Boon Lim

The morbidly adherent placenta—a continuing diagnostic and management challenge

rats induced by fetal exposure to maternal low protein diets. Clin Sci (Lond) 1994;86:217–22; discussion 121. 42 Roseboom TJ, van dM, van Montfrans GA, Ravelli ACJ, Osmond C, Barker DJP, et al. Maternal nutrition during gestation and blood pressure in later life. J Hypertens 2001;19:29–34. 43 Torrens C, Brawley L, Anthony FW, Dance CS, Dunn R, Jackson AA, et al. Folate supplementation during pregnancy improves offspring cardiovascular dysfunction induced by protein restriction. Hypertension 2006;47:982–7. 44 Altobelli G, Bogdarina IG, Stupka E, Clark AJ, Langley-Evans S. Genome-wide methylation and gene expression changes in newborn rats following maternal protein restriction and reversal by folic acid. PLoS One 2013;8:e82989. 45 Bispham J, Gopalakrishnan GS, Dandrea J, Wilson V, Budge H, Keisler DH, et al. Maternal Endocrine adaptation throughout pregnancy to nutritional manipulation: consequences for maternal plasma leptin and cortisol and the programming of fetal adipose tissue development. Endocrinology 2003;144:3575–85. 46 Vickers MH, Sloboda DM. Leptin as mediator of the effects of developmental programming. Best Pract Res Clin Endocrinol Metab 2012;26:677–87. 47 Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry 2010;67:1012–24. 48 Reynolds RM, Personen AK, O’Reiilly JR, Tuovinen S, Lahti M, Kajantie E, et al. Maternal prenatal depression at critical windows during pregnancy is associated with increased placental serotonin and glucocorticoid sensitivity and transfer. Presented at DOHaD 2014: 8th World Congress on Developmental Origins of Health and Disease; 17–20 November; SUNTEC, Singapore.

McDonald transvaginal cervical cerclage since 1957: from its roots in Australia into worldwide contemporary practice

Cervical incompetence (or insufficiency) was first described in the 17th century in The Practice of Physick [Riverius L. et al. (eds), 1658, The Practice of Physick, Peter Cole, London] as the state whereby ‘the orifice of the womb is so slack that it cannot rightly contract itself to keep in the seed’. No well described technique for the management of this problem was documented until 1955, when V.N. Shirodkar, from Bombay, India, introduced the Shirodkar cerclage, in which the bladder was mobilised and a transvaginal purse-string suture was placed in women with recurrent second-trimester loss (Shirodkar VN. Antiseptic 1955;52:299–300).

A paradigm shift in the origin of ovarian cancer: the ovary is no longer to blame

ASHLEIGH MEYN, REGISTRAR, OBSTETRICS & GYNAECOLOGY, CANBERRA HOSPITAL, AUSTRALIA, BOON LIM, CONSULTANT, OBSTETRICS & GYNAECOLOGY, CANBERRA HOSPITAL, AUSTRALIA ....................................................................................................................................................................... O cancer is the most aggressive and lethal gynaecological cancer. High-grade serous carcinoma (HGSC) is the most common subtype, comprising 75% of ovarian cancers, and has the lowest survival rate. Most women with HGSC present with advanced disease (stage III or IV) at which time the 5-year survival is between 20% and 40%. There is currently no effective screening regimen for ovarian cancer and long-term cure rates have not changed dramatically in over 20 years.

From a finger on the pulse to modern technology—the transformation of healthcare in China

.................................................................................................................................................................. China, with nearly 1.4 billion people (22% of the world’s population), is the fourth largest economy in the world. Significant changes have occurred throughout its history, from the different dynasties, the Cultural Revolution (1966–1976), to modern economic reforms. The end of the Cultural Revolution brought modernisation to the health services. Socio-economic reforms and improvements in health services, infrastructure, staff capacities and reduced costs of service utilisation for the poorest saw a narrowing of the rural–urban gap in the provision of maternal healthcare services. Although governmental health expenditure has declined, health outcomes are continually improving. Better access to antenatal care has been provided, but women in rural areas remain less likely to attend. The gap has narrowed for intrapartum care as Chinese women consider birth in a hospital to be important (Wu et al. Matern Child Health J 2012;16:501–9).

The alleviation of pain: a surgical revolution

LEON FOSTER AND BOON LIM OBSTETRICS & GYNAECOLOGY, CENTENARY HOSPITAL FOR WOMEN AND CHILDREN, CANBERRA, AUSTRALIA ....................................................................................................................................................................... The alleviation of post-surgical pain has been the subject of investigation for more than a century. In the first volume and issue of BJOG, Arnold Lea, a clinical lecturer in Obstetrics at the Hospital for Women, Manchester, UK, reported on the growing use of intrathecal cocaine for the alleviation of pain during surgery, a technique strikingly similar to the modern spinal anaesthetic, that had first been used 3 years earlier (Lea BJOG 1902;1:71–88). Similarly, the next issue contained a case report of a third repeat caesarean section with only the infiltration of local anaesthesia into the skin for anaesthesia. The author noted ‘the first part of the operation was virtually painless. . .[but, not surprisingly] there was a good deal of pain during the abdominal stitching, especially in sewing up the fascia’. In women with sufficient ‘nerves’ this was deemed superior to a general anaesthetic, with its risks to both mother and child (Spencer BJOG 1902;1:138–41).

Conservatism in Gynaecology

‘C as a medical term has been described as “the power or tendency to preserve in a safe or entire state” and, therefore, conservative treatment of the uterus may be considered to include all forms of therapy which tend to preserve life and to conserve the function of the female sex organs’. This observation was made by Arthur Leyland Robinson (1887–1959), Professor of Obstetrics and Gynaecology, University of Liverpool, at the British Congress of Obstetrics and Gynaecology in Belfast in 1936 (J Obstet Gynaecol Br Emp 1936;43:634–54). Trained at University College Hospital, London, he was acting Major and surgeon during the war of 1914–18. Following this, he became honorary surgeon to the Women’s and Maternity Hospitals, Liverpool. He was President of the North England Gynaecological Society (1933– 34) and the Liverpool Medical Institution (1940–41). An astute clinical academic, he remarked: ‘the physician should not allow himself to be carried away by personal predilection for a particular procedure, but cultivate a broad outlook upon therapeutics and adapt his treatment to the requirements of the individual patient, choosing that method which offers the best functional result with the least risk to the patient and with minimal sacrifice of tissue’. These were arguably early concepts of evidence-based medicine and conservative management of gynaecological conditions.

Contraception – of potions, pills and social change

JACQUELINE BERRY, RESIDENT IN OBSTETRICS AND GYNAECOLOGY, BOON H LIM, CONSULTANT OBSTETRICIAN AND GYNAECOLOGIST, THE CANBERRA HOSPITAL, AUSTRALIA ....................................................................................................................................................................... T use of contraceptive methods is not a new phenomenon. Practices like coitus interruptus, vaginal pessaries made from crocodile dung and plant extracts and a wide variety of potions, spells and balms have been well documented in the history of virtually every ancient culture. Norman Himes (N Engl J Med 1934;210.11;576–81) postulated ‘the persistence of such folk practices for thousands of years is convincing proof of the thesis that women in all cultures in all ages have desired to control their fertility to have a reasonable number of children at convenient times and under the conditions desired’.

From culdoscopy to peritoneoscopy: a century of advancement in laparoscopy for minimal‐access surgery in gynaecology

Even over a century ago, clinicians recognised the benefits of inspecting intraperitoneal organs without subjecting the patient to a laparotomy. Early investigators described the procedure as ‘laparoscopy’ or ‘celioscopy’, but the first clinical reports named the procedure ‘peritoneoscopy’. Initial reports of peritoneoscopy were noted around 1910, mainly describing the inspection of the upper abdominal viscera. The visualisation of the pelvis remained poor, discouraging most gynaecologists from adopting the technique. Decker and Cherry (Am J Surg 1944;64:40–44) solved the problem with a vaginal approach, by putting the patient in the knee–chest position and inducing spontaneous pneumoperitoneum from the negative pressure created by the position. They perfected the instruments and technique, calling the procedure ‘culdoscopy’. Thomas Jeffcoate introduced culdoscopy into British practice in 1956 (J Obstet Gynaecol Br Emp 1960;4:529–538), describing the advantage of performing the procedure under local anaesthetic as an ‘out-patient’ or ‘office’ procedure: clearly ahead of his time! He maintained the patient in a knee–chest position with the old Clover’s Crutch, and then rolled the patient into position on the operating table (Figure 1).

Pregnancy after endometriosis: a new challenge?

Eastern Townships of Canada: impact of endometriosis. Gynecol Endocrinol 2014;30:34–7. 14 Hjordt Hansen MV, Dalsgaard T, Hartwell D, Skovlund CW, Lidegaard O. Reproductive prognosis in endometriosis. A national cohort study. Acta Obstet Gynecol Scand 2014;93:483–9. 15 Lin H, Leng JH, Liu JT, Lang JH. Obstetric outcomes in Chinese women with endometriosis: a retrospective cohort study. Chin Med J (Engl) 2015;128:455–8. 16 Kendrick SW, Douglas MM, Gardner D, Hucker D. Best-link matching of Scottish health data sets. Methods Inf Med 1998;37:64–8. 17 Fleming M, Kirby B, Penny KI. Record linkage in Scotland and its applications to health research. J Clin Nurs 2012;21:2711–21. 18 Norman JE, Morris C, Chalmers J. The effect of changing patterns of obstetric care in Scotland (1980–2004) on rates of preterm birth and its neonatal consequences: perinatal database study. PLoS Med 2009;6:e1000153. 19 Love ER, Bhattacharya S, Smith NC, Bhattacharya S. Effect of interpregnancy interval on outcomes of pregnancy after miscarriage: retrospective analysis of hospital episode statistics in Scotland. BMJ 2010;341:c3967. 20 Carstairs V, Morris R. Deprivation: explaining differences in mortality between Scotland and England and Wales. BMJ 1989;299:886–9. 21 Spencer K, Cowans NJ. Accuracy of self-reported smoking status in first trimester aneuploidy screening. Prenat Diagn 2013;33:245–50. 22 Buyalos RP, Agarwal SK. Endometriosis-associated infertility. Curr Opin Obstet Gynecol 2000;12:377–81. 23 Helmerhorst FM, Perquin DA, Donker D, Keirse MJ. Perinatal outcome of singletons and twins after assisted conception: a systematic review of controlled studies. BMJ 2004;328:261. 24 Messerlian C, Maclagan L, Basso O. Infertility and the risk of adverse pregnancy outcomes: a systematic review and meta-analysis. Hum Reprod 2013;28:125–37. 25 Pandey S, Shetty A, Hamilton M, Bhattacharya S, Maheshwari A. Obstetric and perinatal outcomes in singleton pregnancies resulting from IVF/ICSI: a systematic review and meta-analysis. Hum Reprod Update 2012;18:485–503. 26 Takemura Y, Osuga Y, Fujimoto A, Oi N, Tsutsumi R, Koizumi M, et al. Increased risk of placenta previa is associated with endometriosis and tubal factor infertility in assisted reproductive technology pregnancy. Gynecol Endocrinol 2013;29:113–5. 27 Brosens IA, De Sutter P, Hamerlynck T, Imeraj L, Yao Z, Cloke B, et al. Endometriosis is associated with a decreased risk of preeclampsia. Human Reprod 2007;22:1725–9. 28 Brosens I, Pijnenborg R, Benagiano G. Defective myometrial spiral artery remodelling as a cause of major obstetrical syndromes in endometriosis and adenomyosis. Placenta 2013;34:100–5.

Obesity in pregnancy: not such a new problem

BOON LIM, OBSTETRICS & GYNAECOLOGY, CANBERRA HOSPITAL, CANBERRA, AUSTRALIA ......................................................................................................................................................................... Over the last three decades, obesity has been recognised as a global health concern, with a rising trend affecting both affluent and developing nations. This is attributed not just to the availability of food, but also to lifestyle and increasing mechanisation (World Health Organization, 2000).