Editorial| Volume 138, ISSUE 1, P1-2, May 2008

Editors’ Highlights

      May 9th is “Europe Day”. On that date in 1950 the French foreign minister, Robert Schuman, called for the creation of a supranational institution to manage the combined coal and steel industries of France and Germany. His purpose, in the aftermath of World War II, was to make another war “not merely unthinkable but materially impossible” and he crystallised this into a practical proposal. Thirty-five years later European leaders recognised the Schuman declaration as the beginning of the European Union (EU) and decided to mark the date, though admittedly this celebration has not yet captured public imagination across the continent.
      Almost 60 years on, pan-European bodies are having mixed success. Next month's football tournament, “Euro 2008”, will excite everyone (or almost everyone) because the language of sport is international, but medicine remains at present still divided by national boundaries. EBCOG, the supranational institution for our own specialty, has so far had little influence on clinical practice and new ideas may be needed. The EU has a rotating chairmanship which changes every 6 months and perhaps EBCOG should consider involving the national societies which are represented in the Council in a similar way. The selected society should prepare and present a special proposal which can be put into action. We recommend this as a method of encouraging the involvement of national societies.
      What's new? European subspecialty societies, such as the European Urogynaecology Association (EUGA) or the European Society for Human Reproduction and Embryology (ESHRE), are very active and patterns of practice are emerging that provide a contrast between us and the United States (US). For example, most European countries provide some public funding for Assisted Reproduction Techniques (ART) whereas in the US this treatment is mainly funded privately. The American approach gives generally higher pregnancy rates related to the number of replaced embryos but in Europe multiple birth rates are lower and infertility treatment may be more widely available.
      In this month's review (page 3) Navarro and colleagues from Granada, Spain, go beyond a simple transatlantic comparison and look instead at 62 national entities – the 52 US states and 10 European countries (or states) – using data collected by ESHRE and the US Center for Disease Control and Prevention. They divide states into those in which ART is entirely private, those with complete public coverage and those with other mixed systems. States which provide only private ART have fewest cycles of treatment and fewest pregnancies but they have the highest ratio of births to treatment cycles and on average they replace three embryos per cycle. States with complete public coverage normally replace only one embryo or to put it more plainly, when considering their priorities they rate patient safety higher than effectiveness.
      Obstetrics and maternalfetal medicine: Oxidative stress is a concept many of us remember only dimly from medical school. We have a vague idea that the body's cells are involved in an endless battle between antioxidants and free radicals and that this is somehow related to many illnesses. Tomatoes and carrots are rich in antioxidants but we remain sceptical about claims that eating them in large quantities will protect us from cancer and heart disease. Nevertheless, oxidative stress seems to be relevant to obstetrics. On page 39 Raijmakers and colleagues from The Netherlands and UK report on the measurement, during and after pregnancy, of oxidised thiols in the blood of normal and pre-eclamptic women. Levels were raised in pregnancy and were higher still in pre-eclampsia, suggesting that pregnancy, and particularly pre-eclamptic pregnancy, is a state of increased oxidative stress.
      As well as being told that that tomatoes are good for us we are told that alcohol is bad for us, during pregnancy at least. Alcohol use during pregnancy is a cause of intrauterine growth retardation (IUGR) but the safe level of consumption is a matter of conflicting advice. The uncertainty may be due to genetic factors. On page 49 Delpisheh and colleagues report a case–control study of 90 mothers with an IUGR baby and 180 controls in Liverpool Women's Hospital, UK. Among IUGR cases the proportion with prenatal alcohol exposure was 45.6% compared with 30.6% in controls. The authors studied the CYP17 gene, which encodes the cytochrome p450 17alpha enzyme, and conclude that the maternal genotype modulates the association between alcohol exposure and IUGR.
      Multiple pregnancies are now routinely identified by ultrasound in the first trimester. Could this early scan predict birthweight discordance, an important risk factor in later pregnancy? Banks and colleagues from Glasgow, UK (page 34) measured crown–rump lengths in 108 pregnancies and checked ultrasound measurements again near delivery. Although disparate growth is exhibited as early as 10–14 weeks’ gestation, it does not accurately predict discordant birthweight. Nor, incidentally, do scans in the third trimester.
      Reproductive medicine and endocrinology: Endometriosis is the subject of both papers in this section. On page 54 Coccia and colleagues from Florence, Italy, report a retrospective survey of patients with this diagnosis, some of whom were treated by surgery alone and others by surgery followed by in vitro fertilisation (IVF). The pregnancy rate after surgery was 37.4% but after the integrated laparoscopy–IVF approach it was 56.1%. Pregnancy was most likely in the 6 months after operation and the authors suggest that if conception has not occurred within a year of laparoscopic surgery, IVF should be offered.
      In the other paper (page 60), Gomes and colleagues from Sao Paolo, Brazil, studied peritoneal fluid and its effect on the function of cultured human granulosa-lutein cells. Peritoneal fluid from women without endometriosis stimulated progesterone production but high concentrations of fluid from women with minimal or mild endometriosis reduced progesterone production, suggesting the presence of factors which may compromise ovarian steroidogenesis.
      Gynaecology and gynaecological oncology: The 5-year survival rate from ovarian cancer has not improved despite new treatments. Immunological factors may affect the prognosis. On page 71 Bishara and colleagues from London and Oxford, UK, report a study of white blood cell subtypes at the time of the initial diagnosis. Low lymphocyte counts and high monocyte and eosinophil counts were associated with higher mortality or risk of recurrence in patients who had been optimally debulked. Better understanding of these associations may open new ways to affect clinical outcome of this disease.
      A new treatment for uterine fibroids is a possibility raised by Han and colleagues from Busan, South Korea, on page 83 Using cultured leiomyoma cells they studied the effect of letrozole, a powerful aromatase inhibitor originally licensed to block oestrogen production in postmenopausal women with breast cancer. Combined treatment with letrozole and prostaglandin E2 (an aromatase inducer) produced lower viability and a higher death rate in the cultured cells, and the authors recommend further investigation of aromatase inhibitors as medical treatment for fibroids. Meanwhile, surgical treatment is still necessary and on page 100 Agostini and colleagues from Marseille, France, report a series of 108 patients treated by vaginal myomectomy through posterior colpotomy. Only 16% of cases required conversion to laparotomy and, not surprisingly, this was more likely with larger and heavier fibroids.
      Surgeons are used to filing photographs in patients’ notes recording the findings at laparoscopy. Technology now makes it possible to produce video recordings of operations, both endoscopic and open. Papadopoulos and colleagues from London (page 89) offered women the chance to view edited highlights before discharge from hospital. Almost all women consented to the operation being recorded and two-thirds wanted to view the recording (a proportion that some might find unexpectedly high). Only small recording devices are required and the authors suggest that these could easily become part of routine ward rounds.
      How much do husbands know about their wife's health? This question was studied by Lerner-Gova and colleagues (page 80), who interviewed husbands and perimenopausal wives separately using the same questionnaire. There was good agreement regarding the number of live children, age at menopause and general health problems but less agreement about obstetric history. Women tend to remember details of their pregnancy and delivery so this result is not surprising. It is reassuring, however, that couples did at least agree on how many children they had.
      Gynaecological urology: Some women are more susceptible to prolapse than others and one factor may be differences in tissue oestrogen receptors. On page 105 Chen and colleagues from Taichung, Taiwan, report differences in the oestrogen receptor gene haplotype between women with and without prolapse. Childbirth is another factor which affects prolapse risk and can also lead to short-term bladder problems. On page 110 Demaria and colleagues from Paris report a study of residual urine volume in 154 primiparous women 3 days after vaginal delivery under epidural anaesthesia. Two hours after delivery, 63% had a retained volume over 500 ml, and on day 3, 36% had a post-voiding residual volume of over 100 ml. There was no clinical factor that could predict which women would have a high residual volume and the authors recommend checking all postpartum women until day 3 with the rather expensive-sounding option of 3D ultrasound scanning.
      Letters to the Editor: This month our letters cover a wide variety of topics from atrial fibrillation during pregnancy to a new uterine manipulator to reduce leakage during hydrotubation. We were interested in the report by Ugurlu and colleagues of serious streptococcal infection arising from the vagina in a postmenopausal woman. Puerperal infection with Streptococcus pyogenes (“Strep A”) was once the most feared complication in our specialty and we must all remember that this versatile and potentially deadly bacterium has not gone away.