Past the tobacco issue and on towards NFOG 2010

The April issue of the journal was a novelty, which the readers hopefully liked. A thematic and substantial volume done in collaboration with authors from several parts of the world and lead by experts on the issue in the Western hemisphere, from where tobacco was indeed originally introduced to Europe. Our colleague Jorge Tolosa from the University of Portland in Oregon, USA, helped us greatly getting this off along with our staff in the Editorial office and at the Publisher, Informa Healthcare. The new Director of WHO in Europe assisted by lending her strong support to this initiative. We are hoping that this publication, which is being kept Open Access for everyone all around the world for 6 months, will have an impact and help to generate further initiatives by doctors, other health care workers like midwives and nurses, and not least politicians. It is imperative to curb the use of tobacco and make it socially unacceptable everywhere, as is gradually happening in many high-income countries and even middle-income countries. This would surely be one of the best things we might do to further the health of women, children and families. Doctors have a duty to stand up as much as they can at a society level to bring about change in this direction. Their voices must resonate through society when it comes to policies on smoking and the use of smokeless tobacco. The big problem is now in the low- and middle-income countries where the tobacco producers try to gain addicts to their dangerous product, and where our colleagues are too weak and overburdened with more acute problems to be able to address an evil that sooner than later will catch up with them. If you have not yet looked at the issue, pick it up and go through it. Then let it be where your key co-workers can see it. The NFOG congress has always been a success. It is a few days program of great lectures, fine presentations, fun and feast. Would one now expect anything else from Copenhagen 2010 on 15–18th June? No. It will surely be good. Copenhagen in June must be one of the more pleasant cities to be in anywhere and our Danish colleagues will no doubt be making their very best arrangements. If you have not yet registered, the time to do so is now. Take note of the pre-congresses on the 15th (AOGS is there too), and if you cannot make it for that day, come on the 16th. Just be there! And now it is the May issue. It commences on something not perceived as pleasant: snoring. Ulla Anttalainen and colleagues from Turku in Finland (pp. 605–611) call our attention to what is often perceived as a problem of middle-aged men, but may increasingly be a medical issue for women in and past the climacteric, linking to the growing prevalence of obesity and cardiovascular disease. Worthy of attention. This is followed by an article confirming data from some previous studies, i.e. from the Nordic countries, that a history of hypertension or pre-eclampsia in pregnancy in first degree relatives means a two- to threefold raised risk for being affected in your own gestation, a not insubstantial increase because these complications affect every one in 8–10 women (Patricia Bezerra and colleagues, Natal, Brazil, pp. 612–617) and the serious forms develop in about one in thirty ongoing pregnancies. Awareness of the family history is a cheap and easily available measure, since it needs just a question and a well-placed tick box in the maternity care notes, it will delineate a risk group and be at least as useful as looking for change in biochemical markers or diastolic notching in the uterine artery. Divya Shah and colleagues from Boston, Ann Arbor and Madison, USA, call our attention again to the inadequate knowledge people have about endometriosis (pp. 646–650). We did place a focus on the quality of life for women who are diagnosed with the disease in a couple of contributions last year (1, 2), but surprisingly little seems to be dealt with this in general outside the patient associations. Knowledge and life quality are related issues, and of similar concern. This study is of some importance. Professionals must not lag behind popular media such as the internet, because providing understandable, credible and correct information from doctors to women with endometriosis will both affect management positively and help women live with the disease, and thus enhance quality of life for those affected. What may make bleeding at cesarean section more of a problem? Toril Kolås and colleagues from Lillehammer and Tromsö in Norway (pp. 658–663) provide some answers of clinical value. There are differences between elective and emergency operations, as one might expect, but to have it set forth clearly and then also quantified is good. Section at full dilatation and obesity are risk factors with relatively narrow confidence intervals, and since they are common, their weight is greater than many of the rarer causes like placenta previa or abruption. As the authors conclude, the results may be used as a guide to when resources should be secured to minimize blood loss, not least in terms of drafting in the most experienced staff to handle the case. Hospitals should have contingency plans for such situations and decide who of their staff are most appropriate for each type of emergency situation. We have an important article this month on pp. 664–669 from the Norwegian Medical Birth Registry (Astrid Bjørstad and colleagues in Bergen) on mode of delivery and fetal macrosomia. The first problem is to define what macrosomia means. Although 4,000 g is commonly used to define this mark in countries like the USA, which may also be relevant in India, China, South-East Asia, South America or Africa, a more appropriate mark in Caucasian Western Europe or even North America may be 4,500 g. What is the relevant definition in the Nordic countries? We have some of the highest birthweights anywhere and a sizable proportion of big babies, but also some of the tallest women. Being over 5,000 g at birth might be called ‘extremely macrosomic’. That was shown to be associated with a 50- to 60-fold increased risk of shoulder dystocia and damage to the brachial plexus and although this is in real terms not so common (3), it is frequent enough and gets worse with the multiplicative effects of rising birthweight, especially over 4,500 g. Look at Table 2 on p. 667. Where should these deliveries take place? All would agree that this should be well equipped hospitals, but it is difficult to detect these cases until late in labor or when the shoulder dystocia actually occurs. With a rising proportion of larger babies, there comes a need to detect them more securely, and ultrasound has not given the answers. At the same time it is by no means certain what one should do. Cesarean section based on ultrasound or clinical assessment is not the answer and will not be until we can select out the phenotypes among fetuses and mothers who are likely to benefit from such a measure. This article is a must for reading and discussing at departmental meetings. In this respect the association of maternal triglyceride levels to larger babies is interesting (Ga Hyun Son and colleagues, Seoul, Korea, pp. 700–704). Another article that is worth discussing is contributed by Malin Holzmann and Lennart Nordström from Stockholm Sweden (pp. 712–714), where they describe the current fetal monitoring tendencies in Sweden. How should labor ward routines be structured? We tend to go by the gold standard of randomized trials and meta-analyses, but these will only be as good as their background material. Given the debates world-wide and the controversies, not least in Sweden in the last few years, I think this well written and short article is definitely worth reading. As I write this flights in most of Western Europe have come to a halt because of a volcanic eruption not so far from where I am. Despite all technologic advances of the last 50 years, nature still beats us to it. Infertility is associated with worse mental health, but this differs between men and women (pp. 677–682 and 683–691). An increasing shift to a higher maternal age in Finland has lead to a rise in the prevalence of Down's syndrome (pp. 715–717).