From preterm birth, placenta and thyroid to the perineum

June this year features the 36th NFOG Congress in Reykjavik, Iceland. It promises to be an excellent event, with well over 700 participants registered. Just as Acta in its 87th year of existence, it is a sign of the vitality of obstetrics and gynecology in the Nordic countries that there has been a unifying congress 36 times during a period of 70 years. The peace and stability in the Nordic countries are reflected in this activity as well as in Acta, and fortunately there are many parts of the world where similar efforts are taking place. The medical community has also an international dimension that is truly remarkable. There is a number of European and worldwide venues that are well established, headed in our speciality by FIGO, with its next world congress in Capetown, South Africa in the fall of 2009. There is a great interest in international meetings among almost all obstetricians and gynecologists, with an ultimate benefit to our patients. Ramkumar Menon from Nashville, Tennessee, USA, working with an active research group in Aarhus University, Denmark, starts off in this issue with a thorough review on some major aspects related to the onset of preterm birth (pp. 590–600). He emphasises the heterogeneity of preterm birth with respect to causative mechanisms, as well as calling attention to its varied clinical presentation and probable genetic susceptibility. Like so many other common syndromes preterm birth is not just one condition, but may have several clinical aspects leading to the same difficult situation: a woman in preterm delivery. The different pathophysiological causes of preterm birth include an adverse vaginal microenvironment, immunological factors in the cervical mucus, excessive sensitivity of the uterine smooth muscle or maternal illness. Sociodemographic factors and genes also influence the risk of preterm birth. So far we lack, however, comprehensive understanding of what brings about spontaneous preterm labour. Though less than two percent of the children in Western countries are born before the 32th week of pregnancy 1, they make up for the bulk of costs in neonatal care units. Many do not survive, others will have severe dysfunctions 2, although the majority will be healthy or have only minor problems. While the rate of preterm birth has been increasing, as mentioned by Dr. Menon, the outcomes for the children are fortunately steadily improving. This review is good reading not only for obstetricians but also for those gynecologists who are faced with advising women on their reproductive chances. Take some moments to study the figures on pages 592 and 593. Pre-eclampsia is a mysterious disease that occurs in pregnancy only. Placental dysfunction is assumed to be a major cause of pre-eclampsia. However, what kind of dysfunction leads to pre-eclamspsia remains unclear. It has been suggested that early onset pre-eclampsia represents a different entity to the pre-eclampsia presenting at term. If this is true, the degree of placenta involvement in the disease pathogenesis may differ in preterm and term pre-eclampsia. The role of placenta in pre-eclamspsia is, however, difficult to study since we still lack knowledge on many normal aspects of placental function. Placental weight may be one indicator of function. In the study by Dahlstrøm et al. (pp. 608–611) the association between placental weight and pre-eclampsia was studied in more than 300 000 singleton pregnancies in Norway during 1999–2005. The weight of the placenta at delivery was adjusted for length of gestation. Four percent of the women were diagnosed with pre-eclampsia. Less than one third of these cases occurred before the 37th week of pregnancy, and in this group low placental weight was more common than in pregnancies without pre-eclampsia. In pregnancies with term pre-eclamspia both small and large placentas were overrepresented. In fact, the mean placenta weight was higher in pregnancies with term pre-eclampsia as compared to pregnancies without pre-eclampsia. This finding supports a hypothesis of preterm and term pre-eclampsia being different entities. However, it also raises many new questions. What causes the variation in placental weight and what is the association between weight and function? If term and preterm pre-eclampsia represent different entities, is the clinical course for the mother and the child also different? The study by Dahlstrøm et al. should encourage studies looking at possible differential mechanisms related to placental function that may lead to pre-eclampsia. An article from London, Leuven and Sidney (Emma Kirk and co-workers, pp. 601–607) presents results from chlamydial screening among women with early pregnancy problems. Chlamydia is a disease of the young, as demonstrated again in this study. where approximately ten percent of the women under the age of 25 years carried the bacteria in the lower vagina, and thus presumably in their cervical secretions. If this reflects a degree of intracervical infection, at least near the external cervical os, it may not necessarily be associated with morbidity, particularly not in younger women. Chlamydia screening of all women in early pregnancy with bleeding or pain was not shown to be beneficial. However, in young, non-pregnant and pregnant women screening is cost-beneficial. Then it is necessary to remember that partner tracing and treatment is of importance to control an epidemic with potentials for causing damage to fertility, both on an individual and a population level 3. Globalisation imposes new demands on doctors, and knowledge of the distribution of disease in other continents may be of importance in clinical practice. The risk of placenta previa in North-American ethnic groups is presented on pages 612–616 (Qiuying Yang and colleagues from Ottawa, Canada). Their study population included more than 16 million deliveries. Beforehand one would have thought that the incidence of placenta previa was similar across ethnic groups, but it is not so. Asian women have a higher risk, about double that of Caucasian women. Possible explanations are well discussed by the authors and worth noting. Birgitta Norstedt Wikner and co-workers from Stockholm and Lund, Sweden (pp. 617–627), have looked carefully at women with hypothyroidism in pregnancy, on thyroxine substitution, and whether there is an obstetrical risk to to the mother or of adversities to the infants. This study is also based on a large study sample. About one percent of the pregnant women took thyroxine and this group had modestly more complications during pregnancy or at delivery, although the risk to the infants was minimal or not existent. Still, these findings cannot be ignored in clinical practice. There are associations between hypothyroidism and co-morbidity in the mother, infertility, miscarriage, induction of labour and increased cesarean section rates, which both gynecologists and obstetricians need to be aware of. Some women continue to bleed heavily after vaginal delivery or cesarean section, even when all first-line methods to control bleeding have been used. Very little is known about risk factors for excess postpartum hemorrhage, hence the women who will need extra care are not easy to identfy. The study by Hatem Mousa and colleagues from Liverpool, UK (pp. 651–661), features a useful figure showing the clinical steps in management of both primary and secondary life-threatening bleeding. Look at page 653 and note the discussion on the various causes of excess postpartum bleeding identified in the study. Acta publishes this month two complimentary articles on anal sphincter injuries and their assessment. It is important to understand why such injuries occur, appreciate their long-term consequences and offer the best primary and secondary management to our patients. Team-work is essential in treating injuries that may give different symtoms. Teamwork should also ensure better quality control, research and above all teaching, to maximize prevention and improve surgical reconstructive surgery (Ingrid Olsen and colleagues, Bergen, Norway, pp. 669–674). Points for observance: Pre-eclampsia is associated with maternal hyperlipidemia that may have an adverse impact on the fetal lipid profile. If persistent it could affect future cardiovascular risk (pp. 628–634). Women heterozygous for factor V Leiden have an increased risk conferred from the maternal side for developing HELLP-syndrome, but there was no relation to polymorphism in the genes governing prothrombin or the folate reductase biomechanisms (pp. 635–642). REGISTERING FOR THE ONLINE VERSION OF ACTA OBSTETRICIA ET GYNECOLOGICA SCANDINAVICA For NFOG members. To register for the online version ofActa Obstetricia et Gynecologica Scandinavica: Go to the journal website http://www.informaworld.com/aogs In the dark blue stripe at the top of the screen, just above the journal name, there is a button called ‘Register’, click on this button. You will be redirected to a page called ‘My Account’, where you should choose the option ‘Personal registration’. The next page is called ‘Create Account’, where you should complete all the mandatory fields with user information (full name, address, postal code, country and region. E-mail address is of course the most important parameter). You will be asked to choose a User name and Password. Remember to tick the box for ‘No third party contact’ and ‘Opt out of marketing emails’ if you want to make sure not to receive any information regarding other journals or books published by Informa Healthcare. 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You will be given some options here, but choose ‘Issue alerts’ and then search for the journal name to sign up for the e-mail alerts (you will receive an e-mail with the table of content of each issue, with direct links to the articles). You may also add ‘iFirst alerts’, to be notified when articles not yet included in a printed issue are published. If you have any further queries about the online services, regarding the registration of your account or alert services, please contact support@informaworld.com for guidance. Informa Healthcare is the publisher of Acta on behalf of the Nordic Federation of Obstetricians and Gynecologists (NFOG).

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