Editor’s Choice

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This month, BJOG hosts not only the usual collection of top-class papers, editorial material and correspondence, but also an outstanding supplement of International Reviews produced to coincide with the 19th World Congress of Gynecology and Obstetrics in Cape Town, South Africa. Edited by Andrew Weeks (Senior Lecturer, University of Liverpool, UK) and Nynke van den Broek (Senior Lecturer, Liverpool School of Tropical Medicine, UK), it is designed to be both readable and informative. It contains full papers, a series of ‘how to’ articles, short commentaries, and pictures, so however much time you have at your disposal, there will be something to educate and entertain. Andrew and Nynke have raised the money to fund the supplement, it will be available free online. We are delighted that through their efforts, and those of their contributors, BJOG can bring you this outstanding and up-to-date perspective on reproductive medicine in the developing world – and there is much within it also that is applicable in developed countries. Having completed more than the usual term of editing for BJOG, Andrew is now stepping down as a full BJOG editor but he (and I) hope that he can produce regular International Review supplements in the years to come.

And another podcast to add to our growing collection accompanies the systematic review on page 1425 of the association of first and second trimester termination of pregnancy (TOP) with subsequent preterm birth. Prakesh Shah and Jamie Zao, on behalf of the knowledge synthesis group at the University of Toronto, included 37 studies to look particularly at the risk of a single TOP on the outcome of subsequent pregnancies. A key finding is that compared to women with no history of termination, even allowing for the expected higher incidence of socio-economic disadvantage, women with just one TOP had an increased odds of subsequent preterm birth (13 studies, odds ratio 1.27, 95% confidence interval 1.12–1.44). We have known for a long time that repeated terminations, or traumatic procedures resulting in damage to the cervix, predispose to early delivery in a subsequent pregnancy. However the finding that even one termination can increase the risk of preterm birth means that we should continue to search for ways of making termination less traumatic, such as cervical preparation with agents such as prostaglandins or laminaria tents. As we understand more about the functional aspects of the cervix during pregnancy (reducing the risk of ascending infection by producing thick mucus loaded with defensins, lysozymes, lactoferrin, calprotectin, immunoglobulins, and neutrophils), it is becoming clearer that these functions must be protected from damage. For example, a recent paper by Fjerstad et al. (N Engl J Med 2009;361:145–51.) has reported in relation to medical termination of pregnancy that changing from vaginal to oral misoprostol reduced post-termination infection rates by almost three quarters, with a further 76% reduction following the use of prophylactic antibiotics. Preventing infection may reduce damage to the functional and immune competence of the cervix. Linked to the Shah & Zao paper is a podcast, which has been organised by editor Vincenzo Berghella of the Jefferson Medical College, Philadelphia, PA, USA. Once you have looked at the paper, I encourage you to click through on our website to the linked podcast, and hear the views of invited experts as they discuss its implications.

Editing BJOG

Being an editor of a major journal such as BJOG is a significant commitment. However, it is also highly educational if one’s objective is to keep at the cutting edge of published research (or even in front of it by getting the first sight of important publications). But having ascended the steep learning curve, editors will often need to concentrate on their ‘day job’. We particularly enjoy having with us trainee editors, most of whom proceed to becoming full editors once they acquire a permanent (as opposed to training) post. Recently, both Lucy Chappell and Arri Coomarasamy have progressed from being trainee editors to full editors on being appointed to senior academic positions (at King’s College London and the University of Birmingham, respectively) but have then decided to step down as editors for the time being as they establish their research portfolios. Andrew Horne, another trainee editor, has recently been appointed as a Medical Research Council (UK) senior fellow and senior lecturer at the University of Edinburgh and while he would now be eligible to become a full editor, he has decided to concentrate on his research for the next few years. The quality of these trainees is evidenced by their academic success and promotion, and we like to think that the experience they have gained with BJOG has contributed to their training. We thank all three for their hard work on our behalf. Their departure does mean that we have the possibility to appoint some new trainees, so if anyone is interested, please contact me at p.steer@imperial.ac.uk. Qualities needed are not just interest and enthusiasm, but also the academic ability to analyse other people’s research, and strong writing skills. Evidence of a research track record and publications of their own are important qualifications.

Full editors currently standing down after a full term of service to BJOG are Paul Hardiman (University College London) and Stephen Dobbs (Queens University Belfast). Both have contributed enormously to the development of BJOG and we thank them warmly. While we still have a full complement of editors interested in assisted reproduction and endocrinology, we would welcome a replacement for Stephen who is a specialist in gynaecological oncology. More than a third of our editors are now based outside the UK, and for this reason we are dropping the distinction between scientific editors and international scientific editors, because in a very real sense all our editors are international in their outlook. The roles undertaken by all editors are identical in principle, and electronic consults are carried out on all appropriate submissions, involving relevant editors wherever they are situated in the world. So we would welcome applications from any appropriately qualified person who would like to join our friendly and supportive team.

Media attention

The Press Office at the RCOG, headed by Gerald Chan, distributes several press releases each month about papers due to appear in BJOG. Many of these achieve substantial publicity in the press, and some are syndicated world wide, helping to raise the profile of the research we publish. Several papers in the current issue had been discussed widely in the UK press and beyond. Particular concerns in the field of IVF have been the problems of multiple pregnancy and the ethics of ovum donation in older women. We have published a series of papers on single embryo transfer as a means of minimising the serious complications associated with multiple pregnancy, and a recent case of a 50-year-old woman who died of eclampsia, HELLP syndrome and cerebral haemorrhage following the delivery of twins conceived by ovum donation (Schutte et al. Reprod Health 2008;5:12) has highlighted that there are maternal as well as fetal/neonatal risks. McKelvey et al. (page 1520), report on 109 women with higher order multiple pregnancy assessed at their fetal medicine unit in London (89 triplets, four quadruplets, and one quadruplet pregnancy). Ninety-four (86%) had conceived with fertility treatment, and 24 of these (26%) had this performed overseas. The reasons for going abroad included the ability to have multiple embryo replacements (avoiding UK constraints), and cheaper treatment. While such therapy may be less expensive for the parents, the cost to the UK taxpayer of dealing with the consequences of preterm birth is substantial, not to mention the ethical aspects of this trade.

A less alarming study that also received considerable press attention was the report by Poston et al. (page 1515) that women destined to give birth preterm had lower salivary levels of progesterone as early as 24 weeks gestation. While progesterone supplementation has now been reported in a number of studies significantly to reduce the incidence of preterm birth, none of the studies have as yet shown a significant improvement in perinatal mortality or long-term outcome. Indeed, a recent report in the Lancet (Norman et al. Lancet 2009;373:2034–40) of a randomised controlled trial and meta-analysis has shown convincingly that progesterone supplementation does not reduce preterm birth rates or improve outcomes in twins. We need to await the results of the many ongoing randomised trials of progesterone supplementation in singleton pregnancy before we can decide whether the low progesterone in women who have preterm birth is causal, or an epiphenomenon.

Too much syntocinon again

Much of my early research over a period of 20 years concerned the measurement of uterine activity, and its augmentation with syntocinon. This gave me a healthy respect for the harm that its use can do. In recent years, there have been a series of papers from Sweden highlighting the medicolegal dangers of its excessive use. In 2007, Jonsson et al. reported that in the period 1996–2003 in Sweden, inappropriate use of syntocinon was involved in over two-thirds of adverse outcomes resulting in disciplinary action (Acta Obstet Gynecol Scand 2007;86:315–9). In a study of severe asphyxia associated with delivery related malpractice from 1990 to 2005, Berglund et al. in this journal reported the incautious use of syntocinon to be implicated in 71% (BJOG 2008;115:316–23). In this month’s issue, Jonsson et al. report their study of 161 neonates born in two University hospitals at or after 34 weeks of gestation with an umbilical artery pH < 7.05 and base deficit ≥12 mmol/l (page 1453). Misuse of oxytocin was implicated in 47%. The chorus of the Pete Seeger song ‘Where have all the flowers gone’ seems appropriate. It is ‘when will they ever learn?’

And finally

This months’ Journal is full of papers with practical implications. For example, consider the issue of induction of labour in women with a previous caesarean section. Some prefer not to do it because of the increase in the risk of uterine rupture, and the use of prostaglandins (especially misoprostol) is particularly problematic because of the risk of uterine hyperstimulation. In their randomised controlled trial, Pennell et al. (page 1443) report that the incidence of uterine hyperstimulation associated with cervical ripening using prostaglandins was 14%, whereas it was zero with mechanical cervical ripening using either a Foley catheter or a double (Atad) balloon. Efficacy in terms of duration of labour and mode of delivery was equivalent with all three techniques, but the Foley catheter offered the best combination of safety and patient comfort.

How familiar are you with the use of carbetocin? It is a long acting synthetic octapeptide analogue of oxytocin, with agonist properties. In the prospective randomised controlled trial, Su et al. (page 1461) report that it was as effective as syntometrine in preventing postpartum haemorrhage, but four times less likely to produce nausea. A paper by Werner Rath currently in press in the European Journal of Obstetrics and Gynaecology and Reproductive Biology suggests that carbetocin has a ‘long duration of action compared with intravenous oxytocin alone and a better cardiovascular side effect profile compared with syntometrine. In addition to being an effective treatment for the prevention of postpartum haemorrhage following caesarean delivery, carbetocin may also become the drug of choice for postpartum haemorrhage prevention after vaginal delivery in high-risk women and those who suffer from hypertensive disorders in pregnancy’. Carbetocin is currently indicated only for prevention of uterine atony after delivery by caesarean section with spinal or epidural anaesthesia (and is not marketed at all in the USA) but watch this space.

Do you need to screen for parvovirus B19 in cases of stillbirth? No, say Sarfraz et al. (page 1492). Is homeopathy or administration of lactobacilli as effective at treating recurrent vulvovaginal candidiasis as itraconazole? No, say Witt et al. (page 1499) supporting conventional medicine over the alternatives.

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