BJOG Editor's Choice

Abstract

The 24/7 news cycle in broadcast and web-based journalism has flooded the world with pundits issuing their opinions after every factual report. As a cynical observer, I have often wondered whether their role is to advance knowledge with their diversity of opinions or whether it is just a filler to lead to the next commercial. What used to be a pleasant interlude now seems like mandated mediocrity with one commentator in agreement, one disagreeing, and one not so sure. BJOG takes a decidedly different view of commentary. When we accept or commission a commentary, or its less lengthy cousin the mini commentary, our hope is to enhance the reader's experience by putting an individual article and its conclusions into a broader perspective. We often present contrary perspectives brought up by peer reviewers that the reader does not have the benefit of seeing. The article from Tanzania on page 940, which found that three out of ten women experience physical or sexual intimate partner violence during pregnancy, and the associated mini commentary (page 947) are a great example of the synergy for which we are striving. Our commentator succinctly reviews the world's literature, delineates how this report fits into other prevalence estimates, compares different assessment methods, and contrasts industrialised countries with the developing world. Dr Martin then calls for more randomised trials of interventions to reduce violence. The interested reader is quickly brought up to speed by a world expert. Many of our articles undergo statistical or epidemiological methods reviews in addition to a clinical content review. Often we want to share with our audience the insights of the methods experts. On page 915 Joshi et al. give us all a methods tutorial on missing data in clinical trials. They not only define missing data but describe its ability to bias findings and diminish precision. Moreover, they give us instruction on how to handle missing data in our trials. Finally, and rarely, we publish unsolicited commentaries not related to articles when the commentator presents opinions of universal importance with conclusions that are generalisable to most of our audience. This is a hard needle to thread, but Ray Garry was able to pull this off in his commentary ‘An obstetrician reborn’, on page 911. His thoughtful essay addresses mid-career burnout and presents the major impact that a skilled obstetrician and gynecologist can have in a developing country. We hope it will not only inform but inspire colleagues to get involved. Nezvalová-Henriksen et al. explore the impact of four nonsteroidal anti-inflammatory (NSAID) drugs (ibuprofen, diclofenac, naproxen and piroxicam) on pregnancy outcome (page 948). Use of the medicines was extremely common in a Norwegian cohort, with over 7% of pregnant women taking one of the four drugs. Drug exposure had no impact on congenital malformations or infant survival. There were weak but positive associations between ibuprofen use and childhood asthma and diclofenac use and vaginal bleeding. Whether these are biological effects of the drugs themselves or ‘confounding by indication’ cannot be determined in a cohort study such as this. Confounding by indication might occur if an inflammatory condition in the mother prompted NSAID use and was associated with inflammatory disease in their offspring. All things considered, this paper should be reassuring about the lack of harms in the large proportion of women who need these medications while pregnant. The revolution in the virology and immunology of human papillomavirus infections has led to major advances in the sensitivity of screening and the ability to immunise against infection. The end result of the progress is an increased ability to prolong screening intervals, avoid screening in very young women, and delay or avoid treatment of low-grade dysplasia. On page 960, Spracklen et al. demonstrate another reason why this progress should help reproductive performance. In their case–cohort study, women with cervical surgery, specifically an excisional procedure, had a two-fold higher risk of prolonged subfertility. They elegantly added a set of women with abnormal cytology, colposcopy and no excisional procedure to their analysis to control for confounders such as smoking or sexuality that could have influenced their results. Women in the colposcopy-only group had a normal time to pregnancy. Epidemiologists should keep that methodology in mind for future analyses and clinicians now have another harm to consider before moving to excision of dysplasia. Funding cycles and career lengths make most of us power our trials to answer questions about immediate results and harms. More often than not, long-term outcomes are not sought after nor waited for. Herman et al. (page 966) took the radical step of following women for a decade after a trial in premenopausal women comparing bipolar with ball endometrial ablation. In contrast to 1-year and 5-year results, the superiority of bipolar ablation disappeared and two out of three women in both study arms had amenorrhoea. Satisfaction was high and equivalent with both techniques. From our patients’ perspectives the duration of benefit would be crucial in their decision making and the high rates of satisfaction at 10 years would allow many women to forego hysterectomy and use either procedure to bridge to a natural menopause. The American College of Obstetrics and Gynecology and Academy of Pediatrics monograph on Neonatal Encephalopathy and Cerebral Palsy, which was endorsed by the Colleges of Australia, New Zealand and Canada made an arterial cord gas an ‘essential’ criterion to establish the intrapartum causation of cerebral palsy. Arterial pH must be <7.0 with base deficit above 12 mmol/l to draw that conclusion. The specimen could be obtained up to 30 minutes from delivery in a clamped cord segment. On page 996, Mokarami et al. turn this on its head and show that samples obtained even 45 seconds after delivery show declining pH and rising lactate levels. The phenomenon was more pronounced after vaginal delivery when compared with abdominal delivery in the absence of labour. Moreover, vigorous newborns had greater drops than depressed babies. Experiments such as this show us the difficulties inherent in establishing reference ranges and thresholds. Office gynaecology has relied for decades on the annual ‘Pap smear’ and bimanual examination to produce a steady flow of patients year after year. With the advances in cervical screening described above, cervical cytological screening intervals are ever-widening, and the limited clinical value of bimanual examination in asymptomatic women, makes the case for annual examinations harder and harder to make. Grewal et al., on page 1016, hammer another nail in the coffin lid and show that by history alone, primary-care clinicians can accurately triage women to reassurance or imaging of their ovaries as part of the clinical pathway in the diagnosis of ovarian cancer. This was all achieved without physical examination. Rather than curse progress and its impact on our clinical volumes, and revenue in the USA, we will need to discover our own set of ‘clinical commentaries’ to add value to patient visits and maintain our roles as women's healthcare providers.