Women in the limelight: a varied issue


  • Reynir Tómas Geirsson

In many high- and middle-resource countries women are now in the majority among obstetricians and gynecologists. This is a development which for womens′s health will entail several advantages, but an exclusion of men from the profession would on the other hand not be an ideal situation. Why should men not be equally interested in reproduction and have the health of women and families at heart? Work in the speciality calls for skills, dedication, empathy and vision. The genders have each their qualities which contribute positively in the clinic, in research, in administration. Also at the operating table, – a men′s domain until recently. Now it is women on whom the limelight increasingly falls, as on the journal front cover this month. A certain mix of gender in the profession is nontheless the best situation, and that includes all its subspecialities and ramifications.

The first article of this issue gives a much needed summary of what is known about using oral contraception without a pause in the pill-taking (Lene Hee and colleagues, Aarhus and Herlev, Denmark, pp. 125–136). The old monthly “pause” is artificial and neither a pharmcological nor physiological necessity. Continuous use will add to contraceptive efficacy and there are potential health benefits as described in this article. No harm has ever been shown from omitting the pause for shorter or longer periods. It should be an individual woman′s choice what she does, and to advise her (and the public) accordingly is a must for anyone in our profession. Then Ageeth Rosman and co-workers in Leiden, the Netherlands (pp. 137–142) review what is evidence-based and what is empiric knowledge in some major guidelines on how to handle external cephalic version of a fetus in breech presentation. There seem to be only a few evidence-based contraindications for trying external version before labor. We have long known that external version is a safe procedure if done under the correct circumstances. However, most obstetricians have their own preferences on when to try and when not. The reverse side of few contraindications (and limited evidence) is a liberal approach. In real life the decision tends to be individualistic with regard to who should be advised to have external version. Therefore it is also necessary to be clear on where the evidence-limits are. Our third review is a kind of “super-review” from the well known London-based women′s health research unit and it′s allied centers in the UK (Rachel Morris and colleagues, pp. 143–151) on how to handle detection of small-for-gestational age fetuses to minimize morbidity and the occasional mortality from that condition. This is high quality work. The evidence summaries in the forest plots are worth noting, and should influence our practice.

Depression after delivery can be profound and morbid for a new mother and very disrupting for her family. The identification of women likely to develop such a condition and offer them timely assistance is thus an important target in the clinical setting. Sara Sylvén and co-workers in Uppsala, Sweden (pp. 178–184), have followed a well-defined cohort to find not surprisingly that previous such episodes link to a new one, but also that a history of prementrual tension and dysphoric disorder is something to be noted in this respect. The discussion on the mechanisms behind this is worth looking at.

Avoiding an unnecessarily deep conization for cervical intraepithelial neoplasia has long beeen recognized as a key element in minimizing complications from this procedure [1]. Hyo Sook Bae and colleagues in Seoul, Korea, have assessed this in a comparatively large material and find an age-related relation. Among younger women who have not completed their childbearing more shallow conization must be a clear goal (pp. 185–192). Adequate screening programs aimed at younger women to find cervical cell changes in time and adequate follow-up is vital, even if HPV triaging is introduced and after HPV vaccination will start to affect population rates [2, 3]. Lower attendance for cervical smears within the organised screening in recent years is a concern in many countries. To keep up awareness and prophylactic measures among young women is a priority and does require that call and recall methods are part of the technology and on-line oriented world of younger generations. Moving towards new HPV-based models will also be a vital step within the organized screening programs that are crucial for success [3].

To induce or not to induce labor at term is an eternal question in obstetrics [4]. Maria Jonsson and co-workers in Uppsala and Stockholm, Sweden (198–203), have again shown that for low-risk parous women induction is best avoided unless there is a clear indication. It is worthwhile to wait for the cervical tissues to be suitably softened and pliable if induction is to be carried out based on epidemiological risks, even for up to a week beyond term. The actual risk differences between expectant or induction management are numerically small [4]. Waiting has always been central to prudent obstetrics. It is the nulliparous, obese and older women who have the highest chance of ending with an emergency cesarean after induction [6].

The antiphospholipd syndrome was recognized as a potential cause of pregnancy complications, including recurrent miscarriage and placental abruption, some 25 years ago. It remains a serious issue and one that can be treated to some degree in order to reduce damage to trophoblast cells in the placental villi and in the maternal circulation. Xin Li Liu and colleagues from Changsa, China, report on the picture emerging in relation to anticardiolipin and b2 glycoprotein antibodies in a sizeable series on pp. 234–237. A recent review is also to be recommended [7] and details i.a. the way in which thrombosis, aberrant prostacyclin/thromboxane balance, and changed functions of adhesion molecules in the trophoblast cell membrane are central to the damage that leads to the clinical syndrome.

Consider attending at

The 4th Nordic Endometriosis Congress (NCE2013) in Turku, Finland on 23.-25. May (www.NCE2013.fi).

The ISSHP European Congress is in Tromsö, Norway, 12.-14. June (International Society for the Study of Hypertension in Pregnancy, www.isshp.org).

Points for observance

Traumatic first childbirth often leads to a delay in having a second child (pp. 210-214).

Progesterone to reduce the chances of preterm delivery in susceptible women is better given vaginally than intramuscularly and has fewer adverse effects (pp. 215-222).

In Denmark (as in other Nordic countries) the offer of prenatal screening for chromosomal aberration is in general accepted by a majority in the population (pp. 230-233)

Monopolar electrocautery is not without dangers and staff training, safety inspections and procedure performance evaluation should be used to minimize risks and injuries (pp. 238-241)