable stillbirths reviews progress in essential areas, identified in the 2011 call to action for stillbirth prevention, to inform the integrated post-2015 agenda for maternal and newborn health. Worldwide attention to babies who die in stillbirth is rapidly increasing, from integration within the new Global Strategy for Women's, Children's and Adolescents' Health, to country policies inspired by the Every Newborn Action Plan. Supportive new guidance and metrics including stillbirth as a core health indicator and measure of quality of care are emerging. Prenatal health is a crucial biological foundation to life-long health. A key priority is to integrate action for prenatal health within the continuum of care for maternal and newborn health. Still, specific actions for stillbirths are needed for advocacy, policy formulation, monitoring, and research, including improvement in the dearth of data for effective coverage of proven interventions for prenatal survival. Strong leadership is needed worldwide and in countries. Institutions with a mandate to lead global efforts for mothers and their babies must assert their leadership to reduce stillbirths by promoting healthy and safe pregnancies.

Rheumatic heart disease in pregnancy is associated with significant maternal and perinatal morbidity in NYHA class III-IV patients.

Variceal bleeding is the most common complication in pregnancies with NCPH. Pregnancies can be allowed and managed successfully in patients with NCPH.

Even though pregnancy is rare with cirrhosis and advanced liver disease, but it may co-exist in the setting of noncirrhotic portal hypertension as liver function is preserved but whenever encountered together is a complex clinical dilemma. Pregnancy in a patient with portal hypertension presents a special challenge to the obstetrician as so-called physiological hemodynamic changes associated with pregnancy, needed for meeting demands of the growing fetus, worsen the portal hypertension thereby putting mother at risk of potentially life-threatening complications like variceal hemorrhage. Risks of variceal bleed and hepatic decompensation increase many fold during pregnancy. Optimal management revolves round managing the portal hypertension and its complications. Thus management of such cases requires multi-speciality approach involving obstetricians experienced in dealing with high risk cases, hepatologists, anesthetists and neonatologists. With advancement in medical field, pregnancy is not contra-indicated in these women, as was previously believed. This article focuses on the different aspects of pregnancy with portal hypertension with special emphasis on specific cause wise treatment options to decrease the variceal bleed and hepatic decompensation. Based on extensive review of literature, management from pre-conceptional period to postpartum is outlined in order to have optimal maternal and perinatal outcomes. ( J CLIN EXP HEPATOL 2014;4:163-171) P regnancy associated with liver diseases is an infrequent situation, but when seen together, presents a complicated clinical situation. Portal hypertension develops as a result of number of etiologies. In the west, cirrhosis is the commonest cause of portal hypertension. In the setting of cirrhotic portal hypertension, pregnancy is very rare due to hepatocellular damage leading to amenorrhea and infertility, the incidence of cirrhosis in pregnancy has been reported as 1 in 5950 pregnancies. 1 Cirrhosis may get exacerbated during pregnancy and has significant adverse effects on the mother and the baby. [2][3][4] In the developing countries, other causes like extrahepatic portal vein obstruction contribute significantly to noncirrhotic portal hypertension (NCPH). Mostly liver function is much better preserved in women with NCPH and pregnancy is spontaneous in these women. Portal hypertension associated with pregnancy is a high risk situation as both pregnancy and portal hypertension share some of the hemodynamic changes. The physiological changes, in adaptation to the pregnancy and fetal needs, worsen the portal hypertension resulting in potentially life-threatening variceal bleed and other complications. Pregnancy is a potential hazard for occurrence of recurrent variceal bleed due to its hyperdynamic state causing increase in flow to the collaterals. 5-7 Therefore management in pregnancy requires knowledge of both the effects of changes during pregnancy on portal hemodynamics and the effects of portal hypertension and its cause on both mother and fetus, hepatotoxic...

Pregnancy in patients with cirrhosis of the liver is uncommon. We reviewed 9 pregnancies in 7 patients with cirrhosis. One patient conceived within 1 month of diagnosis and in another the disease was diagnosed during the index pregnancy. Four patients has associated portal hypertension and 1 of them conceived after lienorenal shunt. Complications associated with these pregnancies were jaundice (1) jaundice plus ascites (2) and gastrointestinal bleeding (1). In 2 patients endoscopic sclerotherapy was done during the index pregnancy. The incidence of preterm delivery was 50% (4 of 8) and the majority (75%) occurred in pregnancies where associated complications were present. There was 1 maternal death in the postpartum period due to fulminant hepatic failure.