Editor’s Choice

Should we FBS with a VBAC?

Although there are many reports of the risk of scar rupture associated with previous caesarean section (CS), the data on uterine rupture in general are scanty and information about the symptoms that precede rupture is surprisingly difficult to find. The paper from Joost Zwart and colleagues (page 1069) in this issue includes the largest series of uterine rupture without a previous caesarean in a Western country so far reported. It examines 210 cases of uterine rupture among all women delivering in the Netherlands during 2004–2006 and has some surprising findings. For example, 13% of all their uterine ruptures occurred in an unscarred uterus, and in nearly 10% of cases the rupture occurred before the onset of labour.

This paper may provide us with some help in deciding whether it is wise to perform FBS in a woman who is labouring after a previous CS, as the authors have characterised the clinical manifestations that precede rupture. Of the 210 cases of ruptured uterus, abdominal pain and CTG abnormalities was the commonest combination of symptoms before rupture (90 women), 43 women had abdominal pain and no CTG abnormalities, and 44 (21%) had CTG abnormalities but no pain. The last of these figures will undoubtedly be useful when discussing risk with the small number of women who wish to have a VBAC at home. We have linked two mini commentaries to this paper (pages 1078 and 1079), representing some of the spectrum of opinion about management of VBAC and the prediction of scar rupture.

Balloons or microwave?

The number of hysterectomies performed for menstrual bleeding disorders in the UK fell from 24 355 in 1993 to 10 559 in 2002, reflecting a move towards medical and surgical treatment aimed at the endometrium. Rather like the stockmarket, the race to the finishing line never really stops, but what is the frontrunner in the surgical race as an alternative to hysterectomy at present? This month we publish the results of two randomised trials comparing Microwave Thermal Balloon Ablation with two other techniques for treating heavy menstrual bleeding. The first (page 1033) compares the method with trancervical resection of the endometrium (TCRE), reporting 10 year follow up of 189 of the 263 women in the original study. The results appear to justify the falling away of TCRE as a surgical treatment for menorrhagia that has occurred in the UK over the last 5 years. The second study (page 1038) compared microwave and balloon ablation in 320 women, with 1 year follow up. Both methods led to high levels of patient satisfaction and reductions in menstrual loss, but the Microwave technique took less time and needed less analgesia.

Centralisation of care for Jehovah’s witnesses who are pregnant?

There are approximately 6 million Jehovah’s Witnesses worldwide, 135 000 in the UK and 1 million in the US. As an approximation, about one in 450 pregnant women in these countries will be of this faith. The paper from Wolfswinkel et al. from the Netherlands on page 1103 confirms the findings of previous reports that Jehovah’s witnesses have a greatly increased risk of maternal death, which in their series was six times the rest of the population. The risk of maternal death because of major haemorrhage was 130 times background and the risk of serious morbidity was three times that in the whole population. The authors found substandard care in a third of cases. In 80% of the cases, this was because of poorly timed hysterectomy. We accompany this paper with an editorial commentary about difficulties in management (page 1108) and a commentary concerning the theological and social aspects of care from Paul Wade of the Jehovah’s witnesses Hospital Information services (page 1109). The facilities that are needed for optimal care, including an on-call cell salvage team, are not available in many hospitals, and the subtleties of what will or will not be accepted by each patient clearly needs to be explored carefully and sensitively. The authors advocate centralisation of obstetric care for Jehovah’s witnesses’, but acknowledge this might not be possible in all cases. Centralisation of care to designated hospitals incorporating a team of an interested obstetrician, anaesthetist and haematologist in large city areas, and the designation of relevant consultants as the ‘Jehovah’s Witness leads’ in hospitals where centralisation is unfeasible seem achievable aims.

Estrogens and endometrial carcinoma

Endometrial cancer is the most common gynaecological malignancy in the industrialised world, and the risk factors such as obesity and unopposed estrogen treatment have been known for years. It is surprising that the molecular basis for endometrial cancer is so poorly understood. As is already the case with breast cancer, identifying genotypes that are associated with an increased risk of the disease may allow care to focus on women at high risk. Estrogen effects are mediated via binding to the estrogen receptors receptor alpha (ESR1) and estrogen receptor beta (ESR2), which results in the activation of a number of co-repressors and co-activators.

A small number of studies have shown that single nucleotide polymorphisms (SNPs) in ESRs alter the risk of developing endometrial cancer, although results are not consistent.

In this issue, we include two studies examining HER-1 and HER-2 polymorphisms as risk factors for endometrial cancer. In the case–control study by Tong and colleagues (page 1046) they compared the incidence of four common single-nucleotide HER-2 polymorphisms in 125 cancer cases and 302 controls. They found no difference between the cases and controls. In contrast, Ashton and colleagues (page 1053) in a larger study of 191 endometrial cancer patients and 291 controls examined the association between two ESR1 SNPs and four ESR2 SNPs. They found that of these, two ESR1 and two ESR2 polymorphisms were associated with an increased risk of endometrial cancer, and that after adjustment for risk factors such as age, BMI, diabetes etc., the relationship between endometrial cancer and three polymorphisms remained. This is obviously an area of study that is in its infancy, but may have important implications for screening programmes for endometrial cancer and the choices women might make when selecting an HRT regimen.

Maternal age and non-chromosomal abnormalities

The relationship between older age and increased risk of chromosomal abnormalities is well known, but the effect of age on non-chromosomal abnormality (NCA) is unclear. The results of a population-based prevalence study NCA using data from EUROCAT congenital anomaly registers found on page 1111 are illuminating. The survey includes a total of 1.75 million births in 15 European countries, covering nearly one-third of all births in Europe. Four percent of these mothers were teenagers, ranging from 9% in the UK to 1% in France and Italy. The registry identified nearly 39 000 cases of NCA. The prevalence of NCA in teenagers was greater than in all other age groups, with a relative risk of 1.11, adjusted for country. Live births occurred in 89% of all cases, and termination of pregnancy (TOP) in nearly 10%. Mothers with NCA in the older age groups were more likely to have had a TOP. Teenagers were almost five times more likely than older mothers to have had malformations resulting from maternal infections, mostly Cytomegalovirus (CMV), perhaps explained by the known association of onset of recent sexual activity with CMV infection. The relationship between maternal risk and age was not the same in all countries, suggesting that other factors such ethnicity, environmental or lifestyle factors are important. The authors discuss the explanation and implications for their findings, which are likely to influence clinical and public health initiatives across Europe.

Urethral slings

The development of tapes introduced through the obturator foramina aimed to limit the rate of bladder injury, and it has been suggested that cystoscopy is not needed with this form of surgery. The paper on page 1120 reports 14 cases where urethral injury has occurred, either with retropubic or transobturator foramen mid-urethral sling procedures, and summarises the findings of 133 studies reporting serious urinary tract injury associated with this technique. The authors conclude that although the incidence of urethral injury at mid-urethral tape procedures is low, they did not find it to be any less with the more recently introduced tapes than with the original TVT. As the sequelae of unidentified peroperative urethral perforation are so serious and difficult to treat, the authors feel the time has not yet come when we can confidently abandon cystourethroscopy with mid-urethral tape procedures.

Training in Obs and gynaecology

Annual teamwork training of midwives and obstetricians to improve management of obstetric emergencies such a major haemorrhage, shoulder dystocia and cord prolapse has become a major part of the workload of most hospitals, but the evidence for its efficacy has only emerged recently. It would be nice to be able to confidently say to our trainees and our colleagues that all this effort is worthwhile. The study from Southmead Hospital on page 1089 reports the effect of team training for the management of cord prolapse on important outcomes such as diagnosis-to-delivery interval. It compares outcomes before (1993–1999) and after (2001–2007) the introduction of training. After training, there was a reduction in median diagnosis-to-delivery interval from 25 to 14.5 minutes. This did not translate into statistically significant improvements in neonatal outcomes, probably because the study was underpowered, but nevertheless the rate of low Apgar scores fell from 6.45% to 0% and the rate of admission to NICU from 38.46% to 22.22%. We accompany this paper with a review article (page 1028) that summarises the evidence about teamwork training and attempts to tease out the most important components of effective training. The authors conclude that training integrated with clinical teaching, with a mix of professionals trained within their own units using realistic simulations and local incentives, is the best model.

Postpartum depression and confusion

Three months ago, the newly inaugurated chairman of the American College of Obstetricians and Gynecologists Gerald Joseph announced that his presidential initiative would be chiefly in the area of postpartum depression, identifying three problems in particular that need to be addressed. ‘First, we need to determine the true prevalence and incidence of postpartum depression. Secondly, the available screening tools to assess potentially at-risk pregnant women often are imprecise and leave much to be desired. And, finally, we need to develop evidence-based guidelines … to screen for postpartum depression’. Such a strategy is much needed, but it may prove difficult to study and treat each area in isolation if the present literature is anything to go by. In this issue (page 1019), we publish a systematic review of the evidence about the benefits of screening for postnatal depression. It seems clear from this review that several important screening studies included enhancements of care and/or an intervention. As a result, it becomes difficult to disentangle the effects of the screening alone from interventions linked to a positive screen. A tripartite approach to research into postpartum depression may be difficult or impossible to achieve, and studies where a screening method is linked to an intervention may be more straightforward to perform and more accurately reflect the clinical problem.