Twins, oral exams, and the power of reading for test takers
As I sat in the dining room of the American Board of Obstetrics and Gynecology on Vine Street in Dallas working on this column, I reflected back on the day's structured case questions in the oral exam and thought how fortunate examinees would have been to read BJOG before taking their test that morning. A large portion of the obstetrics test consisted of questions on twinning and the management of women with twin pregnancies, particularly focused on the prevention of preterm birth (PTB) or mitigation of its consequences. While the increased risk of PTB has been long recognised, only recently have evidence-based strategies existed to modify that risk or reduce its sequelae.
Serra et al. on page 50 in a randomised control trial looked at topical progestins in 290 women with twin pregnancies. Unlike previous negative trials of progesterone in twin pregnancies to prevent PTB they used higher doses (up to 400 mg) to see if failure to show effectiveness was dose related. They were operating under the age-old obstetric rubric of ‘more babies, more drug’. Despite raising the dose they found no benefit vis-à-vis PTB. Figure 2 in this paper shows their survival curves. Before readers give up on progestins in multifetal pregnancies they should read the commentary of Romero related to this article on page 1. He opines that a two-part strategy of screening for increased risk of PTB with endovaginal ultrasound, and only enrolling mothers of twins who have cervical shortening, would have shown a different result. This is an intriguing hypothesis; but before we embrace universal assessment of cervical length in singletons or twins it needs to be tested in a large clinical trial or we risk ending up with another yoke around our neck as is the case with electronic fetal monitoring.
On page 58 Bibbo et al. from New York look at secondary prevention of PTB complications with a second round of ‘rescue’ steroids in twin pregnancies. Their retrospective cohort study showed improved respiratory and visual outcomes in the babies of mothers who received a rescue dose. There were no adverse effects on growth in the multiple-dose babies, but the numbers were small (n = 130) and the study was underpowered to detect harms. Given its observational design, their work can only suggest hypotheses in need of formal testing and should not be used to guide treatment decisions.
Mind, body and health
Learners, and even test takers, want to dichotomise diseases into the purely physical and the psychosomatic. Thinking about this demonstrates the fallacy of the separation, as all diseases occur in bodies with minds and each influences and interprets the other. Two articles in this month's BJOG demonstrate these important interactions between psyche and soma. On page 32 Bjelland et al. from Norway carried out a secondary analysis from the large and successful national cohort—Norwegian Mother and Child Study—and they found that pelvic girdle pain (as a North American I would use the term low back and hips) is common in pregnancy and in over 18% of new mothers it persisted for 6 months postpartum. Nothing there will amaze anyone in practice for long, but what was interesting was that emotional distress during pregnancy actually predicted persistence of pain. While this might be a bidirectional association (distress might be the result of pelvic pain) it clearly demonstrates how important the mind and emotions are for one's health.
On page 75 Rouhe et al. from Finland took the mind–body connection a step further and conducted a clinical trial in mothers at mid-pregnancy and found that 8% had a severe fear of parturition. Controls received usual care but in the intervention arm, the pregnant women participated in six sessions of group therapy designed to reduce their fear. Not only was fear reduced, but the intervention participants had higher rates of vaginal delivery and fewer abdominal deliveries than did controls (Figure 1). Hence, working with the emotions actually changed the course of labour.
Moving beyond my awe at the power of the mind–body connection, an intervention to reduce abdominal delivery in first-time mothers is precisely what the developed world needs. Cook and colleagues, under the tutelage of Marian Knight, used the United Kingdom Obstetric Surveillance System (an entity every developed nation should invest in) and looked at women having five or more caesarean sections. As one would expect, operative morbidity soared largely as the result of abnormalities of placentation. The best way to prevent placenta percreta with bladder involvement is to not do the first section. Our Finnish colleagues show our readers one possible path.
Clip versus cut—nurse versus doctor
Jerry Hulka was one of my professors at the University of North Carolina and the progenitor of the first occlusion appliance for tubal sterilisation. The device bore his name—the Hulka clip—and as residents we applied thousands under his direction. Having worked with the device quite a bit, it was intuitively obvious to us that they would be difficult to apply to a recently pregnant upper genital tract because of increased oedema and hypervascularisation. Cohort studies bore out that impression as true, and Rodriguez et al. in a multicentre trial on page 108 show that high failure rates plague a new titanium clip when it is applied postpartum. The huge need for reproductive health services in the developing world make short cuts attractive on the surface, because should they be proven safe and effective more women would have access more quickly to the care that they need. Renner and colleagues on page 23 present a systematic review of termination of pregnancy performed by advanced practice nurses rather than gynaecological surgeons. They report that the data are limited (only one randomised controlled trial of surgical termination of pregnancy) and applicable only to the first trimester. Before we take short cuts that can help others, regardless of our good intentions, we must first take great care to do no harm. Both of these papers reach that important conclusion regarding expediency.
The real perinatal frontier-lifestyle interventions
The Western world is in the midst of an obesity epidemic and BJOG and other journals are seeing a plethora of observational studies that all come to the same conclusion: ‘obesity is bad’. In fact, it is hard to come up with a condition or outcome that obesity is good for. With that being settled, the real question becomes whether we can alter the natural history of obesity and improve outcomes? It appears that surgery can in the most severely obese, but what about women of reproductive age? In this issue on page 92, Althuizen et al. take the first step in trying to answer that question by carrying out a clinical trial of a four-session counselling session with pregnant women. Their results were nil and the size of their cohort was small with an admixture of women of various sizes, so keep your expectations low for the moment. Nevertheless, it does point out the kind of work we are interested in publishing about obesity. No more ‘obesity is bad’ cohort studies but interventions to try to reduce the harm of that important and prevalent condition.
Happy new year from the new Editor-in-Chief
BJOG is a universal brand in women's health research. It is respected for its scientific quality and editorial integrity. It has a distinctive history, dating back more than a 100 years. I am delighted to be appointed leader of the team that delivers this brand and to have a role in shaping its future. We receive a large number of submissions from all over the world and deal with these through a sizeable team of highly competent and motivated editors. Improving the experience of authors and readers will be our biggest challenge as we move into a world dominated by the internet. In this age, print is shrinking as publishing through social media is rapidly expanding. This trend will no doubt continue. In my term as Editor-in-Chief, BJOG might even see the end of its life in print. This metamorphosis to life online will be challenging. We will make the transition in a harmonious fashion ensuring the highest quality of our brand. We will need to work towards achieving this as best as possible in close collaboration with readers, authors, publishers and research funders. We will develop many ideas: ‘BJOG: 100 years ago’ to learn science through our history and ‘BJOG exchange’ to improve our post-publication peer review to name a couple. Effective dissemination of science is a key BJOG objective. Papers in BJOG will be selected for a continuing professional development programme to enhance their reach. BJOG Journal Club will soon have a significant presence on Twitter, aiming to engage readers with authors and editors. I am open to receiving ideas that stir things up and improve the experience of our readership. Tweet your proposals and follow me at @Profkkhan. We are also looking to appoint new editors and trainee editors. I look forward to hearing from you at email@example.com. Have a great start to the new year with this issue of BJOG.