Editorial| Volume 148, ISSUE 1, P1-2, January 2010

Editor's highlights

Published:November 20, 2009DOI:

      Wolfgang Künzel

      In recent years this Journal has had two Co-Editors-in-Chief, working together in an enjoyable and harmonious relationship. We have divided the work equally and month by month we have alternated in writing the “Editors’ Highlights”. The last article of 2009 was written by Wolfgang Künzel and as usual contained an excellent mixture of clinical wisdom, scientific analysis and a “European View”. What it did not mention was that it would be Wolfgang's last “Editors’ Highlights”, because December 2009 marked his departure from the post of Editor-in-Chief. In the spring of last year he had announced to the Editorial Board his intention to step down at the end of the year. The Board accepted his decision with regret and with gratitude for his long association with the Journal.
      The European Journal of Obstetrics, Gynecology and Reproductive Biology was founded in 1971 with Professor Stolte of Amsterdam as its first editor. In 1978 Professor Tom Eskes of Nijmegen became Chief Editor and one year later Wolfgang Künzel was appointed to the Editorial Board. In 1985 the Journal appointed two new Receiving Editors, one (J. Drife) for authors in the UK and the other (W. Künzel) for authors in what was then the Federal Republic of Germany. When Tom Eskes retired as Editor-in-Chief in 2003, the Publisher invited us both to take over his post. It was an unusual arrangement but we had no hesitation in accepting. Wolfgang has now retired after an unbroken thirty-year association with the Journal.
      During those three decades, as well as having a distinguished academic career he has been a leader of the specialty in Europe. In 1999, when he occupied simultaneously the posts of Secretary-General of the European Association of Obstetrics and Gynaecology (EAGO) and president-elect of the European Board and College of Obstetrics and Gynaecology (EBCOG), he was asked to set up a working party on the amalgamation of these two bodies. The merger duly took place within a few years. As Editor-in-Chief of the European Journal he has had a truly a “European view” and it was typical that last month he highlighted the work of the European Network of Trainees in Obstetrics and Gynaecology (ENTOG) and called for extension of the European hospital visiting programme. He has also had a global view of our specialty, and he will continue to undertake work in West Africa. His concern to improve women's health care in developing countries has shone through many of the articles he has written in these pages.
      As the Journal reverts again to a single Editor-in-Chief, we are aware that the breadth of Wolfgang's experience and expertise will be impossible to replace. Over the last thirty years the political scene in Europe has changed out of all recognition. Our specialty has also changed and indeed so has the Journal, with the appointment of a team of specialty-based editors extending outside Europe. The advent of the internet has produced immense changes in medical publishing, benefiting editors and readers alike. During all these developments Wolfgang's guiding hand has been invaluable. The publishers and all his editorial colleagues are deeply appreciative of his wisdom and loyalty to the Journal. For me, working with Wolfgang through meetings, electronic communication and telephone conversations has been easy and a great pleasure. We all wish him well as he retires from the Editorial chair and continues to enjoy his international activities and to relax with his family.

      What's new?

      Turning to our first issue of 2010, it is a pleasure to note that the flow of review articles is continuing. The first review of the new year is about mid-trimester preterm prelabour rupture of the membranes (PPROM), a difficult problem which complicates 0.7% of pregnancies. The mid-trimester is a critical time in fetal lung development and PPROM can disrupt this process and cause pulmonary hypoplasia, which carries a high risk of perinatal mortality, of around 70%. On page 3, van Teefelen and colleagues from The Netherlands examine the capacity of clinical parameters to predict pulmonary hypoplasia. They carried out a systematic review of 28 studies and found that prediction of lethal pulmonary hypoplasia could be analysed separately in 21 of them. Of the three clinical parameters that they examined – gestational age at PPROM, latency between PPROM and delivery, or oligohydramnios – the best predictor was gestational age. The authors point out that accurate prediction of lethal pulmonary hypoplasia before 24 weeks will help in a very difficult decision-making process, giving parents the chance to opt for termination of pregnancy or delay the decision for a pointless caesarean section.

      Obstetrics and maternal–fetal medicine

      “Elderly primigravida” is a phrase that was in common use thirty years ago to describe women having their first baby after the age of 35. It is rarely heard today, partly because it gave offence and partly because starting a family at that age is no longer unusual. In the UK 15% of pregnancies are to women aged over 35 and 3% to women over 40. On page 21 Hsieh and colleagues from Taiwan report an increasing trend in the mean maternal age at the birth of the first child and a doubling of adverse perinatal outcomes in women aged 35–39 years. It is not surprising that risks are similar everywhere but it is remarkable that social trends which influence obstetric care are now occuring on a global basis.
      A regrettable universal trend is that risk factors for poor pregnancy outcome are dominated by social class. Poor people have more chance of a poor outcome even in developed countries with highly organised healthcare systems. The UK, for example, has had a national health service for over 60 years, but nonetheless maternal mortality is seven times higher among the lowest social class than among the highest and there is a twofold difference in perinatal mortality. A study of this problem in Belgium is reported on page 13. Cammu and colleagues carried out an observational study of 170,948 primiparous women who delivered in Flanders between 1999 and 2006. Logistic regression analysis produced results that are succinctly summed up in the paper's title: the higher the educational level of the mother, the lower the fetal and post-neonatal mortality. This gradient did not apply, however, to neonatal mortality, showing that the special care baby unit is one place where all social classes are equal.
      Gastroschisis is one of a number of conditions that are diagnosed by fetal medicine specialists and treated by paediatric surgeons Two papers in this issue stray across the dividing line between the specialties and address the problem of treatment. On page 31 Hong and colleagues from Shanghai, China, describe seventeen neonates whose viscera could not be reduced immediately after birth. A spring-loaded silo bag was put in place to hold the viscera and a nasogastric tube was used to decompress the gastrointestinal tract. From the second day onward gauze strips were tied around the bag to progressively return the bowel to the abdominal cavity and after 5–8 days it was possible to close the abdominal wall defect. This procedure has increased the survival rate of infants with severe gastroschisis to 94%. The other report, from Goncalves and colleagues from Campinas, Brazil (page 35) is about an experimental study in rats. The authors were able to create gastroschisis artificially and this model allowed them to demonstrate the effectiveness of an artificial hydrogel polymer to protect the eviscerated bowel.

      Reproductive medicine and endocrinology

      Although success rates of assisted conception are steadily improving, perinatal outcome of IVF pregnancies remains worse than after spontaneous conceptions, with double the rates of perinatal mortality, preterm delivery and low birth weight. This may be due to the associated underlying infertility or to factors associated with the IVF treatment. On page 56 Pelinck and colleagues from The Netherlands compare the outcome of 106 pregnancies resulting from IVF treatment with ovarian stimulation and 84 pregnancies resulting from modified natural cycle IVF. All pregnancies were singletons, and all patients were treated in a single centre, so laboratory procedures did not differ between the two groups. The authors found that birth weights of the modified natural cycle singletons were higher than the standard IVF singletons, and were comparable to those born from natural conceptions. They conclude that ovarian stimulation may be a causative factor in the occurrence of low birth weight in standard IVF, and they remind us of the relationship between low birth weight and disease later in life. Already there is pressure on clinics to reduce the number of embryos reimplanted in individual women but these results go further, with evidence for choosing natural cycle IVF if this is an option.

      Gynaecology and gynaecological oncology

      Abnormal bleeding before the menopause is a difficult problem. Endometrial cancer mainly affects postmenopausal women but 20% of cases occur between 40 and 50 years of age and a few even earlier. Abnormal uterine bleeding (AUB) becomes commoner as the menopause approaches but there is no consensus as to the cut-off age for endometrial sampling to exclude endometrial hyperplasia or cancer. On page 86 Iram and colleagues from East Anglia, UK, report a retrospective review of histopathology reports of endometrial samples from 3006 women aged between 30 and 50 and presenting with AUB. The prevalence of atypical hyperplasia and carcinoma was significantly higher in women aged over 45 than in other age groups and in all but one of the women aged under 45 they presented with irregular rather than cyclical heavy bleeding. The authors conclude that age 45 should be the cut-off for sampling the endometrium in all cases of AUB but women with irregular bleeding should be investigated regardless of age. This is sound advice from the largest study in the literature.
      HPV vaccination is being introduced into the national immunization programmes of many European countries. Globally, however, 83% of cervical cancer cases occur in the developing world, where cervical screening is limited by lack of resources. Half of the world's deaths from cervical cancer are in the Asia-Pacific region, where the death rates are lower in the more-developed countries. If HPV vaccination is going to be effective in these countries, women – particularly younger women – need to understand about HPV infection. On page 90 Ping and Sam report face-to-face interviews with female university students in Kuala Lumpur, Malaysia. Of 1083 students approached, 650 agreed to be interviewed and the authors found that their knowledge of cervical cancer risk factors was remarkably poor, with only around 20% having heard of HPV. Only 10% had heard of the newly released HPV vaccine and of those, only 60% knew that it was to protect against cervical cancer. Stigma and embarrassment are barriers to vaccine uptake and the authors suggest that provision of information about HPV should emphasise high HPV infection rates, provide assurance on vaccine safety and efficacy, and aim at eliminating stigma.
      As Wolfgang Künzel would say: enjoy reading all the articles.