Editorial| Volume 151, ISSUE 2, P115-116, August 2010

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Editor's highlights

      August is holiday time in most of Europe, so except for colleagues who take their laptops with them, most readers will be a little late in catching up with this issue of the Journal. Gynaecological urologists may be even later, as the Joint Annual Meeting of the International Continence Society and the International Urogynaecological Association is being held in Toronto on 23–27 August. These two societies hold a joint meeting every five or six years. In 2011 each comes to Europe (one to Glasgow and the other to Lisbon) and in 2012 their venues will be Beijing and Brisbane. Although Canada is a long way from Europe, we imagine that this year many specialists will be attracted by the efficiency of a single meeting.
      After the successful European Congress of Obstetrics and Gynaecology in Antwerp in May, the President's Newsletter appeared with impressive promptness at, summarising the EBCOG Council's spring meeting. The Newsletter provides interesting updates on, for example, the hospital visiting system and the new office-bearers of ENTOG, which now represents some 6500 trainees across Europe. Like the President, we send our good wishes to Professor Bill Dunlop, who has just reached the end of his term of office as President of the Section of O&G of the European Union of Medical Specialties (UEMS). We are pleased to hear that in future both presidencies (of EBCOG and of the UEMS Section) will be held by the same individual. The more we all speak with a single voice, the better.

      What's new?

      The reported incidence of endometrial polyps in subfertile women varies widely, from 1.4% to 41%. The polyps are usually removed, on the basis that it does no harm and may help. On page 117, however, Afifi and colleagues from the UK review the published studies comparing polypectomy and conservative management and conclude that the evidence on pregnancy outcome is inconclusive. One randomized controlled trial reported higher pregnancy rates after polypectomy in women undergoing intrauterine insemination, while two retrospective studies suggested no benefit in women undergoing assisted conception. The authors advise removal of polyps diagnosed before the commencement of controlled ovarian hyperstimulation (COH) for IVF. For those diagnosed during COH, however, the options are to proceed with fresh embryo transfer or to freeze all the embryos, remove the polyp and proceed with transfer later. The choice, say the authors, should depend on the number of embryos, the patient's history and the success rate of the clinic's frozen embryo programme.
      A screening test to predict pre-eclampsia would allow close monitoring of at-risk women and help the investigation of possible prophylactic therapy. Several promising biomarkers have been described, and on page 122. Lapaire and colleagues from Switzerland, UK and Germany discuss the challenges of bringing these into clinical practice. Biomarkers for angiogenesis are at the most advanced stage of development, and the authors focus on two, soluble fms-like tyrosine kinase (sFlt-1) and placental growth factor (PlGF), which can now be analysed using a widely-available automated system. There is good evidence that increased sFlt-1 and decreased PlGF precede clinical symptoms by 5–10 weeks or more, and that measuring them can improve the management of pregnancy. The authors suggest that combination with other biomarkers or uterine artery Doppler may further enhance their predictive accuracy.
      “Colombo and the clitoris” is the eye-catching title of a historical review by Stringer and Becker of Dunedin, New Zealand (page 130). Fifty years after Christopher Columbus first sailed to America, the anatomist Realdo Colombo claimed to have discovered the clitoris. In fact, it had been known to Greek, Persian and Arabic writers although there were misconceptions about its function. Colombo's teacher was Vesalius and his successor was Gabrielle Fallopio, and professional rivalry among these Renaissance men makes the historical facts difficult to establish. The authors also point out that controversy over the function of the clitoris persisted long after the Renaissance.

      Obstetrics and maternal–fetal medicine

      The Internet has transformed the search for knowledge not only for doctors but also for patients. As De Santis and colleagues from Rome point out on page 154, it is now used by more than 40% of the population, both in Italy and in several northern European countries. The authors work for Teratology Information Services (TIS), which is part of the European Network of Teratology Information Services (ENTIS) and which receives approximately 8600 telephone calls a year from women worried about possible teratogenic exposure, and from their healthcare providers. Often the caller has already consulted other sources, including websites. The authors administered a questionnaire to 203 pregnant women who called the TIS between October 2008 and June 2009, and found that 57% had used the Internet to find medical information about their exposure. Of these, 59.5% received evidence-based answers, 18.1% were wrongly told that their exposure was dangerous, 4.3% were wrongly reassured and the rest were unable to interpret the data or could not find relevant information. The authors conclude that information published on websites is no substitute for informed medical advice.
      Socio-economic conditions often have an influence on pregnancy outcome and it is concerning that in many countries ethnic differences have measurable effects on such important indicators as mortality rates. Ethnic minorities have increased in many Western European countries in recent years, and on page 158 Fransen and colleagues from Rotterdam comment that about 20% of the population of The Netherlands now consists of individuals of non-Dutch ethnic origin. Studies in some countries have shown that women from ethnic minorities and from lower socio-economic backgrounds participate less often in screening programmes for Down syndrome. The authors wanted to know if this is the case in The Netherlands. Using the database of the Department of Clinical Genetics which covers all prenatal invasive tests in the south-west of the country, they studied 12,340 women aged 36 years or over who gave birth in 2000–2004. The overall uptake of testing was 28.5%, and women of Turkish or Caribbean origin participated equally or more often than Dutch women. The authors comment that the low uptake may be related to the Dutch pregnancy culture. Even so, they found that uptake was lower still among women of North-African origin and women from a low socio-economic background, and they suggest that this may be due to barriers in access.

      Reproductive medicine and endocrinology

      Women who are obese receive many warnings about the risks that they and their babies run in pregnancy. Some studies have suggested that these include an increased risk of early miscarriage, whether or not the pregnancy has followed infertility treatment. On page 168 Turner and colleagues from Dublin report a study in which they enrolled 1200 women after a first-trimester ultrasound scan had confirmed a singleton pregnancy with a fetal heartbeat present. The mother's height and weight were measured digitally and her body composition was measured by advanced bioelectrical impedance analysis. The mean gestation at enrolment was 9.9 weeks. The overall miscarriage rate of 2.8% was unaffected by the woman's BMI or fat mass parameters. This result will bring some reassurance to obese women once an early scan has shown an ongoing pregnancy.
      Fallopian tube function is the subject of two papers in this issue. Tubal damage due to pelvic inflammatory disease (PID) may result in ectopic pregnancy (EP). The incidence of EP rose during the 1970s and 1980s and thereafter remained stable, but there are now concerns that chlamydia may cause another increase. On page 163 Mol and colleagues from Amsterdam report a study of hospital admissions for PID and EP in Dutch Medical Registries from 1980 to 2005. They found a peak incidence in PID admissions in 1983 followed by a peak incidence of EP in 1988, after which the EP rate declined. Currently, however, younger women again have a high risk of EP. This was not preceded by a peak in PID admissions but may be related to a recent increase in positive tests for chlamydia.
      Chronic PID may cause hydrosalpinx, which is associated with reduced implantation and pregnancy rates during IVF treatment. The mechanism underlying this association is unclear. Li and colleagues from Shanghai, China (page 171) performed mid-luteal endometrial biopsies in 20 women with hydrosalpinx and 21 without hydrosalpinx. They examined pinopodes (small bubble-like structures appearing on the surface of the endometrium during the implantation window) which are a marker of endometrial receptivity. The presence of hydrosalpinx did not affect the density of pinopodes but among these women there was a reduction in immunohistochemical staining for associated molecular markers including LIF. The authors suggest that expression of these cytokines may be sensitive to the effects of hydrosalpinx fluid.

      Gynaecology and gynaecological oncology

      Sexual assault is, sadly, common in all countries. It has been estimated that in the United States one woman in six has been a victim at least once in her lifetime. Both in the US and in Europe, only a minority of rapes or sexual assaults are reported to the police, but when a rape complainant attends hospital it is important that she receives proper medical management. In Belgium, the clinical examination procedure in such cases has been standardized since 1989, when the “Sexual Assault Set” (SAS) was introduced. On page 185 Gilles and colleagues from Brussels report an audit of its use. They carried out a retrospective study of the medical records of 356 patients admitted between 2002 and 2007, of whom 68% were Caucasian and 27% African. The authors found that only about 20% of the complainants received optimal care. Various steps have been taken, including a computerized checklist and the involvement of a social nurse for follow-up, with the aim of reducing the psycho-affective and medical morbidity after these distressing events.
      Open abdominal hysterectomy is still widely performed despite much being written about the advantages of the vaginal and laparoscopic approaches. One of those advantages is short hospital stay. On page 203 Kroon and colleagues from Trollhattan, Sweden, report on “fast track hysterectomy”, which has made the length of stay after abdominal hysterectomy similar to that after laparoscopic-assisted vaginal hysterectomy. In a randomized study of 53 patients undergoing abdominal hysterectomy, the authors found that improvements in anaesthetic technique (using intrathecally administered morphine combined with total intravenous anaesthesia) reduced hospital stay to two days without compromising satisfaction rates. Indeed, these were improved.

      Gynaecological urology

      Surgeons are sometimes accused of paying too little attention to evidence-based medicine and basing their practice on traditional teaching. This stereotype is challenged on page 212 by Hinoul and colleagues from Belgium and The Netherlands, who studied specialists’ willingness to adopt new surgical techniques. Using a questionnaire they presented members of the Flemish and Dutch Societies of Obstetrics and Gynaecology with a series of vignettes describing a new needle suspension technique. Within these varied scenarios there were different combinations of characteristics including length of hospital stay and cost. The authors found that the most important factor determining willingness to adopt the new technique was the level of scientific evidence, followed by the risk of mesh exposure and level of post-operative pain.