First do no (net) harm

Abstract

The quote above highlights the well-used medical phrase “Primum non nocere” or “First do no harm” and is advice used to warn against over treatment.² In Obstetrics and Gynaecology there are many historic examples that highlight the importance of this advice. In this issue of BJOG the controversy surrounding the transvaginal tape (TVT) procedure for urinary incontinence is revisited, with Solhaug and colleagues highlighting the need to evaluate long-term subjective and objective cure rates, treatment satisfaction and pain indices to better understand the impact of TVT procedures on the health and wellbeing of the women we treat. They found that TVT provided high rates of subjective and objective cure at 10 and 20 years after surgery, however obesity was a risk factor for procedural failure. Although 3%–5% of women experienced chronic pain, the majority were satisfied with their procedural outcome, calling into question the decision by many healthcare settings to abandon TVT as an option for managing stress urinary incontinence. Related to this, Tian and colleagues perform a systematic review and meta-analysis of the difference in extracellular matrix metabolism in women with and without pelvic organ prolapse furthering our understanding of the pathophysiology of this common and important disease.

Escalating intervention rates within the field of Obstetrics is alarming and in this issue of BJOG, Lumbiganon and colleagues warn that “globally, a worrying trend is arising: caesarean delivery rates are skyrocketing”. This represents an important geographic and socio-economic health inequity with 44% of babies born by caesarean delivery in Latin America and the Caribbean but only 4% of babies in sub-Saharan Africa. Wealthier, more urban populations experience higher rates than people from socio-economically deprived, rural areas. Khalaf and colleagues present important data highlighting the significant negative long-term impact of pre-labour caesarean delivery on stillbirth rates in subsequent pregnancies. With an increasing rate of non-medically indicated caesarean deliveries globally this is of particular concern.

Long term impacts of pregnancy and subsequent interventions must be further understood and considered. Lumbiganon and colleagues highlight how children delivered by caesarean are at higher risk of respiratory tract infections, obesity and asthma compared to children delivered vaginally.³ Patey and colleagues present data on the impact of maternal health on fetal and infant cardiac health, showing no association between previous maternal bariatric surgery and adverse cardiac outcomes in her offspring, however in no-bariatric pregnancies they found an inverse correlation between maternal glucose control and fetal cardiac systolic function.

Prematurity is the leading cause of disability and death in infants worldwide.⁴ Timing of delivery for small for gestation age foetuses is the important research question tackled by Marijen and colleagues in this issue of BJOG. They demonstrated that in the small for gestational age cohort, an abnormal UCR is significantly associated with a higher incidence of short-term perinatal adverse outcomes, offering a potentially useful tool for discriminating between constitutional small for gestational age and fetal growth restriction. They further report that foetuses that are small for gestational age and show haemodynamic redistribution are unlikely to benefit from early delivery between 34 and 36 + 6 weeks, however further research is needed to confirm teir findings. Hong and colleagues present evidence that low maternal PIGF levels and raised sFlt-1/PIGF ratios show a strong association with an increased risk of preterm birth in both fetal growth restricted and appropriate for gestational age pregnancies, which could be added to prenatal management guidelines to guide steroid and magnesium sulphate prescribing in these settings, with a view to improving perinatal outcomes. Socha and colleagues present data showing the protective effect of antenatal corticosteroids in twin pregnancies on newborn respiratory outcomes and in-hospital mortality rates.

Since my editorial for the January 2023 BJOG issue, our understanding of the impact of the COVID pandemic on pregnancy-related health has improved considerably. In this issue of BJOG, Wen and colleagues explore risks for adverse obstetric outcomes associated with the COVID-19 pandemic period. Whilst they showed higher odds of adverse maternal cardiac and respiratory outcomes in 2020 compared with 2016–2019, at a population level, the pandemic did not directly or indirectly result in major changes in overall obstetric morbidity and common adverse events.

Patient centred care is essential to improve outcomes and overall patient satisfaction. The “first do no harm” mantra sits well within this setting also, aiming to tailor diagnostic and treatment pathways to individual need. Reddington and colleagues show, in a cross-sectional survey, that age and parity are not associated with relief nor regret following elective hysterectomy for benign disease, highlighting that listening to what women want is important to ensure a less patriarchal, more patient-centred women's health service. Geusens and colleagues show, through thematic analysis, the value of online stillbirth stories in providing an opportunity to improve obstetric care. Their findings demonstrate that pregnant individuals want to understand what their options are and be empowered to make decisions about their healthcare choices. They further shed light on the importance of emotional intelligence training amongst healthcare workers to better meet the needs of those experiencing adverse pregnancy outcomes. The incidence of endometrial cancer is rising and improving treatment outcomes is imperative to reducing its devastating effects. In this issue, Maiorano and colleagues present a meta-analysis of randomised controlled trials evaluating the efficacy and safety of immune checkpoint inhibitors plus chemotherapy as first line treatment for advanced endometrial cancer. Included studies with 1303 total participants showed a significant improvement in progression free survival in those treated with immune checkpoint inhibitors, regardless of their tumour mismatch repair status.

Education is key to improving healthcare both for our patients and also for the healthcare workforce itself. Waagaard and colleagues show that the odds of having poor cardiovascular health in middle age is significantly higher in women who have overweight (adjusted odds ratio (aOR) 3.30) or obesity (aOR 7.63), compared with those classified as having normal weight in pregnancy, and they conclude that pregnancy is an important window of opportunity in which to support long-term cardiovascular health. Copp and colleagues show that continued professional development is important since non-evidence backed usage and interpretation of anti-Mullerian hormone blood tests is common amongst general practitioners, with potentially important consequences for patient care especially in the era of direct-to-consumer testing. Artificial Intelligence could provide an important bridge to ensuring high quality patient care especially within a squeezed healthcare service. However, Meyer and colleagues demonstrate that ChatGP is limited in its ability to instruct patients with concerning signs and symptoms and provide specific actionable items in post operative gynaecological settings, concluding that relying solely on this system's instructions may compromise patient safety.

Innovation, especially technologies that could overcome global health inequity, is important for advancing patient care. Jaufuraully and colleagues show how a sensorised glove can accurately detect anal sphincter injury in a pig model and could have real world value in ensuring the detection of obstetric anal sphincter injury to enable its prompt repair. By contrast, Andrew Weeks shows that implementation is as important as innovation in reducing maternal deaths from postpartum haemorrhage. The WHO postpartum haemorrhage roadmap is an important first step, however Weeks remarks that poverty and inequity are the main barriers to improving maternal mortality worldwide and unless these are addressed meaningful improvement in outcomes is challenging to achieve. He suggests that the antenatal treatment of anaemia, provision of high-quality intrapartum care by midwives supported by medical staff, improved management of PPH using evidence-based strategies, robust blood transfusion services and developing high quality of healthcare systems should be prioritised to improve outcomes globally.

Sokol opines that the phrase “first do no harm” is a crude piece of advice because clinicians inflict harm all the time.² Healthcare workers can really only hope that the benefit of prescribed interventions outweigh their inevitable harms. A more accurate mandate would be to “first do no net harm”.² Practicing evidence-based medicine informed by well-designed, robust research provides reassurance to healthcare providers and their patients that the care they provide is the best it can be with our current level of knowledge.