TPW May-June 2021

OBSTETRICS & GYNECOLOGY UPDATE

mortality (relative risk [RR] 1.12) in ACS-exposed infants prophylactic use to reduce the risk of PPH is contro-
born in low- and middle-income countries. Now, a larger versial. In a randomized trial of >4100 women receiv-
randomized trial conducted by the World Health Organi- ing standard uterotonic drug prophylaxis (oxytocin
zation (WHO) in low-resource countries found that ACS or carbetocin) after a cesarean birth, the addition of
administered at 260/7ths to 336/7ths weeks reduced tranexamic acid reduced the composite primary out-
neonatal death (RR 0.84) and stillbirth or neonatal come compared with placebo (blood loss >1000 mLs
death (RR 0.88) compared with placebo. The difference or receipt of a red blood cell transfusion: 27 versus 32
between these results and those of ACT may relate to percent); differences between groups were not statis-
better selection of patients for whom ACS is warranted. tically significant for individual secondary outcomes
In the WHO trial, 90 percent of the infants who were (estimated blood loss, provider-assessed clinically
exposed to ACS were born preterm, compared with only significant PPH, need for additional uterotonic drugs,
16 percent of those in ACT. blood transfusion). Based on these and previous find-
ings after vaginal birth, administration of tranexamic
Nonsteroidal anti-inflammatory acid to prevent PPH is reasonable, especially in high risk
drugs and oligohydramnios patients.

Nonsteroidal anti-inflammatory drugs (NSAIDs) carry Management of oxytocin in the
well known risks to the fetus during the third trimester active phase of labor
of pregnancy but also have rare risks when used earlier
in pregnancy. The FDA recently issued a warning that use In patients undergoing labor induction, there is no con-
of NSAIDs around 20 weeks gestation or later in preg- sensus regarding discontinuation versus continuation of
nancy may rarely cause fetal renal dysfunction leading to oxytocin in the active phase. A previous meta-analysis
oligohydramnios and, in some cases, neonatal renal im- found that discontinuation resulted in lower cesarean
pairment. These outcomes could be seen within 48 hours birth rates. However, in a new large randomized trial
of NSAID use but typically occurred after days to weeks comparing the two approaches in >1200 patients, the
of treatment. The FDA suggests that if NSAID treatment cesarean birth rate was similar in both arms of the trial.
is necessary between 20 to 30 weeks of pregnancy that Although discontinuation lengthened the active phase
it be at the lowest effective dose and shortest duration and reduced the frequency of hyperstimulation and
possible, that monitoring by ultrasound be considered fetal heart rate abnormalities, this did not lead to differ-
for those treated for more than 48 hours, and that the ences in maternal infection or neonatal intensive care
drug be discontinued if oligohydramnios occurs. unit admission. In the active phase, we consider either
discontinuation or continuation of oxytocin reasonable,
Metformin treatment of as long as patients are monitored, with appropriate
diabetes in pregnancy intervention for slow progress or abnormal cardiotocog-
raphy.
Data continue to accrue regarding the potential benefits
and adverse effects of metformin use during pregnancy. Pregnancy and seizure control
In a trial in which pregnant women with type 2 diabetes in patients with epilepsy
were randomly assigned to receive insulin alone or both
insulin and metformin, combined treatment improved Meticulous dosing and monitoring of antiseizure drugs
maternal glycemic control, reduced total gestational during pregnancy in patients with epilepsy is important
weight gain, and reduced the frequency of large for ges- to prevent worsened seizure control. In a recent pro-
tational age and macrosomic newborns; however, the spective cohort study that included nearly 300 pregnant
rate of small for gestational age newborns was higher. In patients with epilepsy, seizure frequency was higher
most patients with preexisting diabetes on metformin, during pregnancy than during the nongravid baseline in
we recommend not continuing metformin beyond approximately one-quarter of patients and in a similar
the transition to insulin before or in early pregnancy, proportion of matched, nonpregnant controls with epi-
given concerns about the increased risks for small for lepsy during corresponding periods of time. However,
gestational age newborns and previous data showing an more pregnant patients required at least one change in
increased risk for childhood adiposity. antiseizure drug dosing (74 versus 31 percent), in many
cases to anticipate alterations in drug clearance during
Prophylactic tranexamic acid at delivery and after pregnancy. These findings will help to coun-
sel patients with epilepsy on expectations for seizure
Tranexamic acid is commonly administered as part of control during pregnancy.
the treatment of postpartum hemorrhage (PPH), but
THE PHARMA WORLD 51



INTERVIEW

Generally speaking, every pregnancy
has got its own risk and needs
to be managed carefully

Prof. Dr. Sehereen F. Siddiqua As an eminent Gynaecologist l Anaemia in pregnancy
Professor and Head of the country, what in your l Intrauterine growth restric-
Dept. of Obstetrics and Gynaecology opinion are the most common
Answer Khan Modern Medical College Gynaecological disorders tion (IUGR)
Joint Secretary, OGSB prevalent among our women? l Intrauterine foetal death (IUFD)
l Multiple pregnancy
The gynaecological disorder varies l Preterm labour
among patients’ demography, educa- l Premature rupture of mem-
tional status, age, marital status, social
class, economical status as well. How- branes (PROM)
ever the most common disorders are: l Antepartum haemorrhage
l Maternal depression
l Abortion & post-abortion com-
plication So far, the management of pregnan-
cy during COVID-19 is concerned, we
l Ectopic pregnancy need to follow the guidelines and
l Uterine Fibroids protocols set by the government and
l Adenomyosis OGSB strictly. There should be at least
l Endometriosis 4 in person antenatal visits and regu-
l Polycystic Ovary Syndrome lar telemedicine service can identify
the problems earlier. We are strongly
(PCOS) advocating more institutional deliv-
l Abnormal Uterine Bleeding (AUB) ery to ensure respectful, safe vaginal
l Ovarian Cysts, benign and ma- delivery and postnatal care which is
the main pillar of safe motherhood.
lignant ovarian tumours
l Pelvic Inflammatory Disease (PID) Has COVID-19 affected the maternal
l Primary & Secondary Infertility mortality rate in Bangladesh?
l Vulvovaginitis
l STD It has become very challenging to
l Pelvic organ prolapse provide maternal care during the pan-
l Genital organ malignancy demic as the patients were reluctant
to come to the hospitals due to fear
What are the elements that of COVID-19, leading to a 9% decline of
constitute high risk pregnancy? hospital-based deliveries as per gov-
What measures can be taken ernment report. Consequently, this
to manage and prevent led to an increase in maternal mortal-
such complications? ity due to unsafe home birth. During
the pandemic, maternal mortality rate
Generally speaking, every pregnancy has increased by 25%-30%. According
has got its own risk and need to be to OGSB, maternal mortality rate at
managed carefully. In COVID pandem- home was 32% before pandemic. But,
ic situation, the whole health system it increased to 54% during COVID-19.
has been seriously affected which
adversely affected maternal health as What are reasons and treatment
well. At this situation, prevalence of of infertility? What can be done
high-risk pregnancy has remarkably to increase the affordability
increased, like: and accessibility of assisted

l Teenage pregnancy
l Gestational diabetes (GDM)
l Eclampsia and pre-eclampsia.

THE PHARMA WORLD 53



INTERVIEW

reproduction technologies reduce this rate according to WHO service, such as internet connection
(ART) in our country? recommendation. disruptions, call drops, unclear voice
and other technical issues.
Infertility is a condition that affects Obstetric Fistula made lives of many
one in six couples at some stage of women miserable. What can be done Recently we have celebrated
life. Cause may be related to husband, to prevent, treat and rehabilitate ‘Safe Motherhood Day’. What is
wife or both partners. In practice, fe- this women suffering from it? your message on this event?
male are considered to be the primary
cause of it but the truth is different. Obstetrical fistula is one of the most Motherhood is the greatest thing and
Male partners are also responsible serious & tragic injury related to ob- also, the hardest thing. It comes with
for 33% cases and 10% cases remain structed labour. Obstetric fistula is a great share of responsibilities. Safe
unexplained. So, treatment should be preventable. It can be largely avoided Mother Day is intended to raise aware-
directed to both partners after proper by: ness about adequate access to care
evaluation of cause. during pregnancy, childbirth and post-
l Delaying the age of first preg- natal period. We should raise aware-
Approximately, one-fifth of sub-fer- nancy ness among all would be mothers for
tile couple conceives spontaneously regular check-up, adherence to doc-
during investigation or waiting for l Cessation of harmful traditional tor’s advice and medication, and com-
treatment. So, proper explanation or practice ply with hygiene, especially in these co-
reassurance should be the first step of rona days to ensure ‘Safe Motherhood’.
treatment. All level of infertility treat- l Timely access to obstetrical care
ments are available in our country in l Enhancement of qualities emer- Safe motherhood means ensuring
some of the private sectors, but op- all women receive the care they need
tions are limited in government hos- gency obstetric care to be safe and healthy throughout
pitals. As the infertility treatment is pregnancy and childbirth. Mother-
expensive, the accessibility to general A surgery can repair the injury, suc- hood should be a time of expectation
population is limited. However, recent cess rate is as high as 90% for less and joy for women and her family and
advancement shows light at the end complex care. The theme of the year her community.
of the tunnel. is “Women’s rights are human rights!
end fistula now”. Every year, thousands of mothers
C-section delivery has become die globally during the childbirth due
very common these days COVID-19 has changed the norm in to lack of proper medical care which
compared to normal deliveries. follow-up of patients and perinatal could be prevented. In Bangladesh, 13
How do you evaluate it? care in general. How effective is mothers die every day which is pre-
telemedicine in this situation? ventable.
Actually the fact is different in Bang-
ladeshi perspective. About 80% de- Due to pandemic situation, telemed- We have witnessed steep rise of ma-
livery occurs in rural area at home icine played a great role. But, it has ternal mortality in COVID-19 pandemic.
through vaginal delivery. Out of the some limitations in case of emergen- The second wave of Covid-19 pandemic
rest 20%, only 8% of deliveries are cy situations occurring during preg- has created real challenge for the gov-
done by caesarean section which are nancy, high risk pregnancy and man- ernment to ensure the major pillars of
at high risk and referred cases and agement of malignancy. COVID-19 Safe Motherhood like family planning
also to save patient’s life. A sincere pandemic has led to rapid imple- (FP), Antenatal care (ANC), postnatal
obstetrician never performs C/S un- mentation of the telemedince to the care (PNC), safe delivery, obstetrical
less it is strongly indicated. provision of maternal and newborn care and postabortion  care  (PAC). So,
healthcare as an alternative to in- to reduce maternal mortality, all preg-
The rate of C/S is relatively higher person consultation. Telemedicine nant women including mothers with
in the urban area specially in the practices include online birth pre- Covid-19 infection, have the right to
tertiary care hospital. The factors paredness class, ANC, PNC by video, high quality obstetric care, before, dur-
contributing to this increase are phone, helpline, online counselling ing and after child birth.
high risk pregnancies, technologi- to meet the challenges of COVID-19
cal monitoring of labour with early restriction. So we should carry out full-scale
detection of foetal distress by the campaigns and activities to increase
CTG, USG etc., C/S after previous However, the barrier encountered awareness about proper health care
section, maternal factors including are lack of infrastructure and tech- and maternity facilities to the preg-
patient’s choice. However, this trend nological literacy, limited monitoring, nant and lactating women. The theme
is increasing worldwide and we are language barriers, lack of non-verbal of this year’s Safe Motherhood Day is
now very much concerned on how to feedback, lack of bonding and dis- “Keep mother and new born safe from
tance from the patients. Besides this, Coronavirus”. l
there are complaints regarding the

THE PHARMA WORLD 55



INTERVIEW

Not only in Bangladesh, Caesarean Section
trend is going higher globally also

Prof. Major (Rtd) Dr. Laila Arjumand Banu As an eminent Gynecologist women face diabetes during preg-
Chief Consultant, Obs. & Gynae of the country, what in your nancy in our country. But in newer
Labaid Specialized Hospital, Dhaka opinion, are the most common study, the incident is much higher.
Gynecological diseases Diabetes complicates pregnancy and
prevalent among our women? the patient herself. If we treat dia-
betes, hypertension, pre-Eclampsia,
Thank you for the question. Actually, eclampsia, then it will not be such
in our country, our women are most- complicated. But, if the diagnosis
ly suffering from reproductive health is done at a later stage then there
complications like RTI (Reproductive will be some complications for both
Tract Infection), Urinary Tract Infec- mother and the baby.
tion, Pelvic Inflammatory Disease,
Infertility, Anemia and also some As per global trend, most
gynecological cancers like cervical doctors around the world
cancer, ovarian cancer etc. prefer normal delivery whereas
the scenario in Bangladesh is
During pregnancy, our women reverse. Your opinion please.
do not visit doctors regularly for
checkup. Instead, they go by some All over the world, the incidents of
superstition? How can we create C.S. is going higher. In USA and Brazil
awareness among our women? still the rate is more than our coun-
try, as in 35% cases they are having
It is a very important question. Dur- cesarean section. There are so many
ing pregnancy women should do ev- factors like- during antenatal check-
erything which will be good for her up and regular exercise for normal
child. In her first visit, doctor should delivery.
get detailed history from the patient
and advice the patient for regular Another reason is that our girls
checkup. are getting educated and for their
career they don’t want two or more
Sometimes patient believe that children. They think that if they go
they should not go to the doctor be- for normal delivery the baby might
fore 12 weeks of pregnancy or if they get harm. This is not correct that
go to doctor, then doctor will ad- only in our country the cesarean sec-
vise some vitamins, iron which will tion is higher but globally also it is
increase the weight of the baby. So increasing.
for creating awareness among them,
we must the community health pro- What is the maternal
viders, when they register the preg- mortality rate of Bangladesh?
nancy they should perform the an- How can we improve?
tenatal check-up to advice patients
about advantage of ANC and also According to the latest study, the
detect high risk pregnancy. rate is 176 per 1,00,000 women so,
the maternal mortality is improving
Some diseases like Diabetes, now-a-days. But according to MDG
Hypertension and Eclampsia (Millennium Development Goal), we
make pregnancy complicated did not achieve the goal. Our aim
and risky. What suggestion you is to have the maternal mortality
have to address the factors? rate 70 per 1,00000 by 2030 and we
should try for this. l
According to a study, about 13%

THE PHARMA WORLD 57



INTERVIEW

High risk pregnancies should be managed by
senior obstetricians to ensure the best outcome

Prof. Dr. Nazma Hoque As an eminent Gynaecologist l Autoimmune disease
Head of the Department of the country, what in your l STDs
Obs & Gynae opinion, are the most common
Dhaka Medical College and Hospital Gynaecological disorders 3. Medical condition occurring
prevalent among our women? during pregnancy: Pregnancy
induced hypertension, preec-
Common Gynaecological disorders: lampsia, eclampsia, GDM, de-
1. Menstrual disturbance as pression, preterm labour, multi-
– Menorrhagia ple pregnancy, foetal congenital
– Metrorrhagia anomalies. placenta previa.
– Abnormal uterine bleeding.
2. Leucorrhoea (Abnormal vaginal For Prevention of risk factor of high
discharge) risk pregnancy
3. Pelvic Inflammatory Disorders
(PID) A. 1st pre conceptional counselling
4. Post-menopausal paravaginal and care to ensure as healthy as
bleeding (P/N) she become pregnant.
5. Post Coital P/V bleeding l Take folic acid 400 mg/d
l Getting immunization
What are the elements that l Getting regular physical activity
constitute high risk pregnancy? What l Avoid tobacco and alcohol
measures can be taken to manage l Control DM, HTN
and prevent such complications?
A pregnancy is considered high risk B. After conception-
when these are potential complica- l Take regular ANC– at least 4 visit
tions that could affect the mother, the l Maintain. Antenatal advice –
baby or both. Take prescribed supplemen-
tary drugs, do investigation
High risk pregnancies should be accordingly & timely.
managed by senior obstetrician to l Hospital delivery is prefer-
ensure the best outcome for the able than home delivery
mother and baby. l Specially high risk group pa-
tients advised to deliver in
Risk Factors hospital.
1. Maternal Age: <17/>35 years.
Risk of miscarriage and genetic de- COVID-19 poses extra challenges
during the already daunting
fects further increases after 40 years. labour and delivery. What can
be done to protect the patients
2. Medical conditions existing be- from COVID -19 and what is the
fore pregnancy: protocol when the mother is
l High Blood pressure tested COVID positive, in terms of
l DM childbirth and postpartum care?
l Obesity To protect mother from Covid-19 eve-
l Heart diseases ryone should maintain Standard pre-
l Lung, Kidney diseases caution for Covid-19 as:-
l Chlamydial infection, HIV
l History of repeated pregnan- l Wearing mask
cy loss l Social distancing
l Familial history of genetic l Hand hygiene
disorder
l Depression If the pregnant woman has any co-
morbidity like DM, HTN or infection, it

THE PHARMA WORLD 59



INTERVIEW

should be treated completely. When Could you please tell us, in brief, (LMIC). Diagnosis and treatment of in-
they are hospitalized advised to at- about the role of laparoscopic fertility is often not prioritized in na-
tain limited attendant with maintain- surgery in gynaecological oncology? tional population and development
ing standard precaution for Covid-19. policies and reproductive health strat-
They should be tested for Covid-19 by For many gynaecologic procedures, egies. Moreover, a lack of trained per-
RT-PCR, as early as possible and re- such as removal of an ectopic preg- sonnel and the necessary equipment
main in isolation till the report. nancy, treatment of endometriosis, and infrastructure, and the currently
ovarian cystectomy, hysterectomy high costs of treatment medicines, are
If the mother is COVID-19 positive (TLH) and Laparoscopic assisted vagi- major barriers in our country for the
they are referred to corona unit or co- nal hysterectomy (LAVH) laparoscopy equal access and affordability of infer-
rona dedicated hospital for delivery or has become the treatment of choice. tility treatments. Government policies
in postpartum period. Standard pro- It has been proved safer and to have could mitigate the many inequities in
tocol should be maintained as usual. a relatively shorter recovery period access to safe and effective fertility
During childbirth, all linens should compared to laparotomy procedures. care. To effectively address infertility,
be disposed safely. All hospital staffs health policies need to recognize that
maintain standard precaution. The laparoscopic surgeries for infertility is a disease that can often
the  gynaecological cancers  are per- be prevented, thereby mitigating the
During post-partum period, the formed for all the endometrial can- need for costly and poorly accessible
mother is advised to take more nutri- cers (uterus), small-sized (<2cm) cer- treatments.
tious diet to increase immunity and to vical cancers and small-sized (<8cm)
remain in isolation. Medicines should early-stage ovarian cancers. It is also Developing guidelines on the pre-
be taken according to her physician’s performed for benign and borderline vention, diagnosis and treatment of
advice. tumours. More recently, laparoscopy male and female infertility, should be
has also been used for staging, in- considered as a standard of quality care
The pandemic has changed the cluding peritoneal washes with bi- related to fertility care. complications
norm in follow-up of patients and opsy, partial omentectomy, and pelvic associated with infertility such as un-
perinatal care in general. How effec- and periaortic lymphadenectomy. safe abortion, postpartum sepsis and
tive is telemedicine in this situation? abdominal/pelvic surgery etc. should
Equal access to fertility care remains be addressed and preventing measures
Telemedicine is very effective in a challenge for low and middle- should be taken. In addition, enabling
follow up of a woman in perinatal care income countries. What can be done laws and policies that regulate third
in Covid-19 pandemic situation be- to increase the affordability and party reproduction and ART are essen-
cause pregnant women can take ad- equitability of assisted reproduction tial to ensure universal access without
vice to maintain her pregnancy or can technologies (ART) in our country? discrimination and to protect and pro-
address any complications, through mote the human rights. Once fertility
it. No need to go to hospital or doctor Infertility affects millions of people of policies are in place, it is essential to
physically, they can contact doctors to reproductive age worldwide. According ensure that their implementation is
take booking when she needs to go to to WHO data, the overall prevalence monitored, and the quality of services
doctors for check-up or investigations. of infertility is estimated at 3.5–16.7% is continually improved. l
in low- and middle-income countries
Inspite this, one must visit physi-
cally to her consultant for ckeck up,
at least 4 times during her pregnancy.

DHoelcltoor! Please send us your Success
Stories, Case St§dies etc.
for publication in

E-mail: [email protected]
Telephone: 88-02-58155677

THE PHARMA WORLD 61



INTERVIEW

We can increase the affordability & equitability
of ART by establishing exclusive ART centres

Prof. Tripti Rani Das The pandemic has changed to reduce hyperandrogenism & insu-
Chairman the norm in follow-up of lin resistance, particularly overweight
Dept. of Obstetrics & Gynaecology patients and perinatal care women with PCOS.
BSMMU, Dhaka in general. How effective is
telemedicine in this situation. Weight reduction of 5-10% can in-
As an eminent Gynaecologist duce an improvement in hirsutism by
of the country, what in your Due pandemic situation telemedicine 40 -55% within 6 months of weight loss.
opinion, are the most common has got immense role in general. But
Gynaecological disorders still it has some limitations in case of – Cosmetic methods
prevalent among our women? high risk pregnancy management & – Physical methods
follow up Management of malignancy – Electrolysis
Most common gynaecological disor- & follow up. – Laser photothermolysis
ders prevalent among our women are:
What is being done to protect the Hormonal therapy
– Abnormal uterine bleeding that patients from COVID -19 and what The basis of action of hormonal ther-
includes is the protocol when the mother is apy is either suppression of androgen
tested COVID positive, in terms of production or blocking of the action
– Polyp childbirth and postpartum care? of androgens on the skin.
– Adenomysis
– Leiomyoma (Fibroid uterus ) When mother is COVID positive, de- – This results in the hairs revert-
– Malignancies - cervical livery & postpartum care should be ing back to vellus –type hair.
– Uterine usual normal protocol ensuring IPC
– – Vulval maintenance. Doctors & other health – It takes 9- 12 months for the
– Choriocarcinama care providers should follow the role maximum effects to be noticed.
– Coagulopathy of infection prevention, should wear
– Ovarian causes PPE, double gloves, masks, goggles, – Can be combined with cosmetic
– Iatrogenic – drug abuse patient’s bed & used materials should measures.
– Non-specific causes be cleaned with chlorine solution (
– Stress in continence Bleaching powder ), all staff should – Combined oral contraceptive pill
– Post-menopausal symptom be evacuated before cleaning, no one – Drospirenone
– Subfertility should enter the room within 1 hour – Cyproterone acetate
– Vaginal discharge of cleaning & meticulous follow-up – Spironolactone
should be given. – Insulin sensitisers
– Metformin hydrochloride
Disorders like polycystic ovary
syndrome (PCOS) and anovulation What are the elements that
due to hormonal imbalances constitute high risk pregnancy?
are the leading cause What measures can be taken
of infertility in women. How are to manage and prevent
they treated? Is there any way such complications?
to prevent such disorders?
PCOs & anovulation due to hormo- The elements that constitute high risk
nal imbalances are the leading cause pregnancy are existing health con-
of infertility in women. Treatment & ditions, the mother’s age, lifestyle,
prevention are enlisted below - health issues and medical conditions
occuring before or during pregnancy.
Management Conditions that can pose risks to the
Weight loss & lifestyle changes: mother or baby include:
Weight reduction has been shown
– High blood pressure
– Lung, kidney, or heart problems
– Diabetes
– Depression
– Obesity
– Autoimmune disease

THE PHARMA WORLD 63

INTERVIEW

– Sexually transmitted diseas- Research published in – Laparoscopy in ART (Assisted re-
es (STDs) productive technology )
the  BMJ  has  linked IVF with a higher
– Long-term (chronic) infections – Evidence based approach
such as human immunodefi- risk Trusted Source  of  pulmonary – PCOS - Ovarian drilling
ciency virus (HIV) – Endometriosis – conservative
embolism, or blockage of the lung’s
A history of miscarriage, problems laparoscopic approach.
with a previous pregnancy, and a fam- main artery, and venous thromboem- – Ovarian cysts – laparoscopic
ily history of genetic disorders are also
risk factors for a high-risk pregnancy. bolism, or blood clots, during the 1st cystectomy
– Myoma uterus – laparoscopic
Medical conditions that occur dur- trimester of pregnancy.
ing pregnancy.  Myomectomy
Pregnancy loss – Proximal tubular block – laparo-
– Preeclampsia The leading cause of pregnancy loss,
– Gestational diabetes whether in IVF or in natural concep- scopic hysteroscopy cannulation
– Overweight, tion, is an abnormal number of chro- – Hydrosalpinx
– Depression. mosomes, known as chromosomal – Ectopic Pregnancy – laparoscop-
aneuploidy. Detecting aneuploidy in
Tips to Prevent a High-Risk Pregnancy the egg or sperm before carrying out ic linear salpingostomy
– Maintain or achieve a healthy IVF, or in an embryo before implanta-
weight before pregnancy. tion, may help increase the chance of The role of laparoscopic surgery in
– Manage pre-existing health con- a successful pregnancy. gynaecological oncology
ditions.
– Take prenatal supplements. In 2013, scientists announced For second look procedure follow-
– Avoid alcohol, tobacco, and drugs. that they had developed a new tech- ing surgical chemo treatment of ma-
– Know the risks of older maternal nology called time-lapse imaging. The lignancy .
age. technique may increase the chances
– Visit the doctor regularly dur- of selecting a suitable embryo for – Surgical staging
ing pregnancy. successful IVF, though further re- – Peritoneal washing with biopsy
search needs to be done. – partial omentectomy
Is an IVF pregnancy considered – Pelvic & periaortic lymphad-
high risk? What are the risks and Multiple Births
success rates of the procedure? When more than one embryo is trans- enectomy
ferred into the womb, there is a high- – laparoscopy assisted radical
IVF pregnancy is considered as a high er chance of having twins, triplets, or
risk pregnancy. more babies. vaginal hysterectomy

The possible risk of IVF drugs include: Pregnancies with more than one Where does Bangladesh stand as
– Nausea and vomiting fetus can result in: far as prevention, diagnosis and
– Nifficulty breathing treatment of infertility is concerned,
– Irritability – Preterm birth or low birth weight compared to the advanced
– Hot flashes – Double the mother’s risk of de- countries? What can be done to
– Enlargement of the ovaries increase the affordability and
– Difficulty sleeping veloping diabetes equitability of assisted reproduction
– Abdominal pain – Significant increase in the moth- technologies (ART) in our country?

Bruising can also result from repeated er’s blood pressure In comparison to advanced countries
daily injections. Bangladesh stands a step behind for
The doctor may recommend that prevention, diagnosis & treatment of
Health risks to the mother there should only be a single embryo infertility. But we can increase the af-
Rarely, the drugs  can cause  ovarian transfer in women with a heightened fordability & equitability of assisted
hyper stimulation syndrome (OHSS). chance of having twins. reproduction technologies (ART) in
This happens when the ovaries over- our country by establishing exclusive
respond to the gonadotrophins, so – Success rate depends on ART centres in every medical college
that too many eggs develop in the – Reason for what IVF done of our country including post gradu-
ovaries. Severe abdominal swelling – Quality of IVF center ate ART training centres. There must
and shortness of breath can result. – Age of the patients be a good lab support including ex-
If OHSS occurs, the doctor may sug- pert embryologist, Skilled post gradu-
gest restarting the whole cycle with a Could you please tell us, in brief, ate doctors & enthusiastic trainee &
lower dose of gonadotropin. about the role of laparoscopic staff. Training should be conducted
surgery in infertility and periodically. l
gynaecological oncology?

The role of laparoscopic surgery in in-
fertility:

– Diagnostic hystero-laparoscopy

64 THE PHARMA WORLD

WHO RESEARCH

Trends and Projection of Caesarian section
rates: Global and regional estimates

Rising rates suggest increasing numbers of medically
unnecessary, potentially harmful procedures.

According to new research from oped countries, about 8% of women pregnancy and childbirth,” said Dr
the World Health Organization gave birth by caesarean section with Ana Pilar Betran, Medical Officer at
(WHO), caesarean section use only 5% in sub-Saharan Africa, indi- WHO and HRP.
continues to rise globally, now ac- cating a concerning lack of access to
counting for more than 1 in 5 (21%) of this lifesaving surgery. WHO recommends some non-clini-
all childbirths. This number is set to cal actions that can reduce medically
continue increasing over the coming Conversely, in Latin America and unnecessary use of caesarean sec-
decade, with nearly a third (29%) of all the Caribbean, rates are as high as 4 in tions, within the overall context of
births likely to take place by caesarean 10 (43%) of all births. In five countries high quality and respectful care:
section by 2030, the research finds. (Dominican Republic, Brazil, Cyprus,
Egypt and Turkey), caesarean sections Educational interventions that en-
“Caesarean sections are absolute- now outnumber vaginal deliveries. gage women actively in planning for
ly critical to save lives in situations their birth such as childbirth prepa-
where vaginal deliveries would pose Worldwide caesarean section rates ration workshops, relaxation pro-
risks, so all health systems must en- have risen from around 7% in 1990 to grammes and psychosocial support
sure timely access for all women when 21% today, and are projected to con- where desired, for those with fear of
needed,” said Dr Ian Askew, Director of tinue increasing over this current dec- pain or anxiety. Implementation of
WHO’s Department of Sexual and Re- ade. If this trend continues, by 2030 such initiatives should include ongo-
productive Health and Research and the highest rates are likely to be in ing monitoring and evaluation.
the UN joint programme, HRP[1]. “But Eastern Asia (63%), Latin America and
not all the caesarean sections carried the Caribbean (54%), Western Asia Use of evidence-based clinical
out at the moment are needed for (50%), Northern Africa (48%) Southern guidelines, performing regular au-
medical reasons.  Unnecessary surgi- Europe (47%) and Australia and New dits of caesarean section practices in
cal procedures can be harmful, both Zealand (45%), the research suggests. health facilities, and providing timely
for a woman and her baby.” feedback to health professionals
Quality, women-centred care about the findings.
Caesarean sections can be essen- needed to address high use
tial in situations such as prolonged of caesarean section Requirement for a second medical
or obstructed labour, fetal distress, opinion for a caesarean section deci-
or because the baby is presenting in Causes of high caesarean section us- sion in settings where this is possible.
an abnormal position. However, as age vary widely between and within
with all surgeries, they can have risks. countries. Drivers include health sector For the sole purpose of reducing
These include the potential for heavy policies and financing, cultural norms, caesarean sections, some interven-
bleeding or infection, slower recovery perceptions and practices, rates of pre- tions have been piloted by some
times after childbirth, delays in estab- term births, and quality of healthcare. countries but require more rigorous
lishing breastfeeding and skin-to-skin research:
contact, and increased likelihood of Rather than recommending spe-
complications in future pregnancies. cific target rates,  WHO underscores A collaborative midwifery-obstetri-
the importance of focusing on each cian model of care, for which care is
Caesarean section rates rising woman’s unique needs in pregnancy provided primarily by midwives, with
globally, though unequally, with and childbirth. 24-hour back-up from a dedicated
increases projected to continue obstetrician
“It’s important for all women to
There are significant discrepancies be able to talk to healthcare provid- Financial strategies that equalize
in a woman’s access to caesarean ers and be part of the decision mak- the fees charged for vaginal births
sections, depending on where in the ing on their birth, receiving adequate and caesarean sections.
world she lives. In the least devel- information including the risks and
benefits. Emotional support is a criti- [1] UNDP - UNFPA - UNICEF - WHO-
cal aspect of quality care throughout World Bank Special Programme of Re-
search, Development and Research
Training in Human Reproduction (HRP).

Source: BMJ Global Health

THE PHARMA WORLD 65



ARTICLE

Diabetes in Pregnancy

Prof. Samsad Jahan ance test (OGTT), but normal blood Screening for GDM
Professor & Head glucose levels during fasting and two
Department of Obstetrics & Gynaecol- hours after meals; diet modification Women with high risk of GDM:
ogy, BIRDEM General Hospital-2 is sufficient to control glucose levels l BMI>30kg/m2
l Type A2: abnormal OGTT com- l First degree relative with Diabetes
Gestational diabetes is formally pounded by abnormal glucose l Personal history of GDM
defined as “any degree of glucose levels during fasting and/or after l Previous macrosomic baby ≥4.5kg
intolerance  with onset or first meals; additional therapy with insu- l Family origin with high diabetes
recognition during pregnancy”.  This lin or other medications is required
definition acknowledges the possibil- prevalence ( South Asian, African-
ity that a woman may have previously Diabetes which existed prior to preg- Caribbean, Middle-Eastern)
undiagnosed diabetes mellitus, or may nancy is also split up into several sub- l Previous poor obstetrics outcomes
have developed diabetes coincidental- types under this system: usually associated with diabetes.
ly with pregnancy. Whether symptoms l Type B: onset at age 20 or older
subside after pregnancy is also irrele- Type 1 and Type 2 diabetes
vant to the diagnosis. A woman is diag- and duration of less than 10 years.
nosed with gestational diabetes when l Type C: onset at age 10–19 or dura- Pre-conception care is essential. If
glucose intolerance continues beyond untreated in first few weeks gestation,
24 to 28 weeks of gestation. tion of 10–19 years. associated with:
l Type D: onset before age 10 or du- l Spontaneous abortions
The white classification, named af- l Birth defects
ter Priscilla White, who pioneered re- ration greater than 20 years.
search on the effect of diabetes types l Type E: overt diabetes mellitus If untreated during 2 or 3 trimester,
on perinatal outcome, is widely used associated with:
to assess maternal and fetal risk.  It with calcified pelvic vessels. l Foetal macrosomia and metabolic
distinguishes between gestational l Type F: diabetic nephropathy.
diabetes (type A) and pregestational l Type R: proliferative retinopathy. abnormalities
diabetes (diabetes that existed prior l Type RF: retinopathy and nephrop- l Birth injury
to pregnancy). These two groups are l Maternal hypertension and pre-
further subdivided according to their athy.
associated risks and management. l Type H: ischemic heart disease. eclampsia
l Type T: prior kidney transplant. l Future diabetes and/or obesity in child
The two subtypes of gestational
diabetes under this classification sys- Diabetes Mellitus in Pregnancy fall Pre-pregnancy counselling
tem are: into 2 categories:
l Type A1: abnormal oral glucose toler- 1. Gestational Diabetes Mellitus l To assess suitability for pregnancy
l To look for complications of diabe-
(GDM) – Any degree of glucose intol-
erance with onset or first recogni- tes, evaluate and treat complica-
tion during pregnancy. Does not ex- tions prior to onset of pregnancy
clude possibility that unrecognised l To achieve optimal control prior to
glucose intolerance may have been and during very early pregnancy
present before onset of pregnancy. l To provide an opportunity for pre-
2. Pre-gestational Diabetes Mellitus- pregnancy advice and folate sup-
diagnosed when the women has plements
diabetes before pregnancy.
Medical assessment in
GDM in first trimester pre-concepion care

l Women found to have fasting hy-  Duration and type of diabetes
perglycaemia or abnormal glucose  Medical history and current Medi-
intolerance in the first trimester
might have pre-existing diabetes cal management plan
 Chronic diabetes complications:
l Should be treated as women with
glucose intolerance before pregnancy → Retinopathy
→ Nephropathy
l First trimester hyperglycaemia – → Neuropathy
high risk of congenital abnormali-  Co-morbid conditions (in addition
ties in fetus to diabetes complications)

THE PHARMA WORLD 67

ARTICLE

→ Hypertension (ideal blood pressure <120/80) (10-30%), l Congenital malformations, l Neural tube defects,
→ Coronary Artery Disease l Cardiac defects, l Caudal Regression syndrome (rare)
→ Hyper-or Hypothyroidism
→ Other auto-immune disease l Macrosomia, l Visceromegaly, l Cardiac enlargement, l
Hepatic enlargement, l Respiratory distress syndrome, l
Recommendations Asphyxia, Birth injury, l Shoulder Dystocia, l Erb’s Palsy, l
Diaphragmatic paralysis and Facial paralysis.
Plan pregnancies, Attain a pre-conception HbA1c of < 7%, If
planning pregnancy: Metabolic complications
l Needs retinal screening prior to conception, l Screen for
diabetes retinopathy and coronary heart disease, l Discon- Long Term Effects
tinue oral hypoglycaemic agents and attain glycaemic targets Childhood obesity, Neuropsychological effects and diabetes.
using insulin,if possible, l Replace ACEI and ARBs to other hy-
pertensives that are safe to take in pregnancy, l Stop statins Preventing Retinopathy Progression

Possible contra-indications to pregnancy Rapid normalization of blood glucose during pregnancy
can trigger retinopathy, Retinal status should stabilized
l Ischemic Heart disease prior to conception, Reassess retinal status each trimester
l Active, unrelated proliferative retinopathy (more frequently if retinopathy is present).
l Renal insufficiency
l Severe Gastroparesis Hypoglycemia (high insulin production in immediate ne-
onatal period due to recent foetal hyperglycaemia), Mother
→ Inability or unwillingness to use Insulin encouraged to breastfeed ASAP; monitor baby’s blood glu-
cose: formula fed or glucose infusion prn, Hypocalcaemia,
Screening magnesium deficiency → apnoeic episodes and fits, Poly-
cythaemia →hyperbilirubinaemia →jaundice
WHO diabetes diagnostic criteria

Condition 2-hour Glucose Fasting Glucose HbA1c
Unit
Normal mmol/L mg/dL mmol/L mg/dL mmol/L DCCT %
Impaired fasting glycaemia
Impaired glucose tolerance <7.8 <140 <6.1 <110 <42 <6.0
Diabetes mellitus
<7.8 <140 6.1-7.0 110-125 42-46 6.0-6.4

≥7.8 ≥140 <7.0 <126 42-46 6.0-6.4

≥11.1 ≥200 ≥7.0 ≥126 ≥48 ≥6.5

Tests for gestational diabetes Management: Obstetrics

Non-challenge blood glucose test Nuchal Translucency Scan, detailed US for foetal anoma-
l Fasting glucose test lies, Foetal echocardiography, serial growth scan, monitor
l 2-hour postprandial (after a meal) glucose Screening glu- foetal wellbeing (droppler US & CTG).

cose challenge test, Oral glucose tolerance test (OGTT) Aim: vaginal delivery between 38-40 weeks, 50% Ceasar-
l Risk to mother with Gestational diabetes ian section because of macrosomia, pre-eclampsia and
l Increased risk of Caesarian Section failed induction of labour.
l Pre-eclampsia (2-4x esp with co-existing microalbumi-
Management: preterm labour & polyhydramnios
nuria/frank nephropathy)
l Polyhydramnios l Tocolytics (e.g. ritodrine, salbutamol) are diabetogenic, l
l Pre-term labour I/M steroid for foetal-lung maturation → destabilize diabetic
l Post-Partum Hemorrhage control, l I/V insulin/glucose infusion if required to ensure
l Temporary worsening of renal function normaglyeaemia.
l Progression of retinopathy
l Increased incidence of infection, severe hyperglycemia/ Management: Intrapartum

hypoglyeaemia DKA l Induced/Spontaneous labour → sliding scale of insulin
l Recurrent GDM Pregnancies to maintain normglycaemia, l Test maternal blood glucose
l Risk of developing T2DM (50% in 5-10 years) hourly, l continuous foetal monitoring advised, l Foetal
scalp blood sampling if CTG abnormal.
Potential complications in infants
of mothers with Diabetes Management: Post Delivery

l Intra-uterine demise, l Spontaneous abortions, l Stillbirth Insulin requirements return to pre-pregnant levels, l If
GDM, stop insulin, l OGTT 6/52 post-delivery ensure diabe-
tes has resolved. l

68 THE PHARMA WORLD

SONOLOGIST SPEAKS

Detection of a problem is the first
big step toward resolving it

Dr. Farzana Alam While it is considered a gold portant scan during pregnancy as it
Sonologist standard for diagnosing foetal is supposed to detect any anomalies.
Medinova Medical Services Ltd. Dhaka abnormalities or maternal This scan looks at all the systems of
complications, what conditions can the foetus like brain and face, heart,
What is the role of make ultrasound imaging difficult? lungs, kidneys limbs etc. and rules out
ultrasonography in Pregnancy? any major physical defect.
Ultrasonography plays a key role in Ultrasound scans, with their limita-
confirming pregnancy, securing in- tions, are known to be the best meth- The fourth scan is usually done in
formation about development of od to diagnose foetal abnormalities 28th -37th weeks to see the growth
the foetus at various stages, and in and maternal conditions. of the foetus, foetal weight, position,
detecting anomalies, if any. This in- and liquor volume.
formation helps determine recom- Although a structural screening scan
mendations for the pregnant woman is undertaken, detection of structural We have not come across any report
toward safe motherhood and healthy anomalies may not be 100%. Detection of adverse effect on the foetus cause
growth of the foetus. Thus ultrasound rates vary and may be reduced by fac- by ultrasound scans. To my knowl-
scans have become an important tool tors like maternal obesity, abdominal edge, ultrasound scans are harmless.
to monitor the progress of pregnancy scars, gestational age, in appropriate
and make decisions, including deci- foetal position and reduced amniotic Did you notice any change
sions to conduct a surgery, in case an fluid volume. Even in the best of hands, in the number of patients
anomaly warrants so. a small percentage of foetal anomalies coming for ultrasonography
might remain undetected. Internation- during the pandemic?
ally accepted detection rate of major
abnormalities is around 70%. Like many other sectors, the pandem-
ic significantly impacted the health-
How often does a pregnant woman care sector. The number of patients
need to do ultrasonography? coming for ultrasound scans went
Can it pose any adverse down as people were afraid of con-
effect on the foetus? tracting Covid-19 virus from hospitals
or diagnostic centres. Patients limited
The normal number of scans that a their routine scans. Infertility patients
woman should go through during on medications delayed their scans
pregnancy depends upon whether and also saw a decline. Besides, there
she has any high risk factors or not. were fewer scans of breast with lumps
But usually 4 to 5 scans are done dur- or pain. Anomaly scans, however, did
ing the entire duration of pregnancy. not lose the pace.
These scans are done at various stag-
es of pregnancy, so that it gives us in- How do you evaluate the role
formation at each stage of pregnancy. of obstetric ultrasonography
in reducing maternal and
The first scan is done in 6th – 8th perinatal mortality?
weeks. Alongside confirming the
pregnancy, it shows the heartbeat of Detection of a problem is the first big
the foetus and detects internal bleed- step toward resolving it. Ultrasound
ing and/ or multiple pregnancy, if any. scans help diagnose conditions like
ectopic pregnancy, threatened abor-
The second scan, done in 11th -13th tion, placenta previa, placenta abrup-
weeks, aims at finding any genetic ab- tion, foetal distress, IUGR, incompe-
normalities through measuring nuchal tent cervix, etc. and thus can reduce
translucency, nasal bones, duct us ve- maternal and perinatal mortality,
nous flow, placental location , etc. through taking cautionary and reme-
dial measures. l
The third scan is usually done in
18th -20th weeks. This is a very im-

THE PHARMA WORLD 69



INTERVIEW

Early detection and early prevention
of complications can ensure safe
motherhood for all the mothers

Dr. Nargis Fatema these are usually benign. Patients should also keep themselves distant
Senior Consultant, Obstetrics & Gy- also come with malignant tumors from the pregnant mother to protect
naecology, Square Hospitals Ltd. like cervical cancer and ovarian can- her from COVID. Pregnancy is itself
cer. Many women come with chronic risky, so if the mother gets COVID, the
As an eminent Gynaecologist of the pelvic pain resulting from heavy men- pregnancy becomes high risk like any
country, what are the most common struation, endometriosis, cysts, pelvic other comorbidities ( HTN, diabetes,
Gynaecological disorders prevalent inflammatory disease, urinary tract immunosuppressing disorders etc.).
among our women in your opinion? infections etc. Lots of women come So, it is difficult to manage COVID in
The most common conditions are to us for infertility. This problem has pregnancy. If any pregnant women is
related to bleeding. That etiology become very prevalent in our society having flu-like symptoms, she should
of bleeding is different according to as many women are marrying late and immediately visit the flu-corner and
the age group. Teenage girls usually trying to conceive at a later age. Many consult with the medicine special-
come due to heavy menstrual bleed- gynecological disorders also cause in- ist in person, as many pregnancy re-
ing, while middle-aged women usu- fertility like Polycystic ovaries. lated problems may be undetected if
ally come with excessive bleeding due consulted only over phone. If a COVID
to some tumors or uterine disorders The times during labour and delivery positive pregnant mother does not
like adenomyosis. There are many is very daunting already and require emergency delivery, we usu-
cases of tumours, for example intra- COVID-19 poses extra challenges. ally prefer to wait till she is negative.
uterine or ovarian tumours which may What is being done to protect the But in emergency conditions, for ex-
be associated with pain, or bleeding- patients from COVID -19 and what ample if the patient is having labour
is the protocol when the mother is pain, bleeding, foetal conditions, high
tested COVID positive, in terms of blood pressure or respiratory distress
childbirth and postpartum care? due to COVID, and the obstetrician
feels that the patient could be bet-
Since the past one and a half years, ter managed if delivered, then, we go
the entire world has been suffer- for emergency delivery. The situation
ing from this pandemic. We have is very difficult for the COVID positive
been fortunate enough to not have mother as she is left alone after de-
faced such critical conditions yet, livery, no attendants are allowed near
like many other countries have. But her; it is very stressful.
it is rising again with the third wave.
In pregnancy, it is best to avoid get- The post-partum care is as usual,
ting COVID at all costs. So, preven- but with added precautions with per-
tion is the best policy here. WHO has sonal protective equipment, respira-
recommended pregnant mothers to tory hygiene, and hand hygiene for
stay home, except the four mandatory both the patient and the attending
perinatal in-person visit with the gy- staff.
naecologist and during emergencies.
They should follow social distanc- The pandemic has changed
ing within their own home also, as the norm in follow-up of
well as follow respiratory and health patients and perinatal care
hygiene. This is very important be- in general. How effective is
cause, many pregnant women are telemedicine in this situation?
getting COVID despite not going out-
side. The working family members There are some protocols and guide-
lines from the WHO for antenatal fol-

THE PHARMA WORLD 71

INTERVIEW

low-up; during the pandemic period roid disease, heart or blood disorders, catheter should remain in place until
the recommendation is at least 4 in- poorly controlled asthma, and infec- well after the end of labour or as long
person visits and 4 online gynaecolo- tions increases pregnancy risks. needed to give the bladder a rest and
gist consultations for average patients. time to heal.
But, for high-risk patients, only follow For prevention, there should be
up during the first trimester is done regular antenatal check-up. The pa- Could you please tell us, in brief,
through telemedicine. But, though she tients should have control over their about the role of laparoscopic
could do the blood tests by opting blood pressure or blood glucose lev- surgery in infertility and
for home sample collection service, el. They should have institutional de- gynaecological oncology?
for ultrasonography she has to come livery. Tertiary hospitals have all the
to the hospital. So, why not follow up facilities available for management of Laparoscopy is a unique and de-
with the gynaecologist also? I am say- high-risk patients. manding technique. We have two
ing this because we cannot assess a types of laparoscopic procedure for
patient fully without seeing her and Bangladesh has recently infertility- one is diagnostic, and the
examining her in person. If any patient celebrated International Day to other is operative or therapeutic. If a
develops any risk factor, such as dia- End Obstetric Fistula. It is one woman fails to conceive even after a
betes and hypertension or develops of the most serious and tragic long time of treatment with drugs, we
any complications due to pre-existing injuries that can occur during need to look in the abdomen, if there
risk factors like obesity, advanced ma- childbirth. How can it be prevented is anything wrong. If we find any prob-
ternal age, pre-existing diabetes, and and treated? What can be done lem with the pelvic organs, ovaries if
hypertension etc., must come to the nationally to rehabilitate women there are any endometriosis or any
facility immediately and follow the suffering from obstetric Fistula? tubal obstruction etc. through lapa-
normal protocol for antenatal visit. roscopy, we go for Assisted Repro-
Fistula is not a recent issue. It is a very duction Techniques. In other cases,
What are the elements that old issue in our society. The preva- we use laparoscopy for cystectomy,
constitute high risk pregnancy? lence of obstetric fistula is decreasing hysterectomy, myomectomy or in
What measures can be taken because we have emergency obstetric some cases cauterization. In oncol-
to manage and prevent care (EOC) all over the country now. ogy, especially in obstetrics and gy-
such complications? Comprehensive EOC facilities and EOC necology, laparoscopic procedure is
training have started in our country not very common. It was primarily
High risk pregnancy is categorised in 20-30 years ago. Since then, we have used to only look at ovarian cancer.
different groups. We always prefer to been able to reduce the incidences of Because in gynecological malignancy,
assess the woman before pregnancy, Obstetric fistula. It still is a social stig- you cannot remove the whole tumour
if she is predicted to have high risk ma. The childbirth injury resulting in through laparoscopy, you have to cut
pregnancy or not, so that we can take uncontrollable leakage of urine and/ it in smaller pieces, thereby increas-
preventive measures beforehand. If or feces leads to physical and psycho- ing the chance of spreading. What
anyone is already hypertensive or logical distress in the woman due to we do is after chemotherapy, we can
diabetic or already has thyroid prob- her husband abandoning her and her check if there is any residual tissue
lems and the conditions are left undi- community isolating her.  and do a biopsy. So, laparoscopy has
agnosed and not stabilised, the preg- a wider application in treating infer-
nancy would become very risky. During prolonged labour, the moth- tility than in malignancy.
er’s contractions continually push the
Very early pregnancy (<17), very baby’s head against her pelvis. Soft tis- Where does Bangladesh stand as
late pregnancy (>35), multiple preg- sues caught between the baby’s bony far as prevention, diagnosis and
nancy, repeated pregnancy loss etc. head and her pelvic bone become treatment of Ob/Gyn disorders
are  some high-risk pregnancies we compressed, restricting the normal is concerned, compared to the
deal with regularly. Another high-risk flow of blood. Without adequate blood advanced countries? What steps
condition is placenta previa, which supply, causing pressure necrosis in do you suggest to improve overall
causes profuse bleeding during preg- the bladder, leaving holes between the women healthcare in Bangladesh
nancy and delivery and requires re- mother’s vagina and her bladder or to ensure safe motherhood?
moval of the uterus to save the life of rectum, causing incontinence.
the patient. Sometimes, even with our I think, we are not very behind. We are
utmost efforts, the life of the patient Fistula can be prevented by well using almost all the procedures that
cannot be saved. High  blood pres- management of the labour and time- the advanced countries are using-
sure, obesity, diabetes, epilepsy, thy- ly, safe delivery by skilled attendants. maybe not so much in the rural area,
Delivery should be institutional, im-
mediate catheterization is crucial. The

72 THE PHARMA WORLD

INTERVIEW

but in the tertiary hospitals, medi-
cal college hospitals, university
college hospitals or many private
hospitals, all surgeries and treat-
ment are available. Very advanced
surgeries, like robotic surgery is
still not available in our country as
it is very expensive and not cost ef-
fective. Patients who can afford it,
can avail it abroad. But, in future, it
is coming up in our country.

For safe motherhood, family
should be aware of the physical,
mental and emotional status of the
mother and they should come for-
ward to make her comfortable and
to give her support in every way.
Pregnant women should always be
in touch with her doctor for regular
antenatal checkup as well as go to
hospital in case of any complica-
tion or emergency. Early detection
and early prevention can save the
mother from so many complica-
tions. All deliveries should be done
by skilled and expertly trained
birth attendants. It is important to
have the delivery by skilled hands,
which is why we need skilled mid-
wives. All the centres should have
good infection control protocol, as
post abortion sepsis is very com-
mon in our country. Brast feeding
should be encouraged. Normal
delivery should be encouraged un-
less contraindicated. Pain manage-
ment can be done by epidural, but
it is still not available in all centres.
We should have blood transfusion
facility available and ready during
delivery at all centres, as bleed-
ing and ecplamsia are the major
cause of maternal death in our
country. Thromboembolism is very
common cause of maternal death
in western countries, but in our
country, the question remains if it
is less prevalent or remains unde-
tected. All in all, prevention is the
best strategy. If we can be aware
and alert of any complications,
and prevent it from occurring, we
can ensure safe motherhood for all
the mothers. l

THE PHARMA WORLD 73