Editorial| Volume 148, ISSUE 2, P103-104, February 2010

Editor's highlights

Published:December 18, 2009DOI:
      Next month, International Women's Day on 8th March will be an opportunity to raise awareness of women's health issues around the world. The continuing high rate of maternal mortality is one of most pressing of these and it is encouraging to see an international coalition, the White Ribbon Alliance (WRA), working hard to draw attention to this preventable cause of death. WRA, launched in 1999 and supported by influential women including Sarah Brown, wife of the UK Prime Minister, has members in 143 countries and national alliances in 15, including Burkina Faso, Nepal and Yemen. Political action is vital but critically ill pregnant women need the skills of obstetricians and we hope there will be increasing co-operation between the WRA and our specialty. Raising awareness is essential but it is only the first step in the journey towards low maternal mortality. The complexity of the problem is illustrated by recent figures from the USA, where the WRA is based, and where the maternal mortality rate per 100,000 live births is 36.5 among black women compared with 11.1 among white women.

      What's new?

      Assisted reproduction has caused a dramatic increase in the incidence of multiple pregnancy in many countries. Naturally conceived twin pregnancies are at higher risk than singletons and the possibility that the risk is further increased among twin pregnancies conceived by IVF has been investigated by McDonald and colleagues from Canada and China (page 105). In an update of their previous systematic review they compared a total of 4385 IVF twins and 11,793 spontaneously conceived twins. They found that IVF twins had small but significantly increased risks of preterm birth, low birth weight and lower mean birth weight compared to spontaneously conceived twins after controlling for at least maternal age. These results are in line with a study of IVF pregnancies in last month's issue of EJOGRB, which suggested that ovarian stimulation may be the causative factor linking IVF with low birth weight.
      The recent history of abdominal surgery has been a story of an increasing range of procedures undertaken through small abdominal incisions, due in large part to the pioneering work of Kurt Semm of Kiel, Germany. The future of abdominal surgery is reviewed on page 114 by Stark and colleagues from Germany and Italy. Many believe this will involve more robotics, which will inevitably mean much more expense. Stark and colleagues, however, suggest that the future will involve “Natural Orifice Surgery” (NOS). General surgeons have begun entering the abdominal cavity via the wall of the stomach and another possible route is the pouch of Douglas. The “transdouglas” approach, say the authors, may be used not only by gynaecologists and urologists but also by general surgeons to access the upper abdomen, and a New European Surgical Academy has been founded to develop NOS. So far, the transdouglas approach has been combined with the abdominal approach but a single-portal transdouglas approach is envisaged in the future. One of its advantages is that entry is under direct vision. Direct optical access also finds favour in the comparative study of abdominal access by Tinelli and colleagues on page 191.

      Obstetrics and maternal–fetal medicine

      Guidelines have become the basis of labour ward practice in many countries. They are an improvement on the old days when each obstetrician had his or her own rules, causing confusion among trainees and midwives. Nevertheless, guidelines may vary from country to country and indeed from hospital to hospital. On page 121 Sheehan and colleagues describe a postal questionnaire survey of the five countries of Great Britain and Ireland with regard to their use of oxytocin at the time of caesarean section. The authors found wide variations in the doses of oxytocin and the use of routine oxytocin infusion with, in one instance, only a minority of clinicians following the national guideline. One reason is that the evidence base for some guidelines is insecure, and the authors recommend more research to remedy this. Guidelines which are not based on robust evidence are likely to be ignored, and with good reason.
      Massive obstetric haemorrhage, however, is an example of a condition in which robust evidence is difficult to obtain but guidelines are nonetheless very helpful. Two papers in this issue deal with different aspects of haemorrhage. On page 125 Elsasser and colleagues from the USA report results from the New Jersey-Placental Abruption Study, a multicentre case–control study originally designed to compare thrombophilic markers in cases of abruption and controls. The authors examined histologic lesions associated with placental abruption and report poor concordance between clinical and histological criteria for this diagnosis. They recommend that the diagnosis of abruption should depend on clinical criteria (possibly including ultrasound) and they make the important observation that the vast majority of cases appear to have a long-standing chronic aetiology. Turning to postpartum haemorrhage, Penninx and colleagues from The Netherlands (page 131) report a retrospective series of 15 patients with blood loss of more than five litres treated by balloon occlusion of the internal iliac arteries. All the patients survived and only four required hysterectomy. Unlike uterine artery embolisation, which has to be done by an interventional radiologist in the radiology department, balloon occlusion of the internal iliac arteries can be performed by a less specialised radiologist in the operating room or even the intensive care unit. The authors say it is particularly appropriate for haemodynamically unstable patients and is now their preferred treatment for massive postpartum haemorrhage.

      Reproductive medicine and endocrinology

      Assisted reproduction technology has brought not only huge benefits for couples but also new ethical dilemmas. Issues which the media have labelled “designer babies” cause much debate among both professional and lay people and require doctors to be well informed about scientific progress. On page 158 Caldas and colleagues from Brazil describe a study carried out on 723 professionals attending a congress of obstetrics and gynaecology in Rio de Janeiro in November 2005. The aim was to assess technical knowledge of pre-implantation genetic diagnosis (PGD) and views on PGD and sex selection. Regarding sex selection, 36% thought it should be the couple's choice and 17% thought it should not, with 43% believing it should be an option only in specific situations. Regarding PGD, only 63% had heard something about it but nevertheless 72% approved of the practice and only 10% disapproved, with the remainder being doubtful. The authors comment on the importance of specialists keeping up to date, not only to counsel individual patients but also to mediate societal opinions.

      Gynaecology and gynaecological oncology

      Recurrent vulvovaginal candidiasis (RVVC) is a difficult clinical problem. Many approaches have been used to try to deal with reservoirs of candida or sources of reinfection but it is becoming apparent that the problem may lie in the relationship between the organism and the immune system. One component of the immune system, mannan-binding lectin (MBL), binds to candida cells and among its biological activities is activation of the complement system. MBL gene polymorphism may explain why some women are more affected than others by RVVC. Henic and colleagues from Sweden and Denmark report (page 163) a comparison of 29 women with RVVC and 30 controls. Serum levels of MBL were higher in cases than controls and higher in culture-positive than in culture-negative women. Levels were also higher in hormonal contraceptive users than in those using barrier or no contraception, though studies have apparently shown that modern oral contraceptives do not increase the incidence of candidal infection.
      Breast disease falls within the remit of gynaecologists in some countries and this month we have two papers on this subject. Breast cancer will affect about 1 in 10 women in Western countries and although it always causes psychological distress some women will have major problems with depression and panic attacks. On page 166 Siedentopf and colleagues from Germany report the use of a questionnaire to identify predictors of somatic and psychological problems. They studied 333 consecutive patients with breast cancer and found that 23% needed professional psychosocial support. Breast reconstruction after mastectomy is psychologically beneficial and the aesthetic result is better if the nipple–areola complex (NAC) can be preserved. There is a risk, however, that occult cancer cells in the NAC may cause recurrence. Pirozzi and colleagues from Brazil point out on page 177 that previous studies have produced conflicting results regarding the correlation between tumour characteristics and nipple-involvement status. The authors studied mastectomy specimens from 50 women and found NAC involvement in 12. The risk was higher in women aged <50 and when the tumour was <3 cm from the NAC. It was also higher with ductal carcinoma in situ with micropapillary pattern or extensive in situ component – histopathological factors which may not be known at the time of surgery.
      In last month's issue we commented on a study of students in Malaysia which concluded that more education about HPV is needed there. This month, Mehu-Parant and colleagues report a study of 606 first-year college students in France, whose mean age was 19 and 8.3% of whom had already been vaccinated against HPV. Two-thirds were sexually experienced but knowledge of HPV infections and their prevention was limited. Forty-three percent were eligible for catch-up vaccination according to French recommendations. The authors conclude that the first year at college is an opportunity for vaccination and that, as in the Malaysian study, improved education about HPV-related diseases and their prevention is needed.

      Gynaecological urology

      The pace of progress in the treatment of stress urinary incontinence continues to increase, no doubt as a consequence of the fact that gynaecological urology is now firmly established as a subspecialty. Following the introduction of tension-free vaginal tape by Ulf Ulmsten in the early 1990s, it was suggested that it might be safer to pass the tape through the obturator foramen instead of behind the pubic bone. The outside-in approach was described by Delorme in 2001 and the inside-out approach by Delaval in 2003. There have been a number of comparative studies but what matters are the long-term results. On page 199 Lipias and colleagues from Athens describe four-year follow-up of a series of 115 patients treated by the inside-out approach combined in 41 of the patients with anterior colporrhaphy. Objective cure rates for both the TVTO alone and the combined procedure were over 80% and complication rates were very low. The authors comment that these results are promising but even longer-term results are required.

      Letters to the Editor – Brief Communications

      There is a pleasing trend for this section of EJOGRB to include the results of studies condensed into “Brief Communications”. On page 202, for example, Watson and Owen from Glasgow, UK, report a retrospective study of 326 women undergoing operative vaginal delivery, 13% of whom had no episiotomy. The “no episiotomy” group had no increase in the incidence of obstetric anal sphincter injury, suggesting that a selective approach to episiotomy may be justified. And on page 207 Gupta and colleagues from UK report a series of three cases of stratified mucin-producing intra-epithelial lesion (SMILE) of the cervix, a rare variant of endocervical columnar cell neoplasia which causes clinical uncertainty because management guidelines are lacking. We like authors to be as concise as possible and our reviewers sometimes recommend that a full-length paper would be more effectively reported as a Brief Communication. Readers are encouraged to look out for clinically important studies, as well as interesting case reports, in the pages at the back of the Journal.