2. Wigglesworth JS, Singer DB. Textbook of Fetal and Perinatal

Pathology. London, UK: Blackwell, 1998.

3. Kalousek DK. Fetal death, stillbirth and neonatal death. In: Gilbert-

Barness E, editor. Potter’s Atlas of Fetal and Infant Pathology, 1998:

50–54.

N. J. SebireGreat Ormond Street Hospital for Children, London Departmentof Histopathology, London, UK

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Remote consequences of transcervical resection of theendometrium

Sir,We congratulate Cooper et al. on their five-year follow up of

patients following transcervical resection of the endometrium ormedical treatment for menstrual problems. They conclude thattranscervical resection of the endometrium ‘does not lead to anincrease in the number of subsequent hysterectomies’ and recom-mend the procedure ‘being offered to all eligible women seekingtreatment for heavy menses’1. Mean age of the transcervicalresection of the endometrium group was 41 years and hysterectomyrate was 19% at five years follow up, compared with 41 years and18%, respectively, in the medically treated group.

The endometrial–myometrial interface is the site of a significantnerve plexus2. In a small series of women undergoing transcervicalresection of the endometrium, we have observed nerves in theresected chippings. Furthermore, in women with severe adenomyo-sis, there is denervation of large areas of the uterus. Not knowing thelong term consequences of the operation, are the authors confidentthat the transcervical resection of the endometrium group will notrequire hysterectomy for adenomyosis in their remaining repro-ductive years? Is there any difference in their management of 35-and 45-year-old patients with excessive menstrual loss, or wouldthey recommend endometrial resection to both?

References

1. Cooper KG, Jack SA, Parkin DE, Grant AM. Five year follow up of

women randomised to medical management or transcervical resection

of the endometrium for heavy menstrual loss: clinical and quality of life

outcomes. Br J Obstet Gynaecol 2001;108:1222–1228.

2. Krantz KE. Innervation of the human uterus. Ann NY Acad Sci 1959;

75:770– 784.

M. J. Quinna, N. Kirka, M. C. Slackb & M. D. Harrisb

aDepartment of Gynaecology and Pathology, HinchingbrookeDistrict HospitalbDepartment of Gynaecology and Pathology, PeterboroughDistrict Hospital

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Somalis in Sweden: are bigger babies better?

Sir,The Editor comments on the ‘startling’ finding that Somali

women in Sweden reduce their food intake in pregnancy in order

to have a smaller baby, in his remarks on the article by Essenet al.1 in the same copy of the Journal. This finding should not bestartling. Rush2 has pointed out that in many different cultureswomen deliberately reduce their intake of food in order to try toensure a smaller baby. A big baby can mean obstructed labour andperhaps death of both baby and mother. There is often truth infolklore. In obstetrics, because of high perinatal mortality in smallbabies and obsessions with growth retardation, we have too longassumed that bigness in babies is necessarily good.

Over the last 25 years, women in Europe and America havebecome heavier, with increased body mass indices. Babies havealso become heavier and these two factors are probably related.While there are obviously many things which have driven up thecaesarean section rate, increase in baby weight may be one ofthem. Although this idea does not meet with universal agreement,most studies show that bigger babies mean higher caesareansection rates3. The best single predictor of baby weight is pre-pregnancy maternal weight rather than weight gain in pregnancyper se. Undoubtedly, severe caloric restriction will reduce babyweight2. The factors which control baby weight are many andcomplex but, in countries where obesity is becoming an epidemic,we should think again about this matter. It should not be surprisingthat where high body mass indices are bad for maternal healththey may also be harmful for the baby in the short and long term.The Somali women’s concern about having babies that are too bigmay not be so daft as it sounds.

References

1. Essen B, Johnsdotter S, Houelius B, et al. Qualitative study of preg-

nancy and childbirth experiences in Sweden. Br J Obstet Gynaecol

2000;106:1507–1512.

2. Rush D. Nutrition and maternal mortality in the developing world. Am J

Clin Nutr 2000;72(Suppl):2125 – 2405.

3. Parrish KM, Holt VL, Easterling TR, Connell FA, Logerfo JP. Effect of

changes in maternal age parity and birth weight distribution on primary

caesarean delivery rates. JAMA 1994;271:443 –447.

W. A. ListonSimpson Memorial Maternity Pavilion, Edinburgh, UK

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The effectiveness of the levonorgestrel-releasingintrauterine system in menorrhagia: a systematicreview

Sir,Dr Stewart et al.’s comment on effectiveness of the levonor-

gestrel-releasing intrauterine system (LNG-IUS) in the treatmentof menorrhagia based on five small randomised trials and call forcomparative trials on cost effectiveness or health related quality oflife.

We recently reported results of a randomised trial on the qualityof life and cost effectiveness of the LNG-IUS versus hysterectomyin the treatment of menorrhagia1. Of 598 women referred formenorrhagia, 236 were eligible and randomly assigned to theLNG-IUS (n ¼ 119) or hysterectomy (n ¼ 117). Menstrual bloodloss was objectively measured. Health related quality of life(HRQoL) was assessed using the SF 36 health survey and theEQ-5D questionnaire. Total costs were calculated. Anxiety,depression and sexuality-related factors were also assessed.

CORRESPONDENCE 87

D RCOG 2003 Br J Obstet Gynaecol 110, pp. 83–93