Health politics, placental proteins, preeclampsia and pneumothorax

You may be a little startled by this month's cover photo: a young woman with a syringe and needle. It is there to remind us of several current problems. One is the use of what sometimes are called ‘recreational drugs’. Of course, this has nothing to do with recreation, but rather leads to personal decline and tragedy, also for families and society, like the use of alcohol, which is marketed in a way that fuels overindulgence, and tobacco, which we featured in a similar sense in the April issue on tobacco and pregnancy. Hardly a day passes for us at work without encountering these problems in one form or another; and daily news do not leave these matters untouched. As obstetricians and gynecologists working largely with younger people we are in a unique position among fellow doctors, along with general practitioners and pediatricians, to do our bit to combat these ills early in life and work toward healthier individuals and a better society. The picture could also on a more positive note remind us of the necessity to proceed with human papilloma virus vaccination for young women, which has commenced in three of the Nordic countries. However, in Iceland there is only a decision to vaccinate, but not on when to start and no decision has been reached in Finland. There was a Nordic meeting in March in Copenhagen arranged to review national vaccination policies, which we will cover better in one of the next issues. In our profession we must often be proactive and advocate for the well-being of women. That way we also indirectly take part in leading change in other parts of the world where vaccination for HPV could save lives and resources to an even greater degree than in the Nordic countries. We start, however, on the matter of prenatal diagnosis, that is, pregnancy-associated plasma protein A or PAPP-A. This choroidal/placental substance, which already is measured in most pregnant women as part of the offer of early screening for chromosomal and few other anomalies, appears to hold potential as a marker for several pregnancy problems and could be useful in order to target antenatal care better. Ida Kirkegaard and her colleagues in Aarhus, Denmark (pp. 1118–1125), explain lucidly what this is about in a well-illustrated overview. To keep abreast of developments this should not be bypassed. Jaana Marttala and colleagues from Oulu, Finland, also publish their research on this very topic on pp. 1226–1228 and show this protein to be of potential use as a marker for stillbirth and intrauterine growth restriction. This is followed by a second overview article, from Stergios Doumouchtsis and Sabaratnam Arulkumaran in London, UK (pp. 1126–1133), on how to handle the morbidly attached placenta, an increasing problem in the wake of rising cesarean section rates. Prof. Arulkumaran, the RCOG president and a world-leader in our field, gave a lecture on this topic at last years FIGO-conference to a full house. That says all there is required. We are privileged to publish this article. There is considerable interest in how to control serious obstetric hemorrhage and the article by José Palacios-Jaraquemada and Angel Fiorillo from Buenos Aires, Argentina, on that topic (pp. 1222–1225) falls in line with this. Monique Brandes and colleagues in s'Hertogenbusch and Nijmegen in the Netherlands show again how assisted reproduction techniques contribute to multiple pregnancy rates (pp. 1149–1154). That this is a mixed blessing for subfertile couples has been realized in the Nordic countries. We have published on single embryo transfer and its benefits (1,2), where the Nordic countries have been in the lead. There are arguments for and against single embryo transfer, particularly for older subfertile women, but no one would contest that singleton pregnancy is clearly best for all; not least for women who are in the last part of their childbearing years. Official regulations are necessary in this field, but their interpretation and administration is a matter of medical policy, where doctors should lead. On pp. 1162–1167, Fang Xie and colleagues, who work in a group in Vancouver, Canada, known for research on preeclampsia, report on the inflammatory nature of the endothelial disease at the center of the manifestations of preeclampsia. The link to cardiovascular disease in later life, first introduced in modern times in this journal (3), is of much current interest (4) and this article centers on the possible link between a common childhood viral infection and damage that could predispose to later preeclampsia, probably given the existence of a set of genetic and immunological feto-maternal imbalances (4) that have to be present for expression of the disease phenotype. This viral inflammatory concept was introduced before by the same group in this journal (5). The article by Julia Spaan and colleagues in Maastricht, Netherlands (pp. 1202–1205), conveys a related important matter, again suggesting that women who develop high blood pressure in pregnancy fare worse than others in later life. Reduced renal function compared to controls is what this team reports, both after the index pregnancy and in later life. Is this a reflection of a genetic tendency, pre-existing infectious damage or damage from the hypertensive and/or preeclamptic pregnancy itself? This will no doubt continue as a focus for intense research in the next years. This journal often reminds readers in the Nordic countries and elsewhere of the problems that women face in the low-resource countries of the world, where diseases like malaria may be very prevalent. Chioma Oringanje from Calabar in Nigeria provides this months' reminder showing how pervasive malarial infestation can be (pp. 1206–1209). Screening for chromosomal aberrations in early pregnancy is the current gold-standard with nuchal translucency and biochemical screening combined. Helen Madsen and colleagues from Aarhus in Denmark suggest that this can be done even earlier than now, at 6–7 weeks amenorrhea (pp. 1218–1221). This may be indicative of a new development and worth noting, and it also has links to the PAPP-A story. There is less gynecology in this issue than there often may be, but the article by Päivi Härkki and colleagues from Helsinki, Finland (pp. 1192–1196), on endometriosis on the diaphragm and spontaneous pneumothorax that can occur at menstruation in these women, is a timely reminder of a serious condition. This condition is ‘catamenial’. Look at the Introduction of this article for an explanation of that word, unless you are among the minority who might know what it stands for. There is often merit in a thorough evaluation of such case series to cast light on the nature of a particular condition and how it tends to behave in clinical practice. Points for observance: Self-reported birthweight can be used as a proxy for actual birthweight when research is done on women in later life women, but is less accurate for low and high birthweight, which may underestimate true effects and the extremes of the weight range (pp. 1134–1139). Pregnancy has a moderate and positive influence on physical fitness and health half a year after delivery despite less regular physical activity during pregnancy (pp. 1140–1148). The apparent effect of parity on the occurrence of prediabetes is attributable to the confounding effect of maternal age rather than to high parity (pp. 1182–1186). Guidelines for medical termination of pregnancy are necessary if haphazard and personal preference regimens are to be avoided (pp. 1210–1213).

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