Changing scenes after decade

At the end of the first decade of the 21st century much of what was taken for granted is changing. This month the journal touches on several matters of central interest which should not be by-passed. Margit Dueholm, our Editor in Aarhus, Denmark, calls attention to the changes occurring with regard to the indications for hysterectomy after introduction of the levonorgestrel-releasing intrauterine system (LNG-IUS) on pp. 1302-1304. She draws on the article by Satu Heliövaara-Peippo and her colleagues from all the university departments and two other centers in Finland (pp. 1389-1396), where it is convincingly shown, with data from a randomized trial, that short-term benefits of hysterectomy with regard to lower abdominal and back pain are outweighed over a longer time by more positive health effects of the LNG-IUS. Much health expenditure is saved in the long run as well and risks with regard to complications are not comparable. The understanding and management of dysfunctional bleeding is changing and this will be followed by new endocrine approaches to management (1, 2). Hysterectomy techniques have also changed to some degree, but it is still a major operation, which may have wider effects on the body and where it now seems the indications must be more carefully chosen. This is further highlighted in another study from Finland (Kaisa Taipale and co-workers, pp. 1402-1410) on costs and quality of life in relation to hysterectomy, where again caution with regard to indications is advocated. Not all women improve equally from this operation. In Copenhagen representatives from around the world will just now be gathered to debate the serious matter of climate change. That this concerns doctors more than most other people is shown convincingly by Øjvind Lidegaard from Copenhagen, Denmark in the Commentary on pp. 1305-1306. The World Medical Association (WMA) has issued a declaration on the potential health effects of climate change, which he quotes. That report makes for sobering reading and should be looked at on the net. For obstetricians and gynecologists it will be our contributions to population control that are most relevant, since the bulk of pollution and atmospheric change is man-made and directly connected to over-population in the world. In our personal and working environments there are also many aspects to be addressed where each one may contribute to slowing down or even reversing the wasteful everyday use of resources that we all know about. It has now been decided to establish a discussion link on this at http://www.nfog.org, the home page of our Nordic society. We feature two reviews this month. A high-level Canadian group lead by Prakesh Shah and Vibhuti Shah in Toronto, present a systematic review on how low birthweight, pretem birth and being growth restricted are inter-generationally linked and how this continues to run in families (pp. 1307-1318), which clearly has resonance for maternity care. However, it is wise to remember the experience from the Nordic countries where better living conditions and healthcare during the last century improved dramatically on these very conditions, making birthweight the highest and perinatal mortality the lowest anywhere. This is followed by another review from the group of Khalid Khan in Birmingham, UK (Angelos Tsourapas and co-workers, pp. 1319-1330) on strategies to prevent preterm birth. The cost-effectiveness of different preventive models was studied and casts light on what treatments may be most relevant in this regard, while at the same time the need for much more evidence becomes apparent. It is not always possible to finalize a planned study, but still it may have a relevance and should not go unreported. Lars Krag Moeller and colleagues at several Danish centers (pp. 1331-1337) tried to run a randomized study on the effects of methotrexate compared to laparoscopic surgery for ectopic pregnancy. They were superceded by time and could not recruit the number of patients calculated beforehand as described in their Discussion, which can be commended to the readers. They point to the fact that observational and epidemiologic studies will often have to provide us with accumulating evidence over time, as randomized studies may not be possible or suffice. This has been called reality-based evidence (3). And methotrexate seems a safe alternative for hemodynamically stable women and connected to better fertility in the following years. A protracted labor usually calls for oxytocin. That this is often not used appropriately is shown by Lotta Selin and colleagues from Trollhättan and Gothenburg, Sweden (pp. 1352-1357). It may be the classical question of what comes first, oxytocin or the underlying and often complex reason for dystocic labor. This work provides reason to re-examine what we may be doing with this seemingly so beneficial and innocuous drug. The authors rightly call for better clinical research and debate about oxytocin use. Two overriding problems in assisted reproduction have been the high rate of multiple pregnancies and ovarian hyperstimulation with ensuing sometimes lifethreatening illness. The move to elective single embryo transfer has largely resolved the former issue, although many older women are still having more than one embryo transferred. How ovarian hyperstimulation can best be avoided, is, however, still not resolved. Annika Kahnberg and colleagues from Mariehamn in Åland (Finland) and Gothenburg, Sweden (pp. 1373-1381) have looked at this. They tried to assess what would be most predictive and found that the number of medium or large ovarian follicles gives the best warning of impending overreaction in relation to the hCG dose. The obvious implication is that those who fall into a risk category must be carefully monitored and a low threshold of hospitalization kept up. This is an article for all those working with assisted reproduction, because their expert knowledge is required to minimize the risk and to be available in the clinical setting when the woman starts to feel ill. Much work is still needed in this field to optimize the treatment schedules as the authors point out, but this study is a step forward. The two confidently smiling young colleagues on our front cover are indicative of what the future holds with many more women at the helm, not least in obstetrics and gynecology. How do we avoid gender inequality in our specialty and uphold the just interest and aspirations of those male doctors who are interested in reproduction and reproductive health? They are going to be needed no less than the women. Points for observance: Attention to the father's reaction to a stillbirth should be considered in order to minimize the risk of depression in the mothers (pp. 1358-1364). Lateral (or mediolateral) episiotomy during normal delivery may help to avert sphincter injury in a first delivery if used restrictively, but not in parous women, unless instrumental delivery is needed. (pp. 1365-1372). A single serum β-hCG on the 14th day after embryo transfer may be best to predict an ongoing pregnancy (pp. 1382-1388).