Editors Choice

DOI: 10.1111/j.1471-0528.2011.03140.x
www.bjog.org

Editors Choice
Stress and pregnancy outcome
Pregnancy can of itself be stressful. Many
women are troubled, some severely, by a
multitude of pregnancy-related symptoms,
from hyperemesis through sciatica to insomnia. An important role of the obstetrician is
to differentiate pathology from physiology,
and when symptoms are physiological, to
reassure the woman by explaining that the
symptoms commonly result from changes to her
physiology that benefit the fetus. For example, one can describe the relationships between
plasma volume expansion and swollen ankles,
and hyperventilation and shortness of breath/
muscle cramps, and explain that correcting
these changes would be harmful to the baby.
Unfortunately, many women are subjected
to external stresses that affect pregnancy
adversely, such as war, natural disaster, abuse
in childhood, rape and physical assault.
Although some women are resilient enough
to return to normal functioning once the
stresses are relieved, a significant proportion
continue to experience functional disturbances sufficient to be classed as having
post-traumatic stress disorder (PTSD). Even
in parts of the world not affected by war or
natural disaster, PTSD is surprisingly common. For example in one study from the
superficially idyllic Island of Oahu (near
Hawaii, with a population approaching
1 million and containing the city of Honolulu, and Pearl Harbour) it was found to
affect one in 12 pregnant women (Morlan
et al. Psychosomatics 2007;48:3048). Apart
from its inherent undesirability, does PTSD
affect the physical outcome of pregnancy?
This question is addressed on page 1329 by
Seng et al. They found that women with current PTSD had babies that were, on average,
283 g lighter than a trauma-exposed but
resilient cohort (with no persisting PTSD),
and 221 g lighter than a non-traumaexposed cohort. Although some important
confounders such as low educational status
and pre-existing chronic medical conditions
were taken into account in their multivariate
analysis, it is necessary to demonstrate a causal pathway before it can be assumed that

preventing PTSD will improve birthweight.

On page 1339, Dimitrios Siassakos in his
Journal Club article highlights the fact that
more prenatal care was not associated with
better outcomes, and asks the key question;
what can be done to improve matters? John
Thorp in his commentary on page 1283 suggests a number of intervention trials that
could be carried out to see if birthweight can
be improved by treating the condition. On a
related theme, Flach et al. on page 1383
studied 13 617 mothers and their babies during pregnancy and at 42 months postnatally.
They found that domestic violence during
pregnancy was associated with maternal
depression, both during pregnancy (odds ratio
4.02) and postnatally (odds ratio 1.29), and
moreover was associated with an increased
incidence of behavioural problems in the
child at 42 months (odds ratio 1.87). Longterm prevention of PTSD and domestic
violence will involve politicians and social
interventions as much as action by doctors
and midwives, but we can at least draw
attention to the problem and act as health
advocates.

Vitamins and cervical cancer

The importance of vitamins for human
health was first conclusively demonstrated in
the 18th century when James Lind performed what is regarded by some as the forerunner of the randomised controlled trial
(he did a controlled trial but without a formal randomisation procedure), which
showed that using lemons and limes (containing vitamin C[itrus]) was effective for
treating scurvy. This innovation in the British Navy gave rise to the use of the term
limey as a nickname for British sailors. In
the next century came the use of fish oil to
treat rickets. But the isolation of pure vitamins only took place in the years between
1913 and 1941. Their dramatic potency in
curing deficiency syndromes led to widespread enthusiasm for their use in everything
from preventing/treating the common cold
(which for double Nobel laureate, Linus
Pauling, became an obsession, see JAMA

2011 The Author BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG

1971;24:12949) to the prevention of preeclampsia (another false dawn). Pauling in

conjunction with the British surgeon Ewan
Cameron also introduced the idea of using
vitamin C to treat cancer (Cameron and
Pauling. Chem Biol Interact 1974;9:
27383), although controlled trials subsequently showed no benefit (Creagan et al.
N Engl J Med 1979;301:6879). On page
1285, Seung-Kwon et al. report the results of
their systematic review of casecontrol studies of the association between vitamin or
antioxidant intake and the incidence of cervical cancer. They found a significant preventive effect (i.e. a lower incidence with a
high intake) in relation to B12, lycopene,
vitamin E, folate, vitamin C and beta-carotene (arranged in order of decreasing preventive efficacy). Linus Pauling would no
doubt have been pleased with their findings.

Wheezing and puking in pregnancy

About one in 10 pregnant women have
asthma. A meta-analysis of its effects by
Murphy et al. on page 1314 suggests that it
is associated with an increased incidence of
low birthweight, smallness for gestational
age, preterm delivery, and pre-eclampsia.
However, these associations could be
reduced to non-significant levels by active
asthma management. In my clinical experience, many women use insufficient steroid
inhalations during pregnancy, perhaps
because they are concerned about adverse
effects of steroids on the fetus. They should
be advised that the risk of the asthma is
greater. In contrast, regular use of beta
stimulants can have adverse long-term
cardiovascular effects, and should be discouraged. A key symptom is shortness of
breath at night, and the dosage of inhaled
steroids should be increased until the
symptom disappears.
Although suggested benefits of early pregnancy nausea include avoidance of ingestion
of potential teratogens, and hypertrophy of
the placenta consequent upon reduced calorie intake, leading to improved fetal growth
later in pregnancy, there is more concern

Editors Choice

when the vomiting becomes severe and the

condition is then labelled hyperemesis gravidarum. The meta-analysis by Veenendaal
et al. on page 1302 reveals that this condition is also associated with an increased incidence of low birthweight, smallness for
gestational age and preterm birth. These
effects may be mediated through reduced
pregnancy weight gain. Interestingly, affected
women were more likely to give birth to a
girl (odds ratio 1.27, 95% CI 1.211.34).
How should you assess the severity of a
womans condition? The most widely used
tool is the wonderfully named PUQE index
(pregnancy unique quantification of emesis/
nausea score, based on the number of daily
vomiting episodes, the length of nausea per
day in hours, and the number of retching
episodes), which has replaced the previous
standard measurethe Rhodes score (Koren
et al. Am J Obstet Gynecol 2002;186:S22831).
As with asthma, their findings suggest that effective treatment is important not just to relieve
symptoms, but to improve pregnancy outcome.

Post-operative peeing
If a woman has retention of urine following
removal of the urinary catheter after vaginal
hysterectomy, would you manage her with
a further spell of an indwelling catheter, or
recommend clean intermittent catheterisation? Perhaps you should consult her before
deciding? The paper by Hakvoort et al. on
page 1324 shows that women would much
prefer clean intermittent catheterisation,
even when there is a significant risk of urinary tract infection.

Antibiotics in pregnancy and adverse

outcome
The Oracle II follow-up study showed that
administration of erythromycin and co-amoxiclav to women in threatened preterm
labour significantly increased the chance of
their children later developing cerebral palsy
(Kenyon et al. Lancet 2008;372:131927).
On page 1374, Santos et al. report that use
of sulfamethoxazole/trimethoprim in the last
two trimesters of pregnancy increases the
risk of babies being small for gestational age
(odds ratio 1.61, 95% CI 1.162.23) whereas
other antibiotics showed no such relationship.
This represents another argument for only
treating women with antibiotics during pregnancy when there is clear evidence of likely
benefit, and never giving antibiotics just in case.

Changes to the editorial structure of

BJOGand other improvements
In the years since I have been editor-in-chief
of BJOG, our Impact Factor has increased
from 2.126 in 2006 to 3.349 in 2010, and our
ranking among journals specialising in
obstetrics and gynaecology has risen from
seventeenth to sixth (second among general
journals publishing original research). Our
Immediacy Index ranking (the average number of citations of articles in the year of publication) over the same period has risen from
tenth (Immediacy Index 0.432) to second
(Immediacy Index 1.142), giving us the top
rank among obstetrics and gynaecology journals publishing original research. The number of main articles submitted to us each
year has risen from just over 500 to 900, and
the number of systematic reviews has risen
from 25 to over 80. To cope with this additional work, the number of scientific editors
(including trainees) has risen from 12 to 30.
We pride ourselves on the quality of our refereeing and editing, overseen by managing
editor Emily Jesper and her assistant Lizzy
Hay. Dave Atha conducts the manuscripts
speedily through our electronic Document
Management System (AllenTrack) while our
Publishers (Wiley-Blackwell) offer free copyediting for a proportion of accepted papers
(particularly helpful when authors do not
have English as a first language).
To recognise the increasing stature of
BJOGand also the increasing workload
for the Editor-in-Chiefthe Royal College
of Obstetricians and Gynaecologists has
now appointed three deputy editors-inchief, who will further increase the speed
and detail with which submissions are
evaluated and improved. This process is
what distinguishes papers in our journal
from unevaluated postings on websites
(whether they be institutional or individual), where quality assurance is largely
absent. Current deputy editor Mike Marsh
is having his job description expanded, and
he will be joined in evaluating maternity
papers by John Thorp. Mike Marsh is a
consultant obstetrician and gynaecologist at
Kings College Hospital, London, UK, and
Honorary Senior Lecturer at Kings College
School of Medicine, London, and the Institute of Psychiatry, London, UK. John M
Thorp is McAllister Distinguished Professor
in the Department of Obstetrics and Gynecology and Division Director for Womens
Primary Healthcare at the University of

North Carolina, USA. Gynaecological

papers will be dealt with by Pierre MartinHirsch, consultant gynaecological oncologist at Lancashire Teaching Hospitals Trust
and Regional Network Lead Clinician for
reproductive and childbirth research. This
major increase in staffing will allow us
to consider in even more detail how to
enhance the service we provide to authors
and the added value the journal provides to
its readers. This is what justifies the cost of
subscription to the journal! Our mission is
not just to select and validate, but also to
improve readability and presentation of
data, making the job of keeping up-to-date
easier for our readers.
Some examples of developments to
improve the way we communicate material
submitted to us that we have already
achieved, or which are in the pipeline,
include: special issues and virtual issues
(available on our website, for example, journal club papers, gynaecological oncology,
papers from India, international reviews,
most cited) bringing together papers with a
specific focus. In any spare half an hour, you
can listen to our podcasts, either online or
downloaded. You can be friends with us on
Facebook (www.facebook.com/pages/BJOGAn-International-Journal-of-Obstetrics-andGynaecology/145874402142037), or follow
us on Twitter (https://twitter.com/#!/BJOG
Tweets), and thereby keep up with our rapidly developing services. Our planned video
channel will be accompanied by a BJOG
mobile App, giving rapid access to article
abstracts. You can also sign up to e-TOCS
(electronic table of contents, www.bjog.org/
details/news/1075169/Sign_up_for_new_BJOG_
content_alerts.html), alerting you each month
to our latest papers, and receive our e-Newsletter.
Our long-term aim is to become the
major international portal by which the
global obstetric and gynaecological community will keep up-to-date with the latest
developments in our specialty. We will continue to prioritise the publication of original data, supplemented by reviews and
commentaries on recent innovations. We
intend to make access to this information
as easy and enjoyable as possible. If you
have any comments on our current
performance, or our future strategy, please
e-mail me at p.steer@imperial.ac.uk. j

Philip Steer
Editor-in-Chief

2011 The Author BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG