Editorial| Volume 151, ISSUE 1, P1-2, July 2010

Editor's highlights

      In these pages we often comment on global issues of women's health and we have drawn attention to the apparent lack of progress towards Millennium Development Goal 5 – a 75% reduction in maternal mortality rates (MMR) by year 2015. Recently new estimates were publicised suggesting that progress is better than expected, but rather than causing widespread pleasure they were criticised for being over-optimistic. A damaging row over figures was avoided, but only just. Although numerical targets are useful for focussing attention it is important to remember that the countries with the greatest problems are those in which the data are least reliable. Women's lives are saved by local action, not national number-crunching.
      One local initiative, in Northern Nigeria, has previously been mentioned in this column (October 2008 and April 2009). Ten hospitals in Kaduna and Kano are closely monitoring their indicators of maternal health, including MMR and fetal mortality rates (FMR). These indicators, anonymised, are regularly discussed by representatives of the participating hospitals as part of an audit process designed to create, monitor and improve standards. The 2009 report of the Institute of Quality Assurance in Obstetrics for Kano State and Kaduna State is now available and shows that overall the MMR has been almost halved, falling from 1.79% in early 2008 to 0.94% in late 2009. Interestingly, the caesarean section rate has also fallen. These results are encouraging, although the FMR remains virtually unchanged at over 8%. Our Editor Emeritus, Wolfgang Kunzel, is a consultant to this project and we are grateful to him for sharing this good news with us. We congratulate Dr Hadiza Galadanci, consultant at Aminu Kano Teaching Hospital, who is responsible for the collection and evaluation of data and for the regular review meetings, and we hope her example will be followed by others.

      What's new?

      Protein messengers are the subject of much research which, at least in its early stages, is unseen by clinicians. The discovery of a new protein involves slowly clarifying its functions and at some point, naming it. Different groups may propose different names and the one that is agreed may not reflect what turns out to be the protein's major function. The dimeric protein “calprotectin” was named in 1990 because it is a calcium-binding molecule but even then it was known to be produced by leukocytes and to have antimicrobial actions. Its levels in extracellular fluid increase in inflammation, and faecal calprotectin is now used to detect inflammatory bowel disease. Calprotectin's importance in obstetrics and gynaecology is becoming apparent and on page 3 Kostakis and colleagues from Athens publish the first comprehensive review of its many roles in our specialty. Their review ranges from breast and ovarian cancer to pre-eclampsia and HELLP syndrome, and the authors suggest possible clinical roles as a diagnostic marker or pharmaceutical target. We were interested to see that one constituent of the protein is secreted by trophoblast in early pregnancy and probably protects the fetus from attack by macrophages.
      Tension-free vaginal tape (TVT) is sometimes used to treat women of reproductive age and we suspect that if the woman subsequently becomes pregnant most colleagues would recommend a caesarean section. In our second review (page 10), Kohorst and colleagues from Ulm and Memmingen, Germany, report a young woman previously treated with a TVT who did indeed have an elective caesarean section at 39 weeks’ gestation. After delivery her stress incontinence recurred but was successfully controlled with pelvic floor exercises and she has remained well. Although their patient underwent operative delivery the authors have reviewed the literature and advise that vaginal delivery after TVT is not contraindicated: the mode of delivery should be discussed and agreed individually.

      European view

      Last month we mentioned that we would publish another guideline from the French College of Obstetricians and Gynaecologists, and it appears on page 14. This authoritative summary of current best practice in the diagnosis and management of adult female stress incontinence will reassure many readers about their practice. It recommends, for example, urodynamic investigation before surgery except in cases of pure stress incontinence, when clinical assessment is sufficient – but only if that assessment is fully comprehensive, as specified in the guideline. Elective caesarean section and systematic episiotomy are not recommended for prevention of urinary incontinence. Reading this guideline will remind senior practitioners how practice has changed and how this subspecialty has developed in a relatively short time. The pace of progress is underlined on page 101 by a report from France on >5-year follow-up after transvaginal cystocele repair with polypropylene mesh: the rate of repeat surgery was low.

      Obstetrics and maternal–fetal medicine

      In a maternity service which is free at the point of use, patterns of care are decided by the Ministry of Health, perhaps advised by researchers who claim to know what women want. Clinicians sometimes suspect that this advice is influenced by financial considerations and tailored to what the ministry wants to hear. A study of English women's views on antenatal care is reported on page 33 by Deverill and colleagues from Newcastle-upon-Tyne, UK. One hundred women, pregnant for the first time and attending for their 20-week ultrasound scan, were asked about their preferences for care in the rest of the pregnancy. The study took the form of a “discrete choice experiment”, which gives women a choice between different packages of care. Each woman was presented with 16 choice sets of two varying care packages, and the researchers analysed all the choices to find the ideal package. They conclude that the women preferred local care and preferred 10 clinic visits to seven, though they would accept certain trade-offs to reduce the number of visits. These results show how much pregnant women value the reassurance provided by regular contact with professionals.
      Variations in obstetric practice between neighbouring countries are a source of fascination to us. Spatula-assisted delivery is virtually unknown in the UK but, as reported by Boucoiran and colleagues from Nice, France, spatulas have become the preferred instrument in several institutions in France and elsewhere (page 46). The authors report a series of 1065 consecutive spatula-assisted deliveries at Nice University Hospital over a four-year period. The success rate (98.2%) and the rate of third- and fourth-degree perineal injuries (6.2%) were similar to those reported in the literature with other instruments. The use of non-articulated instruments sounds attractive but when undertaking operative delivery we all prefer instruments with which we are familiar and comfortable.

      Reproductive medicine and endocrinology

      Contraceptives, as their name suggests, are generally thought of as preventing conception but there can be uncertainty as to their exact mode of action. For some people, there is a moral difference between preventing contact between sperm and egg, and preventing the implantation of a fertilised oocyte. On page 56 Lopez-del Burgo and colleagues from Pamplona, Spain, report a study of 848 women aged 18–49, most of whom were married and had at least one child. Forty-five percent stated that they would not consider using a method that may work after fertilisation and 57% would not consider one that may work after implantation. The authors conclude that information about mechanisms of action of birth control methods should be disclosed to women so that they can make informed choices. It is, however, difficult to know whether “may work” ever becomes “does work”. Evidence of a post-fertilisation mode of action is hard to obtain and it would be unfortunate if a woman were deprived of a contraceptive option because of a theoretical possibility that never happens in reality.
      Hepatitis C is a chronic condition affecting about 200 million people worldwide. It is transmitted by infected blood and the prevalence varies from 1% in Northern Europe to over 10% in Egypt. The hepatitis C virus (HCV) was identified in 1989 and sexual transmission is thought to be infrequent. On page 52 Savasi and colleagues from Milan, Italy, report a study of 16 men co-infected with HCV and HIV-1. Thirteen blood plasma samples were positive for HCV-RNA and using nested PCR the investigators found HCV-RNA in five semen samples. The viral RNA was present in seminal plasma or non-sperm cells but not in spermatozoa before or after swim-up. The authors conclude that sperm washing should be performed before assisted reproductive techniques in HCV patients.

      Gynaecology and gynaecological oncology

      Hysterectomy is still a commonly performed operation, though rates are falling in some countries. A decision that needs to be discussed with the woman beforehand is whether or not to preserve the ovaries, but there has been controversy over the effect of hysterectomy on ovarian function, with the suggestion that it may alter ovarian blood flow and lead to premature ovarian failure. On page 82 Lee and colleagues from Seoul report on ovarian arterial blood flow as assessed by Doppler ultrasonography in 32 premenopausal women during the 3 months after hysterectomy for benign disease. Six underwent total abdominal hysterectomy (TAH) and the other 26 laparoscopically assisted vaginal hysterectomy (LAVH). The authors also measured serum anti-Mullerian hormone levels, and all results were compared with 21 age-matched controls. There were no differences between patients and controls, or before and after surgery, or between the TAH and LAVH groups. This is reassuring information to be used during pre-operative counseling.
      Cervical cancer remains the second most common cancer in women worldwide. The standard treatment of early cervical cancer is radical surgery and radiotherapy, with inevitable loss of fertility, but there is now increasing interest in ways of curing the disease while preserving fertility for young women with this condition. Yao and colleagues from Guangzhou, China (page 77) report on 10 patients aged 28–30 with FIGO stage 1A2 or 1B1 cancer and tumours less than 2 cm in diameter. They were treated with abdominal radical trachelectomy (ART) with preservation of the uterine artery, a stent to avoid intrauterine adhesions and mesh to prevent cervical incompetence and uterine prolapse. Follow-up ranged from 4 to 68 months and no recurrence was detected. Two patients became pregnant (one through IVF) and both had successful deliveries by caesarean section, at 38+ and 34+ weeks, respectively. The authors comment that traditionally ART involves division of the uterine arteries, leaving the uterus reliant on the ovarian arteries only. While acknowledging that their patient numbers are still small, they conclude that their technique of functional reconstruction in ART is a promising fertility-sparing option.

      Gynaecological urology

      Vaginal prolapse has adverse effects on sexual functioning but these have not been well studied, perhaps because sexual problems are not perceived as a priority in the age-group affected by prolapse. Sexual wellbeing, however, is an important part of general health in older as well as younger women, and on page 106. Caruso and colleagues from Catania, Italy, report a study of sexual function in 23 women, mean age 60.6, suffering from third- and fourth-degree cystocoele. The women were studied by questionnaires and by Doppler ultrasonography of the clitoral arteries, before and 12 months after surgical treatment of their cystocoele. The surgical procedure was a double transobturator tension-free approach to mesh insertion. The questionnaires showed a considerable improvement in physical, social and emotional functioning after operation, and an improvement in the partner-related factor score. The Doppler studies showed no significant decrease in clitoral blood flow. The authors call for more research on the effects of mesh insertion on sexuality but these initial results provide reassurance and indeed encouragement for patients considering this procedure.