Editorial| Volume 138, ISSUE 2, P125-126, June 2008

Editors’ highlights

      In the February issue we made you aware of the Congress of the European Board and College of Obstetrics and Gynaecology at the beginning of March in Lisbon. Those of you who attended can confirm the high attendance of about 1700 colleagues from all over Europe and the excellent atmosphere. The meeting had a real European flavour and there were outstanding presentations and lectures. At the opening ceremony Dr. Eberhard Müller-Heubach of Winston-Salem, USA, a past president of the American Gynecological and Obstetrical Society, gave an impressive insight into research in our specialty and experience in the USA. Live surgery was a special attraction of the meeting, with teams from France, Germany and Italy demonstrating their techniques in myomectomy, supra-cervical hysterectomy and urinary incontinence. Other excellent plenary sessions and special lectures covered the whole specialty. Do not miss the next congress, which will take place in Antwerp in 2010.
      What's new?
      Review: The distribution of endometrial tissue in the female body and its implantation have for a long time been a reason for speculation. The location of endometrial tissue in the pelvis and abdomen seems to be closely related to retrograde menstruation, though the ability of the tissue to reach bone and other organs is attributed to haematological distribution or metaplasia. The review by Bricou and coworkers from France and the USA on page 127 presents new evidence to support Sampson's “menstrual regurgitation” theory of endometriosis, published in the American Journal of Obstetrics and Gynaecology in 1927 under the title “Peritoneal endometriosis due to premenstrual dissemination of endometrial tissue into the peritoneal cavity”. Based on their own experience and a review of the literature, Bricou and coworkers underline the importance of anatomical asymmetry and the circulation of peritoneal fluid and give a reasoned explanation for the localisation of endometriotic tissue with a preference for pelvic lesions on the left side. The article is well worth reading.
      Obstetrics and Maternal–Fetal Medicine: Only 5.3% of all births take place exactly at day 280 of pregnancy. Labour begins before the calculated date of delivery in about 50% of cases, 26.5% of women deliver on days 281–287 and 15.5% on days 288–294. Only 2.2% of deliveries take place after that date. To reduce fetal mortality, labour should be induced if pregnancy proceeds ten or more days beyond term or if other reasons exist. Induction used to be a difficult procedure but prostaglandins have provided many advantages. On page 135 Marconi and coworkers from Milan, Italy, report a randomized comparison of two dinoprostone preparations – gel and insert – for the induction of labour. They conclude that both are effective in cervical ripening but there was a significantly reduced time to vaginal delivery with dinoprostone gel in multiparous patients. An interesting approach to cervical ripening before first trimester curettage is also shown by Chen and coworkers from Berlin (page 176). They compared the nitric oxide donor isosorbide mononitrate (ISMN), the prostaglandin misoprostol and the hygroscopical cervical dilator Dilapan-S in 65 pregnant women with missed abortion. ISMN was the least effective but Dilapan-S could be an alternative to prostaglandin as it does not cause preoperative contractions.
      Pre-eclampsia and eclampsia are still a cause of high maternal and fetal mortality in developing countries. Blood pressure is one of the most important determinants of the disease, since it indicates maternal vasoconstriction with its impact on uterine perfusion. Steyn and coworkers from Stellenbosch, South Africa (page 141) studied 44 women admitted with severe pre-eclampsia before 34 weeks’ gestation and managed expectantly for at least 8 days with regular blood pressure measurements. They concluded that a combination of mean diastolic blood pressure and day–night blood pressure difference may be a supplementary measurement of the disease severity and a guide to prognosis. Prediction of pre-eclampsia was also investigated by Rizzo and coworkers from Rome (page 147), looking at uterine artery Doppler velocimetry and placental volume at 11–14 weeks’ gestation. Pre-eclampsia developed in 4.1% of the 348 women studied and the combination of abnormal uterine artery Doppler and low placental volume was a better predictor than either test alone.
      Premature rupture of membranes and premature delivery are often associated with cerebral palsy and neonatal handicap. The causes may be hard to identify: uterine infection may be one cause but fetal hypoxia cannot be always excluded. Lipopolysaccharides (LPS) are endotoxins produced by gram-negative bacteria and on page 152 Garnier and coworkers from Germany and Austria use a sheep model to investigate their impact on the fetal circulation with special attention to the placenta. Injection of 100 ng LPS induced fetal tachycardia and mild hypoxia, but acidemia was absent. In the placenta there were major changes of the proliferation pattern in both maternal and fetal compartments. It would also be of interest to learn whether there were dramatic changes in different areas of the fetal brain.
      Perinatal mortality in European countries is among the lowest worldwide but different ethnic groups among the native population make different contributions to the overall rates. With this in mind, Alderliesten and coworkers from Amsterdam, The Netherlands (page 164) investigated the impact of ethnicity in 137 cases of perinatal death. The results are interesting. Surinamese and other non-Western mothers had a higher perinatal mortality due to early preterm delivery. Care in labour was similar in all groups but Surinamese mothers began antenatal care later and reported problems later than other groups, even though they speak Dutch fluently. Better communication, tailored to ethnic groups, is needed.
      Reproductive Medicine and Endocrinology: Elevated plasma homocysteine (Hcy) is a risk factor for cardiovascular disease. On page 180 Palep-Singh and coworkers from Leeds, UK, report a pilot observational study in 71 women, investigating possible associations between plasma Hcy, the single nucleotide polymorphism (SNP) 2756 A > G in the methionine synthase gene, and the polycystic ovary syndrome (PCOS). Plasma Hcy levels were not influenced by the SNP 2756 A > G but were significantly higher in women with PCOS compared with non-PCOS controls. PCOS and low whole blood folate were associated with higher plasma Hcy concentrations. Counselling regarding folic acid may be appropriate for reducing long-term adverse effects of PCOS.
      Gynaecology and Gynaecological Oncology: Ovarian cancer is in general discovered too late, with unfavourable effects on prognosis. Ovarian endometrioma is associated with an increased incidence of ovarian cancer. On page 187 Kobayashi and coworkers from Japan report on the Shizuoka Cohort Study on endometriosis and ovarian cancer. A total of 6398 women with ultrasonographically diagnosed ovarian endometriomas were observed for a median time of 12.8 years. Forty-six (0.72%) developed ovarian cancer. An independent risk factor was a tumour size of >9 cm in postmenopausal women. The authors discuss the role of ultrasound screening and comment that early and aggressive therapy including surgery may be needed to prevent ovarian cancer in this high-risk group.
      Ma and coworkers from Hangzhou, China (page 204), provide an interesting insight into the mechanism of apoptosis of T-cells in patients with ovarian cancer. Soluble Fas (sFas) is a protein that inhibits the binding of Fas to the Fas ligand and blocks Fas-mediated apoptosis of carcinoma cells. In cases of ovarian carcinoma, elevated sFas is correlated with apoptosis of T-cells in peripheral blood and peritoneal fluid, which may play a role in immunodeficiency. More investigation is needed to explain the up-regulation of sFas in these patients.
      Cystosarcoma phyllodes accounts for 0.5% of all breast neoplasms. Impressive results in treating it are given on page 217 by Lenhard and coworkers from Munich, Germany, who report 33 cases with 5- and 10-year survival rates of 89.5% and 84.3%, respectively. Women with mastopathia often suffer the dread of developing carcinoma of the breast. Radowicki and coworkers from Warsaw (page 212) measured serum prostate-specific antigen (PSA) in women with fibrocystic disease and in controls. PSA was higher in cases of mastopathy and the authors hypothesize that it may be a new marker for the assessment of benign breast disease. We would appreciate the opinion of readers on both these articles on breast disease.
      Prevention of cervical carcinoma by immunisation against HPV is one of the most important goals in gynaecological oncology. HPV infection is transient in most cases but some persist for years and carry the risk of cervical cancer. The 20 types of HPV can be divided into three groups with low, intermediate and high risk of oncogenicity and it is important to know their prevalence rates in a population. Sapy and coworkers from Debrecen, Hungary (page 194) provide these data. They performed 3480 virus identifications in women with positive cytology at cervical screening and identified 91 low-risk cases (2.6%), 1072 high-risk cases (30.8%) and 59 double infections (1.7%). There was a significant decrease in both low- and high-risk infections beyond 35 years of age but the decline in high-risk infection occurred later, so the relative frequency of high-risk HPV did not fall. Routine screening for cervical cancer has to stay until immunisation is shown to be as effective as screening.
      Gynaecological Urology: Meshes are being applied more and more to support the pelvic organs if a prolapse has to be treated. The aim is to prevent recurrence, which occurs in one quarter of operated cases. On page 232 Milani and coworkers from the Netherlands report an observational cohort study conducted at two urogynaecologic centres, in Delft and Nijmegen. The 71 patients were operated with an “ultra light weight titanized polypropylene mesh” and follow-up was conducted after 6–14 months with a validated urogynaecological questionnaire. Morbidity was minimal but mesh erosions were detected in 5.6%. This is lower than in previous studies but the follow-up was relatively short. More observations are needed on mesh-related morbidity, preferably in the form of controlled studies.
      Enjoy reading the papers.