Editorial| Volume 131, ISSUE 1, P1-3, March 2007

Editor's highlights

Published:February 10, 2007DOI:
      International Women's Day (IWD) is being celebrated on March 8th this year, as indeed it is every year. We suspect that this annual event has escaped the notice of many obstetricians and gynaecologists, though those using the Internet on that date may wonder why Google has changed its logo to include the female symbol. IWD was first observed in 1909 in the United States as part of a campaign by the Socialist Party of America against poor working conditions for women. The day was adopted by socialists across the world, notably by Soviet Russia, and it remains an official holiday in many countries of the former USSR. In 1975 the United Nations began sponsoring IWD and it is now supported by governments including the US and Australia, by leading multinational companies and by a number of universities.
      Some may complain this is mere symbolism but we think it is important to remember the battles fought by women in developed countries in the last century to achieve such essentials as the right to vote and the right to be educated. In England, Cambridge University, which was founded in 1209, did not award degrees to women until 1947. Similar battles are still being fought in many countries. In India the female literacy rate has increased to 54% but still lags behind the male rate of 76%. In Afghanistan the figures are 21% and 51%, respectively. Worldwide, female literacy is inversely related to maternal mortality rates: both are indicators of a nation's attitude to women.What's new? This month we have two contrasting reviews. On page 4 Augustin and Majerovic from Zagreb review current knowledge on non-obstetrical causes of an acute abdomen in pregnancy. Appendicitis is the commonest cause and, as is well known, is more difficult to diagnose in pregnancy because of changes in the classical signs. If perforation of the appendix occurs the fetal loss rate may be as high as 35%. The authors suggest that ultrasound is helpful in the diagnosis of appendicitis as well as in cholecystitis. They also discuss the place of laparoscopy and conclude that cholecystectomy can be performed laparoscopically until the early third trimester. Faced with an acute abdomen in a pregnant woman, both obstetricians and general surgeons may feel they are on unfamiliar ground and this review is timely and helpful.
      On page 13 Peng and colleagues from Ishikawa, Japan, present a review of Whole Genome Amplification (WGA) techniques and their application to pre-implantation genetic diagnosis and prenatal diagnosis. The polymerase chain reaction (PCR), introduced more than 20 years ago, allowed analysis of DNA in a single cell but this could be done only once and independent confirmation of the genotype was impossible. By 1993, when Kary Mullis won the Nobel Prize for inventing PCR, methods for circumventing this limitation had already been described. Zhang and colleagues in Los Angeles developed “primer extension preamplification” (PEP) and Telenius and colleagues, working in Cambridge, England, described “degenerate oligonucleotide-primed PCR” (DOP-PCR). Peng's review describes these and more recent WGA developments such as “multiple displacement amplification” (MDA). The speed of advance in techniques which underpin our clinical work is startling, and it is important for clinicians not to fall behind in understanding them.Obstetrics and maternal–fetal medicine: “Hay fever”, the seasonal form of allergic rhinitis, affects many people and in summer attention is anxiously focussed on the pollen count. Symptoms of allergic rhinitis can be severe and pregnant women may worry that the stress might affect the baby. On page 21 Somoskovi and colleagues review data from the Hungarian case–control surveillance of congenital abnormalities and conclude that allergic rhinitis has no teratogenic potential. Interestingly, they found a strong protective effect against preterm delivery. Unexpected research findings sometimes turn out to have considerable significance and we hope this surprising finding will be followed up.
      Years ago, when rupturing the membranes was the only way to induce labour, there was little concern about oligohydramnios in labour and its effect on the fetus. More recently, however, studies have shown that amnioinfusion in labour is of benefit when meconium is present or in cases of umbilical cord compression. On page 40 Puertas and colleagues from Granada, Spain, report a randomised trial of 86 women in labour after preterm premature rupture of the membranes. One group received transcervical amnioinfusion through a two-way catheter and the other did not. Amnioinfusion reduced the frequency of cardiotocograph abnormalities, and the rate of intervention for non-reassuring fetal status fell from 52% to 14%. The treatment did not increase maternal or fetal morbidity but produced a small but significant improvement in umbilical artery pH at delivery.
      The Baltic states, Estonia, Latvia and Lithuania, underwent dramatic social changes after gaining their independence following the fall of communism. Incomes grew, obstetric care improved and there was a dramatic reduction in the number of teenage mothers. In 1992 the fertility rate in young women aged 15–19 was 50.5/1000 but by 2002 it had fallen to 21.9/1000. Haldre and colleagues from Tallinn (page 45) report an Estonian Registry study of 51,980 women aged 13–24 years. Risks of low birth weight and preterm birth were higher among teenagers and did not change during the study period. Other countries too have found that as health care improves for the majority of pregnant women, teenagers get left behind.Reproductive medicine and endocrinology: Turkey is also a country in transition, as we have mentioned before in these pages. One manifestation of this has been expansion of family planning associated with improvements in health services. On page 52 Bozkurt and colleagues from Ankara report a questionnaire study of 2365 women of reproductive age. The proportion who had never used contraception was less than 20%. The study mainly included married women and the mean age was 38, but for all age groups including women under 30, the most widely used contraceptive method was the intrauterine device (IUD), which is used by 55% overall. Most IUD users were completely satisfied with this method. It is interesting how preferences regarding contraceptive methods vary from country to country. In the UK, for example, less than 8% of women use the IUD. As the authors point out, a study carried out in Ankara is probably not representative of Turkey as whole. It would be interesting to see a similar study of rural areas.
      Emergency contraception (EC) is still controversial, with most debate focussing on how available it is or should be. There is still some uncertainty about its effectiveness, with calculations being made about how many pregnancies might have occurred if EC had not been used. An interesting aspect is highlighted by Espinos-Gomez and colleagues from Barcelona, who studied a group of 69 women requesting EC. The authors checked the number of sperm in the vagina at the time of the request. In 35% no sperm could be seen and in the others the count was much lower than in a control group of women who were trying for pregnancy. In the study group the sperm count was the same whether the problem had been condom slippage or breakage or unprotected sex. The authors suggest that women requesting EC are already at a reduced risk of pregnancy.
      Liquorice (or licorice) is perceived in some countries as candy but its medicinal properties have been known since ancient times. Its active constituent, glycerrhetic acid, has mineralocorticoid effects. On page 61 Armanini and colleagues from Padua and Verona, Italy, report its use in combination with spironolactone, an antagonist of aldosterone. Their hypothesis was that licorice would counteract the volume depletion induced by spironolactone and possibly enhance its anti-androgenic activity in the treatment of polycystic ovarian syndrome (PCOS). They studied 32 women with PCOS treated with spironolactone, 16 with added licorice and 16 without. Symptoms of volume depletion were seen in 20% of the latter group and none of the former group. The combined therapy also reduced the prevalence of metrorrhagia. The licorice was given as a dried extract of the boiled root, not as candy.Gynaecology, gynaecological oncology and urology: Traditionally, endometrial cancer is treated surgically, with radiotherapy reserved for patients at higher risk of recurrence. The benefits of adjuvant radiotherapy remain controversial, however. On page 76 Kodama and colleagues from Okayama, Japan, describe a study on 167 patients with stages IB, IC and II endometrial cancer, and stage III cases with positive peritoneal cytology. Adjuvant chemotherapy was offered to women with risk factors such as invasion of the outer half of the myometrium or positive peritoneal cytology. Histologic grade 3 was an independent prognostic factor and chemotherapy appeared to improve the survival rate among these patients, but not among patients with other risk factors.
      Congenital uterine abnormalities are described in detail in undergraduate textbooks but the clinical significance, at least of minor anomalies, is uncertain. Pace and colleagues from Rome (page 81) draw attention to the debate about the arcuate uterus, which some studies, but not others, is associated with poor reproductive outcome. The authors describe 36 women who underwent metroplasty for arcuate uterus. Uterine artery Doppler velocimetry was performed before and after surgery and there was an improvement in impedance as assessed by lower mean pulsatility indices. The authors suggest that metroplasty not only improves the shape of the uterine cavity but also leads to better perfusion.
      Another report from the Baltic republics, this time from Vilnius, Lithuania, is on page 85. Berlingieri and colleagues performed a retrospective study of 879 women with ectopic pregnancy and found that tubal rupture was more common in women aged over 35 and in cases where the pregnancy was located in the isthmus. Standard risk factors for ectopic pregnancy were not associated with an elevated risk of rupture. This series covered the period 1993–1997, when vaginal ultrasound and quantitative serum beta-HCG measurements were not routinely available. Without these modern aids to diagnosis, the overall incidence of tubal rupture was 29.5%.Letters to the editor: Laparoscopy during pregnancy, discussed in our first review article, is the subject of a communication from Krakow, Poland (page 102). Klimek and Wicherek describe 25 women who underwent laparoscopic surgery in pregnancy, mainly for removal of an ovarian cyst but in two cases for appendicectomy and in one case for myomectomy. Six procedures were performed because of an acute abdomen. The average gestation at laparoscopy was 8.7 weeks and there were no complications during surgery. Two patients miscarried, one had a stillbirth at 26 weeks, one had an urgent caesarean section at 32 weeks and the rest delivered at term. The authors recommend laparoscopy as the procedure of choice for surgical emergencies in pregnancy.