Martin Quinn

The aetiology of pre‐eclampsia, 1945–1953

XUE QING WU, CONSULTANT, YAO YAO CAI, RESIDENT, WEI TING XIA, RESIDENT AND MJ QUINN, VISITING SCHOLAR, FIRST AFFILIATED HOSPITAL, MEDICAL UNIVERSITY OF WENZHOU, WENZHOU, CHINA ....................................................................................................................................................................... A Tremain Hertig (1904– 1990) was a professor of pathology at Harvard Medical School who was the first to describe the ‘narrowing of uterine arterioles’ in pre-eclampsia in 1945. In his original report (and in almost every report since), there is a partial or complete ‘halo of hyalinised (“empty”) cells’ around the injured vessels that corresponds to the site of a ‘halo of injured nerves’ in many gynaecological syndromes (Figure 1A, B; Hertig Clinics, 1945;4:602–13). In 1953, John Sophian (1894–1975), who later became an obstetrician at St Mary’s Hospital for Women, Plaistow, discovered uterorenal autonomic pathways in rabbits. He observed immediate blanching of the kidneys after inflating balloons in rabbit uteri, and, that persistent distension led to acute renal failure, whereas prior renal denervation abolished the effect (J Obstet Gynaecol Br Emp 1955;62:37–47). In 1948, in the same laboratory, Josep Trueta (1897–1977), a Catalan surgeon who became Professor of Orthopaedics in Oxford, described the ‘Oxford shunt’, where crush injuries to animal limbs resulted in the diversion of renal blood flow from the cortex to the medulla, with subsequent hypertension and proteinuria (Proc R Soc Med 1948;41:339–42).

Complications of hysterectomy.

Deliberate decisions to perform most hysterectomies by the vaginal route may not necessarily be in the best interests of the patient. Division of healthy (nonattenuated) uterosacral ligaments not only diminishes the support of the superior vaginal segment but also divides the nerve bundles contained within them. These nerves appear to supply the upper vagina and contain parasympathetic ganglia. Extensive dissection of the uterovesical fold at vaginal hysterectomy may also compromise the nerve supply to the vesical neck and anterior vaginal wall. Abdominal hysterectomy can be performed with minimal, sharp dissection of the uterovesical fold and removal of the cervix without division of the uterosacral ligaments that insert predominantly into the superior vaginal fornix (an intrafascial hysterectomy). The third clamp is applied to the level of the superior border of the ligament with the uterus and cervix being removed by a circumferential incision of the superior vaginal fornix. Surgical planning should give attention to the quality of the uterosacral support of the superior vaginal segment. There is no dichotomy between subtotal and total abdominal hysterectomy. The absence of reliable, medium term (5–10 years), prospective information about the consequences of any form of hysterectomy is an important omission in the gynecological literature. Increasing apprehension about the rates of subsequent surgery for stress and urge urinary incontinence, genital prolapse, and ovarian complications should make this a pre-eminent concern in contemporary gynecological practice. Any form of hysterectomy in parous subjects with prior intrapartum damage may be the decisive event that commits a woman to regular, subsequent, reconstructive pelvic surgery. Increasing scrutiny of the indications for many kinds of gynecological surgical intervention should be anticipated if we are unable to answer such fundamental questions.

Intrafascial hysterectomy: the third way?

Sir, Drs Ewies and Olah demonstrate some of the benefits and risks of subtotal hysterectomy, including a significant prevalence of cervical stump problems. It is frequently supposed that there is a dichotomy between the subtotal and the total abdominal hysterectomy; a third option is an intrafascial operation where the cervix is removed and the uterosacral ligaments are preserved. The important anatomical points are:

Prevalence of Endometriosis During Abdominal or Laparoscopic Hysterectomy for Chronic Pelvic Pain.

and other complications after delivery. Lastly, the difference in pathogenesis also may underlie the divergence in responses to anticomplement therapy. Two years after initial reports of its use for atypical hemolytic uremic syndrome in 2009, eculizumab was approved in 2011 for atypical hemolytic uremic syndrome in the United States and the European Union, based on its efficacy observed in two small single-arm trials and one retrospective review of off-label cases. In contrast, eculizumab has shown no or modest efficacy for disorders such as dermatomyositis and rheumatoid arthritis that are also associated with complement activation, presumably owing to immune-mediated triggers. The case reported by Drs. Burwick and Feinberg exhibited responses to eculizumab for less than 3 weeks, and there have been no additional reports, to our knowledge, that further support the use of eculizumab for HELLP syndrome.

Medical evacuation of the uterus and subsequent preterm labor

Quinn. Medical evacuation of uterus and preterm labor. Am J Obstet Gynecol 2016. 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 TO THE EDITORS: Several systematic reviews draw attention to a relationship between medical or surgical evacuation of the uterus and subsequent preterm labor though do not suggest potential mechanisms. Saccone et al conclude that “Prior surgical uterine evacuation for either induced termination of pregnancy or spontaneous abortion is an independent risk factor for preterm birth. These data warrant caution in the use of surgical uterine evacuation and should encourage safer surgical techniques as well as medical methods.” With the restrictive family planning policies in China in recent years, many women have had recurrent or “late” (>12 weeks), surgical or medical evacuations of the uterus. Both may result in injuries to the uterosacral ligaments and the uterovaginal nerves that run through the center of these ligaments. Excessive traction to the cervix during surgical evacuation may cause asymmetric injuries to these ligaments (Figure, A) whereas excessive uterine activity associated with medical evacuation (10-15% of women in some series) may result in symmetric attenuation or complete absence of the uterosacral ligaments (Figure, B). Concomitant injuries to vasomotor nerves result in narrowing of arterioles throughout the lower genital tract that is associated withmany of the “great” obstetric syndromes including midtrimester loss, preterm labor, and pretermpremature rupture ofmembranes.Medical evacuation complicated by excessive uterine activitymay increase the risk of preterm labor compared to surgical evacuation (<12 weeks) in some groups of women. Many Chinese women experience high rates of subfertility, ectopic pregnancy, and pregnancy complications including preterm labor. We believe that denervation of the lower genital tract may create the conditions for “opportunist” infection and some forms of preterm labor. Other surgical interventions such as conization of the cervix may contribute to increasing rates of preterm labor through similar mechanisms. Both may be largely preventable. -

Remote consequences of transcervical resection of the endometrium

Sir, We congratulate Cooper et al. on their five-year follow up of patients following transcervical resection of the endometrium or medical treatment for menstrual problems. They conclude that transcervical resection of the endometrium ‘does not lead to an increase in the number of subsequent hysterectomies’ and recommend the procedure ‘being offered to all eligible women seeking treatment for heavy menses’. Mean age of the transcervical resection of the endometrium group was 41 years and hysterectomy rate was 19% at five years follow up, compared with 41 years and 18%, respectively, in the medically treated group. The endometrial–myometrial interface is the site of a significant nerve plexus. In a small series of women undergoing transcervical resection of the endometrium, we have observed nerves in the resected chippings. Furthermore, in women with severe adenomyosis, there is denervation of large areas of the uterus. Not knowing the long term consequences of the operation, are the authors confident that the transcervical resection of the endometrium group will not require hysterectomy for adenomyosis in their remaining reproductive years? Is there any difference in their management of 35and 45-year-old patients with excessive menstrual loss, or would they recommend endometrial resection to both?

The aetiology of parous endometriosis.

Sir, Having read the article by Nordstrom et al., we felt uneasy. As anyone who has practised obstetrics knows, fetal scalp blood sampling is a procedure that is both unpleasant and uncomfortable for a labouring woman to endure. It carries well documented attendant risks to both mother and baby. Therefore, we were surprised that in this study, labouring women were exposed to the indignity and discomfort of having fetal scalp blood sampled on up to seven occasions. We discussed the study in outline with the chairpersons of six medical research ethics committees in the north of England. All chairpersons were emphatic that their committees would not grant ethical approval for such a study. The need for three of the authors to travel from their home countries of Sweden, Japan and Singapore to Malaysia in order to conduct this study seems extraordinary. We question why they did not conduct the study in their own home countries. After all, there was no special requirement to be enrolled into the study, other than being unusual enough to agree to undergo multiple fetal scalp blood sampling procedures. Might it be that ethical approval would not have be granted in their home countries and they had to travel to somewhere less developed and less affluent in order to find a country that would permit such a study? We sincerely hope this is not so. Personal suspicions aside, we are anxious to see that the BJOG maintains the high regard with which it is held, by not accepting for publication any study that would be unlikely to have had ethical approval granted in the British Isles.