November notes on important gynecology and obstetrics

The progesterone containing intrauterine device has been one of the major advances in women's health during recent years and it's potentials are not yet fully exploited. With firmly Finnish origins, it is not only the contraceptive actions, but also the way it has changed the management of menstrual abnormalities during the later reproductive years (1), the positive impact in conditions such as endometrial hyperplasia or endometriosis and other sex-hormone conditioned indications (2), which has made it so important. Endometrial progesterone receptors seem to be down-regulated to be extent of becoming non-functional (3). Kristina Gemzell-Danielsson and her two co-authors write from Stockholm, Sweden, Berlin, Germany and Helsinki, Finland on pp. 1177–1188 on the current use of the levonorgestrel intrauterine system in a highly informative overview article. The use can clearly be extended and it is not only suitable for parous women as was generally assumed until recently. Not unlikely will we see refinements and extensions of the indications, a better understanding of direct effects on all uterine cell types and of the way the hormonal environment as a whole is affected. We continue with a review from Lene Hee in Aarhus, Denmark (pp. 1189–1199) on biomarkers for preterm labor. The search continues for ways to predict which women may be at risk and what the true relevance or magnitude of the risk is. This is inevitably confounded by the complicated sociodemographic background factors such as age, poverty, smoking, drug use, vaginal flora changes and infection risks that are part of the etiology behind preterm delivery and which must be battled against to limit the damage from being born before organ maturity. In the clinical everyday situation it is often necessary to estimate an individual likelihood for preterm delivery. What often complicates evaluation of the studies on biomarkers is that varying cut-off points of 32, 34 or 37 weeks are used. Most of us would agree that the last one does not have much clinical relevance, because the babies do well if serious infection and asphyxia can be avoided. For some research purposes, such as on the role of infection in the onset of labor, it may still be of value to consider the borderline 35–37 weeks. Another review concerns a growing problem of how to preserve the uterus when a young woman develops cervical cancer. Li Xu and colleagues from Chongqing and Taiyuan, two very large capital municipalites of their respective large Chinese provinces (pp. 1200–1209), discuss what trachelectomy involves in their introductory remarks and then continue with a readable systematic review which may be of interest to not only gynecologic oncologists, but also those working in high-risk obstetrics. The alternative to this operative procedure, which young women with early stage cervical cancer may have, is radical hysterectomy, after which adoption or surrogacy become the only ways of achieving a desired family. The problems associated with those options are widely known. The first main research article this month is on robot-assisted surgery in obese women. The authors, Barbara Geppert, Celine Lönnerfors and Jan Persson, are from the leading group in this field in the Nordic countries, in Lund, Sweden (pp. 1210–1217). This article provides important information for all who do laparoscopic surgery on these women and want to stay abreast of developments within this topic. The two pictures of a patient (published with her consent) say much about the topic, so having seen these you might be interested to return to the text! We have from time to time addressed the topic of violence to women and rape in AOGS articles (4-6). Cecilie Hagemann and colleagues in Trondheim and Oslo, Norway, write on this topic on pp. 1218–1224. Victims of such heinous crime ought to be cared for by specific teams of experts, who also might be consulted where distance does not allow direct access, in order to obtain all the evidence and do so in the best possible way. Without that charges may not be pressed. It is already difficult enough to do so for the woman, not least when the perpetrator is not a stranger. She must have competent help from people with knowledge and experience in how the situation should be handled. Such teams will also provide the necessary support for tackling the post-traumatic phase that follows and can be so severe and prolonged. Päivi Tommola and her colleagues from Helsinki in Finland (pp. 1225–1231) then show the positive effects of surgical treatment for the severe vulvar vestibulitis syndrome and this makes essential reading for anyone involved in caring for these women, whether in specific clinic teams or public/private practice, while Maria Coccia and colleagues from the four Italian cities of Florence, Rome, Bologna and Naples show again, in a carefully selected and sizeable material, how endometriosis affects fertility adversely during assisted reproduction (pp. 1232–1238). Preeclampsia is another of those syndromes in obstetrics and gynecology where a constant search for likelihood markers has been ongoing. Most such studies have been cross-sectional and have often not had an ideal design. A study on many of the currently most studied markers, such as the one by Maria Palm and associates from Uppsala, Sweden (pp. 1244–1251), where longitudinal changes of such markers are shown, is as here more difficult and requires adequate statistical methodology. Then the study of Eva Anderberg and colleagues from Lund, Malmö and Helsingborg in Sweden (pp. 1252–1258) on follow-up of women with gestational diabetes, is also of importance, not least with the current international developments in relation to this in mind, after the HAPO-study (7). Given the serious health implications of a continuing diabetic state, the authors show clearly that a lower oral glucose tolerance threshold will be better for identifying a population of women who in the prime of life are at risk of later diabetes and thus a potentially reduced life-span. In twin pregnancy it is the monochorionic situation which carries most of the risk for adverse outcome that is seen during pregnancy, while at the delivery itself the risks for complications may be more akin to that seen with dichorionic babies. Rhona Mahoney and colleagues from Dublin, Ireland, show the former well in a study on pp. 1274–1280. Intrauterine death of one twin is associated with growth restriction, which is the result of feto-fetal transfusion and a resulting vascular and nutritional imbalance. All professionals agree on the value of autopsy for babies that die in utero. Yet this is not infrequently refused by the parents, sometimes because the explanation of what it involves is inadequate. Carola Holste and colleagues from the Stockholm area, Sweden, show that mothers do not regret an agreement for perinatal autopsy and they also suggest that personal contact with the perinatal pathologist might help, with specific questions being better answered both before and after the autopsy (pp. 1287–1290). At less than 4cm dilation abdominal palpation to determine occiptoanterior position at the onset of labor is inaccurate in primparas presenting at the labor ward (pp. 1259–1266). Emotional distress in pregnancy is not associated with a small-for-gestational age newborn (pp. 1267–1273). For uterine leiomyomas uterine artery embolization is safe and well-tolerated with a good long-term result (pp. 1281–1283). Visit http://www.nfog.org for information on the 38th NFOG Congress on June 16th–19th 2012 in Bergen, Norway, on the NFOG Fund, the Thesis registry, NFOG and FIGO news, the Nordic Obstetric Surveillance Study (NOSS) and for a short-cut to AOGS on the NFOG website or at Wiley-Online Library. Establish YOUR personal on-line access.