The 4th and 5th Millennium Development Goals (MDG), proclaimed in 2000 by the United Nations, aim at reducing child mortality by two thirds and eliminating two thirds of maternal mortality by the target date of 2015. At a global conference, “Women deliver”, held from 18th to 20th October 2007 in London, however, health politicians, international non-governmental organisations (NGOs) and professional bodies had to confess that these goals are still far away from being reality.
Knowledge about the causes of child and maternal mortality has been available for a long time. It is well known that home deliveries without fast access to hospitals, or delivery in poorly-equipped hospitals, contribute to a great extent to child and maternal mortality. It is known that inadequately trained doctors, midwives and traditional birth attendants may not have the information to support a woman during her pregnancy and may not give the woman the information she needs for a healthy childbirth. It is known that many women are poorly informed about safety measures during pregnancy – prevention of severe haemorrhage, infections, or protracted labor and resulting obstetric fistula – and are not participating in antenatal care.
Why is this knowledge not used and translated into action? Is it indifference and negligence of women, midwives and doctors towards prevention or is it the fault and carelessness of health officials who fail to provide the framework for an adequate health care system? In order to meet MDGs 4 and 5 steps have to be taken to investigate the structure of hospital service, reduce home deliveries and achieve better quality in the process of antenatal care and delivery to improve the outcome – i.e. reduce maternal and neonatal mortality. This will not work without governmental support in individual countries. Achieving the MDGs 4 and 5 is not a matter of awareness – this knowledge is already available – but of willingness to change the tragedy of mothers and children in the afflicted countries. We as obstetricians and gynaecologists must be ready to deliver our contribution.
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You may have noticed that the current issue of the EJOGRB has only 52 pages, half the usual number. This is because we exceeded our page budget in previous issues this year. Our limited number of pages is also the reason for the continuing backlog of articles and part of the reason for our rejection rate of about 60%. We are pleased that there will be a limited increase in our page budget in 2008.
Reviews: It is now almost 50 years since the German Professor Widukind Lenz from Hamburg was impressed during the years 1960 and 1961 by the number of infants with malformations of their arms and legs. The increased incidence was so untypical that he looked for various causes and discovered that all mothers had taken the drug thalidomide, distributed in Germany since 1957 under the name Contergan. The story seems now to have been forgotten by a number of mothers since psychotropic medications are used by a growing number of women of reproductive age. It is therefore of value to read the review article by Campagne from Madrid, “Fact: Antidepressants and anxiolytics are not safe during pregnancy” (page 145). His recommendation is to look for alternative drugs, particularly at very low gestational ages and in late pregnancy since they can affect the fetus at these stages.
Obstetrics and maternal-fetal-medicine: There are many factors which can affect fetal development during pregnancy. These include not only maternal diseases such as hypertension, infections and metabolic influences but also factors which could be prevented such as alcohol consumption, excessive weight gain and cigarette smoking. Weight gain following smoking cessation was investigated by Favaretteo and coworkers from Porto Alegre, Brazil, in 4000 pregnant women in six Brazilian cities from 1991 to 1995 (page 149). The conclusion was that cessation of smoking was significantly associated with a small maternal weight gain which might also be of benefit to the fetus.
Malformations of the uterus show a wide variance ranging from uterus didelphys to an arcuate uterus. One problem caused by these malformations is insufficient blood supply to the pregnant uterus which is reduced by half in cases of a uterus with two horns. Surgical intervention by removing the septum or combining the horns improves the chance of avoiding premature labor or abortion. Tomazevic and coworkers from Ljubljana investigated the influence of a small uterine septum on preterm birth. They studied 730 women who underwent hysteroscopic resection over a 10-year period and whose subsequent pregnancies were recorded on a national database. Women in “Group A” had a small septum and in “Group B” had a subtotal or total septum. Hysteroscopic removal of the septum reduced the preterm birth rate in both groups, from 33.9% and 36.5% to 7.2% and 8.0%, respectively. The resection of the larger uterine septum (group B) reduced the very preterm birth rate from 12.5% to 3.1%. According to the authors premature birth caused by uterine malformations is in most cases preventable.
A different causal factor for preterm birth was investigated by Hossain and coworkers from Seattle, USA (page 158). They found that vaginal bleeding in pregnancy is associated with a 1.57-fold risk of premature delivery. The risk was increased to 6.24-fold if bleeding was present in the first and second trimester. It would have been of interest to get some information about the type and number of associated infections. Treatment with antibiotics after receiving an antibiogram could be another way to reduce the risk of premature labor.
Reproductive medicine and endocrinology: Differential diagnosis of gestational trophoblast disease is usually straightforward but can sometimes be difficult. Complete hydatidiform mole (CHM), partial hydatiform mole (PHM) and hydropic abortion (HA) are three inter-related but distinct conditions. On page 170, Maggiori and Peres from Sao Paulo, Brazil, describe the use of immunohistochemistry and chromosome in situ hybridisation to make the definitive diagnosis in difficult cases. The authors conclude that there is no single criterion for distinction between CHM, PHM and HA.
An interesting experiment in a mouse model regarding fertilization, embryo development and cleavage rates in mice exposed to cigarette smoke was conducted by Hassa and coworkers from Eskisehir, Turkey (page 177). As expected, smoking exposure had a significant impact on fertilisation rate, embryo development and cleavage rate. Vitamin E had no influence. This is additional evidence to persuade patients that it is sensible to stop smoking when in preparation for IVF.
Gynaecology and gynaecological oncology: One of the effects of sildenafil (“Viagra”) is well-known throughout the world but it is clearly a drug that can be applied for many purposes. In an experimental model in the rat, studies conducted by Batukan and coworkers from Kayseri, Turkey show that it can be used to advantage for the prevention of adhesions (page 183). The severity but not the extent of the adhesions is markedly reduced if sildenafil is given in a dosage of 15 mg/kg bodyweight. It still remains for investigators to check its effectiveness in the human.
Chronic pelvic pain affects a substantial number of women in the fertile age range. The cause in many cases is endometriosis of various degrees. Razzi and coworkers from Siena, Italy, (page 188) investigated 40 women who had recurrent dysmenorrhea and/or pelvic pain after conservative surgery for endometriosis. Twenty women received Desogestrel and 20 women were treated with an oral contraceptive containing estradiol and desogestrel. Both treatments were found to be effective, safe and low-cost therapy.
Endometrial ablation quickly became popular in England in the early 1990s as a method of treating heavy menstrual bleeding (HMB). Endometrial resection and rollerball ablation require considerable training and experience, however, and simpler “second generation” techniques such as microwave or thermal balloon ablation have been developed. On page 191, Reid from Luton, UK, examines trends in the English National Health Service statistics from the years 1989/1990 to 2004/2005. Endometrial ablation is now more common than hysterectomy for heavy uterine bleeding and second-generation methods are now more commonly performed than hysteroscopic ablation. The number of hysterectomies for HMB continues to fall but the total number of operations for HMB has not changed since the year 2000. The author expects that endometrial ablation will continue to increase in practice in England concludes that it has not yet fully come of age.
Article info
Publication history
Published online: November 15, 2007
Accepted:
November 4,
2007
Identification
Copyright
© 2007 Elsevier Ireland Ltd. Published by Elsevier Inc. All rights reserved.
