Should women drink alcohol during pregnancy?
Although smoking tobacco is agreed by everyone to be harmful during pregnancy (as at other times), the issue of alcoholic drinks is more complicated. There is no doubt that over indulgence can be catastrophic, and the burden of disease from alcoholism is very large. However, some of us take refuge in the fact that many studies report that some forms of moderate alcohol intake, in particular of red wine, can be beneficial for health. The difficulty of treating the minority who abuse alcohol by restricting its availability to the majority was well illustrated by the failure of a policy of prohibition in the USA in the early years of the past century. Because alcohol continues to be freely available in most Western cultures, it is very common for pregnant women to ask their caregivers about the safety of alcoholic drinks during pregnancy. In August 2006, we published an article by Jones et al. from the University of California which argued that the only safe amount of alcohol during pregnancy was no alcohol. They challenged the Royal College of Obstetricians and Gynaecologists’ (RCOG) statement number five (available on the RCOG website at www.rcog.org.uk/resources/Public/pdf/alcohol_pregnancy_rcog_statement5a.pdf) that ‘there is considerable doubt as to whether infrequent and low levels of alcohol consumption during pregnancy convey any long-term harm, in particular after the first trimester of pregnancy’. They suggested that this statement be re-evaluated to recommend abstinence, in line with the US Surgeon General’s most recent recommendations. This month, we publish on page 243 a systematic review by Henderson et al. from the National Perinatal Epidemiology Unit in Oxford, UK. Their conclusions were that ‘at low to moderate levels of consumption, there were no consistently significant effects of alcohol on any of the outcomes considered’. Perhaps, the argument really centres around whether a recommendation that consuming alcohol is safe enough for women who can restrict their intake to low or moderate levels encourages those prone to over indulgence and whether instead we should be encouraging total abstinence to support the minority who find alcohol difficult to deal with.
Caesarean sections again
In this month’s issue, we continue the process of refining our knowledge of the long-term complications of caesarean section. On page 253, Ash et al. describe the alarming occurrence of a subsequent pregnancy in the caesarean section scar itself. Not many of us will have seen such cases, so if you come across one, the information gathered together in this review will be invaluable. Equally worryingly, Gray et al. in the second article this month from the National Perinatal Epidemiology Unit in Oxford, UK, report on page 264 a 50% higher risk of stillbirth in pregnancies following a previous caesarean section. They link this with the known increased rate of placenta praevia and accreta in pregnancies after caesarean section and suggest that the common aetiology may be abnormal placentation. It is becoming clear that an important part of counselling women who request elective caesarean section without an obvious medical indication is to discuss with them not only the immediate morbidity of the procedure but also how many further children they are planning to have, as this has a major impact on the risk–benefit ratio.
Is magnesium sulphate given to the mother of benefit to the baby?
The MAGPIE trial, published in the Lancet in 2002 (Lancet 2002;359:1877–90), showed unequivocally in an international, multicentre randomised controlled trial that magnesium sulphate given intravenously is the anticonvulsant of choice for women with eclampsia. It is also effective for preventing the first eclamptic seizure, without substantive short-term harmful effects on either mother or baby. In this month’s journal, we publish the follow-up data of this important trial, relating both to the baby (page 289) and the mother (page 300). Exposure to magnesium sulphate while in utero was not associated with a clear difference in the risk of death or disability for children at 18 months after delivery. These data provide reassurance about the long-term safety of magnesium sulphate for the children at the dosage used in this study but do not suggest any particular benefit. The same is true of the outcome for the mother over the 2 years after birth. The wider significance of these important results, published this month in the print version of BJOG but available in ‘online early’ since December, are discussed in a recent editorial in the Lancet (Lancet 2007;369:13–14). A related question is whether antenatal administration of magnesium sulphate is neuroprotective for babies born preterm. This has been controversial because a few earlier studies showed apparent benefit (Pediatrics 1995;95:263–9) whereas later studies showed harmful effects (J Perinatol 2006;26:57–63). An important issue in this debate is whether the dosage administered is crucial. On page 310, we publish an important article by the PREMAG group in France, who recruited 573 women into a trial of antepartum intravenous magnesium sulphate infusion. When the trial was stopped after 6 years, data from 688 infants were available. Poor outcome was slightly less frequent in the babies of mothers given magnesium sulphate, but the differences were not statistically significant. The authors concluded that ‘more research is needed’. Plus ça change……
Despite having had a complete issue of BJOG allocated to the reproductive effects of obesity, we have far from exhausted this topic. The article by Heslehurst et al. on page 334 reports that not only does obesity have a negative effect on maternal and fetal outcomes but also increases the cost of maternity care. The costs range from having physically to strengthen equipment (everything from antenatal clinic chairs to operating theatre tables) to the increased use of ultrasound scans because abdominal palpation was not informative. So is obesity a personal problem, medical problem or a public health problem? Probably all the three, hence the difficulty in knowing exactly who has the responsibility for doing something about it. One of the known associations with maternal obesity is poor progress in labour. This is commonly attributed either to fetal macrosomia or to adipose tissue obstructing the birth canal. On page 343, Zhang et al. introduce the intriguing new concept that part of the problem is reduced uterine contractility as a result of impaired calcium flux secondary to raised cholesterol levels.
Probably the most common cause of postpartum haemorrhage is uterine atony, but vaginal and/or perineal damage can play a major role. Maternal posture in labour has been a topic of great interest over the past 25 years, but on balance, it seems that only the supine position is definitely contraindicated. Every other position that the mother can take up has benefits and disadvantages, hence the important role of choice. On page 349, De Jonge et al. report that birth in a sitting or semisitting position increases the risk of haemorrhage from perineal damage, compared with the recumbent position. This echoes similar findings relating to the use of birthing chairs or birthing stools. When postpartum haemorrhage becomes catastrophic, ligation of the internal iliac artery is an option. The experience of most obstetricians with this procedure is limited, so it is valuable to have in this month’s BJOG a report (with excellent clinical photographs) of no less than 110 cases. Joshi et al. on page 356 have accumulated this impressive experience working in Pune in India. An alternative is uterine compression suturing, originally described by B-Lynch in this journal in 1997. A simplified version described by Hayman, Arulkumaran and Steer in 2002 (Obstet Gynecol 2002;99:502–6) has become quite popular, and on page 362, Ghezzi et al. describe its use in 11 cases. In only one case was it necessary to proceed to hysterectomy. El Daief and Kirwan on page 369 report that uterine compression sutures can also be used to deal with uterine trauma secondary to termination of pregnancy in the second trimester.
Articles published in BJOG have a wide impact not only in the obstetric and gynaecological community around the world but also in the general media. Within the last year or so, articles published in BJOG have been making the news. The article by Shennan et al. (January 2006) on the unexpected increase in preterm birth associated with midtrimester treatment of bacterial vaginosis with metronidazole made the front page of a number of daily newspapers in the UK. More recently, the article by Maconochie et al. (risk factors for first-trimester miscarriage, published online early in December 2006 and in the print version of the journal last month) attracted much media interest, while in January, a set of articles plus a commentary by editor Pierre Martin-Hirsch on cervical screening and treatment of cervical intraepithelial neoplasia attracted coverage in the Times (of London), the Daily Mail and BBC online, plus many others. Readers were invited to listen to Pierre explain the background to the articles in detail in BJOG’s very first podcast (why not seek it out on the Blackwell website and enjoy his relaxed and informative commentary—there will be plenty more podcasts in the months to come). The articles even stimulated an email from the Head of UK cervical screening services to all lead colposcopists, carrying a link to the article by Bruinsma et al., which we chose as our ‘free access of the month’. As part of our service to readers worldwide, we now choose one key article per month which is available to all without charge. Another important recent change is that authors can purchase ‘free access’ at a cost of £1250. Free access to published articles is now a condition of funding required (and paid for) by many major sponsors of research such as the Medical Research Council and the Wellcome Trust. These changes are all part of the quiet revolution in publishing that is gathering momentum. BJOG intends to stay at the forefront of these developments.
Articles we would like and articles we are not so keen on
BJOG is interested in publishing more articles on basic science—as long as their relevance to clinical medicine is clear and properly explained. So if you have a colleague who is a basic scientist—or if they happen to read this editor’s choice—please encourage them to submit articles on aspects of their work that they would like to bring to a wide clinical audience. Our basic science editor Shanti Muttukrishna, who works at University College London, would be very happy to help you translate and explain your scientific insights to a clinical audience. In contrast, we would prefer not to have so many submissions of case reports on clinical rarities. In 2006, we received 360 case reports but published only 13 of them (4%). To every author, their case is important because they learned a lesson that was relevant to them (and their patient). But how many readers would see such a case in the next year, and if they did, would they have read and remembered the case report? We have just revised our instructions to authors and have said we do not wish to receive case reports unless they are the first account of a new procedure, or complication thereof (for example, new complications of uterine compression sutures) or are a new slant on a relatively common problem (for example, new ways of dealing with uterine inversion). Please see our new instructions to authors for details. Submissions of full papers are currently rising at 20% per year; these we are delighted to receive!