Editor's Highlights

Hydatidiform mole is a fascinating condition as well as a potentially lethal one. Geographical variations in incidence are well recognised, but it is less well known that women who have had a previous mole have an increased risk of recurrence, with estimates ranging from a fivefold to a fortyfold increase. If a woman has had two hydatidiform moles the subsequent risk is thought to be 1 in 6.5 pregnancies. These findings are summarised in our first review (page 3) by Williams and colleagues from Birmingham, UK, who discuss the rare condition of familial recurrent hydatidiform moles. Most moles contain only paternal chromosomes but an inherited predisposition in some women appears to underly the condition of familial biparental hydatidiform mole, which includes chromosomes from both parents. The authors suggest that the condition, originally described in consanguineous families, may be less rare than previously thought, and they advise that if a woman has a second molar pregnancy a careful family history should be taken. Cytogenetic investigation may then clarify whether she is at high risk. The authors have found that counselling couples with this condition has been met with disbelief and oocyte donation has been declined, and they point out that consideration of the families’ cultural and religious beliefs is critical.

Pelvic pain is a common symptom in women of reproductive age but only a small minority of cases are due to torsion of the adnexae. Its relative rarity is not the only reason that adnexal torsion is difficult to diagnose, as explained on page 8 by Huchon and colleagues from Paris. They discuss the range of diagnostic methods available, including Doppler, CAT scan and MRI, but conclude that a sure and certain diagnosis can be made only by laparoscopy. Diagnosis and treatment must be performed as an emergency in order to preserve the woman's fertility. The authors advise that conservative treatment is usually preferable even when the adnexa appear to be necrotic.

The long-term outcome after preterm birth is a concern to obstetricians and paediatricians but data on this subject are necessarily based on cohorts of babies born many years ago. As standards of neonatal care continue to improve in terms of survival rates, it is important to know if this improvement is reflected in better long-term outcome. On page 13 Brévaut-Malaty and colleagues from Marseille, France, report the longitudinal follow-up of a cohort of 350 singleton infants born at less than 32 weeks’ gestation between 1997 and 2001. The survival rate of the cohort was 80.8% and the authors were able to follow up 71.4% of the survivors. In 68%, no abnormalities were found. Risk factors for major or minor disorders at school age were gestational age < 28 weeks, chronic lung disease at birth and an abnormal electroencephalogram before discharge. Abnormal brain ultrasonography predicted major disorders. The authors conclude that improvements in perinatal care since 1997 have not improved long-term outcome.

Recurrent miscarriage is usually defined as three or more miscarriages but this definition is based on clinical empiricism. Because the incidence of clinically recognized spontaneous abortion is around 15%, a woman may easily have two miscarriages without there being any underlying cause. Patients are therefore advised that investigation is necessary only if a third pregnancy is lost, though a woman who has just had her second miscarriage may find this advice difficult to accept. On page 24 Bhattacharya and colleagues report an analysis of the impressive database in Aberdeen, UK, on 151,021 pregnancies between 1950 and 2000. After adjusting for the two other important risk factors, age and smoking, the authors found that after one miscarriage the chance of a second miscarriage doubled and that after two the odds ratio rose to 3.0. Three miscarriages, however, did not increase the risk any further. One miscarriage was followed by a slight increase in the risk of preterm delivery but two or three miscarriages did not increase the risk further. The authors recommend initiating investigation for recurrent miscarriage after two rather than three miscarriages.

Semen analysis still involves looking at spermatozoa down a microscope and is mainly concerned with their mobility. With intracytoplasmic sperm injection (ICSI), however, mobility is not important but there is a need to identify spermatozoa without DNA damage. Although this is difficult, high power microscopy (>6000×) can identify intranuclear vacuoles which may reflect a higher probability of molecular defects. On page 42 Mauri and colleagues from Sao Paolo, Brazil, report a study evaluating the effects of “intracytoplasmic morphologically selected sperm injection” (IMSI) by comparing it with ICSI. They studied 30 couples with a history of failed IVF/ICSI. A total of 331 oocytes were randomly assigned to IMSI (with sperm selection at 8400× magnification) or conventional ICSI (with sperm selection at 400× magnification). There were no differences in fertilisation rates or in embryo quality on day 2, and the results were not influenced by the presence or absence of male factor infertility.

Exercise, for many city dwellers, is a matter of going to the gym once or twice a week in the hope that this will counteract the effect of an otherwise sedentary lifestyle. The effects of formal exercise are well studied but less attention has been paid to habitual physical activity including household chores. On page 52 Lara and colleagues from Port Alegre, Brazil, report a study of the influence of habitual physical activity on body composition in 34 early postmenopausal women receiving hormone replacement therapy (HRT). They found a reduction in waist circumference (but not BMI) with HRT in both active and inactive women but body fat was reduced more in active patients. There is a simple, if unsurprising, message here for women taking HRT, and indeed for the rest of us.

Robotic surgery is a relatively recent innovation in gynaecology and other specialties. Like many new ideas in medicine it sounded at first like science fiction. The idea of being operated on by a robot is both frightening and attractive, as it seems to offer elimination of both human feelings and human error. In reality, of course, a surgical robot is simply a piece of complex and expensive equipment interposed between surgeon and patient, and in the words of Sarlos and colleagues from Aarau, Switzerland (page 92) “after the first excitement over the innovative and sophisticated technology has settled there also should be some consideration for a critical assessment of technique and costs.” The authors compare their first 40 consecutive total robotic hysterectomies with a matched series of conventional laparoscopic hysterectomies and provide a balanced view of their advantages and disadvantages. With robotic surgery operating time was slightly longer and postoperative stay was slightly shorter. For the surgeon, the ergonomics and range of motion of instruments were better with robotic surgery. Nevertheless the average cost was significantly higher, even without taking into account the considerable costs of purchasing and maintaining the robot. The authors point out that this is the first such matched case–control study relating to hysterectomy and they conclude that randomized controlled trials are imperative to evaluate the cost-effectiveness of robotic surgery.

Breast screening is a routine part of health care and may involve mammography and ultrasound examination. In a small minority of patients the breasts appear normal but the axillary lymph nodes are suspicious, either on palpation or on ultrasound examination. Schwab and colleagues, also from Switzerland, identified 51 such patients among approximately 7500 women undergoing opportunistic breast screening. Investigation of the lymph nodes, by either needle or open biopsy, showed 33 benign and 18 malignant results, only one of which was breast cancer. Among the benign results were four cases of tuberculosis. The authors recommend that in most cases fine needle aspiration and/or core needle biopsy will clarify the diagnosis.

With the wide range of surgical procedures now available for the treatment of prolapse and incontinence, comparative studies are highly desirable to help surgeon and patient choose the most appropriate operation. Such comparisons are not straightforward, however, as the effects of the procedure may depend on the outcome chosen (prolapse, incontinence, or sexual function) and, as ever, benefits have to be balanced against risks. On page 97 Ignjatovic and colleagues from Nis, Serbia, report a series of 76 patients who presented with both pelvic organ prolapse and stress urinary incontinence. Of these, 39 were treated with either transobturator or tension-free vaginal tape along with colporrhaphy, and 37 were treated with Prolift and midurethral sling. Improvement of continence was similar in both groups, and there was no improvement in sexual life in either group. Prolift produced a better correction of prolapse but had a higher rate of additional procedures, and the authors recommend that it should be reserved for women with more severe prolapse of grade III–IV.

Herbal products receive little attention from medical science because their benefits are assumed to be due to a placebo effect, but nevertheless they are widely used. Information on their use in pregnancy is provided by two letters in this issue. On page 102 Cuzzolin and colleagues from Verona, Italy, report that 46.7% of a sample of 199 women had taken one or more herbal products during pregnancy, and more than half of these women were regular (i.e. daily) users. Users were more likely to be well-educated than non-users, and believed that these natural substances are safer than drugs. This belief (based not on evidence but on lack of evidence) is called into question on page 107 by Moussally and Berard of Montreal, Canada. Investigating possible links between various herbal products and the risk of prematurity, they analysed 3191 responses to a questionnaire mailed to women on the Quebec Pregnancy Registry. After adjusting for possible confounders they concluded that exposure to flax during the last two trimesters of pregnancy increased the risk of preterm birth almost fourfold. Flax contains phytoestrogens but this result raises more questions than answers. The authors point out that they have no information on dosage or frequency of use and that recall bias cannot be excluded, and they call for more studies to confirm this association.