Editorial| Volume 152, ISSUE 2, P117-118, October 2010

Editor’s highlights

      When we last wrote about the Millennium Development Goals (MDGs) we mentioned MDG5, which is about improving maternal health. There are, however, seven other goals with targets just as challenging as the 75% reduction in maternal mortality asked by MDG5. The aim of MDG3 is to “promote gender equality and empower women” and its target is the elimination of gender disparity in all levels of education by 2015. In June of this year, publication of the Millennium Development Goals Report revealed a mixed picture of success and slow progress across the various MDGs. As far as education is concerned, the gender gap in developing regions has almost disappeared but this is because in some areas, such as Latin America and the ex-Soviet countries, more girls than boys are enrolled in higher education, while in others, like Southern Asia and sub-Saharan Africa, boys greatly outnumber girls in colleges and universities.
      In Europe we like to think that gender discrimination is a thing of the past but the Global Gender Gap Report, published in 2009 by the World Economic Forum, suggests otherwise. It ranks countries by a “Global Gender Gap Index”, covering health, education, attainment and political empowerment. Nordic countries occupy the top four places, just ahead of New Zealand. Most (but not all) western European countries are in the top 17 on the list of 134 countries. The United States is at number 31, eastern European countries are generally lower and Greece is at number 85. (Japan, incidentally is near the bottom, at number 101.) Such league tables are often a source of amusement but this one is a reminder of Europe’s diversity and, for EJOGRB, of how difficult it is to ensure that a European journal is relevant to all parts of our continent.

      What’s new?

      Uterine fibroids are common and usually asymptomatic. They tend to regress at the menopause and expectant management is often all that is necessary. Growth can be monitored by ultrasound, and MRI now makes it easier to discriminate fibroids from ovarian tumours. If treatment is required, the range of options has increased dramatically in recent years and now includes laparoscopic myomectomy, uterine artery embolisation and magnetic resonance-guided focused ultrasound surgery (MRgFUS). On page 119 Duan and Sirohiwal present a review based on the very extensive experience of their centre in Rohtak, North India. They emphasise that the recent advances in diagnosis and treatment make it possible to individualise the management to each patient’s needs.
      Malaria may have been eradicated from Europe but it still kills about a million people every year in Africa, Asia and Latin America, with children under five being at highest risk. Three thousand African children die of malaria every day. Pregnant women are also especially susceptible. As well as causing maternal anaemia, placental malaria causes abortion and low birth weight, which leads to an estimated 75,000-200,000 infant deaths annually. On page 126 Mens and colleagues from Amsterdam, The Netherlands, explain the molecular basis of the placental susceptibility to Plasmodium falciparum, and the steps leading to adverse pregnancy outcomes. Combatting malaria is one of the aims of MDG6, and April 25 was designated “World Malaria Day 2010”. Progress is being made, particularly in the provision of insecticide-treated mosquito nets to allow children to sleep safely. As well as these preventive measures, however, research needs to continue on placental immunopathology with the aim of developing specific interventions for those most at risk.
      Following our recent publication of the French National College of Gynaecologists and Obstetricians (CNGOF) guidelines on urinary incontinence, and on Turner syndrome and pregnancy, we now present a third CNGOF guideline (page 133). It is on menorrhagia, and like the others it is highly relevant to clinical practice. It covers investigation, medical treatment and conservative surgical techniques. Hysterectomy is not recommended as the first-line treatment of menorrhagia but if it becomes necessary it should be performed by the vaginal or laparoscopic routes. Not surprisingly, there are many similarities with the 2007 UK guideline on heavy menstrual bleeding, published by the National Institute for Health and Clinical Excellence (NICE), although NICE gave less priority to laparoscopic hysterectomy. We are grateful to Professor Henry Marret, our Specialty Editor for Gynaecology, for facilitating the publication of English translations of the CNGOF guidelines. It would be interesting to know how closely such evidence-based guidelines are followed in France, the UK and elsewhere in Europe.

      Obstetrics and maternal-fetal medicine

      Specialists in perinatal medicine strive to preserve the lives of the unborn but as the science of prenatal diagnosis advances, this subspecialty bears the brunt of the hardest decisions about termination of pregnancy when fetal abnormalities are discovered. In many countries abortion remains a highly contentious moral issue. On page 148 Jotkowitz and Zivotosfsky from Israel comment on the highly charged atmosphere that surrounds the debate, which is usually framed as a battle between incompatible ethical principles. The authors also point out the contradictions revealed by opinion polls which show that people can at the same time believe that abortion is murder but say that it should be legal. This thoughtful paper will strike a chord with many obstetricians, as it sets out the reasons for reframing the abortion debate to allow for a more nuanced approach. With prenatal diagnosis becoming ever more sophisticated it is essential, if increasingly difficult, to ensure that decisions are based on up-to-date and comprehensive information. Doctors and patients understand this but getting the point across to pressure groups will be more difficult.
      With caesarean section (CS) rates rising almost everywhere, concern is increasing about the long-term complications of operative delivery. If a subsequent pregnancy implants in the uterine scar, placenta praevia accreta may bring the risk of life-threatening haemorrhage in the third trimester. Scar implantation may also cause symptoms in the first trimester, and when a woman with a previous CS presents with bleeding, an ultrasound scan may raise suspicion of a caesarean scar pregnancy. In the past, hysterectomy may have been the only way to stop the bleeding but on page 152 Takeda and colleagues from Tajimi, Japan, describe five cases treated conservatively. Precise localization of the placenta was achieved with sophisticated imaging, including colour Doppler ultrasonography, MRI and three-dimensional computerized tomographic angiography. When total or subtotal invasion of the anterior uterine wall was diagnosed, initial treatment was by transcatheter arterial chemoembolisation with dactinomycin. Subsequent medical or hysteroscopic management allowed uterine preservation in all cases.

      Reproductive medicine and endocrinology

      Two topics that have featured in recent issues of the Journal are again the subject of papers this month. Cryopreservation of ovarian tissue, as well as requiring clinical expertise and careful counseling of the patient, depends critically on successful laboratory techniques. Although some babies have been born following transplantation of cryopreserved ovarian tissue, the overall success rate is low. Further research on freeze-thaw protocols is needed. On page 176 Jee and colleagues from Seoul report a study on mouse ovarian grafts, comparing vitrification with or without sphingosine-1-phosphate (S1P), an inhibitor of apoptosis. The results were encouraging. After warming and transplantation, the morphological integrity of primordial follicles was superior in the S1P group.
      Helping women with polycystic ovarian syndrome (PCOS) to lose weight is important but challenging. A study of the approach taken by gynaecologists is reported by Sharma and colleagues from Nottingham, UK, on page 181. They sent a questionnaire to 1140 consultants practising in the UK, asking about the advice on diet and methods of weight reduction that they routinely offered to women with PCOS. Responses were received from 107 (9.4%) consultants, almost all of whom provided advice on diet and exercise as their first-line strategy for weight management. However, the amount of specific information provided was variable and compliance with national guidelines was suboptimal. The paper draws attention to new guidelines published by the Androgen Excess and PCOS Society, which suggest that lifestyle management is effective as first-line management. The authors also comment that the low response rate in their survey may highlight a lack of interest in this area.

      Gynaecology and gynaecological oncology

      Haemostatic disorders may cause menorrhagia, and the first recommendation in the CNGOF guideline mentioned above is a specific targeted history, asking about any personal or family history of disorders of haemostasis. The guideline states that the prevalence of von Willebrand disease among women with menorrhagia averages 10%. Nevertheless, in practice this cause may be overlooked. On page 191 Knol and colleagues from Groningen, The Netherlands, report a retrospective chart review of 112 consecutive patients referred with menorrhagia to a general gynaecology clinic in 2006. The effectiveness of treatment was evaluated by a structured telephone interview in April 2008. Only two patients had had haemostatic evaluation and neither had von Willebrand disease. At follow-up, among the 71 patients with unexplained menorrhagia, 17 had been successfully treated with a Mirena IUD, eight had had a hysterectomy and eleven had accepted persistent menorrhagia. Most patients were happy with their treatment but the authors suggest that systematic haemostatic testing may improve patient care, and are now undertaking a prospective study to test this hypothesis.
      Cervical cancer screening has been in widespread use for about fifty years but invasive cervical cancer (ICC) has not yet been eliminated. It is well recognized that the women at greatest risk are least likely to be reached by screening programmes. On page 200 Zucchetto and colleagues from Italy and France report a study of 438 women with ICC identified from the cancer registry of the Friuli Venezia Giulia region in northeastern Italy. Sixteen per cent had failed to respond to an invitation for screening, another 16% had not been invited because they were aged over 64, and another 6% had not yet received an invitation. Forty-four per cent of the women had had their ICC detected at screening, and these women had a lower risk of death than those who had not been screened. The authors conclude that lack of screening among older women and lack of compliance were the main limitations to cancer prevention. The study also showed better survival rates when cancer was diagnosed after organized screening.

      Gynaecological urology

      The reported prevalence of faecal incontinence (FI) after pregnancy varies widely, depending on the definition and the timing of follow-up. In this month’s obstetric section, Badiou and colleagues from France report (page 168) that of 184 primiparous women who responded to a questionnaire 15 months after delivery, 3.8% reported FI. The risk was not increased by a prolonged second stage of labour. In the gynaecological urology section, Yang and colleagues from China report (page 214) on a study involving telephone interviews with 1889 primiparous women within six months after delivery. The prevalence of FI (including loss of flatus) was very low at 0.69% and was associated with forceps delivery and episiotomy. However, the authors point out that the CS rate in China has increased dramatically in the past decade, mainly due to maternal request, and 55% of the 1889 women in this study had been delivered by caesarean section.