Editorial| Volume 155, ISSUE 2, P117-118, April 2011

Editor's highlights

      Medical trainees today have limited opportunities to experience medicine in other European countries. Undergraduates are allowed a short time away from their own medical school but they often choose to travel outside Europe and experience a different style of medicine. Europe's centres of excellence, besides their rich historical diversity, have much to teach one another about medical science and clinical practice—as they regularly demonstrate in the EJOGRB. We are pleased to see that trainees in our specialty are maintaining international links through the European Network of Trainees in Obstetrics and Gynecology (ENTOG). Their 21st European Meeting and Exchange Program will take place in the UK on 2–7 May. Trainees will visit hospitals in London and attend both a social gathering and a meeting at the Royal College of Obstetricians and Gynaecologists. The organisers have overcome the inevitable challenges of hospital bureaucracy but this year they will also have to cope with the aftermath of a royal wedding on 29th April. No doubt London will be even livelier than usual. We hope the trainees will find the week enjoyable and educational.

      What's new?

      Ovarian enlargement is commonly found at first-trimester ultrasound examination. Usually it resolves as pregnancy continues but when it persists into the second trimester the obstetrician is faced with a problem. This is discussed on page 119 by Aggarwal and Kehoe from Oxford, UK, in a review which identified 33 relevant papers covering more than 2500 pregnancies. Up to 80% of the cases of ovarian enlargement were asymptomatic but symptoms were more likely in cases of malignancy, and the proportion of malignant tumours in the studies ranged from 2.15% to 13.5%. Ultrasound appearances are the best guide to management. Tumour markers have a limited role in pregnancy but MRI may help in doubtful cases. Surgery, whether open or laparoscopic, does not have an adverse impact on overall obstetric outcome, and if indicated should be done in the second trimester. The authors call for national tumour registries to help produce meaningful guidelines for the management of this obstetric dilemma.
      Our second review focuses on assisted reproduction. The most difficult step in in vitro fertilisation (IVF) is achieving successful implantation after embryo transfer (ET). It seems logical to advise the woman to rest after ET and this is the practice in many clinics. Bed rest, however, is time-consuming and may actually be stressful, and there is no evidence that it reduces the chance of implantation failure. On page 125 Li and colleagues from Chongqing, China, present a systematic review of this issue. They identified three trials including 724 randomised subjects. The authors conclude that the quality of the studies was high and that there is insufficient evidence to support the routine use of bed rest in women undergoing ET in IVF cycles.

      Obstetrics and maternal–fetal medicine

      Renal transplantation is now seen by the public as almost a routine procedure, but the reality is that women who become pregnant after receiving a donor kidney constitute a high-risk group, with the potential for both maternal and fetal problems. On page 129 Aivazoglou and colleagues from Sao Paolo, Brazil, report a recent series of 34 pregnancies in 31 renal transplant patients, two of whom had a multiple pregnancy. Fifteen patients experienced graft dysfunction, which in 10 cases was due to pre-eclampsia. In most patients the dysfunction was temporary and renal function was unchanged a year after delivery, but in two cases the dysfunction was related to rejection and in one this ended in graft loss. Although renal dysfunction in pregnancy is not thought to have an additional impact on graft prognosis, the authors still advise that all pregnant patients with solid organ transplants must maintain their immunosuppressive therapy.
      Women with a cardiac abnormality are another at-risk group. On page 146 Gelson and colleagues from a tertiary centre in London report 19 pregnancies in 14 women with a systemic right ventricle. In this rare abnormality, due to either surgical or congenital correction of transposition of the great arteries, the right ventricle has to support the systemic circulation, and the strain that this causes is considerably increased by pregnancy. The authors compared these 19 pregnancies with 76 controls. As cardiac disease is now the leading cause of maternal mortality in the UK, it is impressive that there were no maternal deaths in this series of high-risk patients. Cardiac complications, however, occurred in six cases, and were more common in women who had had cardiac dysfunction before pregnancy. Obstetric complications occurred in four cases, not significantly higher than in the control group, but neonatal complications were more frequent, due to both prematurity and fetal growth restriction. The authors emphasise that preconception counselling is highly desirable, as is tertiary care during pregnancy.
      Pre-pregnancy counseling (PPC) is the subject of a report by Anwar and colleagues from Hull, UK, on page 137. Among women with pre-gestational diabetes, retrospective studies have shown that PPC is associated with reduced rates of congenital malformations and pregnancy complications. Only about one-third of diabetic women, however, receive PPC. As randomized controlled studies are lacking, it is possible that the reduction is due to motivated and better-educated women attending for PPC, rather than to the intervention itself. The authors retrospectively studied all diabetic women who attended their centre for PPC and then became pregnant, between 1997 and 2007. They identified a total of 57 women. When these women booked for antenatal care they had significantly lower levels of HbA1c compared with the PPC visit, and most were taking folic acid. These results demonstrate clear benefits to the patient during the time between PPC and booking, and the authors conclude that PPC is a meaningful consultation.

      Reproductive medicine and endocrinology

      Polycystic ovarian syndrome (PCOS) has been found to be associated not only with infertility but also with decreased sexual satisfaction. Sexual satisfaction is known to be reduced by obesity but on other hand sexual functioning is improved by increased testosterone activity—which, like obesity, is part of the syndrome of PCOS. Mansson and colleagues from Sweden have investigated this issue, and on page 161 they report a questionnaire study of sexual functioning in 49 women with PCOS and 49 age-matched controls. The two groups had the same number of partners and about the same frequency of sexual intercourse, but the women with PCOS were generally less satisfied with their sex lives. The authors recommend that in future trials of treatment for PCOS, sexual functioning should be an outcome as well as the traditionally targeted symptoms.
      Combined oral contraceptives (COCs) have been around for half a century but they continue to be the subject of research as formulations change. During the 50 years since the first trials of COCs, scientific standards have become more rigorous, and prescribers and licensing authorities demand detailed information about the effectiveness and side-effects of new formulations. On page 171 Koltun and colleagues from the USA and Germany report a placebo-controlled trial of a COC containing a low dose of ethinyl oestradiol combined with a novel progestogen, in the treatment of moderate acne vulgaris. A total of 893 subjects were recruited and the COC produced both subjective and objective improvements in acne lesions. This COC has also shown acceptable contraceptive efficacy in four open-label studies involving 2386 women, as reported on page 180 by Anttila and colleagues from several countries.

      Gynaecology and gynaecological oncology

      Endometriosis is a cause of infertility but so is pelvic surgery, and it is a cruel irony that surgery intended to remove endometriosis may produce adhesions, which are themselves a reason for failure to conceive. The risk of adhesions is especially high if surgery is performed close to the ovaries. On page 183 Carbonnel and colleagues from Paris report a study to investigate whether lifting the ovaries out of the pelvis (“ovariopexy”) can reduce the risk of adhesions and improve fertility following surgery for severe endometriosis. The authors’ retrospective series included 218 patients undergoing laparoscopic surgery between 1997 and 2009. In all patients the ovaries were suspended to the anterior abdominal wall at the end of the procedure, using a non-absorbable suture which was removed five days later. Twenty-four patients underwent second-look surgery one year later, and 50% had no or smooth adhesions. In 2009 all patients were sent a questionnaire and 80% responded. Of these, 55% had conceived and of those, 84% had delivered. The authors conclude that transient ovariopexy is a safe and effective technique, but that prospective comparative studies are needed to confirm this.
      Opportunistic screening to prevent cervical cancer may involve taking cervical smears from pregnant or postpartum women, but in this group of patients there is a limited evidence base for the management of mild abnormalities. On page 213 Tam and colleagues from Hong Kong discuss the management of atypical glandular cells (AGCs) diagnosed during pregnancy and the puerperium. “Atypical glandular cells of undetermined significance” (AGUS), a diagnostic category of the 2001 Bethesda System, is defined as glandular cells showing changes beyond reactive or reparative changes but lacking unequivocal features of invasive carcinoma. So far, only one series has reported the prevalence of AGUS in pregnancy and the puerperium. Tam and colleagues now report on 91,133 such smears taken between 1995 and 2008, among which there were 70 with a diagnosis of AGC or AGUS. Follow-up data were available on 40 of these cases, with a mean follow-up of 43 months. Thirty had positive pathology including 18 with CIN III and three with squamous-cell carcinoma. The authors conclude that although AGUS in pregnancy is uncommon, the chance of significant cervical pathology is high and colposcopy should be performed in these patients, irrespective of the presence of co-existing cervical lesions.

      Gynaecological urology

      In the 16 years since tension-free vaginal tape (TVT) was first described by Ulmsten and Petros, incontinence surgery has made much progress, including the development of another new approach, transobturator tape (TOT). Another recent development has been increasing interest in new symptoms developing after surgery. For both patient and surgeon, it must indeed be depressing to find that an operation has cured one symptom, only to replace it with another. On page 229 Lleberia-Juanos and colleagues from Catalonia, Spain, describe a study comparing the incidence of de novo urgency in 366 women who had undergone surgery for stress urinary incontinence—in the form of TVT in 243 cases and TOT in 123 cases. The patients were followed up regularly and de novo urgency became steadily more common over time, affecting 22% of the women at 36 months. At the later visits urgency was less common in the TOT group than in the TVT group, but as the authors point out, only a small number of the TOT patients had prolonged follow up, and further larger studies are needed.