Editorial| Volume 130, ISSUE 2, P145-147, February 2007

Editors’ highlights

Published:December 30, 2006DOI:
      The FIGO World Congress in Kuala Lumpur, Malaysia, from 5 to 10 November 2006 was a great success for the organisers. About eight thousand participants from all over the world attended the meeting. It was the best attended congress, so far, since the foundation of FIGO by De Watteville in 1954 in Geneva, Switzerland. Since then, every three years FIGO has organised a World Congress of Gynaecology and Obstetrics, the last one being in 2003 in Chile. FIGO's other activities include:
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        the organisation and administration of safe motherhood projects around the world, designed to reduce maternal mortality in developing countries
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        the awarding of modest grants to societies involved in the organisation of national workshops on maternal mortality and on safe motherhood
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        the organisation of international workshops and the De Watteville Lecture, in collaboration with IFFS
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        the awarding of fellowships,
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        the publication of a World Report on Women's Health, published every three years to coincide with the World Congress.
      The topics at the 2006 congress covered the whole of obstetrics and gynaecology and were presented in keynote lectures, seminars, plenary sessions, and oral and poster presentations. All presentations confirmed a huge gap between what has been achieved so far in the various countries of the developed world and what has to be done in the developing countries in the future. Maternal mortality and perinatal mortality are reliable instruments to judge the progress of the health care system in a country. This was addressed in an excellent keynote lecture by Dr. Paul F.A. Van Look, Director of the Department of Reproductive Health and Research of the World Health Organisation, focussing on maternal health and maternal mortality. In his worldwide overview he clearly showed which regions have to improve the health care system to eradicate the “hostage drama” of maternal death. The next world congress will be organised in Cape Town, South Africa in 2009. We look forward with great expectations to the reports especially to those countries of the African continent where maternal mortality is still the highest worldwide.What's New?Reviews: Developed countries currently face the problem that more and more women are of advanced age at their first pregnancy. Therefore diseases such as hypertension, gestational diabetes, diabetes and others are increasing and boost the number of high risk pregnancies. Cancers of the ovaries, the breast and the uterus are also rising with advancing age of women. Treatment of cancer generally comprises radical surgery and aggressive chemotherapy, leading to a loss of fertility. The review from Maltaris and colleagues from Mainz and Erlangen, Germany (page 148) focuses on the impact of cancer treatments on fertility and on the various surgical and assisted-reproduction innovations that are available to provide the woman with the option of further pregnancies. GnRH analogue treatment can preserve fertility in some patients but at present, cryopreservation of ovarian tissue appears to be a very promising method of providing a cancer patient with a realistic chance of preserving fertility.
      “Absence of evidence of harm is not the same as evidence of absence of harm” is the conclusion of an article by Shah and van Geijn (page 156) dealing with the risk of off-licence prescribing in pregnancy. In the UK, obstetric claims account for over 70% of National Health Service litigation expenses and the situation in other countries may be similar. Prescription of off-licence drugs in pregnancy is commonplace but makes doctors vulnerable to medico-legal challenge. Any allegation of medical negligence is not only potentially costly, distracting and time consuming to defend, but also distressing, insulting and personally hurtful to the doctor. The authors’ objective is to identify the risks associated with off-licence prescribing in pregnancy and to offer practical advice on how to minimise and manage them. The paper is well worth reading.Obstetrics and Maternal-Fetal Medicine: Prostaglandins have been used for many years as a method for cervical ripening in post-date pregnancies. Along with nitric oxide (NO), they are considered to be the central mediators of cervical ripening. Prostaglandin synthesis is catalysed by cyclo-oxygenase (COX). The question investigated by Bullarbo and colleagues from Gothenburg, Sweden (page 160) was whether the NO donor isosorbide mononitrate (IMN) influences the expression of COX1 and COX2 in cervical tissue. Vaginal application of IMN increased the expression of COX2 in cervical tissue but not COX1. This observation may be of importance in the process of vaginal ripening at term and the basis for the development of new drugs for cervical ripening.
      The Hawthorn effect describes the tendency of performance to improve when it is being studied. This phenomenon was investigated by Leung and colleagues from Hong Kong, China (page 165) by looking at the incidence of birth trauma and birth asphyxia related to instrumental deliveries. It was lower in the study period (0.6%) and post-study period (1.0%) compared to the pre-study period (2.8%). This again shows that analyses of observations lead to better performance and contribute to a cycle of continuous improvement. This lesson has still to be learned by many, including health personnel in both developed and developing countries.
      The Apgar score includes five parameters that describe the condition of the neonate, usually at 1, 5 and 10 min of life. Although often criticised it is still a good approximation to get an impression of the quality of the management of labor by the obstetrician. The question asked by Hogan and colleagues from Lund, Sweden (page 169) is therefore justified: how often is a low Apgar score in term newborns due to asphyxia? The results are convincing: hypoxic ischemic encephalopathy (HIE) or hypoxic death were found in 70% of cases with an Apgar score below 4 and in 14% with scores of 4–6. There were no deaths or HIE in controls with scores of 9–10. Similar relations could be established for abnormal CTG before birth, interventions for fetal distress and cord artery pH below 7.15. It would have been interesting to learn the opinion of the authors as to how many cases of HIE or death could have been prevented by an early decision to conduct a caesarean section.
      Premature delivery is a life threatening complication for the fetus and an expensive event for the health care system. Many attempts have been made over the years to reduce the incidence but without much success. Each simple method to predict premature delivery is therefore of value. The measurement of cervical length by ultrasound seems to support early diagnosis, as demonstrated by Ozdemir and colleagues from Duzce and Eskisehir; Turkey (page 176). They measured cervical length in 152 asymptomatic women with singleton pregnancies at 10–14 weeks and again at 20–24 weeks of gestation. Preterm deliveries occurred in 10.5% of women. Cervical length was not different between the groups at 10–14 weeks, but at 20–24 weeks it was 37.8 mm in women who had term deliveries and 28.4 mm in preterm deliveries. It would be interesting to look at individual “cervical length curves” as a routine measurement for each pregnant patient and to introduce a specific treatment to prevent premature labor and delivery.
      Sphincter defects after vaginal delivery were investigated by Starck and colleagues from Malmö, Sweden (page 193) in 32 nulliparous women. 16% already had a small endosonographic anal sphincter defect before delivery and 25% had new defects. The effect of episiotomy on defects was also addressed: 6 of the 8 women with new defects had undergone episiotomy versus 5 of the 24 women with no new defects. One might conclude that episiotomy does not prevent anal sphincter defects but the number of observations is small, so it is difficult at present to decide whether episiotomy is beneficial in preventing sphincter defects. The method of episiotomy-cutting – lateral, medio-lateral, median – at the right time also has to be considered, i.e. was it early enough, before tears in the tissue take place? We would like to publish other papers addressing this controversial topic.Reproductive Medicine and Endocrinology: Patriarca and colleagues from Sao Paulo, Brazil, (page 202) investigated 15 patients and showed an increase of dermal thickness and collagen after topical therapy with 0.01% estrogens for a minimum of 13 months and a maximum of 40 months. It might be reassuring for women who reject oral estrogens to know that topical application of 0.01% estrogens is not reflected in circulating blood levels. This could be of benefit for many reasons.
      Homocysteine (Hcy) is an amino acid formed by the demethylation of methionine. Mild or moderate homocysteinemia is related to the development cardio-cerebrovascular disease and recurrent arterial and venous thromboembolism. High Hcy levels are accepted as an independent risk factor for cardiovascular diseases. The study regarding the effect of hormone replacement therapy on homocysteine levels conducted by Kurtay and Ozmen from Ankara (page 206) did not achieve the expected results: homocysteine levels were the same whether treated by oral administration of combined therapy, transdermal therapy or placebo.
      An interesting report of hormonal emergency contraception among married women comes from Marafie and colleagues from Kuwait (page 216). The information is based on a questionnaire distributed to 66 married women within a Kuwaiti family's social network. The authors discuss the results of the survey in the context of the literature. The gap in women's awareness between European countries and countries of the Middle East might be a result of the information given to girls in school education and access to youth-related magazines. The article gives an interesting insight into behaviour and how to handle a very personal matter.Gynaecology, Gynaecological Oncology and Urology: The established relationship between HPV infection and cervical carcinoma has stimulated numerous groups of researchers to investigate this fascinating topic. The HPV–PathogenISS Study Group from Italy and Finland, represented by Branca and colleagues from Rome, presents a paper demonstrating upregulation of proliferating cell nuclear antigen (PCNA) in close association with high risk HPV (HR-HPV) and progression of cervical intraepithelial neoplasia (CIN) (page 223). Expression of PCNA increased in parallel with the grade of CIN, with major upregulation upon transition to CIN3. Intense PCNA expression was a 100% specific indicator of CIN. Expression of PCNA did not, however, predict clearance and persistence of HR-HPV after treatment of CIN. This marker is considered by the authors as a potential screening tool for cervical cancer.
      The development of hysteroscopic instruments paved the way to remove fibroids located under the mucosa of the uterus. Polena and colleagues from Paris (page 232) performed transcervical resection of submucous fibroids in 235 women, investigated the rate of complications (2.6%) and conducted a follow-up in 84% of the cases. The long-term success rate was 94.4%. Among the failures, a repeat hysteroscopic procedure was necessary in four patients, hysterectomy was performed in three cases and abnormal bleeding was diagnosed in four cases. The conclusion of the authors, however, is that hysteroscopic transcervical resection of submucous fibroids is a safe and highly effective method – a view which is supported by most of the gynaecologists who are familiar with this sophisticated operative procedure.
      The application of operative laparoscopy in teaching hospitals and other institutions is very much dependent on personal skill, an open mind to new procedures, availability of instruments and teams familiar with the methods. Kolkman and colleagues from Leiden, The Netherlands, investigated the attitude of 102 hospitals by a questionnaire according to three levels of difficulty (page 245). Level III was considered to be the most difficult one and comprised myomectomy, total laparoscopic hysterectomy and sacropexy. Diffusion of the methods increased slowly. Diffusion of laparoscopic assisted vaginal hysterectomy (LAVH) was only 58%. The conclusion of the authors is that acceptance is still limited. What about the diffusion of the method in other European countries?
      Vaginal hysterectomy is not a risk factor for urinary incontinence on long-term follow-up, according to de Tayrac and colleagues from Nimes, France (page 258). The conclusion is based on a self-report questionnaire from 117 patients who had vaginal hysterectomy, compared to a control group. The patients’ characteristics were similar in both groups. This finding is important and helpful in patients counselling prior to operation.
      Exciting work is also described in the remaining papers, including telomerase activity and expression of hTERT gene as an indicator of anticancer treatment in ovarian cancer (Sun and colleagues from Beijing and Berlin, page 249) and an economic evaluation of specialist nurse supported discharge in gynaecology (Dawes and colleagues from Glasgow, UK, page 262). We would very much appreciate your opinion on articles and we will respond with fast publication including a reply from the authors. Keep the Journal lively with your responses.