Winter is here, it is cold outside. From my windows I can see that the Sound between Denmark and Sweden is covered with ice – like in the cold winter of 1658 when the Swedes used the frozen waterways to transport military troops. We were defeated and lost one third of Denmark to the Swedes.

Like in those days, we did not expect a cold winter this year. Leading up to the Climate Summit in Copenhagen last December we had all expected a warm winter. Based on observational studies and extrapolations – admittedly poor evidence not higher than level 5 – we believed that the carbon dioxide we produced in recent years had changed the climate. And we thought that we would be able to control the weather by a slight change in behaviour.

Did we insult the weather gods? Did we get too close to their jurisdiction? Was it Hybris to even suggest and discuss a plan for how to avoid climate changes? The answer is blowing in the cold wind.

In times of uncertainty and even despair, it is nice to know that we have ACTA – the journal that publishes only scientific papers. Even if this issue of ACTA does not provide evidence that changes the World, it may give you some thoughts and ideas to come closer to an understanding of the nature of women, and the results of our care and interventions.

In this issue of ACTA you will find an invitation to come to the European (EBCOG) and Nordic (NFOG) meetings this late spring. The chairman of EBCOG, Peter Hornnes, appraises the state of the current level of collaboration and harmonisation within Europe: It is too soon to have common European guidelines – they are simply unattainable. However, EBCOG wants to develop common standards – not to regulate the actual medical treatment – but to set up a framework to point out which issues we need to address and how. Examples of such standards are found in the guest comment.

A European project on serious rare complications at delivery has been initiated by Marian Knight and Peter Brocklehurst from NPEU, Oxford. The project is based on reportings from delivery units in UK, who does not collect background data like the Nordic countries. In this issue of ACTA, colleagues from Italy (Stivanello et al.) report on peripartum hysterectomy and how far you can get with routine registration, without prospective collection of data in a specific project.

The Nordic countries have started to collect case based data on peripartum hystertectomy, uterine rupture, placenta accreta and excessive postpartum bleeding using identical specific questionnaires – the NOSS project ( – and will in this way update our knowledge on risk factors and current treatment modalities in these serious complications. We already have information on the background population and medical history and follow up in cases and controls in our medical birth registries and patient registers, which will enable us to get a more complete picture of the consequences of different attitudes towards cesarean delivery in obstetrics.

In a commentary three UK researchers convey a dream that serum biomarkers may be used for a diagnosis of ectopic pregnancies in the future. Admittedly, we will need a lot of research before we have a kit – and we still need to select the women to test.

Bols et al. have written an outstanding and very detailed systematic review of longitudinal studies on fecal incontinence after delivery – one of the subjects raised when we discuss mode of delivery and when we repair sphincter ruptures. They found that a third or fourth degree tear was the only factor that was associated with subsequent fecal incontinence. Now we only need good studies on how to prevent the ruptures – it seems that good Norwegian studies are on their way.

Tyldum et al. in a well-defined cohort could not find any protective effect of pre-pregnancy physical activity on preeclampsia risk. This is an important message to convey to the prepregnant women who are on endorphins. The study is a good example of well-designed studies that profit from our routine registration for follow up in the Nordic countries. But we still need good research on the effect on physical activity during pregnancy.

Röösst et al. present data from Bolivia – the first study to present socio-demographic factors related to near-miss morbidity in a low-resource setting. They find that non-attendance to antenatal care is associated with increased risk of severe maternal morbidity, and conclude that targeted initiatives to increase routine ANC may reduce severe maternal morbidity and mortality, both in urban and rural areas. Hopefully this important message will reach the Bolivian authorities and health care politicians – and that the study will create awareness in other countries with the same problem as well.

Staboulidou et al. have introduced structured ultrasound training courses for identification of fetal malformations in Germany. The trainees felt that they had improved knowledge after the course and that the course was appropriate. Also, they had improved scores on a 10 multiple-choice questions on fetal malformations. The quality is measured by a questionnaire and not by identification of fetal malformations in ultrasound images – but the questionnaire score is probably a good proxy variable for “the real thing”. But the results are not surprising – training is good – and there may come a time when we expect educational research papers to include a comparison with other types of training and measure the impact on “real life”.

Some colleagues apparently believe in prophylaxis of very high doses of steroids preoperatively to women with drug allergy before they have elective caesarean section. Antonio de Vivo et al. have studied 212 consequetive women and found that body mass index, wound length and corticosteroid administration correlated with wound complications.

Cytokines have been extensively studied in the recent decade. However, in this issue of ACTA, Roland et al. present the first demonstration that IL-18 is potentially linked to oxidative stress in preeclampsia, since its level correlates with the concentration of the powerful antioxidant CoQ10. These results also associate the immune system with the oxidant/antioxidant imbalance observed in preeclampsia. The complex association between the immune system and preeclampsia will probably be a favorite research object for many years to come. Some days it fills you with joy and sometimes you think of all the resources spent.

Even though you sometimes get high from reading scientific papers, in these days the Danes may also take the advantage of having a real winter and enjoy the fresh air and endorphins in the skitracks – shared with pedestrians and horses that are not used to respect these parallell lines in the trails.

Points for observance:

Focal intracavitary lesions are common in women with abnorma lpre-menopausal bleeding that is not responding to usual medical treatment and minimally invasive options provide a useful management option (pp. 367–372).

Laparoscopic cystectomy of dermoid cysts in premenopausal women is a safe procedure (pp. 390–392).