Is the cervix worth saving?
When I began training in gynaecological surgery in the UK in the early 1970s, there was a general feeling that ‘subtotal hysterectomy is for wimps’. Because (as explained so clearly in a commentary by Ray Garry on page 1597) total abdominal hysterectomy is a more challenging procedure than the subtotal operation, the ‘macho’ element among the predominantly male surgeons at the time pushed one very firmly in the direction of removing the cervix. I do not recall ever having considered the possibility that leaving the cervix might have advantages. ‘It might become malignant, so it has to be removed’. However, attitudes have changed. Whether this relates to the influx of women into our specialty changing the approach to removal of the female reproductive organs, or whether it is because of the widespread adoption of laparoscopic techniques, is an interesting question. To some extent, differences in the rates of supracervical hysterectomy are probably because of historic geographical custom. For example, in Sweden, over half of all hysterectomies are subtotal, compared with only 4% in the UK. On page 1605, Lieng and her colleagues from Norway highlight the fact that the laparoscopic supracervical procedure is also easier to perform, less invasive, and carries a lower risk of ureteric injuries and infectious complications than laparoscopic total hysterectomy. Learning laparoscopic surgery is difficult anyway, and perhaps the relative ease of the supracervical procedure is particularly attractive in this context. They report that 90% of women having a supracervical hysterectomy are satisfied with their surgery. Professor Garry concludes with a plea for a randomised controlled trial to resolve current uncertainties.
Anyone for endocarditis prophylaxis?
For 25 years, I have been looking after women with heart disease in pregnancy. For the past 15 years, I have been doing joint clinics with cardiologists and have lost count of the times I have heard the advice ‘don’t forget your antibiotic prophylaxis if you go to the dentist or have an operation’. Earlier this year, the National Institute for Health and Clinical Excellence in the United Kingdom issued revised advice that such prophylaxis is unnecessary (NICE Clinical Guideline 64: Prophylaxis against infective endocarditis). This has created practical difficulties in the clinic because women who have for 15 or 20 years assiduously taken prophylaxis are now being told that it was unnecessary. Reversing such a fundamental piece of advice erodes confidence. In relation to childbirth, many of us have been following a middle road, recommending prophylaxis only for women having a caesarean section (when antibiotic prophylaxis is recommended anyway) or a difficult instrumental delivery, or for women who have had endocarditis previously or who have major structural heart disease including artificial valves or cyanosis. On page 1601, Tower and colleagues review the situation, pointing out that the recommendation to abandon prophylaxis stems from a lack of evidence of benefit, rather than convincing evidence of ineffectiveness. They highlight the need for more good quality data in this area.
Why do accidents occur?
The drive to improve clinical governance has highlighted the importance of answering this question. The natural human tendency is to blame the healthcare professionals when the patient has a poor outcome, and this approach is only too evident in our mass media. Stories of ‘medical and midwifery incompetence’ litter the newspapers, radio and TV, with accusations being reported in lurid detail. Individuals and organisations are prevented by patient confidentiality from presenting their side of the story, and the usual outcome of legal cases (exoneration of the professionals) is rarely reported, leaving a false impression in the minds of the public. Finally, however, approaches that emphasise the importance of ‘systems errors’ are being adopted, highlighting the fact that mistakes are often best prevented by improving procedures rather than disciplining staff. Qualitative research can give important insights into why things go wrong, and one such case is described on page 1611. Schonman and colleagues analyse in detail how fatigue led to a gradual deterioration of surgical technique, resulting in a ureteric injury. In his associated Minicommentary, Prof. Ellis Downes reports the recent formation of the ‘The Clinical Human Factors Group’ which aims to share good practice with regard to surgical safety; their website can be found at www.chfg.org.
Proud to be pregnant
Those of us who promote the public acceptance of pregnancy and breastfeeding need to remember that not all women can reveal their pregnancy to their local community with the confidence that this news will be well received. We can readily imagine that if the pregnancy is unwanted, a woman will wish to conceal it, but as Stokes and colleagues point out on page 1641, there can be many other reasons why pregnancy is concealed. An important reason is that women can feel that they lose control over their lives once it is known that they are pregnant. Unfortunately, secrecy can cause problems with inappropriate medication and inappropriate treatment of pregnancy-related symptoms. In her attached ‘journal club’ contribution, Editor Julia Hussein provides structured questions to facilitate discussion of this paper with trainees. However, it is not just trainees but all of us who can potentially benefit from considering the important questions that she poses.
Immunotherapy for cervical cancer
In 1911, Sir Bloomfield Bonnington’s famous prescription for illness in George Bernard Shaw’s ‘The Doctor’s Dilemma’ was to ‘stimulate the phagocytes’. Bernard Shaw was a close friend of Sir Almroth Wright, a polymath pathologist who worked at St Mary’s Hospital in Paddington (London) in the early 1900s and who pioneered immunotherapy. He developed many vaccines, some of which worked. One of his most ineffective was a vaccine against syphilis, which was, however, so popular that it financed the building of a whole research wing! His belief in immunotherapy caused him to inhibit the development of penicillin by one of his staff, Sir Alexander Fleming, for many years, because he did not think it could possibly be effective because its short half-life in the blood. This limitation, as we now know, can be overcome by giving huge doses. Because of his iconoclastic views on this topic, he became known to the students at St Mary’s as ‘Sir Almost Right’. However, his warnings about the development of antibiotic resistance have proved to be prescient, and the importance of immunology in relation to many diseases is now recognized. On page 1616, Woo and colleagues report their studies on the immune-related intraepithelial cell population in the cervix in both low-grade and high-grade cervical intraepithelial neoplasia. Their conclusion is that the early infiltration of these cancerous lesions by highly cytotoxic effector cells protects against progression. In his associated Minicommentary, Editor Pierre Martin-Hirsch says that these findings indicate that immune therapies should be aimed at early lesions if they are to be most effective. Whether the cytotoxic effector cells can be ‘stimulated’ remains conjectural.
The importance of miscarriage
Losing a wanted pregnancy is always distressing. However, I have commented before in my editor’s choice that often women are given the wrong advice ‘to get pregnant again as quickly as possible’, presumably in the belief that this will help them get over their loss. However, many excellent papers over the last 10 years have indicated that the optimal interval between pregnancies is 18 months to 2 years. But surely if the first pregnancy was only an early miscarriage, this would not make any difference to the subsequent pregnancy. The paper by Bhattacharya and colleagues on page 1623 indicates that this view is incorrect. Compared with 21 118 women pregnant for the first time, 1561 women with a previous miscarriage were 1.5 times more likely to have a threatened miscarriage, 1.3 times more likely to have an induced labour, 1.4 times more likely to have a postpartum haemorrhage, and 1.5 times more likely to have a preterm birth after 34 weeks (2.8 times higher if the first miscarriage was after 12 weeks). As they did not study the interval between the miscarriage and the pregnancy, it is possible that some of this additional risk can be ameliorated by recommending that women wait for 18 months before embarking upon another pregnancy.
Immigration and pregnancy care
During 2008 in the UK, the pressure placed upon the maternity services by mass immigration has finally come to public attention. About one in three babies born in the UK are now to immigrant mothers, a figure that rises to over 50% in London. Publicity has mainly been focused on the birth rate, which in many areas has risen by 15–20% over the past 5 years. However, less attention has been paid to the higher rates of pathology in immigrant women, for example, gestational diabetes in South Asians, HIV in women from sub-Saharan Africa, and previously undiagnosed cardiac disease. On page 1630, Small et al. report that the increased incidence of maternity problems associated with immigrant mothers is not confined to the UK. They studied the pregnancy outcomes for over 10 000 Somali-born women giving birth in six major developed countries. Interestingly, unlike women from other parts of Africa, they were less likely to give birth preterm (pooled OR 0.72, 95% CI: 0.64–0.81), but they were more likely to have a caesarean section (pooled OR 1.41, 95% CI: 1.25–1.59) or a stillbirth (pooled OR 1.86, 95% CI: 1.38–2.51). The increased rate of caesarean section is particularly worrying in a community where large families are the norm, raising the spectre of high rates of placenta praevia and accreta in years to come. One possible reason for the high caesarean section rate is that the majority of these women have had traditional genital cutting and infibulation (also referred to as female genital mutilation, and previously as female circumcision). The causes of the increased rate of stillbirth were not clear, but may include lack of engagement with the maternity services leading to inadequate investigation of fetal growth restriction, delay in seeking health care in emergencies, and difficulties with communication. There can be no doubt that while immigration can bring economic benefits, wealth generation needs to be balanced by increased expenditure in relevant parts of the medical services, if immigrants are not to be inappropriately disadvantaged compared with the indigenous population.
More on ST segment analysis
Studies of the use of ST segment analysis (STAN) of the fetal electrocardiogram (ECG) to aid in the detection of fetal hypoxia and acidosis, and reduce the need for fetal blood sampling, have featured frequently in BJOG during the last 2 years. On page 1669, Melin and colleagues report a further such study. Having introduced the technique to their routine service following the randomised trials in Sweden, they audited their experience with it from 1 April 2002 until 31 September 2007. They found that of the 17 445 deliveries during that period, 20% were monitored by STAN. ST events together with an abnormal or intermediate fetal heart rate pattern occurred in two-thirds of cases where the baby was born with severe metabolic acidaemia, but in less than half (48%) of cases with moderate metabolic acidaemia. Moreover, they found no association between ST events during the first stage of labour, and cord artery pH, and emphasise that ST events in association with a normal fetal heart rate pattern are common and do not appear to be of any clinical significance. Equally, the presence of a severely abnormal fetal heart rate pattern indicates delivery even when there are no apparent ECG changes. Once again, the message is that STAN is an adjunct to high-quality fetal heart rate pattern interpretation, not a replacement for it.