Editorial| Volume 141, ISSUE 1, P1-2, November 2008

Editors’ highlights

Published:October 06, 2008DOI:
      Like most journals in our specialty, EJOGRB appears every month. Our “Editors’ Highlights” is therefore prepared a few weeks ahead, and today as we write there is a flurry of concern in the media that taking antibiotics during pregnancy may increase the risk of cerebral palsy. This was the result of a press conference in London prior to on-line publication in The Lancet of a paper reporting 7-year follow up of the ORACLE study, a randomised trial of antibiotics to treat premature labour. Among the women who had had intact membranes, the incidence of subsequent reported cerebral palsy in the children was 1.7% in the control (no antibiotics) group but 3.3% in the group which had received erythromycin. This difference, although small, may lead to headlines stating that “antibiotics double the rate of cerebral palsy”. UK official bodies, including the Royal College of Obstetricians and Gynaecologists, worked hard to avoid panic by providing information and pointing out that antibiotics, when used appropriately, save lives of both mothers and babies.
      Weekly general medical journals are now used to dealing with the media, and editors and health officials have learned the hard way that news management is critically important to avoid patients being harmed by over-reaction to scientific papers. Positive results are of course much more likely to receive publicity than negative results. “No news is good news”, as the saying goes, but bad news sells more newspapers. With this background in mind, we draw your attention to the paper on page 31 by Bar-Oz and colleagues from Israel and Croatia. They conducted a prospective multi-centre study of 118 women exposed to new macrolide antibiotics in the first trimester of pregnancy, comparing them with 953 women in comparison groups, and conclude that exposure to the new macrolides in early pregnancy does not represent an increased risk of congenital malformations strong enough to require induced abortion. This is a good news story. It is sad but not surprising that its on-line publication attracted little media attention.

      What’s new?

      Preterm labour continues to resist our attempts to find ways of preventing it but research on this important subject continues to move steadily forward. In this month’s review, Holst and Garnier of Cologne, Germany, discuss our current knowledge of the links between preterm birth and inflammation, looking first at the role of intrauterine infection and the association between inflammation and perinatal brain lesions. Their review then focuses on genetic predisposition to infection and the role of genetic polymorphisms. Such variations may be the reason why some individuals, but not others, develop harmful inflammatory responses, and polymorphisms may therefore increase or decrease the risk of preterm birth. This very interesting review should be read in conjunction with the research paper by Uma and colleagues (mentioned below), which looks at the effect of gene polymorphisms on preterm labour in the context of the renin-angiotensin system. These lines of genetic research give some hope that real progress is being made toward the tantalising goal of preventing preterm labour.

      Obstetrics and maternal–fetal medicine

      Hyperemesis gravidarum (HG) can be difficult to treat and can cause serious and potentially fatal illness. Here too, genetic influences play a role. The condition shows interesting variations among different ethnic groups – with, for example, a low incidence in Scandinavian countries and a high incidence in China – and a genetic predisposition is also suggested by the finding that concordance rates are higher among monozygotic than dizygotic twins. Fejzo and colleagues from USA have investigated the familial aspects of HG and on page 13 they report the results of an on-line survey of 1224 self-reported cases. Approximately 28% reported that their mothers had experienced severe nausea and vomiting while carrying them and 19% of sisters with a pregnancy history had had HG. The authors suggest that this provides strong, though preliminary, evidence of a genetic component to this condition.
      The genetics of preterm labour have already been mentioned. One aspect is gene expression at the maternal–fetal interface in early pregnancy. This influences the development of the uteroplacental circulation, and we know that vascular insufficiency is linked to the pathogenesis of preterm labour. The renin-angiotensin system plays an important role in the development of the uteroplacental circulation. On page 27 Uma and colleagues from UK and Ireland report a study of angiotensin-converting enzyme (ACE) activity and ACE gene polymorphisms in relation to preterm birth. They performed a cross-sectional study of 113 term pregnancies and 18 preterm pregnancies and found that the distribution of maternal ACE genotypes was similar for term and preterm births but preterm infants were more likely to be of the DD genotype. The authors conclude that the infant’s genotype may influence the risk of preterm birth among appropriately grown fetuses. They caution that larger studies are needed but nevertheless the difference that they report is significant and looks convincing.
      Snoring is more common in pregnancy than among non-pregnant women and pregnant women may be more susceptible to sleep apnoea. This could be clinically important because of reports linking sleep apnoea to fetal growth restriction. Yin and colleagues from Nottingham and Watford, UK (page 35) report an observational study of 50 non-pregnant volunteers and 178 women in the second half of pregnancy, of whom 69 had hypertensive disease and 33 had fetal growth restriction. No relationship could be found between sleep apnoea and either of these pregnancy complications. This careful study, however, conflicts with another larger study which found that snoring doubled the risk of both conditions, so the question is still open.

      Reproductive medicine and endocrinology

      The experience of infertility is a cause of stress to both men and women and can lead to symptoms of depression. Doctors treating infertile couples are under pressure to provide effective treatment and if depression becomes apparent the doctor may feel tempted to prescribe psychotropic medication. On page 49 Faramarzi and colleagues of Iran report that pharmacotherapy in the form of fluoxetine can improve symptoms of depression in infertile women but when they compared this antidepressant with cognitive behavioural therapy (CBT) in a randomised controlled trial they found that CBT was more effective in relieving depression. The authors conclude that group CBT is cost-effective in these patients but they wisely caution that the results of this study should not be applied to women with severe depression.

      Gynaecology and gynaecological oncology

      Lactobacilli are essential to vaginal health in premenopausal women but there is doubt over whether the simple insertion of lactobacilli (for example, in unsweetened yoghurt) directly into the vagina is an effective treatment for vaginal infections. By contrast, there is increasing evidence that oral ingestion of lactobacilli, besides affecting the gastrointestinal microflora, can also alter the vaginal flora. Studies so far have been limited to premenopausal women but on page 54 Petricevic and colleagues of Vienna report a randomised, double blind, placebo controlled study of oral lactobacilli in postmenopausal women. Compared to the control group, the intervention group showed a highly significant reduction in bacterial vaginosis as measured by Nugent scores. The authors comment that oral probiotic supplements are beginning to gain ground in gynaecology but point out that their encouraging results will require confirmation in a large-scale study including PCR analyses.
      Colposcopy is a subjective clinical skill in which the practitioner has to make decisions based on visual pattern recognition. The need to ensure that these skills are acquired and maintained is a priority for specialist associations and in some countries colposcopists are required to undertake a specified number of procedures every year in order to be allowed to practise. On page 75 Bekkers and colleagues of The Netherlands and Australia report on 18,241 colposcopies performed at the Royal Women’s Hospital, Melbourne, Australia, over a 6-year period. There was no difference in overall performance between inexperienced and experienced colposcopists, though the former showed greater sensitivity in identifying high-grade lesions, while the latter had higher positive predictive value. The authors emphasise that the role of colposcopy is to assess size, site and extent of a cervical lesion, not the severity of the abnormality.

      Gynaecological urology

      Gap junctions are something that most of us remember dimly from lectures on electron microscopy at medical school. Their role is to facilitate cell-to-cell communication and they are made up of protein clusters called connexins. Although they may play a major role in detrusor instability, it has not yet been possible to identify gap junctions in human detrusor muscle by electron microscopy. On page 83 Kuhn and colleagues from Bern, Switzerland and Southampton, UK, report biochemical investigation, using RNA extraction and PCR amplification, of connexin 43 (Cx43) in bladder biopsies from patients with detrusor overactivity and women with stable bladders. Cx43 could be found in both groups but it was not always detectable and no difference between the groups could be found. The authors conclude from this pilot study that Cx43 may not have a role in idiopathic detrusor instability but we hope this interesting line of research will continue.

      Letters to the Editor—Brief Communication

      Having included, for technical reasons, large numbers of letters in our last two issues, this month we return to normal. Two Brief Communications have particular clinical relevance. On page 87 Frati and colleagues report the successful use of uterine artery embolisation to control haemorrhage from cervical choriocarcinoma. Prompt referral to an appropriate centre is essential. On page 88 Olamijulo and Aderibigbe describe deep venous thrombosis after laparoscopic treatment of ectopic pregnancy, and give helpful advice on how to reduce the risk of this complication.