Japan neonatologist association had surveyed of survival rates of infants less than 24 weeks of gestation born during 1995 to 2001 and during 2002 to 2004. There was no survival on 20th and 21st weeks of gestations, while survival rates of 22 and 23 weeks had increased from 18% to 31% and 43% to 56% respectively between two studies time periods. Their follow up data at 5 years old reviled as follows; rates of cerebral palsy (CP) with/without mental retardation (MR), MR only, blindness and infants of any aforementioned neurological sequels were 17%, 26%, 8% and 44%, respectively. Main causes of death of these infants are mostly due to extreme prematurity including fragile skin and immature immunity. To improve the outcome of infants at 22 to 23 weeks of gestation, meticulous and gentle care is essential while knowing the viability limit based on their up-to-date statistics.

 Aim: The perinatal data of Japan listed in official materials were analyzed with statistical studies.

Results: One hundred and 13 years have passed after the first report of maternal mortality in Japan. The maternal mortality reduction rate was 1/2.5 in the first 50 years in home deliveries, while the reduction rate was 1/46 in succeeding 63 years in the deliveries in hospitals and clinics. Perinatal mortality reduction was closely correlated with maternal mortality and the reduction rate was 1/16.2 after 1950. Comment: The progress of medicine, medical and neonatal care would be directly effective to definitely improve maternal and perinatal mortalities in Japan. Conclusion: The progress of perinatal medicine in 113 years was analyzed after the first report of maternal mortality in 1899. The progress of medicine, medical and neonatal care would be beneficially influenced to improve the maternal and infantile states.

Objective: To describe the professional responsibility model of ethics in perinatal medicine, based on the fetus and pregnant woman as patients, to guide the deliberative practice of perinatal medicine. Methods: We describe secular medical ethics and its two fundamental principles, beneficence and respect for autonomy. We articulate the ethical concept of the fetus as a patient on the basis of the ethical principle of beneficence. Results: In the deliberative practice of perinatal medicine guided by the professional responsibility model, the perinatologist should always identify and balance beneficence-based obligations to the fetal patient and beneficence-based and autonomy-based obligations to the pregnant patient. Directive counseling is appropriate when the fetus is a patient. Non-directive counseling is appropriate when the fetus is not a patient. Conclusion: Counseling pregnant women about the clinical management of their pregnancies should always identify and balance beneficence-based obligations to the fetal patient and beneficence-based and autonomy-based obligations to the pregnant patient.

 The purpose of this article is to analyze the evolution and progress made in Perinatal Medicine in Spain over

the past 40 years. Advances made in the range of technologies used in Perinatal Medicine and their implementation are described: ultrasonography, biophysical and biochemical monitorization (cardiotocography, fetal pH testing, etc.), prenatal diagnosis, amnioscopy, etc. Therapeutic approaches are also discussed: therapeutic uterine activity, fetal intrauterine treatment (medical and surgical), analgo-anesthesia in obstetrics, obstetric surgical technique, conducted when the threat of premature delivery exists, etc. The individuals who made these different advances are cited throughout the text, as are the contributions of Spanish Perinatologists to these areas. For many years Spanish Perinatology was influenced by the so-called “Montevideo School” created by Caldeyro-Barcia. The specialty later embraced all the innovations contributed by European and American investigation groups. Perinatal results have improved progressively over the years. Spanish levels of maternal and perinatal death are now amongst the lowest in Europe. Not only has the existence of a quality National Health System contributed to these improvements but the dynamism developed in perinatal medicine at some of the country’s major hospitals as well.

 Aims: Fetoscopic laser surgery has been widely accepted of optimal treatment for Twin-Twin Transfusion

Syndrome (TTTS) in monochorionic twin pregnancies. To avoid surgical complication and to improve the outcome, various techniques employed in our institution. The aim of our study is to assess the clinical outcomes of TTTS after laser surgery with combined various techniques. Methods: We performed 171 cases of fetoscopic laser surgery for TTTS from 2002 to 2011 in our institution. Various techniques employed in our studies to improve the learning of laser surgery and to achieve successful outcome were; (1) A very thorough mapping of vascular anastomoses before and after ablation; (2) Obliteration of arterio-venous anastomoses from donor to recipient should be done first, (3) Trocar assisted technique using gentle indent the trocar withdrawing the scope shortly, to ablate anastomoses easily, (4) A virtual line was drawn by laser at the hemodynamic equator to avoid residual anastomoses, and not to miss small anastomoses. Results: Laser photocoagulation was performed since 2002 in our institute, compiling 171 cases. Overall survival was 78% with 5% neonatal morbidity. Both twins survived for 64%, and the survival of one twin was 93%. The recurrent TTTS rate was 1%, and the residual vessel rate was 2%. Conclusion: A successful outcome for fetoscopic laser surgery is achievable and the outcome is improved in severe TTTS cases by these techniques.

 It has been suggested that the assessment of fetal behavior and developmental processes in different periods

of gestation may make possible the distinction between normal and abnormal brain development, as well as early diagnosis of various structural or functional abnormalities. Early detection and prevention of perinatal neurological damage are one the most important tasks of perinatal medicine. Development of modern imaging method, four dimensional sonography, provided us new insight into fetal behavior. The aim of this review is to present prenatal neurologic screening test for the assessment of fetal behavior, based on four dimensional ultrasound. Test is named Kurjak Antenatal Neurodevelopmental Test (KANET). Up to know assessment of fetal behavior using KANET provided very promising results.

 Objectives: In Sub Sahara Africa, it is estimated that about 10% of pregnant mothers will develop complications

that must be attended by medical staff with skills on Comprehensive Emergency Medical Operative Care (CEMOC), but their heavy shortage, specifically in rural areas, is a major cause of the high maternal and perinatal mortality in the region. Improvement of the situation was the aim of this study. Methods: In view of this, we trained 36 Non physician Clinicians (NPCs) from 18 disadvantaged Rural Health Facilities. From each of the 18 facilities, we selected one Assistant Medical Officer (AMOs) and one Nurse. The AMOs underwent a 12 weeks training on CEMOC including surgical skills while the Nurses underwent also a 12 weeks training on Anesthesia and Resuscitation of the new born. Results: By the end of the training, the AMOs did 483 C/S under supervision and no maternal death occurred while the Nurses administered anesthesia and no maternal death occurred. We are now following up the NPCs in their rural health facilities to see their impact on maternal and perinatal mortality.

 Aim: To clarify improvements in maternal and perinatal mortalities in the world.

Methods: Calculation of UNICEF data, quotation of reference and statistical analysis. Results: Global maternal mortality was slightly improved; along with the increase of countries of maternal mortality lower than 20, while the mean global mortality more than 20 was unchanged, and the highest maternal mortality were 2,000. Maternal mortality was high in high total fertility rate and low when total fertility rate was less than 3. Maternal mortality was high when less than 5, mortality was high. Maternal mortality was reported to be significantly lower when the birth space was 36 or more months. Perinatal mortality was reported only in limited countries, while the mortality was closely correlated to maternal mortality. Thus, perinatal mortality was estimated from maternal mortality, where mild improvement was noted in the increase of countries of low estimated mortality, and the peak of estimated perinatal mortality decreased from 130 to 120. Conclusion: Maternal mortality was slightly improved, but it was unchanged in high mortality countries. The mortality was low in low total fertility rate. Perinatal mortality was estimated from maternal mortality, because they were closely correlated.

 From the daunting figures for maternal, perinatal and infant mortalities and morbidities of the past, in the last three

to four decades, Portugal has set remarkable standards of care with the gratifying results of, either overlapping or even surpassing, those of many of the western countries. This is the case for maternal mortality at just over 5-8/100,000 live births per year and perinatal mortality at below 5/1.000 live births, in the last ten years. Although a decrease in maternal and perinatal mortalities has also been achieved in all European countries Portugal was one of those with the most significant falls. Rationalization of human and financial resources was instrumental, with sophisticated technologies playing a subsidiary role for the high risk pregnancies and sick neonates. Above all, it has been a successful example of collaboration and goodwill between professionals and politicians alike regardless of the, often, conflicting interests.

Aims: Invasive techniques in fetal diagnosis and therapy are gradually changing to noninvasive methods, which would be presented in this article as well. Methods: Noninvasive methods in fetal diagnosis are reviewed. Results: External ultrasonic Doppler autocorrelation fetal monitor; ultrasonic Doppler fetal actocardiogram; ultrasonic 2D, 3D, 4D imaging methods, pulsed Doppler blood flow record, color and power Doppler flow mappings, gray level histogram width method in the prediction of neonatal RDS in preterm fetal lung; other tissue characterization techniques and recent noninvasive prenatal test (NIPT) in fetal diagnoses, high intensity focused ultrasound ablation for the TRAP sequence in monochorionic twins in fetal therapy were presented. Conclusion: Noninvasive methods were introduced to fetal studies to perform fetal diagnosis and therapy safely

 Maternal mortality rate (MMR): Qatar’s MMR dropped from 49/100,000 in 1990 to 9.02% in 2012. Qatar’s MMR

had been zero for several years between 1995 and 2000; for the rest of the years, it had been between 7 and 11/100,000. Qatar’s MMR over the last decade has not only been significantly low, as compared to the global MMR of 260/100,000 and regional MMR of 320/100,000 in Eastern Mediterranean Region as given, it is also comparable to the MMR of many high income countries, both from the West and East. Qatar’s antenatal coverage is 94%. Qatar’s reproductive health system is based on 99.45% hospital deliveries. During 2011, the State of Qatar had a 25% national C section rate. The relative risk of neonatal mortality was significantly higher among C section deliveries, particularly in emergency C Section deliveries. Neonatal mortality and perinatal mortality rates: The Relative Risk of Neonatal Mortality in Qatar decreased by 87% between 1975 and 2011, though the population increased by 10 fold and number of deliveries by 7.2 folds. This is a superb achievement; which encompasses both early and late neonatal mortality. Qatar’s neonatal mortality rate corrected for lethal congenital anomalies and futility (cNMR) was 3.26/1000 during 2011. Qatar’s 2011 NMR (4.9/1000) and cNMR (3.26/1000) are comparable to selected high income countries; both from the west and east.

Perinatal drugs in Italian Republic became a national entity with the inspiration in Rome in 1984 of the Italian Society
of perinatal drugs. Some pioneering works from late 60s are done antecedently primarily by teams of investigators
based mostly at the colleges of Parma (Bruno Salvadori), Florence (Corrado Vecchi) and Rome (Emilio Imparato),
followed within the 70s by teams in Modena (Giorgio Montanari), Rome (Antonio Pachi’, Ermelando Cosmi, Giovanni
Bucci) Milano (Giorgio Pardi), and others. it’s through the inspiration and implementation of the Italian Society that the
event of perinatal drugs in Italian Republic has taken a giant breakthrough. above all, the Society created 2 sets of tips
on the “Organisation and management of perinatal medicine” that marked the organisation, blending and advancement
of perinatal centers in Italian Republic, and therefore the systematic audit of perinatal drugs statistics transfer Italian
Republic among the countries within the world that have the simplest perinatal organisation, and therefore the best
perinatal statistics in term of maternal and fetal-neonatal mortality and morbidity.

Germany and the Netherlands are wealthy countries in close neighborhood within Europe. They both have a general
health care insurance system and a tradition of recognized research in perinatal medicine. Nevertheless, there are
significant differences in the way how obstetric training and care are organized: Germany had two different health care
systems (East/West) from 1945 to 1990, in the Netherlands, home deliveries are still common. Today, the number of
gynecologists per patient is much higher in Germany compared to the Netherlands. In Germany, training of residents is
still not supervised whereas in the Netherlands there is a long tradition of audits of the training facilities. Amazingly, in
Germany there is no established guideline group of the professional boards whereas in the Netherlands, all guidelines
are democratically established, recognized by the boards and made transparent to patients and physicians. The
scientific output in high-impact journals is much higher in the Netherlands compared to Germany. Lessons to learn are to
adapt the number and quality of our future obstetricians including participation in research lines and interpretation of the
literature. There is a need for a standardized audit and accreditation system for training in Germany. This also implies
the establishment of competent guidelines, standards and confidential inquiries not only for pre- and postgraduate
training but also for transparency towards the patients.
Given the differences between both countries we hopefully can learn from each other to improve future care of the
fetal and maternal patient and thereby neglect harmful sides and introduce useful aspects.

The prevalence of cerebral palsy has not decreased despite major improvements in clinical care in antenatal/
neonatal period as well as intrapartum period. In about 70% of cases, cerebral palsy results from events occurring
before birth that can disrupt normal development of the brain. The antepartum risk factors should include fetal brain
mal development and intrauterine brain injuries, which are unclassifiable into congenital brain anomalies and may exist
inconspicuously during pregnancy and even after birth. Especially, neuronal migration disorder and acquired brain
damage in utero should be responsible for postnatal neurological impairment. Imaging technologies including three
dimensional ultrasound have been remarkably improved and contributed to prenatal evaluation of fetal Central Nervous
System (CNS) development and assessment of CNS abnormalities in utero. In this article, objective and precise imaging
diagnoses of fetal CNS including migration disorders and acquired brain damages. Furthermore, 3D bidirectional power
Doppler angiography has depicted fine cerebral vessels of medullary veins which may relate with timing of insult as well
as with postnatal neurological prognosis. It is promising to clarify the developmental mechanism of CNS damages with
advanced ultrasound diagnostic techniques in the near future. Postnatal unexplained neurological deficits may strongly
relate with intrauterine brain development therefore fetal neurology has great responsibility and an important role in
perinatal medicine.