Please note that letters and emails to the editor should be no .... HIV data and statistics [www.who.int/hiv/topics/mtct/data/en/index1. html]. Kate Harding FRCOG.
DOI: 10.1111/j.1744-4667.2012.00118.x
2012;14:215–217
The Obstetrician & Gynaecologist
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http://onlinetog.org
Please note that letters and emails to the editor should be no more than 500 words with a maximum of five references.
Prevention of vertical HIV transmission
Dear Sir It was good to read about positive developments related to HIV in pregnancy.1 However, many HIV infections go undiagnosed.1 Under these circumstances, labour management remains important in preventing vertical transmission, while it is a minor factor combined with highly active antiretroviral therapy (HAART). Similarly, labour management has had little influence in preventing rhesus sensitisation since anti-D became widely available: how many drain the placenta in the third stage if the mother is or could be rhesus negative? A 1995 paper2 discusses how to prevent vertical HIV transmission (one of the worst outcomes): be careful not to nick the child during caesarean section use mucus extractors rarely, as maternal fluids appear to be extra dangerous if pushed into an easily damaged nose and mouth use chlorhexidine lubricant on a (preferably rubberised) vacuum cup do not rupture the membranes; if ruptured, expedite delivery with oxytocin perform episiotomy, if needed at all, as late as possible. The paper also advises clamping the cord as soon as possible. This latter opinion has nearly disappeared from the relevant literature. The circulatory barrier between mother and child can increasingly be breached in the third stage of labour, a deadly hazard when the baby continues pumping blood through the placenta. Many large African hospitals can perform viral load tests; a study involving unbooked and untreated (seemingly) HIV-positive mothers would be easy. It could entail early cord clamping and replacing the baby for 10 minutes with a pulsating pump filled with sterile normal saline and then quantifying HIV-1 RNA intermittently. This could be organised ethically, while it seems unethical to promote late cord clamping, as the World Health Organization does, without studying its safety. I am also worried about vacuum extraction disappearing from the African (district) doctor’s armamentarium.3,4 Vaccum extraction is also rare in Latin America, partly
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explaining the high caesarean section rates, but there the total fertility rate is so low (2.2), contraceptive use so widespread (67% prevalence of modern methods in women aged 15–49) and labour so often professionally attended (89%) that the damage is limited.5 I am convinced that thousands of African women die every year of ruptured uterine scars, mostly outside hospitals.4 Annually, there are 50 000–100 000 new fistulae from obstructed labour, while scars rupture much faster than fistulae develop. Many African doctors argue that vacuum extraction is too dangerous if HIV cannot be excluded. This potential danger should be quantified and balanced with the local caesarean section complication rate, the probability of future uterine rupture, the HIV prevalence, parity, number of children still desired, projected access to reliable long-acting contraception for the next 20 years or so, breastfeeding practices, HIV screening uptake, assisted reproductive technology and the decision-to-caesarean section interval for cases where vaccum extraction would work (perhaps delay promotes HIV transmission more than well conducted vacuum extraction).5 This balancing act could lead to different conclusions for a district hospital in Uganda (total fertility rate 5.9, modern contraception use 18%, skilled attendance at births 42%, HIV prevalence in women 15–24 years 4.8%) from one in Botswana (total fertility rate 2.6, modern contraception rate 42%, skilled attendance at births 94%, HIV prevalence 11.8%).5 References 1 Byrne L, Fakoya A, Harding K. HIV in pregnancy: an international perspective. The Obstetrician & Gynaecologist 2012;14:17–24 [http://dx.doi.org/10.1111/j.1744-4667.2011.00076.x]. 2 Verkuyl DAA. Practising obstetrics and gynaecology in areas with a high prevalence of HIV infection. Lancet 1995;346:293–6 [http://dx.doi.org/10.1016/S0140-6736(95)92171-0]. 3 Maaløe N, Sorensen BL, Onesmo R, Secher NJ, Bygbjerg IC. Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals. BJOG 2012; Feb 14. Epub ahead of print [http://dx.doi.org/10.1111/j.1471-0528.2012.03284.x]. 4 Verkuyl DAA. Think globally act locally: The case for symphysiotomy. PLoS Med 2007;4:e71 [http://dx.doi.org/10.1371/journal. pmed.0040071].
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5 UNFPA. State of World Population 2011. New York: United Nations Population Fund; 2011. p. 110–121 [http://foweb.unfpa.org/SWP2011/ reports/EN-SWOP2011-FINAL.pdf].
3 World Health Organization. HIV/AIDS. Mother-to-child transmission of HIV data and statistics [www.who.int/hiv/topics/mtct/data/en/index1. html].
Douwe Verkuyl
Kate Harding
PhD FRCOG
Refaja Hospital, Stadskanaal, the Netherlands
Laura Byrne Authors’ reply
Dear Sir We thank Dr Verkuyl for his interest in our article.1 The advice from the World Health Organization on delayed cord clamping is based on studies in the developing world, which have shown substantial benefit to delayed clamping.2 We need to avoid previous errors made in this field (for example, the recommendation of bottle feeding in women with HIV in low-resource countries, which led to an increase in deaths from gastroenteritis), since one could theorise that in lowresource countries the proven reduction in anaemia from delayed clamping outweighs the theoretical increased risk of mother-to-child transmission from this intervention. Research in this field must look at real endpoints (i.e. the rate of mother-to-child transmission in early versus delayed clamping) in women with HIV, rather than the level of virus in cord blood or the level of maternal blood in the fetal circulation. Rates of HIV diagnosis and treatment are increasing, even in resource-poor countries. The latest data from the World Health Organization show that there has been an increase in testing from 9% to 42% of the pregnant population in subSaharan Africa, where over 90% of women with HIV live.3 Across all low- to middle-income countries, 48% of women with HIV have been given effective treatment (i.e. HAART) and a further 11% have had some treatment (e.g. single-dose nevirapine in labour). These results are not as good in Northern Africa, the Middle East and Western and Central Africa, where the rate of effective treatment ranges from 4 to 18%. While we are also worried about caesarean section leading to risk of scar rupture in future pregnancy, our article supports operative vaginal delivery and only suggests that, where there is an option, forceps should be used in preference to vacuum extraction. This should not increase caesarean section rates. References 1 Byrne L, Fakoya A, Harding K. HIV in pregnancy: an international perspective. The Obstetrician & Gynaecologist 2012;14:17–24 [http://dx.doi.org/10.1111/j.1744-4667.2011.00076.x]. 2 Mathew JL. Timing of umbilical cord clamping in term and preterm deliveries and infant and maternal outcomes: a systematic review of randomized controlled trials. Indian Pediatr 2011;48:123–9 [http://dx.doi.org/10.1007/s13312-011-0031-z].
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FRCOG
St Thomas’ Hospital, London, UK MRCP
The Royal London Hospital, London, UK
Ade Fakoya
FRCP
University College, London, UK
The management of endometrial polyps in the 21st century
Dear Sir We read with great interest this review from our colleagues at the Royal London Hospital.1 We would like to add the following points, especially with regard to fertility. The mechanisms by which endometrial polyps impair fertility are abnormal sites for implantation, mechanical impairment of sperm transport and the creation of an inflammatory response. The cause–effect relationship, however, is not clear. The incidence of endometrial polyps in the subfertile population has been reported as between 7.68 and 32%.2 Increased body mass index is a recognised risk factor for the development of endometrial polyps in women undergoing in vitro fertilisation. Increased risk of malignant transformation has been observed in women with polycystic ovary syndrome and those with increased numbers of polyps in the premenopausal age group.3 In a recent study by Yanaihara et al.4 it was reported that the majority of polyps were found in the posterior uterine wall and that excision of the uterotubal junction improved pregnancy rates. The same study observed endometrial hyperplasia in 6.9% of women with endometrial polyps in the subfertile population. A recently published matched controlled study5 which evaluated the effect of endometrial polyps on pregnancy and implantation rates following in vitro fertilisation embryo transfer did not demonstrate that hysteroscopic resection of endometrial polyps aids conception rates. This illustrates the heterogeneity of the groups and the need for randomised controlled trials. Postmenopausal bleeding in a woman on tamoxifen needs to be highlighted. The Mirena® intrauterine system appears to prevent the development of benign endometrial polyps in women with breast cancer taking tamoxifen over a 1-year period, although there is no evidence that it prevents endometrial hyperplasia or adenocarcinoma in these women.6 Furthermore, in these
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Letters and emails
groups hysteroscopic polypectomy with endometrial ablation seems to be a safe and effective method.7
References 1 Annan JJ, Aquilina J, Ball E. The management of endometrial polyps in the 21st century. The Obstetrician & Gynaecologist 2012;14:33–38 [http://dx.doi.org/10.1111/j.1744-4667.2011.00091.x]. 2 Hickley MD, Milki AA. 1000 office based hysteroscopies prior to in vitro fertilization: feasibility and findings. JSLS 2004;8:103–7. 3 Kilicdag EB, Haydardededeoglu B, Cok T, Parlakgumus AH, Simsek E, Bolat FA. Polycystic ovary syndrome and increased polyp numbers as risk factors for malignant transformation of endometrial polyps in premenopausal women. Int J Gynaecol Obstet 2011;112:200–3 [http:// dx.doi.org/10.1016/j.ijgo.2010.10.014]. 4 Yanaihara A, Yorimitsu T, Motoyama H, Iwasaki S, Kawamura T. Location of endometrial polyp and pregnancy rate in infertility patients. Fertil Steril 2008;90:180–2 [http://dx.doi.org/10.1016/j. fertnstert.2007.05.072].
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5 Check JH, Bostick-Smith CA, Choe JK, Amui J, Brasile D. Matched controlled study to evaluate the effect of endometrial polyps on pregnancy and implantation rates following in vitro fertilisation – embryo transfer (IVF-ET). Clin Exp Obstet Gynaecol 2011;38:206–8. 6 Chin J, Konje JC, Hickey M. Levonorgesterel intrauterine system for endometrial protection in women with breast cancer on adjuvant tamoxifen. Cochrane Database Syst Rev 2009;(4):CD007245. 7 Gao W, Zhang L, Li W, Li J, Wang W, Zhao W, et al. Three year followup results of polypectomy with endometrial ablation in the management of endometrial polyps associated with tamoxifen in Chinese women. Eur J Obstet Gynaecol Reprod Biol 2012;161:62–5 [http://dx.doi.org/10.1016/j.ejogrb.2011.10.014].
K Sivanesan
MRCOG
St Bartholomew’s Hospital, London, UK
T Al-Shawaf
FRCOG FRCS (Edin)
St Bartholomew’s Hospital, London, UK
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