Obstetrics in October and endometriosis

This month's issue is largely an obstetric one. Over the publication year we have a more or less even distribution of gynecology and obstetrics, but it can happen that an overweight of one or the other is created among accepted articles, just as now after the summer months. But there is still a major gynecologic review from one of the foremost current research groups on endometriosis, lead by Paolo Vercellini in Milano, Italy (pp. 1074–1082). He and his colleagues go into the issue of recurrence after primary surgery when the disease is discovered and the women are trying to have a child. What is the chance for that happening and what can we tell the women? The likelihood of achieving a pregnancy in this so often difficult disease is reduced from the outset as we all know, but particularly so when it recurs and if a second operative procedure has been required. Almost half the women with endometriosis have had a relapse by five years after the diagnostic operation, when both the disease itself and sometimes the surgery also have made the outlook bleaker. This justifies the current development to concentrate this type of surgery at centers of excellence so as to ensure the most competent handling of the patients in a multifaceted team-approach. It is indeed no less vital for women with suspected endometriosis to be primarily operated upon and to receive the subsequent medical therapy from those of us who have most experience and best facilities. The primary surgery should be planned and executed at a subspeciality level, much like gynecologic cancer and this is also argued by Paolo Vercellini and his colleagues. This article is certainly worth your attention. For a good look at what is new in endometriosis and to see some of the patients’ viewpoints, have a look at the World Endometriosis Societies’ web-site, http://www.endometriosis.org. Then it is on to the obstetric side. First there comes another good review, on antenatal steroid treatment for preterm SGA/IUGR babies by a Dutch team from Utrecht, Tilburg, and Leiden (Helen Torrance and co-workers, pp. 1068–1073). The available data are in reality not so massive and we are left with confirmation of what has been said before, namely that steroid treatment may not make that much of a difference when the fetus is small and stressed and presumably full of its own endogenous steroids. Yet most of us would often not dare but to ‘err on the safe side” and give steroids before delivery so as not to be blamed by parents or other colleagues. More and better constructed multicenter prospective studies are required to give answers on the where and when in these cases. The vital role of adequate training in obstetrics and gynecology is receiving renewed attention as better training programs are being set up in Europe, including the Nordic countries, and as better teaching aids and simulation training is being developed and implemented. Jette Led Sørensen and colleagues from Copenhagen, Denmark, and the well-known medical education center in Dundee, Scotland, write on pp. 1107–1117 about how training may be evaluated and what it's impact is. They confirm that structured training matters a great deal and this applies not only to the individual who is being trained, but also to the organization we serve and at a multi-professional level. Look at the discussion in this article. Jorge Burgos and his colleagues from Bilbao in Spain have tried to estimate whether success in external cephalic version is related to the size of the baby. They have used quite sophisticated but nonetheless comprehensible methodology to show that there is no relation (pp. 1101–1106). The reasons why a baby ‘gets stuck’ in the breech presentation are not well understood and probably due to several factors adding up, but fetal size is not one of them. In Helsinki, Finland, Minna Tikkanen and colleagues are contributing wide-ranging knowledge on a rather neglected issue, placental abruption. We will be publishing more of their work so noticing now what they have to say on pp. 1124–1127 on maternal death in this respect is worthwhile. The comprehensive and very large Finnish registers are used, something that we in the Nordic countries have been particularly successful in creating over the last 40 years. If in the low maternal mortality setting of Finland abruption is a higher risk to life than other serious pregnancy complications, one may just imagine the difficulties that exist where services are poor or even do not exist as is still the case in many poor areas of the world. Do women get enough information about choices in antenatal screening ask Kjerstin Wiklund and colleagues from Linköping, Stockholm, and Uppsala in Sweden. Are they conditioned by society into a certain pattern of action, i.e. to accept the offer of screening, but without giving much thought to what might happen if a screening test in pregnancy comes out positive, for example, for fetal malformation and chromosomal anomaly? That is not self-evident. Professional people may tend to underestimate the public in an open and informed society. Women know what they want and get information from many sources, not just professionals, who may think that they need more time and effort to educate the women and their partners correctly. Prospective parents may have quite good knowledge, even on ethical issues, before they encounter professionals like doctors and midwives. It may not be necessary for them to know all details if the main picture is clear, as the results and discussion in this report indicate. We will be publishing more on this topic. A small but special part of the Nordic countries are the Faroe Islands. Data from that community on pregnancies some 70–80 years ago (Gunnhild Helmsdal and Sjúrður Olsen, Copenhagen, Denmark, pp. 1145–1147) indicate that fever in pregnancy may imprint on the fetus some adverse features contributing to excess mortality later in life, not to a great degree but still discernible. This is yet again a piece of evidence suggesting that the intrauterine environment has a profound influence on how we fare in later life with regard to health and much exploring is still to be seen in this field. Then you might go through the article by Karljin Wouters and colleagues from Zaandam, Amsterdam and Haarlem in the Netherlands on delaying delivery of the second twin (pp. 1148–1152) and consider the alternate mode of delivering the fetal head stuck in the pelvic inlet at cesarean section described by Seema Chopra and colleagues from Chandigarh in Northern India (pp. 1163–1166). There is indeed quite a lot that is of interest in this issue, for obstetricians and gynecologists alike. Let us remember how intermixed these two arms of our speciality are and that they can hardly exist except together. Then there will be good reason to sit down and take a little time to go through this months’ AOGS. Growth-restricted fetuses redirect their reduced blood volume to the placenta with an unchanged cardiac output and redistribute hepatosplenic flow (pp. 1118–1123). Doctors in Finland have a low cesarean section rate for themselves and their spouses, which is reflected in the moderate general rates for Finnish women (pp. 1138–1144). Women with insulin-dependent diabetes mellitus have adverse fetal outcomes in up to a third of their pregnancies, particularly if they smoke and are in poor pre-conceptional glycemic control (pp. 1153–1157). A weight gain of less than 7 kg in a pregnancy appears to be safe for both mother and fetus (pp. 1158–1162).