Editor's highlights

This month we have two contrasting reviews. One addresses the commonest malignant disease among women and the other is about a condition so rare that until now only eight cases occurring in pregnancy have been described in the English-language literature.

Breast cancer is common and, as we mentioned last month, is the responsibility of the gynaecologist in some countries. Survival rates have steadily improved with better screening and treatment but when surgery involves axillary dissection it is followed in about 26% of cases by lymphoedema of the arm. This distressing side-effect is treated by physiotherapy and on page 3 Devoogdt and colleagues from Belgium review the effectiveness of Combined Physical Therapy. This treatment has an intensive phase and a maintenance phase, each of which has several components including skin care, compression and Manual Lymphatic Drainage. The authors analysed ten randomized controlled trials, one pseudo-randomised and four non-randomised trials. They conclude that Combined Physical Therapy is effective for lymphoedema but the effectiveness of its different components remains uncertain. Doctors are often vague about the methods and effectiveness of physiotherapy and we are pleased to present this review of the science behind this discipline, which is so important to many patients’ quality of life.

Evans syndrome, a combination of immune thrombocytopenia (ITP) and autoimmune haemolytic anaemia, is a rare condition, estimated to affect between 1.8% and 10% of patients with ITP. It can occur alone or in the presence of another autoimmune disease and its treatment may involve teratogenic drugs. The options for treatment in pregnancy are therefore limited. On page 10 Lefkou and colleagues from London report two cases of Evans syndrome in pregnancy, and they present a systematic review of all ten such cases so far reported. They conclude that the disease runs a more benign course in pregnancy than in the non-pregnant state but a minority of fetuses are affected by transplacental passage of antibody, with resultant morbidity and mortality. Nevertheless, with appropriate treatment women with Evans syndrome can have successful pregnancies.

National guidelines have become an important part of clinical practice in many countries but they are rarely shared internationally. One reason is that circumstances vary from country to country, and another is that a national sense of ownership is necessary if a guideline is going to be used in everyday practice to help patient care. We suspect, however, that a third reason is simply the difficulty that we all have in understanding a guideline written in a foreign language. This is where a journal like the EJOGRB can play a part. We are delighted that Henri Marret, one of our Specialty Editors for Gynecology, has facilitated the translation of the French guidelines on the management of ovarian cancer in pregnancy (page 18). These guidelines were written by Professor Marret and his colleagues on behalf of the French Working Group on Gynecological Cancers in Pregnancy and have been rigorously reviewed by the relevant specialist societies and the national college in France. We are not aware of any other guidelines on the management of ovarian cancer in pregnancy, and we hope that this publication will assist clinicians facing the problem of striking a balance between what is best for the fetus and what is best for the mother in this difficult situation. We hope also that these will not be the last national guidelines to be shared with other countries in the pages of the Journal.

Migration into Europe, and indeed within Europe, is well known to be associated with health disparities between migrants and the indigenous population. Three papers in this month's issue address this issue with regard to perinatal care. On page 37 Gagnon and colleagues from Canada and France address the question of how best to monitor the effects of migration on perinatal health. There is currently no consensus on which indicators to use. An expert panel was therefore convened by the Reproductive Outcomes and Migration international research collaboration and the EURO-PERISTAT project, and a Delphi consensus process was undertaken involving 38 experts from 22 countries. There was a strong consensus for including country of birth in core perinatal health indicator sets, and length of time in the country was also recommended. The group would like to see special studies on immigration status, language fluency and ethnicity.

Information on country of birth is available in Spain, and on page 52 Fernandez and colleagues report a study using data from the National Statistics Institute and the Movement of Natural Persons and death statistics. Maternal mortality was highest among sub-Saharan nationalities, as it is in most if not all countries which have investigated this problem. The study also revealed differences between provinces within Spain. In our Correspondence section D’Antona and colleagues from Padua, Italy, report a study in the Veneto region, which has the second highest immigrant population in the country. The authors ask the question “Are we doing the best we can?” and they conclude that although there are differences in the health care provided to native and immigrant women, the Italian Health System manages to provide adequate care to all, irrespective of ethnicity and social status.

Polycystic ovarian disease is also the subject of three papers in this issue, one of which is in the “Obstetrics and maternal-fetal medicine” section as it deals with the outcome of pregnancy in women with this condition. Altieri and colleagues from Bologna, Italy (page 31) conducted a study of 229 women from a consecutive series of 516 women delivering in their academic hospital. Fifteen were diagnosed with pre-pregnancy polycystic ovary syndrome and this subgroup had significantly higher risks of gestational diabetes and preterm birth. On page 68 Swanton and colleagues from Reading and Oxford, UK, report on the outcome of IVF in a cohort of 290 women including 111 with normal ovaries, 101 with polycystic ovaries (PCO) and 78 with polycystic ovarian syndrome (PCOS). Women with PCO and PCOS had higher rates of severe ovarian hyperstimulation syndrome and of requiring avoidance techniques such as coasting, but live birth rates per cycle were similar in the three groups. On page 72 Chen and colleagues from Guangzhou, China, report a study of 19 adolescent women with PCOS, 23 adult women with PCOS and 20 adolescent controls. A range of plasma hormone levels, including metastatin, were measured at the beginning of each cycle or bleeding episode. In the adolescents with PCOS, metastatin levels were raised and were correlated with LH and testosterone levels. Metastatin is a ligand of GPR54, a receptor which may be the gatekeeper of the reproductive cascade, and the authors suggest that it may affect the development of PCOS in adolescents.

Cancer of the vulva, which accounts for 5% of malignancies of the female genital tract, mainly affects elderly women but the mean age at diagnosis is steadily decreasing. As with any malignant disease, prognosis is important. This is normally determined by tumour stage and lymph node status but attempts have been made to use additional prognostic parameters. Serum levels of C-reactive protein (CRP) have been evaluated in other gynaecological malignancies but are not helpful in vulval cancer. The modified Glasgow Prognostic Score (mGPS), however, uses a combination of elevated CRP and hypoalbuminaemia and has been associated with poor prognosis in other cancers including advanced breast and ovarian cancer. On page 102 Hefler-Frischmuth and colleagues from Vienna evaluate its potential in vulval cancer. They undertook a retrospective study of 93 consecutive patients and found that although mGPS is associated with survival in univariate analysis, it does not provide independent prognostic information in vulval cancer.

Paget disease of the vulva is rare, accounting for 1% of vulval neoplasms, and many aspects of this condition are controversial. On page 86 Shaco-Levy and colleagues from the USA and Israel attempt to resolve some of these controversies by presenting one of the largest series ever reported. They reviewed the medical records and pathology slides of 56 patients treated for true Paget disease at Duke University, North Carolina, between 1980 and 2008. Substantial delay in diagnosis was common, and recurrence after surgery occurred in 32% of patients. Only one patient died of the disease, but the authors recommend long-term follow up as disease may recur many years after initial treatment.

The number of women requiring surgery for prolapse is expected to rise sharply in western countries in the coming years as their populations include more and more people over 65. Implants are increasing being used as part of the surgical treatment, and biological meshes have a lower risk of graft erosion than synthetic meshes. Porcine dermal collagen implant has been reported to have varying success rates, and on page 112 de Boer and colleagues from The Netherlands report on 78 patients with stage 3 prolapse treated by porcine implant. The patients were followed up for one year. The overall cure rate was 75% and the success rate was higher in younger women. The authors comment that only a randomized controlled trial can determine whether or not these results are better than conventional surgery or non-resorbable mesh.

We recently mentioned that our correspondence section sometimes includes brief descriptions of large studies and this month (page 120) Nasiell and Lindqvist from Stockholm report a study which includes more than 32 million controls from the Swedish National Birth Registry and National Patient Registry. They found 29 cases of aortic dissection among the pregnant population and 18 in the non-pregnant population, and conclude that pregnancy involves a 25-fold increased risk of the condition. Nonetheless, it is still rare in pregnancy and the diagnosis may be difficult. The authors explain which patients are at increased risk and they recommend that these patients should have close surveillance of the large vessels by ultrasound.

On page 121 Marrs and colleagues from Las Vegas, USA, report a one-year study of postpartum hormone levels and mood changes. Nine women were followed up for a year after delivery and DHEAS levels were higher than expected in four women who experienced psychiatric distress. The authors suggest investigating this hormone when postpartum psychiatric symptoms are refractory to treatment.