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Two healthy women in a summer market

Our cover in this month of July shows two women in among flowers in a setting typical of a Nordic summer scene; pleasant and prospering. We are lucky in this part of the world to enjoy some of the best living standards, social security and egalitarian approaches to be found on the planet, even if we know that not all is ideal in the distribution of wealth, rights and opportunities. But still it is much ahead of so many other countries, even in Europe. In the background there is man at work, to remind us that “the guys” are also there. For obstetricians and gynecologists women are though always in the foreground. We start this month with an important commentary by Azadeh Houshmand and her colleagues in Copenhagen, Denmark (pp. 739–45), on earlier criteria and those used now for diagnosing gestational diabetes. It has not been easy to see how the criteria were originally arrived at, i.e. how the medical community decided what should be called gestational diabetes. How have the reference values been set up? From a historical perspective and right up to and beyond the HAPO study (1) and the new IADPSG criteria (2). We are here presented with a comprehensive story and a transparent recounting of developments, of the current status and the ongoing debate. This is a must read for all of us in obstetrics and gynecology, because of the prevalence of gestational diabetes, obesity and PCOS in our daily practice and the importance these syndromes will have for women’s health. Knowledge about the basis for the current diagnostic and management recommendations is essential, whether or not the recommendations are likely to undergo some change in years to come. This is followed by a review from Denise Delahaije and co-workers in Maastricht, the Netherlands (pp. 746–61), on the incidence of two psychiatric symptoms after preeclamptic disease, anxiety and depression – something that easily is ignored and clearly under-researched during pregnancy, after conclusion of delivery and in postpartum management. Another similar review is incidentally being published simultaneously in the psychiatric literature (3) and shows much the same. Maternal depression, in particular, is not surprisingly associated with a complicated pregnancy where the baby may be very preterm and where severe complications may ensue for the mother. The risk may in part be based on those with psychiatric symptoms being more vulnerable beforehand (4). There may in addition be quite wide-ranging psychosocial background factors which add to vulnerability for some women. It is more likely than not that pregnant women use complementary and alternative treatment options available over-the-counter or offered by variously educated persons (5). Helen Elden and colleagues in Gothenburg, Sweden, present on pp. 775–82 a randomized trial on one such modality, craniosacral therapy. It is good to have a rather well conducted study of this type and not a surprise that the effects are doubtful. The world authority is this field, Prof Edzard Ernst, wrote a letter to this journal 10 years ago (6), where he points to our fragmentary knowledge on such therapies. It is worth looking at his writings through PubMed in this time and age, when any bookstore is full of books on these topics and the internet is clogged with varying advice on the goodness of anything from herbal medicines and vitamin-combinations to acupuncture, all perceived by the public and even some professionals as “natural” and therefore innocuous and even beneficial, while the evidence is in general not showing any benefit and in some instances harm. Even in studies like this one the assessment of subjective symptoms is difficult and interpretation not easy because placebo-effects and beliefs come into play and cloud the best study design. Obstetricians and gynecologists have a duty to be on the guard to protect the public against exploitation from a powerful army of people who may be well-meaning, but are also often ignorant. Huge financial interests are also involved. In this randomized trial the effects were at best “small and clinically questionable” as the authors say themselves, and why should doctors advise anyone to pay for that sort of treatment? Yet we felt it was worthwhile to publish this study to remind the readers of just this point. There has long been much discussion on the potential harm that might result from ultrasound in relation to fetal development, not least the effects of Doppler mode application. No definite harm has ever been proven. The article