Editors’ Choice

Authors


This special issue of BJOG is given over to the theme of the long-term health of women and their babies, and a series of diverse and fascinating papers have emerged in response to the call for submissions. In choosing this topic as the theme for a special issue, the BJOG editorial team were reflecting the increasing recognition that the effects of conception and pregnancy on the health of women and their babies do not end once the umbilical cord is cut; that the impact of gynaecological treatment is only just beginning when women are discharged from hospital; and that modern lifestyles can have a profound effect on women’s reproductive health. The unifying theme of the papers included in this issue is the need for a long-term methodological perspective. The increasing recognition of this need is evident in the longitudinal design of several of the studies reported here. Others have perhaps relied more on happenstance and an eye for opportunity by building on existing datasets or cohorts recruited for an original study with earlier outcome measures and using these to undertake long-term follow up. One might argue that ideally studies, and particularly clinical trials, should be designed with long-term outcomes as the primary focus from the outset. Paul Hilton, in his review of this ‘holy grail’ in the evaluation of treatment for pelvic floor dysfunction (PFD) on page 139, cogently rehearses the arguments in favour of this approach and highlights women’s expectations of surgery for PFD being of positive long-lasting benefit and not just for a few weeks after surgery. However, several important factors can militate against the longitudinal view in practice. One of the major barriers is in obtaining sufficient funding to recruit women for trials or observational studies and then to follow large enough numbers for long enough to look at outcomes beyond the most immediate. Research funding bodies mainly work on the basis of 3-year, or sometimes 5-year, funding, which is rarely sufficient to plan for primary outcome measures many years downstream of the intervention or exposure of interest. The temptation, and indeed practical reality, is therefore for the initial primary outcome to be one which can be measured much earlier in the natural history of events since a funder is unlikely to be forthcoming if there is not a tangible product for their money. The researchers then have to rely on entering the funding process again to secure sufficient resources to pursue the important long-term outcomes. An equally valid complementary view is that if cohorts or trial recruits already exist, then it would be wasteful to miss the opportunity to undertake further follow up when important long-term research questions can potentially be answered. Sample size is often an issue in these circumstances and the Editor’s minicommentary on page 229 addresses some of the arguments in relation to small trials and the contribution they can make despite evident lack of power. For long-term outcomes to be investigated using data from an earlier study, it is self-evident that these data need to be available. The increasing tendency for research ethics committees, which represent the public interest, to require researchers to destroy all data at the completion of a study is a worrying trend. We believe that in appropriate circumstance, it behoves all researchers to provide robust arguments, encompassing suitable confidentiality and security safeguards, for the long-term retention of data so that they are available for longitudinal study. It is only through dialogue with ethics committees that a shared understanding of the value, need, and opportunity for long-term follow up will be reached. Until that point, precious data will continue to be squandered and the opportunities for long-term follow up will be lost, and this can hardly be in anyone’s interest.

Pregnancy complications and the prediction of future maternal and child health

During pregnancy, almost every organ of the mother’s body has to work harder in order to meet the demands of the developing fetus. Failure to rise to this challenge leads to gestational syndromes, usually in the third trimester of pregnancy, when the demand is greatest. As soon as the baby is born, the maternal challenge is over, or at least that is what we used to think. Evidence from several large studies has recently provided enough information for us to inform postpartum women about some of their long-term health risks according to their profile of pregnancy complications. For obstetricians to discharge women back to primary care after an arbitrary 6 weeks without acknowledging these risks is an outdated practice that needs to change.

In this issue of the journal, we are reminded of an example of this concept that we have been familiar with for a long time, gestational diabetes mellitus (GDM). Russell et al. on page 257 demonstrate that women who have had GDM have a high risk of developing diabetes in future. Most obstetricians organise 6-week postpartum glucose tolerance tests for women who have had GDM, but most women do not turn up for them and most obstetricians do not chase them up. This gesture to postpartum follow up is wholly inadequate. Furthermore, the postpartum GTT only identifies impaired glucose tolerance present at the time when the test is performed. Women who have had GDM have a life-long increased risk of future diabetes. Their primary care physicians need to be aware of this risk and a fasting glucose, or a modified GTT (it need not be a full GTT), needs to be repeated every 1–3 years according to the woman’s personal risk profile. Most important of all is advice to the mother—she needs to be aware of her increased risk and encouraged to take personal responsibility, at a time when she is relatively young, for lifestyle changes that will lower her likelihood of future diabetes. This advice also needs to be extended to women who have had pre-eclampsia or pregnancy-induced hypertension. These women have a life-long increased risk of future essential hypertension, ischaemic heart disease, stroke, and venous thromboembolism. Early pre-eclampsia is associated with the greatest risk of future cardiovascular disease, and women who have had recurrent pre-eclampsia appear to have the worst prognosis. Similarly, mothers of low-birthweight babies are at increased risk of ischaemic heart disease. Furthermore, low-birthweight babies themselves are at increased risk of cardiovascular disease in later life. Pike et al., on page 153, have written an excellent update review of fetal programming of adult disease. They explain how in utero adaptations by a ‘hungry fetus’ may enhance immediate survival, especially if followed by an overfed childhood, at the expense of long-term adult survival. It is less clear how clinicians should advise parents of a growth-restricted fetus in order to reduce the risk of premature cardiovascular disease in their offspring. Certainly, the rise in childhood obesity urgently needs to be reversed. Pike et al. recommend that we focus again on lifestyle changes, but they also discuss interesting therapeutic possibilities. The study by Burrage et al. on page 265 informs us of a novel role for fetal carotid bodies in adapting to maternal undernutrition during pregnancy. Understanding the mechanism of fetal adaptation to undernutrition is essential if we are to understand how transient in utero adaptations have life-long consequences on affected offspring. With such understanding, it may be possible to develop novel therapies, administered in a timely manner that could reverse the potential life-long negative effects on the offspring.

Postpartum care and follow up has for too long been a Cinderella subspecialty—indeed if only it were granted that status! Women need to complete their pregnancy armed with important information about their future health risks and that of their offspring. Such knowledge, if acted upon, would provide individual women with an opportunity to reduce their long-term morbidity and mortality and overall would be of major public health benefit. At present, there is a yawning gap between the end of obstetric care and the involvement of primary care, resulting in less efficient and more costly secondary prevention when ‘the horse has already bolted’. We hope that this theme issue will be an inspiration to change entrenched practices and improve the long-term public health for women and their offspring.

Obesity, hysterectomy, urinary symptoms, and surgical fashions

Risks associated with obesity are many and often so profound that the previous BJOG theme issue in October 2006 was dedicated to this topic. The increased risks associated with obesity include type II diabetes; hyperinsulinaemia and insulin resistance; dyslipidaemia; raised blood pressure; cardiovascular disease and strokes; cancers of the breast, endometrium, and colon; pulmonary disease, sleep apnoea, osteoarthritis and orthopaedic problems; and various endocrine disorders and pregnancy complications. To this jolly list, we can now add the risk of hysterectomy. Although the relationship is by no means a linear one, as described by Cooper et al. on page 188, obesity in later life is clearly associated with an increased likelihood of hysterectomy. Hysterectomy itself carries risks. The immediate and short-term risks have been well quantified and are known to be more common in obese women. It is for this reason that hysterectomy in obese women is something that neither the surgeon nor the anaesthetist relishes. With the increasing prevalence of obesity, the findings of this study are a cause for concern. Reports of long-term outcomes following hysterectomy, particularly of urological symptoms and diagnosis, are rarer. On page 203, Allahdin and colleagues report that hysterectomy is associated with an increase in urinary incontinence symptoms within 10 years of the operation, as well as increases in hospital referrals for incontinence, urological investigations, and treatment for incontinence, when compared with transcervical resection of the endometrium (TCRE). Minimally invasive methods of managing menorrhagia by various endometrial ablative methods (including thermal balloon ablation and TCRE) are now well recognised to be clinically effective, safe, and cost-effective, and prevent the need for hysterectomy in many women. This study provides yet another reason why ablative procedures should be considered before hysterectomy. A randomised trial by Bonger’s et al. on page 197 reports on the long-term effects of two ablative procedures, NovaSure and ThermaChoice. Numerous fashionable ablative techniques have come and gone in the past decade, but probably urogynaecology is currently the most beset by fashions without a reliable evidence base. Hilton’s review, on page 230, is a timely call for long-term outcome data from the urogynaecology world where operations, devices, and techniques change at a rate that would be the envy of high street fashion retailers. The important questions of who drives these changes and why are subjects that every ethical urogynaecologist needs to consider carefully. Ultimately, which of today’s fashions become an long-lasting classics should only be determined through high-quality, preferably randomised, evaluations that report on short-, intermediate-, and long-term clinically relevant outcomes. Hilton provides advice on which outcomes to look for. To get the ball rolling, we publish two studies that provide long-term outcomes of tension-free vaginal tape (Jelovsek et al. on page 223 and Ward et al. on page 230). We welcome more long-term evaluations of various devices and techniques that have made their way into clinical practice.

And finally…

All too often political imperatives drive us into ‘short-termism’. We hope that the papers in this special issue will inspire clinicians to reflect and consider a long-term view of evidence as it relates to their practice. We have a duty to consider the public health, which means responding to patient’s problems in a way that safeguards their future—and that of their children—as well as their immediate needs.

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