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• W2084080896 abstract "As you receive this April issue the scent of spring is already in the air in the southern part of the Nordic countries, let alone more southerly parts of Europe, while further north we are still enjoying the remains of winter. In many ways it is quite a wintry time with a worldwide economic crisis, which forces us belatedly to re-evaluate many of the things we have taken for granted. Our ways of life have come at a price in the more affluent parts of the world. In other and poorer countries life goes on much the same, with less, and in places almost nothing. We are also approaching a world summit on climate change in Copenhagen later this year where world leaders will grapple with the other major concerns of our time. Can we as obstetricians/gynecologists do anything from the viewpoint of our profession in a positive way to ease the pressure on the world climate, even in minor ways? Every little thing counts. Should we review what we use and prescribe in terms of chemical substances? Should we reassess the way we use electricity in our institutions, disposables, water and how we deal with hospital refuse? Or how much we spend on flying to conferences? Is it time for us as a profession to lead the way again in medicine? We have done so before, with laparoscopy, contraception, effective screening, changing old habits as a result of evidence-based medicine and more. Could a forum be created where obstetricians and gynecologists were to raise professional climate- and resource-related issues and debate actively the way forward? If any medical specialty is connected to life it is this one. An Acta Commentary this month centers on the timing of postoperative chemotherapy after primary surgery for ovarian cancer. According to Erling Larsen and Jan Blaakær of Aarhus, Denmark (pp. 373–377), surprisingly little is known about this, but conceivably it could be quite critical. Most colleagues treating these so vulnerable patients probably go by what they learnt from their peers or by what they think is best for the individual patient. Here is clearly an area identified that needs much more research and is an ideal setting for prospective randomized studies. The handling of triplets is by no means a straightforward issue and it is often necessary to draw on studies of twins or singletons or on the assembled experience from a series of such pregnancies as Romain Guilherme and colleagues from Paris do (pp. 386–390). What they show is that early referral to centers of excellence is necessary, i.a. to ascertain chorionicity so that levels of risk for adverse outcome can be assessed confidently and antenatal care tailored to this. One problem that is persistent in fetal medicine is the difficulty in distinguishing between small-for-gestational age and intrauterine growth restriction, the first term being based on birthweight with variable cut-off levels where the 10th centile is really not good enough, and the second a syndrome with some definite characteristics. These authors, as so many others, had difficulty in making this distinction, without which a basis for management is more problematic. For some 30 years a solution has been called for pre- and postnatally and is still not there. The study by Cecilia Ekéus and coworkers from Stockholm, Sweden (pp. 397–401), on epidural analgesia is a good example of what may be achieved when a clinical observation and query is combined with the assets provided by one of the Nordic medical birth registers. The results of this observational study is that women with large infants will more often need epidural anesthesia and that prolonged labor and increased use of instrumental delivery, usually attributed to the epidural, can be explained by fetal size. Unfortunately, the authors were not able to include acute cesarean deliveries, which might have strengthened the results. Here we have another example of a study that should and could easily be replicated in another Nordic country where information on acute cesarean delivery in women with intended vaginal delivery is available in the national birth registry. This is a thought-provoking study, with a good hypothesis and a good way of changing focus from the potential adverse effects of epidurals to selection bias. Clearly some of the adverse influences ascribed to epidural anesthesia, such as prolonged labor and instrumental delivery, may in fact have more to do with fetal size. Hanne Kjærgaard and colleagues in Copenhagen have attempted the difficult task of analyzing inadequate progress in labor in women where everything could have been expected to be normal (pp. 402–407). How this should be done is controversial and the article drew comments from it's two international reviewers as to the definition of dystocia and the way the study material was selected. At the same time it must be acknowledged that it is an issue that needs more research and there are different approaches and views as to how such research may best be conducted. In the end we were satisfied with the presentation of the material and its value. One-third of the women delivering their first child experienced dystocia and delivery was not straightforward. This applied to both the first and, not least, the second stage of labor. Did we know this before? Yes, but vaguely, and here we have figures and good background data and discussion. Women who have intellectual disability may easily be left out of the main concern of health professionals. It is therefore of use to have the article by Maria Arvio and colleagues from Lammi, Lathi and Helsinki, Finland (pp. 428–433), who have investigated the bone density status and hormonal profiles of a group of such women given progesterone-only contraceptives. There are risks in suppressing estrogenic activity in order to achieve endometrial atrophy and amenorrhea. Gynecologists advising on the treatment of these women must be aware of this potential long-term complication. There are several cancer related articles in this issue, all with important messages on risk, diagnosis, and treatment. Nan-Hee Jeong and colleagues at several Korean centers suggest that antioxidant micronutrients acting against oxygen-free radicals of the carotenoid type are lower in women with endometrial cancer (pp. 434–439) and may have a similar effect in ovarian cancer (pp. 457–462). Gabrielle Hölscher and co-workers from the Munich Cancer Registry in Germany attribute improved survival in sex-cord stromal tumors of the ovary to better and earlier diagnosis and improved surgical methods (pp. 440–448), while Marie Soegaard and coworkers in Copenhagen and Aarhus, Denmark and London, UK (pp. 449–456), show that ovarian cancer in a first-degree relative is a stronger risk factor for early-onset (<50 years, OR 5.3) ovarian cancer compared to later onset/discovery of the disease, in particular as regards non-mucinous tumours. Then Tomasz Milczek and colleagues from Gdansk, Poland (pp. 463–467), review their experience of intraperitoneal chemotherapy in ovarian cancer. This quite difficult and potentially toxic second-line treatment is currently again under debate and should not be overdone as it may outweigh any benefit for survival 1. Again an area where prospective multicenter randomized studies are needed and should be feasible. In this months Short Reports, the experience of transabdominal cerclage from Lea Thuesen and co-workers in Copenhagen, Denmark (pp. 483–486), is likely to attract attention, not least because of their claim that this should be a first-line operation for suspected cervical insufficiency, rather than the transvaginal route. It would be surprising if all those with experience of transvaginal cerclage would be willing to abandon that procedure, which for so long has been a mainstay of dealing with cervical insufficiency. Interval laparoscopic abdominal cerclage is being developed and will be increasingly useful. As an alternative to open surgery that would be an option. But it is necessary to compare this prospectively to the established transvaginal and even the transabdominal methods done in pregnancy. A multicenter study would be required as the patients are fortunately not so many (<0.5% of pregnancies) 2. At the end of the issue the Letter section is larger than usual, and should not be bypassed. In particular, we call attention to the exchanges on post-partum hemorrhage management. With reference to the December-Editorial in AOGS 3, there are two retraction statements for which no comments are needed. Postoperative infections are not prevented by chlorhexidine vaginal cleansing and vaginal saline alone might increase the risk (pp. 408–416). Sleep disturbances during the climacteric may receive insufficient attention and treatment (pp. 422–427)." @default.
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