TPW March-April 2023

INTERVIEW THE PHARMA WORLD 51 Prof. Dr. Kohinoor Begum Dept. of Gynaecology & Obstetrics Popular Medical College Counselor, BCPS “Safe motherhood means access to information and services for safe childbirth” and 28% of Bangladeshis had hypertension. And Eclampsia causes 24% of maternal mortality in Bangladesh, so it is important to address these problems. To reduce the risk and complications we need: l Pre conceptional counseling-If already she is diabetic/hypertensive, try to control the condition first, then try for pregnancy. l Screening of high-risk patient is important during ANC l Regular and adequate antenatal care for early identification & start of treatment to prevent complication l Proper Intra natal (hospital delivery) & postnatal care is a must. l Overall increase in awareness of general people regarding the high risk pregnancies. What causes eclampsia? What is the difference between eclampsia and preeclampsia? What warning signs to look for? How is it managed? Eclampsia is seizures that occur in pregnant people with preeclampsia. Symptoms of eclampsia are high blood pressure, headaches, blurry vision and convulsions, that occurs in the second half of pregnancy. Risk factors includes: l Gestational or chronic hypertension (high blood pressure) l Being older than 35 years or younger than 18 years l Pregnancy with twins or triplets l First-time pregnancy l Diabetes or another condition that affects your blood vessels l Kidney disease l Family or personal history of preeclampsia or eclampsia. l Autoimmune condition. l Poor diet or have obesity (a BMI greater than 30). Eclampsia is a severe form of preeclampsia along with seizures. It’s considered a complication of preeclampsia, but it can happen without signs of preeclampsia. These seizures can cause confusion and disorientation or put the pregnant person in a coma. Many people will have warning signs before having a seizure caused by eclampsia. Some of these signs are: l Severe headaches. l Rapid /generalized swelling of the hands, face or ankles. l Difficulty breathing. l Nausea or vomiting. l Decreasing urination. l Abdominal pain (especially on the upper right side). l Blurred vision, seeing double or loss of vision. l Bleeding tendencies from different sites Treatment of Eclampsia include: As an eminent Gynaecologist of the country, what in your opinion, are the most common Gynaecological disorders prevalent among our women? Common gynaecological problems in Bangladesh are: l Menstrual problems → Dysmenorrhoea (endometriosis, PID) → Abnormal  vaginal  bleeding (Fibroid, Polyp, Adenomyosis, AUB-O) → Amenorrhoea (Primary/secondary) l Vaginal  discharge with or without pruritus vulvae l Swellings of the vulva (Barthoin gland cyst, Bartholin abcess) l Malignancy (cervical cancer,ovarian cancer, Endometrial cancer) l Menopause-Post menopausal syndrome, post menopausal bleeding l Genital tract malignancies. Some diseases like Diabetes, Hypertension and Eclampsia make pregnancy complicated and risky. What suggestions do you have to address the factors? Diabetes, hypertension are quiet common now a days. In Bangladesh, 8.4 million adults lived with Diabetes in 2019

THE PHARMA WORLD 53 a) Medications for eclampsia during pregnancy like: → Anticonvulsant medication or magnesium sulfate infusion to prevent seizures. → Blood pressure medication to lower blood pressure-if BP is >160/100mmHg-use drugs by parenteral route. → Corticosteroids to help develop and strengthen the fetus’s lungs if time permits. b) Obstetric management. The best treatment for eclampsia is giving birth- whatever be the duration of gestation .If cervical condition is favourable –vaginal delivery can be allowed. c) Postnatal care is also important to minimize the complications d) Long term F.U is also important-for both mother & baby because both of them can have cardiovascular complications in later life. Caesarean section rates continue to rise alarmingly.  What, in your opinion, is the number one reason for choosing C-sections over vaginal birth nowadays? Are there any long-term effects of C-sections on the mother? No one factor could be identified as a primary cause for choosing C-section over vaginal delivery. The reasons for this increase are multifactorial and not well-understood. Changes in maternal characteristics and professional practice styles, increasing malpractice pressure, as well as economic, organisational, social and cultural factors have all been implicated in this trend. Factors associated with higher rate of caesarean section include increase in women’s age, pregnancy with associated medical conditions, pre-pregnancy body mass index, infant’s birth weight; first-time mothers; mothers living in urban areas; early identification of high risk pregnancy, decrease in operative vaginal deliveries and mothers giving birth in private hospitals, maternal request, and fear of litigation in obstetric practice. Long term effect of caesarian section On mother: Complications of surgery-might lead to long term morbiditylike incisional hernia,adhesions leading to chronic pelvic pain,subacute/acute intestinal obstruction,ureteric injury etc. Risk for future pregnancy include: l Risk of the incision scar tearing during a later pregnancy or labor (uterine rupture), l Placenta previa (the growth of the placenta low in the uterus, blocking the cervix), l Morbid adhesion of placenta (when the placenta grows deeper into the uterine wall) -Placenta accreta, increta, and percreta that can lead to severe APH, severe bleeding during surgery sometimes needing caesarean hysterectomy, might have severe PPH. On children: Children born by C-section also suffer increased rates of diseases, including asthma, type I diabetes, allergies, obesity, as well as reduced overall cognitive functioning and lower academic performance depending on the indications. What are the ways to optimize childbirth and ensure safe delivery for mother? l Proper selection cases for vaginal birth. l During antenatal care. The mother should be physically and mentally fit along with her guardians, as one of the important cause of C -section is patients choice (mainly due to fear of normal vaginal delivery). We should motivate her about the benefits of a normal delivery for her and her baby. l Good care during normal labor (respectful maternal care) is associated with a positive outcome for both mother and her baby. l Positive attitude from all concerned persons including patient, her relatives and obstetrician can make it possible to have a smooth normal delivery provided there are no medical and obstetrical complications. What steps do you suggest to improve overall womens healthcare in Bangladesh and ensure safe motherhood? Safe motherhood means ensuring that all women have access to the information and services they need to safely go through pregnancy and childbirth. The goal is to ensure the well-being of mothers through a comprehensive approach of providing, preventing, promotive , curative and rehabilitative health care. Components of safe motherhood include : l Education on safe motherhood l Prenatal care l Promotion of maternal nutrition l Adequate delivery assistance in all cases l Provisions for obstetric emergencies including referral services for pregnancy, childbirth and abortion complications l Postnatal care, Post abortion care Suggestions l Investing in family and community education, l Skilled birth attendants and referrals, or l Improved transportation networks for timely arrival to the hospital. The accessibility and provision of high quality emergency obstetric interventions are essential for improving maternal survival l Hospital administration must thoroughly and systematically investigate the healthcare delivery system malfunctions that are contributing to maternal deaths and devise urgent remedial solutions. l Reducing inequalities in accessing professional care is key to attaining the goal for good quality and compassionate maternal health. l The challenges are how to deliver services and scale up interventions, particularly to those who are vulnerable, hard to reach, marginalized, and excluded. l Within the developing countries the challenges are reducing the inequalities between rich and poor in professional delivery care to achieve safe motherhood and reach the SDG for maternal health. n

54 THE PHARMA WORLD The United States Department of Health and Human Services issued new recommendations on the selection and continuation of antiretroviral therapy (ART) during pregnancy. The major practical changes include: l Atazanavir and raltegravir are no longer preferred ART agents during pregnancy but are reasonable alternative agents if preferred agents cannot be used. l Patients who become pregnant while on the injectable cabotegravir-rilpivirine regimen can now continue the regimen throughout pregnancy with frequent viral load monitoring (every one to two months). l For patients who acquire HIV despite using cabotegravir as part of an HIV pre-exposure prophylaxis (PrEP) regimen, ritonavir-boosted darunavir is preferred over dolutegravir for ART initiation during pregnancy. Prophylactic antibiotics before vaginal birth Antibiotic prophylaxis to reduce the risk of postpartum maternal infection is standard practice before caesarean birth but not for laboring patients planning to give birth vaginally. However, in a randomized trial among nearly 30,000 patients ≥28 weeks of gestation in early labor planning a vaginal birth in seven low- and middle-income countries (LMIC), a single 2-gram oral dose of azithromycin reduced the composite risk of maternal sepsis or death compared with placebo (1.6 versus 2.4 percent). Neonatal sepsis and death rates were unchanged. Based on these findings, we would consider use of azithromycin prophylaxis in LMIC and clinical settings that mirror the trial settings, but not in other countries or settings. Change in fibroid volume across gestation The effect of pregnancy on fibroid volume has been unclear because of the lack of prospective longitudinal data from a large diverse obstetric population. To address this gap, a prospective cohort study performed six obstetric ultrasounds at timed intervals between 10 and 41 weeks of gestation in nearly 2800 patients at 12 clinical sites in the United States. Change in total fibroid volume was affected by initial volume: increasing by 2 percent per week in patients with initially small volumes (diameter ≤1 cm), no or minimal change in those with initially medium volumes (diameter 1 to <3 cm), and decreasing by 2 percent per week in those with initially large volumes (diameter ≥3 cm). Change in volume was also affected by maternal age, race/ethnicity, parity, and miscarriage history. These findings will be useful in counseling patients with fibroids about what to expect during pregnancy. ART selection during pregnancy Maximum oxytocin dose in labor Although many labor and delivery units limit the maximum oxytocin infusion dose to no more than 40 milliunits per minute during labor with a live fetus in the third trimester, doses as high as 90 milliunits per minute were used without adverse maternal or fetal effects in a recent trial. Given these and previous data of the variability in uterine response to the medication, we favor titrating the oxytocin dose according to the oxytocin responsiveness of the individual patient, primarily based on their contraction and fetal heart rate patterns, without regard to an arbitrary maximum dose. Blood loss at delivery in placenta accreta spectrum A meta-analysis of 20 studies evaluating red blood cell (RBC) use in nearly 1100 patients with placenta accreta spectrum (PAS) found that, on average, five RBC units were transfused per patient at delivery. In the largest study (338 patients), a median of two units were transfused but the range was 0 to 108 units. These findings illustrate the variability in blood loss and the potential for horrific hemorrhage in PAS. They also highlight the importance of notifying the blood bank and ensuring that adequate blood products are available at delivery in these cases.

55OBSTETRICS & GYNAECOLOGY UPDATE THE PHARMA WORLD Infertility treatment and pediatric cancer risk The risk of cancer in children conceived with assisted reproductive technology (ART, such as in vitro fertilization) has been debated, in part because it is difficult to separate the impact of the treatment from that of the underlying fertility disorder. In a recent cohort study including over 2.3 million parent-child triads followed for a median of 6 years, conception with ART was associated with an increased risk of pediatric cancer compared with nonART conception in subfertile patients or unassisted (natural) conception, but the absolute increase was small (65 cases per million person-years). Updated guidance on neonatal hyperbilirubinemia The American Academy of Pediatrics (AAP) has updated its clinical practice guidance on management of hyperbilirubinemia in term and late preterm newborns ≥35 weeks of gestation. Key changes from earlier guidelines include: l Initial newborn screening can be performed either with a laboratory test (ie, total serum bilirubin [TSB]) or transcutaneous bilirubin (TcB) device; abnormal TcB results require confirmation with TSB l Guidance for follow-up after newborn bilirubin screening has been updated l Higher treatment TSB thresholds are used for initiating phototherapy and exchange transfusion l New guidance is provided for “escalation of care” to rapidly address dangerously high bilirubin concentrations Association between tamoxifen and endometrial pathology in patients with breast cancer Tamoxifen, a selective estrogen receptor modulator, is used as adjuvant therapy or chemoprevention for selected patients with hormone-sensitive breast cancer or at increased risk for breast cancer; however, it is associated with an increased risk for uterine pathology. In one of the largest studies, a retrospective study including over 78,000 premenopausal patients (mean age 42 years) with breast cancer in Korea who were followed for an average of six years, those treated with versus without tamoxifen had higher rates of uterine disease (32 versus 7 per 1000 person-years), including (in descending order of frequency) endometrial polyps, endometrial hyperplasia, endometrial cancer, and other uterine cancers (rare). Use of ovulation induction drugs does not affect colon cancer risk Ovulation induction drugs are used for anovulatory infertility. While these drugs increase circulating estradiol levels, no increased risk of estrogen-sensitive cancers, such as breast and ovarian cancers, has been observed. In addition, the risk of colon cancer, which may also be impacted by hormonal factors, does not appear to affected. This was demonstrated in a population-based cohort study of nearly 150,000 women where no significant change in colon cancer risk was observed with the use of clomiphene citrate, exogenous gonadotropins, human chorionic gonadotropin, or gonadotropin-releasing hormone agonists. Source: Up To Date Ibrexafungerp for recurrent vulvovaginal candidiasis Treatment of recurrent vulvovaginal candidiasis (RVVC) has mainly consisted of long-term use of azole drugs such as fluconazole. In a phase 3 trial evaluating extended treatment with either ibrexafungerp, a novel triterpenoid antifungal, or placebo after initial fluconazole treatment in patients with RVVC, more patients receiving extended ibrexafungerp remained without evidence of RVVC four weeks from final dose (65 versus 53 percent). Based on this trial, the US Food and Drug Administration recently approved RVVC as a new indication for use of ibrexafungerp [24]. Although the duration of treatment benefit and efficacy against non-Candida species are not yet known, ibrexafungerp offers patients with RVVC another treatment option.

INTERVIEW THE PHARMA WORLD 57 Prof. Dr. Salma Rouf Professor & Head of Obs & Gynae Green Life Medical College Ex-Head of Obs & Gynae Dhaka Medical College & Hospital Treasurer-OGSB “To ensure safe motherhood women’s health care needs to be improved first” As an eminent Gynaecologist of the country, what in your opinion, are the most common Gynaecological disorders prevalent among our women? The most common gynaecological disorders prevalent in our women are: l Excessive and abnormal vaginal discharge. l Chronic pelvic pain and other sorts of pain during menstruation. l Abnormal uterine bleeding including irregular menstrual cycle, prolonged flow, and heavy menstrual bleeding. l Genital organ prolapse i.e descent of uterus, bladder, rectum, urethra. l Delay or inability to conceive l Abdominal Lump. Some diseases like Diabetes, Hypertension and Eclampsia make pregnancy complicated and risky. What suggestions do you have to address these factors? Some medical disorders come as comorbidities in pregnancy and make pregnancy complicated and high-risk. These should be addressed rightly and carefully for a better pregnancy outcome. For patients with known diabetes, HTN, and thyroid disorder, my suggestions include: l Pre conceptional counselling (PCC): Each and every woman should have a PCC when she decides to get pregnant. Though it is not very feasible in our country. But is a must for women with comorbidities. l These women should be recognized as high risk pregnancy and be dealt with in that way. l High-risk pregnancy needs frequent visits, regular investigation, of complications, and danger signs and foetal monitoring. All these should be counselled to the patient. l She should be counselled about her diagnosis, she may need a change of treatment before conception. What causes eclampsia? What is the difference between eclampsia and preeclampsia? What warning signs to look for? How is it managed? The exact cause of eclampsia is unknown. But there are some factors that increase the risk of eclampsia like-having diabetes, high blood pressure, kidney diseases, having autoimmune conditions like SLE, antiphospholipid syndrome, having HTN or history of preeclampsia (PE) in a previous pregnancy etc. Hypertension in pregnancy means the rise of blood pressure in pregnant women. When these women have protein urea and/or oedema, then it is called pre-eclampsia. And when PE is complicated with convulsion, then it is eclampsia. Women with PE may develop some warning signs, or im-

58 THE PHARMA WORLD pending signs before convulsion eclampsia such as severe HTN (≥160/110 mg), headache, blurring of vision, nausea upper abdominal pain, oliguria or anuria, pulmonary oedema, etc. Eclampsia is an obstetric emergency and requires prompt action withl Admission and general management l MgSo4 (magnesium sulphate to control convulsion l Antihypertensive drugs l Maternal and foetal monitoring l Termination of pregnancy l Prevention of complications like AKI, ARDS, HELLP syndrome. Caesarean section rates continue to rise alarmingly not only in Bangladesh but globally as well.  What, in your opinion, is the number one reason for choosing C-sections over vaginal birth nowadays? Are there any long-term effects of C-sections on the mother? While in some situations, a C-section is not only preferable but mandatory, in some situations it is unnecessary. In my opinion, the number one reason for choosing caesarean delivery over vaginal birth nowadays is –“fear of vaginal delivery”. These fears include fear of episiotomy, fear of labour pain, fear of abnormal labour, fear of foetal distress, fear of instrumental delivery and also fear of ultimate need of a C-section. The prevalence of maternal mortality and morbidity is higher after a C-section than after vaginal delivery. C-section has some long-term adverse effects on maternal health and the next pregnancy. For example, increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth and preterm birth and other physical problems like headaches, hip pain, problems of daily activities, suffering physical problems, and breastfeeding problems. What are the ways to optimise childbirth and ensure safe delivery for the mother? Although we are improving, we need to go much further to reach the goal of maternal mortality some important factors include: l Improving the moderns contraception prevalence rate: l Birth in health facilities with skilled birth attendants. l Access to emergency obstetric and neonatal care. l Developed referral system l Well-developed adolescent sexual and reproductive health What steps do you suggest to improve overall women’s healthcare in Bangladesh and ensure safe motherhood? To ensure safe motherhood women’s health care needs to be improved first. This should include: l Adequate health promotion l Ensure health service at the grassroots level l Health security l Decentralisation of health services l Increase hospital delivery rate Along with these, other important steps are– l Female education l Job security l Gender equality n

THE PHARMA WORLD 59 INNOVATION Excitable Nanoparticles Destroy Endometriosis Lesions Researchers at Oregon State University developed a nanoparticle system that can aid with the removal of endometrial lesions in a minimally invasive fashion. In endometriosis, endometrial tissue grows outside of the uterus, causing pain and affecting fertility. Surgery to remove these lesions is often unsuccessful and repeat surgeries are often required. The research team’s nanoparticle technology can aid in minimally invasively destroying such lesions. The iron oxide nanoparticles can be delivered intravenously and are targeted to accumulate in endometrial lesions, and also handily act as an MRI contrast agent. By applying an alternating magnetic field externally, clinicians can then induce the particles to produce localized heating, destroying the endometrial lesions. Ovarian Organoids to Study Reproductive Health A biotechnology company called  Gameto collaborated with Harvard Wyss researchers to develop human ovarian organoids that will allow the study of reproductive and other health issues using tissues that closely mimic those in human patients. Another application may lie in allowing people with fertility issues to conceive. This new approach involves using induced pluripotent stem cells (IPSCs) and transcription factors to create human granulosa cells and then co-culturing these cells with human primordial germ cell-like cells (hPGCLCs) to create the “ovaroids.” So far, the tiny structures have shown that they can secrete sex Organoids. They allow such scientists to avoid ethically questionable animal research and instead focus on human tissues that behave quite like the real thing. Extracellular Vesicles to Protect Lungs and Brain in Premature Birth Premature babies require supplemental oxygen, but this can damage their lungs, causing a condition called bronchopulmonary dysplasia (BPD). In the meantime, their brains are also at risk because of low oxygen. Now, Canadian researchers have been investigating the potential of mesenchymal stem cells (MSCs) to help protect and regenerate such tissues. The cells release nanosized extracellular vesicles that are easier to administer, store, and manufacture. Interestingly, they can also cross the blood-brain barrier, unlike MSCs, and so may have the potential in treating issues in the brain. and a recent study in mice suggests that extracellular vesicles from such cells could provide therapeutic benefits. In this new study, the researchers investigated if MSC-derived extracellular vesicles could alleviate both issues in mice with simulated BPD. Excitingly, the extracellular vesicles acted to prevent both lung and brain injury. THE PHARMA WORLD 59

INTERVIEW Prof. Dr. Nazma Hoque Professor & Head, Dept. of Obs & Gynae Gynaecological Oncology Unit Dhaka Medical College, Dhaka As an eminent Gynaecologist of the country, what in your opinion, is the most common Gynaecological cancer prevalent among our women? In developing countries like ours carcinoma of breast and cervix are the leading cases of women cancer in women, although worldwide cervical cancer (CaCx) ranks fourth, following breast, colorectal and lung cancer. The rate of cervical cancer is on the rise. What is your observation on this? The incidence of cervical cancer is steadily declining in developed countries. It is due to taking vaccination (HPV vaccine), doing regular screening and if needed therapeutic procedures. But, in developing countries, the situation is reverse due to inadequate screening facilities. What are the risk factors for developing cervical cancer (CaCx)? Possible risk factors for developing cervical cancer are: 1. Abnormal sexual behavior due to: l Early sexual intercourse or early marriage (≤ 16 years) “Cervical cancer can be prevented by timely Vaccination, effective screening procedures & proper genital hygiene” l Early age of first pregnancy (≤ 20 years) l Too many and too frequent child birth. l Multiple sexual partners. l Husband who has multiple sexual partners. l Husband’s previous wife died of cervical cancer. 2. Have sexually transmitted infections (STI) like HPV (type 16, 18, 31, 33), HSV type 2, Chlamydial infection etc. 3. Poor maintenance of genital hygiene 4 Low socio-economic condition 5. Illiteracy among women 6. Immuno suppressive states due to → HIV infection → Organ transplantation women 7. Long time (>5 years) continuous use of oral combined pill (OCP) 8. Smoking/Tobacco use. 9. Dietary deficiency (vit. A, C, E, Folic Acid) 10.Inadequate screening f or cervical cancer. Are there ways to prevent it? Yes, cervical cancer is the only female genital cancer which is preventable and curable. Even we can achieve elimination according to WHO strategy 90–70–90. That means if 90% of girls are fully vaccinated and 70% of women screened by the age of 35, 90% of cases can be prevented 90% of women with invasive cancer can be managed. Ways of CaCx prevention are: a) Primary prevention by HPV vaccination schedule: for 9–14 years girl 2 doses vaccine (0-6 month) for 15-25 years women also upto- 45 year women-3 doses vaccine at (0-1m-6m) → also by increasing awareness to the community about risk factors of Cacx. b) Secondary prevention by screening for cervical cancer – schedule from 30 to 65 years women 5 yearly- it should be done. Procedures are: → Pap’s smear/VIA test → HPV, DNA test → Colposcopy If any positive report found presence of CaCx, the patient should be treated immediately. What are your suggestions to optimize womens’ healthcare regarding cervical cancer in our country? Cervical cancer is a preventable cancer. Health education about risk factors for this cancer should be given to all people through- mass media, seminar, in primary education to maintain good health for girls/women. Cervical cancer can be prevented by timely Vaccination, effective screening procedures & proper genital hygiene n THE PHARMA WORLD 61

THE PHARMA WORLD 63 INTERVIEW Prof. Dr. Begum Nasrin Chairman Department of Obstetrics & Gynaecology, BSMMU “Routine ante-natal care and hospital delivery can reduce maternal mortality and morbidity” What are the elements that constitute highrisk pregnancy? What measures can be taken to manage and prevent such complications? All pregnancies carry risk, however “high risk” pregnancy is defined as any pregnancy that carries increased health risk for the pregnant woman, fetus or both. A woman’s pregnancy might be considered high risk if shel Is already suffering from any chronic medical disorder (hypertension, diabetes mellitus, heart disease, connective tissue disorder), depressive illness, HIV. l Develops any complication during pregnancy (preeclampsia, eclampsia, gestational diabetes, placenta praevia, multiple pregnancies). l Is aged 17 or younger, 35 or older, underweight or overweight before becoming pregnant. l Is a smoker, alcoholic and or addicted to any other drugs. To prevent complications of pregnancy, all pregnant women should be under regular antenatal checkup. If any complication develops, the multidisciplinary consultation should be taken. Women who are suffering from chronic medical disorders like hypertension, diabetes should be well-controlled before planning pregnancy using alternative medications which are safer for pregnancy. Folic acid supplementation 3 months before pregnancy helps to prevent birth defects. What is the main cause of preeclampsia? What are the early signs to look out for? How can we prevent preeclampsia in pregnancy? Pre-eclampsia is one of the most common complications of pregnancy, where there is a rise of Blood pressure above 140/90 mm of Hg after 20 weeks of gestation. The exact cause of pre-eclampsia is not known. It occurs in 3-7% of all pregnancies. Risk factors of this condition include- 1st pregnancy, past history of pre-eclampsia, multiple pregnancies (twin or triplet), family history of pre-eclampsia, obesity, age more than 35 years, and history of diabetes, kidney disease or thyroid disease. Along with high blood pressure, other features of preeclampsia include – proteinuria, low platelet count, increase liver enzyme, severe headache, blurring of vision, pain in the upper part of the abdomen, nausea or vomiting. Pre-eclampsia is a complication of pregnancy that is not preventable but complications associated with it are preventable. Regular antenatal check-up, early detection and treatment can prevent the life-threatening complications of As an eminent Gynaecologist of the country, what in your opinion are the most common gynaecological disorders prevalent among our women? Polycystic ovarian syndrome (PCOS) is one of the most common gynaecological problems, affecting 6-12% of women of reproductive age. PCOS is a heterogeneous androgen excess disorder that presents with different degrees of reproductive and metabolic dysfunction; it is associated with insulin resistance and metabolic syndrome. Diagnostic criteria include varying combinations of three features: Oligo/ anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology. Identifying and treating adolescents with PCOS is of prime importance, an adult woman with PCOS have a 10 fold increase risk of developing type-2 diabetes and a 2-fold increase risk of developing metabolic syndrome. Additionally PCOS is associated with adverse reproductive outcomes, including- subfertility and psychiatric co-morbidities. Early diagnosis is vital, as behavioral modification and life-style changes during adolescence play an essential role in the prevention of future complications and morbidities.

64 THE PHARMA WORLD pre-eclampsia like eclampsia, HELLP syndrome, abruption placenta, pulmonary embolism, renal failure and many other complications. Early referral, hospital admission, treatment of high Blood pressure, injection MgSO4 and timely delivery can help to save the life of a mother suffering from pre-eclampsia. Endometriosis is a very serious condition. What are the causes and management there of? Is there any way to reduce the chances of developing it? Endometriosis is a gynaecological condition that can affect women of any age, including teenagers. It is a progressive disease which is associated with severe life-impacting pain during periods, sexual intercourse, bowel movement and/or urination, chronic pelvic pain and sometimes depression, anxiety and infertility. Exact cause of endometriosis is thought to be multifactorial, meaning that many different factors contribute to its development. Among them retrograde menstruation, cellular metaplasia and stem cell theory are thought to be most important. There is no known cure for endometriosis and treatment is usually aimed at controlling the symptoms. Treatment can be given with medication and/ or surgery depending upon patient’s age, symptoms and desire for fertility. Contraceptive steroids, non-steroidal anti-inflammatory medications and analgesics are common therapies. Medical treatment for endometriosis focuses on either lowering the estrogen or increasing the progesterone in order to alter the hormonal environment that promotes endometriosis. These medical therapies include combined oral contraceptive pills, progestins and GnRH analogues. Surgery can be done to remove endometriotic lesions and scar tissue. However, success in reducing pain symptoms and increasing the pregnancy rate often depends on the extent of the disease. Treatment options for infertility due to endometriosis include laparoscopic removal of endometriosis, controlled ovarian stimulation with intra-uterine insemination (IUI) and in vitro fertilization (IVF) but success rates vary. Caesarean section rates continue to rise. What is the number one reason for choosing C-sections over vaginal birth? Are there any long-term effects of C-sections on the mother? In the last 2-3 decades it is observed that there is a rising trend of caesarean delivery compared to previous years. This rising trend is observed not only in Bangladesh, but also in other developed countries; it is now a global issue. Regarding the reason of this rising trend of caesarean delivery, it is very difficult to say the number one cause, rather there are many factors behind this issue. Among the reasons for increasing caesarean delivery important factors are- patient’s choice, lack of painless delivery facilities in most of the hospitals and lack of labour room in most of the private clinics, economic benefits of the hospitals, legal issues and last of all no universal protocol for pregnant women regarding mode of delivery. If 1st baby is delivered by caesarean section then in more than 90% cases next baby is also delivered by the same procedure. Repeated caesarean delivery is associated with many complications of the mother like- rupture uterus, PAS disorder, chronic pelvic pain due to adhesion, increase risk of VVF during next caesarean section or hysterectomy. So the government, policymakers and professional bodies need to take immediate coordinated measures to develop strategies to reduce the rising trend of caesarean delivery. Where does Bangladesh stand regarding prevention, diagnosis and treatment of gynaecological disorders, compared to the advanced countries? There are many gynaecological conditions those are preventable. Among them breast cancer & cervical cancer are important. Breast cancer is the first most common cancer and cervical cancer is the second most common cancer among the women. Through routine screening, cervical cancer can be diagnosed in its pre-cancerous stage and if treated in this stage, cervical cancer can be prevented. In Bangladesh for preventing cervical cancer and early diagnosis of breast cancer, Government of Bangladesh have established National centre in BSMMU, where training is given to the doctors, nurses and other health workers on different methods of cervical and breast cancer screening (VIA, Colposcopy, SBE, CBE). The trained health workers are working in the District, Thana and Union level at VIA, Colposcopy and Breast clinic for prevention of cervical cancer and earlier diagnosis of breast cancer and refer those patients to higher center for treatment purpose. Besides these gynaecological problems, there are many pregnancy complications that are responsible for maternal mortality. Eclampsia, PPH and sepsis are most common causes of maternal mortality in Bangladesh. We have a very strong health infrastructure for our population. The government of Bangladesh have established community clinic in union level. Women of our country are getting service at the grass-root level. Routine ante-natal care, timely referral to higher centers and hospital delivery can reduce maternal mortality and morbidity from these obstetric complications. What steps do you suggest to improve overall women healthcare in Bangladesh and ensure safe motherhood? To improve overall women healthcare in Bangladesh we need tol Increase coverage of antenatal care, screening of high-risk pregnancies and referral to higher centre l To increase institutional delivery & delivery by skilled birth attendants. l Improve women’s nutritional status. l Empower women to obtain better healthcare l Strengthening midwifery services l To improve public health awareness To ensure safe motherhood we have to strengthen family planning services, ensure ANC, PNC and post-abortion care. Finally we have to control STD/HIV/AIDS to improve obstetric and newborn care. n

HEALTH TIPS Walks in the Park help Ward Off Postpartum Depression New moms who live among greeneries may be somewhat less vulnerable to  postpartum depression, according to a new study. The study which included 415,000 new mothers, found that for every 10% increase in “street-level” green space, the risk of postpartum depression declined by about 4%. The study points to several reasons: physical activity, de-stressing ability of green spaces and social connection. Research has found that, on average, people who regularly spend time in green spaces have lower blood pressure, heart rate and levels of the “stress” hormone cortisol. Mediterranean Diet Cuts Women’s Odds of Heart Disease Steering clear of red meat, dairy and processed foods in favour of vegetables, fruits, nuts, extra virgin olive oil and whole grains will do a woman’s heart good, a new review shows. How much good? Women who most closely followed the Mediterranean diet — which also features legumes, fish and shellfish— appeared to lower their long-term risk for heart disease and premature death by nearly 25%, compared with women who didn’t. In the review, the investigators analysed a total of 16 studies and collectively, they weighed the potential heart health benefit of the Mediterranean diet among more than 722,0000 adult women. After analysing, the team found that those women who followed a Mediterranean diet most closely appeared to have a 24% lower risk for heart disease and a 23% lower risk for dying as a result of any disease, when compared with women whose eating habits were least in alignment. Vitamin D Could Be Weapon against Type 2 Diabetes Vitamin D supplements are typically used to guard against bone loss and fractures, but new research offers up another possibility: For folks with pre-diabetes, they may help lower the chances of a full diabetes diagnosis. Across three clinical trials, investigators found that over three years of vitamin D supplements lowered the risk of pre-diabetes progressing to type 2 diabetes by 15%. The analysis included just over 4,000 pre-diabetic participants who took vitamin D3, at a dose of either 4,000 IU a day, or 20,000 IU per week. Over three years, just under 23% of supplement users developed type 2 diabetes, versus 25% of placebo users. That’s a modest difference, but looking at the bigger picture, vitamin D can at least delay diabetes in 10 million of pre-diabetics worldwide. However, readers should take note that Vitamin D is stored in body fat and there is the potential for very high levels to cause problems, such as kidney stones when taken over 4000IU/day. THE PHARMA WORLD 65

66 THE PHARMA WORLD CONCERN E very two minutes, a woman dies during pregnancy or childbirth, according to the latest estimates released in a recent report by United Nations agencies. This report, Trends in maternal mortality, reveals alarming setbacks for women’s health over recent years, as maternal deaths either increased or stagnated in nearly all regions of the world. The report, which tracks maternal deaths nationally, regionally and globally from 2000 to 2020, shows there were an estimated 287,000 maternal deaths worldwide in 2020. This marks only a slight decrease from 309,000 in 2016 when the UN’s Sustainable Development Goals (SDGs) came into effect. While the report presents some significant progress in reducing maternal deaths between 2000 and 2015, gains largely stalled, or in some cases even reversed, after this point. Premature births and babies born with low birth weight is on the rise in Dhaka city due to poor air quality, found a recent study published in the Journal of Climate Change and Health. Between 2014 and 2017, the incidents of low birth weight increased from 20.6 percent to 36 percent while pre-term births jumped from 9 percent to 15.2 percent due to the mothers’ exposure to air pollution. The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and the Maternal and Child Health Training Institute of the Directorate General of Family Planning conducted the study on 3,206 samples. “Our study was done in a very data scarce setting, but it presents comparatively clear evidence of the strong association between these negative birth outcomes and air polluPremature births in Dhaka on rise for poor air A WOMAN DIES EVERY 2 MINUTES DUE TO PREGNANCY OR CHILDBIRTH

THE PHARMA WORLD 67 In total numbers, maternal deaths continue to be largely concentrated in the poorest parts of the world and in countries affected by conflict. In 2020, about 70% of all maternal deaths were in sub-Saharan Africa. In nine countries facing severe humanitarian crises, maternal mortality rates were more than double the world average (551 maternal deaths per 100,000 live births, compared to 223 globally). Severe bleeding, high blood pressure, pregnancy-related infections, complications from unsafe abortion, and underlying conditions that can be aggravated by pregnancy (such as HIV/AIDS and malaria) are the leading causes of maternal deaths. These are all largely preventable and treatable with access to high-quality and respectful healthcare. The COVID-19 pandemic may have further held back progress on maternal health. Noting the current data series ends in 2020, more data will be needed to show the true impacts of the pandemic on maternal deaths. Community-centered primary health care can meet the needs of women, children and adolescents and enable equitable access to critical services such as assisted births and pre- and postnatal care, childhood vaccinations, nutrition and family planning. However, underfunding of primary health care systems, a lack of trained health care workers, and weak supply chains for medical products are threatening progress. Roughly a third of women do not have even four of a recommended eight antenatal checks or receive essential postnatal care, while some 270 million women lack access to modern family planning methods. Exercising control over their reproductive health – particularly decisions about if and when to have children – is critical to ensure that women can plan and space childbearing and protect their health. Inequities related to income, education, race or ethnicity further increase risks for marginalized pregnant women, who have the least access to essential maternity care but are most likely to experience underlying health problems in pregnancy. “It is unacceptable that so many women continue to die needlessly in pregnancy and childbirth. Over 280,000 fatalities in a single year is unconscionable,” said UNFPA Executive Director Dr Natalia Kanem. “We can and must do better by urgently investing in family planning and filling the global shortage of 900,000 midwives so that every woman can get the lifesaving care she needs. We have the tools, knowledge and resources to end preventable maternal deaths; what we need now is the political will.” The report reveals that the world must significantly accelerate progress to meet global targets for reducing maternal deaths, or else risk the lives of over 1 million more women by 2030. n Source: The Daily Star tion,” said Mahin Al Nahian, research investigator of ICDDR,B, while sharing the findings of the study. Dhaka topped the list of cities around the world with the worst air quality. Air pollution in Dhaka has become a critical public health concern,” said the report titled ‘Air pollution and pregnancy outcomes in Dhaka’. The study, which is based on normal birth samples, found female foetuses are at higher risk of low birth weight while males are more prone to premature birth due to poor air quality. And exposure to air pollution during the second trimester causes the most harm to the babies as it hampers the development of foetal organs and physiological processes. It may be that nutrient transfer from the mother’s blood across the placental barrier is impeded by exposure to airborne contaminants or simply the transfer of oxygen may be negatively affected. This constrains foetal growth. Source: Daily Star FAST FACTS Cervical cancer is the fourth most common cancer among women globally, with an estimated 604 000 new cases and 342 000 deaths in 2020. About 90% of the new cases and deaths worldwide in 2020 occurred in low- and middleincome countries Women living with HIV are 6 times more likely to develop cervical cancer compared to women without HIV. Cervical cancer can be cured if diagnosed at an early stage and treated promptly.. Each year between 50 000 to 100 000 women worldwide are affected by obstetric fistula, an abnormal opening between a woman’s genital tract and her urinary tract or rectum. The development of obstetric fistula is directly linked to one of the major causes of maternal mortality: obstructed labour. Endometriosis affects roughly 10% (190 million) of reproductive age women and girls globally. At present, there is no known cure for endometriosis, and treatment is usually aimed at controlling symptoms. 10% of women worldwide have endometriosis - that’s 176 million worldwide. The prevalence of endometriosis in women with infertility be as high as to 30–50%. Vitamin D, a hormone and a vitamin, has been shown to play a role in insulin resistance and egg development

INTERVIEW THE PHARMA WORLD 69 “We should improve nursing & patient care services in every facilities in order to improve overall health care of our women” As an eminent Gynaecologist of the country, what in your opinion, are the most common Gynaecologist disorders prevalent among our women? Prevalence of gynaecological disorder depends upon patients age socio economic & educational status, nutritional status and also environmental factors of the patient etc. In general, common gynaecological problems are menstrual disorder, early pregnancy bleeding due to abortion, ectopic pregnancy, molar pregnancy etc. Genital tract infections, STDs are also very common in the reproductive age. If we consider genital organ tumours like fibroid uterus, various types of ovarian tumours are also common in all ages. When a patient complains of heavy and painful menstruation, painful micturition & defecation, we should consider endometriosis & adenomyosis. On the other hand, a syndrome comprising excessive weight gain, high BMI, menstrual irregularity, hirsutism with metabolic syndrome mostly relates to PCOS, which affects about 1 in 8 women during reproductive age. However PCOS, endometriosis, adenomyosis, PID all land up in subfertility as a long term consequence. Regarding adolescent health problem, PCO, endometriosis, menstrual disorder & infection are the common disorder. Teenage pregnancy, abortion, post abortion complications and pregnancy related complications are the burning issue of adolescent health in our country. In menopausal age, hot flush, postmenopausal syndrome, osteoporosis, genital organ prolapse, urinary incontinence and all types of gynaecological malignancies are common in all demographical aspect. Endometriosis can often lead to infertility and is itself a very serious condition. What are causes, complications, and treatment thereof? Obviously endometriosis became a nightmare as 50% of cases are associated with infertility. Endometriosis is mostly idiopathic. There are some theories where it might be developmental in origin. At the same time, retrograde implantation and even surgical site implantation of endometrial lesions might cause endometriosis. EM is a painful disorder which causes pelvic pain, painful menstruation, defecation. Excessive menstrual disorder & infertility are also the commonest presentation as consequence of EM. Severity of the pain may not be reliable indicator of extension of the disease. There are various treatment options i.e., non-hormonal and hormonal therapy. Non hormonal therapy includes NSAID, Tranexamic acid for controlling pain and bleeding. There is a wide range of hormonal therapy. Progesterone combined oral pill, Danazol, GnRh Prof. Dr. Sehereen F. Siddiqua Professor and Head Dept. of Obstetrics and Gynaecology Anwer Khan Modern Medical College Joint Secretary, OGSB

70 THE PHARMA WORLD analogues are used as a medical management. Dienogest, considered as a miracle molecule, is being widely used nowadays. Laparoscopy is the gold standard for “see and treat” for endometriosis. To improve fertility preservation, laparoscopy is the best option for a wide range of conservative surgeries even up to reconstructive surgery. However, expert hand is required to perform such delicate wide dissection extensive surgery. What are the first signs of cervical cancer? Can cervical cancer be cured? What are your suggestion to increase awareness and promote early screening of cervical cancer? Cervical cancer is evident when the disease is much advanced. At early-stages, it usually stays asymptomatic. However, when symptoms of early-stage cervical cancer do occur, they may include– l Contact bleeding l Post-Coital bleeding l Inter menstrual bleeding l Irregular P/V bleeding l Vaginal discharge. l Pelvic pain Disease at an advanced stage may be presented with – l Weight loss l Foul smelling pervaginal discharge l Unilateral leg edema l Jaundice l Respiratory Symptom Cervical Cancer is curable if it is treated in early stages and optimum surgery done in expert hand. 28 patients die from Cervical Cancer everyday. To prevent cervical cancer, massive awareness is required. According to WHO by 2030 we need to reach the following targets– l 90% women should be vaccinated before the age of 15 years. l 70% women has been screened by the age of 35 years, and again by 45 years l 90% of cervical cancer patient should be treated in all stages. Caesarean section rates continue to rise. What, in your opinion, is the number one reason for choosing C-section over vaginal birth? Are there any long-term effects of C-section over vaginal birth? Are there any long-term effects of C-sections on the mother? There are various indications of C/S, but the most common indications are fetal distress and previous caesarian section, which is about 25% of total C/S. If Caesarean section is performed with optimum care by an expert obstetrician, long term effect to the mother becomes almost negligible. Safe motherhood begins before conception with proper nutrition and healthy life-style. Planned Pregnancy, appropriate prenatal care, safe delivery by trained person, perfectly instructed delivery, early and effective treatment of complications if any, all are the essential elements of safe motherhood. The times during labour and delivery is very daunting for the mother. What can be done to care of the mother pre- and post-pregnancy to ensure safe motherhood? To ensure the best outcome of pregnancy we need to ensure optimum health status of mother prior to becoming pregnant. So, pregnancy planning is an important issue where we should evaluate the mother whether she is safe for getting pregnant. We should ensure folic acid supplementation at least 2 month prior to trying for pregnancy. Her medical conditions should be evaluated and managed earlier. Once she is pregnant, she should be supervised by regular antenatal care. High risk group of pregnancy should be managed in special setup with multidisciplinary approach. All pregnant women has the right to proper intra natal care and safe delivery in order to ensure healthy maternal & neonatal outcome. Institutional delivery practice is our slogan to achieve SDG 2030 where we can reduce MMR up to 70/1000 LB. Where does Bangladesh stand regarding prevention, diagnosis and treatment of gynaecological disorders, compared to the advanced countries? What steps do you suggest to improve overall women’s healthcare? Bangladesh is now in a very promising & challenging position with regards to treating all gynaecological & obstetrical patients efficiently within our limited resources. Our specialists are expert enough to deal with all types of gynaecological & obstetrical emergencies, advance surgery as per global standard. Our experts are efficiently dealing with feto maternal medicine, high risk pregnancies, urogynaecology, gynaecological oncology, infertility & reproductive medicine and are practicing in both Public & Private hospitals. We have many expert gynaecological endoscopic surgeons, who are proficiently doing advanced gynaecological endoscopic surgeries and providing commendable services for our distressed women. Our midlevel young generation OBGYN doctors are also doing commendable work in their facilities. Our society OGSB is guiding them in collaboration with the government. Being a middle income country our medical services & facilities are almost comparable to our neighboring countries, and we are trying to render our best efforts to provide better health services for our women within limited resources. But it is really difficult to compare with advanced countries where their medical services system is much advanced along with their health and socio-economic status. If we want to improve the quality of our services, the government should promote private medical institutions, as 80% health services are provided by the private medical services of our country. For our doctors, we need regular training facilities home & aborad. More research work in the hospitals and standard laboratory practice should be advocated. All the hospital should be well equipped to maintain their standard protocol and ethical medical services. Every hospital should have their own evidence based standard protocol of patient management. Apart from OBGYN practice, all the academic hospitals should have the facilities for sub speciality services and training program for the future generations. We should improve nursing care & patient care services in every facilities in order to improve overall health care of our women. n

Progesterone (PdG) Test Wands to Maximize the Chances of Conception Hormonal imbalances that entail irregular or absent periods and ovulation dysfunction are the most common causes for female infertility. Mira medical has launched a new device which allows women to better understand their reproductive health and identify when they are most likely to conceive. The technology is easy to use, and involves placing a wand in a urine sample, and then inserting it TECHNOLOGY THE PHARMA WORLD 71 INVO Bioscience, a Florida company, has won European regulatory approval for its INVOcell culture and retention device. The product is part of the INVO Solution, which involves introducing sperm to an egg within the INVOcell device and then placing the device within the vaginal cavity of the woman seeking to become pregnant. After three days of incubation within the woman, the device is removed, and the resulting embryos can be analyzed in a lab. The optimal candidates are chosen and then transferred into the uterus. The overall procedure provides a more natural incubation process, with conception happening in vivo. Source: Medgadget In Vivo Incubation System for More Natural IVF into a small egg-shaped analysis device. Soon after, the user can read the results on a smartphone app, where trends and data about hormone levels are displayed. Mira offers different hormone wands which quantifies the concentrations of luteinizing hormone (LH), which is an indicator of ovulation, E3G, the estrogen metabolite, which is a key component in understanding reproductive health and fertile window, and pregnanediol glucuronide, which is a progesterone m e t a b o l i te in urine that c o n f i r m s ovulation.

INTERVIEW THE PHARMA WORLD 73 Dr. Nargis Fatema Senior Consultant OBGYN, Square Hospitals Ltd. “High rate of caesarean delivery can be optimized if both the service providers and the pregnant mother with her family work as a team” menstrual bleeding is the best way to prevent the progression to severe disease and ultimately to subfertility. What is your advice to patients who are having trouble conceiving? What are ways to improve reproductive health and increase fertility? Couples who are having trouble conceiving, need detailed history taking, appropriate investigations and early diagnosis of its cause, and finally timely intervention if needed to assist in conception. Trying to conceive in an earlier age, a healthy lifestyle, and maintaining a good body weight may be helpful in increasing fertility. Equal access to fertility care remains a challenge for low and middle-income countries. What can be done to increase the affordability and equitability of assisted reproduction technologies (ART) in our country? ART is a costly process not only for  the limited availability of ART specialists but also for the higher price of consumables and medicines. The establishment of HRT services in Government facilities, reducing the price of medications and developing skilled manpower in many more facilities with the assistance of Government centres may help. Unnecessary IVF should be discouraged like in PCOD, for those who have at least one child.  Caesarean section rates continue to rise.  What, in your opinion, is the number one reason for choosing C-sections over vaginal birth? Are there any longterm effects of C-sections on the mother? High rate of caesarean delivery can be optimised if both the service providers and the pregnant mother with her family work as a team. Good counselling in all low-risk pregnancy for vaginal delivery and proper monitoring of labour with well-trained birth attendants and a proper referral system should be there. The main challenge at the end of labour is pain and patience. The family should have the mentality to except minor complications which may be associated with any type of delivery. The most difficult aftereffect of caesarean birth is if she has a placenta previa or scar pregnancy in the future, which might be life-threatening for her. The times during labour and delivery is very daunting for the mother. What can be done to take care of the mother pre- and post-pregnancy to ensure safe motherhood? Pre pregnancy evaluation, regular and appropriate antenatal care, timely intervention, timely referral if indicated, post natal care with postnatal exercise, breastfeeding advise, birth spacing, contraceptive advise and services may all help to ensure safe motherhood. n As an eminent Gynaecologist of the country, what are the most common Gynaecological disorders prevalent among our women in your opinion? The common gynaecological problems I have to deal with everyday are menstrual abnormalities like excess bleeding for fibroid uterus and Adenomyosis, subfertility, ovarian tumours, endometriosis related issues, genital prolapse, urinary infection, yeast infection, postmenopausal bleeding, repeated pregnancy loss and many more.  Endometriosis can often lead to infertility and is itself a very serious condition. What are the causes and management thereof? Is there any way to reduce the chances of developing it? Endometriosis is associated with subfertility in 40% of cases and there are around 30% of infertile couples having endometriosis with or without other causes of subfertility. There are many theories regarding the development of endometriosis. The most common causes believed are retrograde menstruation which is associated with excessive bleeding, metaplasia of colonic epithelium and genetic factors. Lymphatic spread is also considered a cause of endometriosis. Early detection and control of

THE PHARMA WORLD 75 INTERVIEW Prof. Dr. Shahanara Chowdhury Obstetrics, Gynaecology and Infertility Specialist Chittagong Medical College & Hospital “Only limited services are available in the Government setup with a scarcity of logistics and manpower” At the later age – uterine and ovarian tumors, genital prolapse, AUB, cervical or other genital cancers, urinary complaints like different incontinences , UTI can occur in all ages . What is your advice to patients who are having trouble conceiving? What are ways to improve reproductive health and increase fertility? The couple needs proper evaluation to find out the cause for not conceiving. First of all a thorough history should be taken from both the husband and wife, i.e., their age factor, occupation, whether they stay together or not, coital history, any medical disorder specifically Diabetes or any hormonal problems, history of STI , past obstetric history,  menstrual history, history of any drugs, smoking, recreational drugs, any pelvic surgery in the past , CBC, blood sugar, etc.,. Afterward an extensive examination of both, especially their genital organs followed by some investigations likewise semen analysis of husband and pelvic USG and if necessary some hormonal assessment like TSH , prolactin , AMH, and others like FSH and LH. In suspected cases, tubal patency tests are needed. The rest of the tests will depend on the cause of infertility. To improve fertility,  pregnancy before 30 years of age, a healthy lifestyle, a balanced diet, maintaining body weight, avoiding smoking, treating any diseases, and avoiding stressful life is necessary. Seeking professional advice earlier if the couple fails to conceive after one year of trying. Endometriosis can often lead to infertility and is itself a very serious condition. What are the causes and management thereof? Is there any way to reduce the chances of developing it? The exact causes are yet to be known, but some theories are there for its causation like Samson’s theory of celomic metaplasia, retrograde spoilage, some genetic predispositions and higher expression of Human leukocyte antigens (HLA) pregnancy-associated plasma protein-A (PAPPA) gene also said to exist. Strong familial predispositions are also found to be demonstrated in many of the studies.  Regarding the management, it depends on the type of symptoms, marital status and age and demand of the patient, the status of pain, fertility status and future fertility desires, USG findings and presence and size of the mass As an eminent Gynaecologist of the country, what are the most common Gynaecological disorders prevalent among our women in your opinion? The most common gynaecological disorders vary according to the age range with an overlap. At the young age – irregular menses, excessive menstrual blood loss, pain during menses(dysmenorrhea), PCOS, white discharge with occasional itching, nowadays endometriosis and or ovarian cysts. At the child bearing age or in the reproductive age – the common presentations include different types of abnormal uterine bleeding (AUB), PCOS, endometriosis, failure to conceive (infertility), different types of tumors as for uterus (fibroids, adenomyosis), cervical discharge or changes like (CIN), excessive white discharge with genital itching due to yeast infection, ovarian cyst or tumors and pregnancy related problems.

THE PHARMA WORLD 77 or Endometrioma, history of previous treatment, the financial condition of the patients also important. The mainstay of management are pain relief by NSAIDs, and other pain killers, medical management by hormones like OCP, , GnRH analogue etc., fertility treatments like ovulation induction, IUI and in many cases of grade 3 or 4 endometriosis IVF is the better option. Regarding surgery, clearance surgery with careful excision of the Endometrioma, minimum use of diathermy, restoration of turbo-ovarian relationship by adhesiolysis, removal of endometriotic patches should be followed. Decision for surgery should be taken very carefully with consideration of future fertility issues, her AMH levels and the experience of the surgeons and facilities for laparoscopic surgery. Equal access to fertility care remains a challenge for low and middle-income countries. What can be done to increase the affordability and equitability of assisted reproduction technologies (ART) in our country? The evacuation and treatment for infertility is time-consuming, as well as costly for most couples, especially in low-middle income country like ours. At the same time, the availability of the services is also limited. Different management options and protocols are there and treatment protocols vary from one to another. However, availability of the fertility specialist and institutional services are essential for expanding the scope of the treatment. At present only limited services are available in the Government setup with a scarcity of logistics and manpower. Policies should be taken for low-cost availability of services to remain the mainstay of overcoming those challenges. Caesarean section rates continue to rise.  What, in your opinion, is the number one reason for choosing C-sections over vaginal birth? Are there any longterm effects of C-sections on the mother? There is a rising incidence of C-sections (CS) throughout the globe, and also in Bangladesh. The causes are many more, and some are absolutely essential and some are due to possibilities of some impending complications related to vaginal delivery. The most common indications for CS in the present context are malpresentation, placenta previa, following ART, previous CS, previous bad obstetric history, fetal distress, and CS on maternal request. There are many long-term effects following CS i.e., infection, PAS in a subsequent pregnancy, PID, adhesions in the scar, and difficulty in future operations etc. The times during labour and delivery is very daunting for the mother. What can be done to take care of the mother pre- and postpregnancy to ensure safe motherhood? It is of utmost importance to take preparation before pregnancy regarding maternal health improvement, correction of any maternal comorbid condition, correction of anemia, nutritional deficiencies and infections and finally taking pregnancy in correct health condition both mentally and physically also financially. During delivery, maintaining respectful maternity care is a must, and after delivery, post-natal care, nutrition, physiotherapy, psychological support and most importantly contraception and birth spacing should be emphasised. n

78 THE PHARMA WORLD HRT May Reduce the Risk of COVID-19 Death in Post-Menopausal Women Post-menopausal women who have higher oestrogen levels as a result of taking hormone replacement therapy (HRT) may have a lower risk of death from COVID-19 than women with natural levels of the hormone, according to a new Swedish study. The aim of the researchers was to see how oestrogen might impact the death rates of post-menopausal women who had COVID-19. The study sample included a total of 14,685 women ages 50 to 80 who received a COVID-19 diagnosis. Women on HRT were 50 per cent less likely to die of COVID-19 than women with natural oestrogen levels. The women who had decreased levels of oestrogen because of adjuvant endocrine therapy for breast cancer were more than twice as likely to die of COVID-19 compared with the control group. Birth Control Pills Rise Breast Cancer Risk Taking progestogen-only  birth control  pills comes with a 20% to 30% heightened risk of breast cancer. It is about the same degree of risk associated with taking pills that contain both progestogen and oestrogen, new research finds. For the study, researchers analysed nearly 10,000 women with breast cancer under the age of 50. Researchers also included data on more than 18,000 closely matched controls. About 44% of women with breast cancer and 39% of matched controls had a hormonal contraceptive prescription. About half the prescriptions were for progestogen-only medications. The relative increase in risk of breast cancer was 23% in those with combined oral pills; 26% in those with progestogenonly pills; 25% in those with injected progestogen, and 32% with an intrauterine device releasing progestogen. High Blood Pressure in Pregnancy Tied to Thinking Problems Later A new study links  high blood pressure during pregnancy with cognitive issues later in life, adding to known risks such as stroke and heart disease. Women with  preeclampsia may have even more cognitive decline later compared to those with gestational high blood pressure, which does not affect kidneys or other organs, according to the study. Researchers combed the medical records of 2,239 women for information about past pregnancies. Overall, women with high blood pressure during pregnancy had a greater mental decline than those with normal blood pressure during pregnancy and those who had not given birth. Results were more pronounced for those who had preeclampsia compared to women whose blood pressure was normal throughout pregnancy. Preeclampsia Could Slow Foetal Development Common pregnancy complications like  gestational diabetes  and preeclampsia may slow infant development in the womb, according to a new study. This leads to newborns being biologically younger than their gestational age. Researchers estimated the infants’ biological or “epigenetic” age based on molecular markers in their cells. They also wondered whether some exposures could advance biological age prematurely, even in the womb. To study this, researchers collected DNA samples from 1,801 newborns. Babies who were exposed to preeclampsia or gestational diabetes in the womb had slower biological development than babies without the exposures. Researchers saw a more noticeable difference in female babies than in male babies.

THE PHARMA WORLD 79RESEARCH UPDATE Increased Risk of Heart Disease and Diabetes in Women with Irregular Periods Irregular periods  may be predictive of future heart disease and type 2 diabetes, according to a new research. The Australian study found that women who reported irregular menses were 20 percent more likely to develop cardiovascular disease (CVD) and 17 percent more likely to develop type 2 diabetes compared with women with regular menstrual cycles. After analyzing the data using Cox regression models for over 13 thousand women, researchers found an increased risk for both CVD and type 2 diabetes, leading them to conclude that menstrual cycles “appear to be an early indicator for heart disease and diabetes.” These findings highlight the importance of screening for diabetes and heart disease in women with irregular menstrual cycles, PCOS and early menopause. New Drug Combo Buys More Time for Advanced Endometrial Cancer Patients Researchers have discovered that two drugs might be better than one for women who have advanced endometrial cancer. Combining chemotherapy and immunotherapy or a monoclonal antibody at the same time helped these patients live longer without their  cancer  progressing, especially those who had a mismatch repairdeficient tumor. The new study found that adding the immunotherapy drug pembrolizumab to a standard chemotherapy regimen of  carbopl atin and paclitaxel cut the risk of advanced or recurrent cancer returning by up to 70%. The improvement was an average of 13.1 months before the disease progressed in women who received the combination treatment, compared to 8.7 months for those on chemotherapy alone. New Clues to Early Miscarriage and How to Predict Them Miscarriages are devastating and often seem to happen out of nowhere, but researchers may have found a new high-tech way to predict which pregnancies are likely to end in miscarriage and which ones are not. The use of 3D ultrasound imaging with virtual reality technology can create a hologram of a developing embryo to see if it is maturing on schedule. The longer it takes for an embryo to develop, the more likely it is to result in a miscarriage. Embryos in pregnancies that ended in a miscarriage took four days longer to reach the final Carnegie stage than those that resulted in a healthy baby, the study showed. Pregnancies that ended in a miscarriage were also linked to a shorter embryo length from the top of the head (crown) to the bottom of the buttocks (rump). COVID in Pregnancy Might Raise Odds for Developmental Delays in Sons Boys born to women who had COVID-19 during pregnancy may be at risk for Neurodevelopmental Disorders, a new study suggests. Delays in speech and motor function were the most commonly diagnosed conditions in these children at 12 months. They were seen in boys but not in girls, the study authors said. “Boys are known to be both more vulnerable to neurodevelopmental diagnoses and more likely to have adverse responses to in-utero exposures to SARS-CoV-2,” said lead researcher of the study. However, it is not clear that changes found at 12 and 18 months are indicators of persistent risks for disorders such as autism spectrum disorder, intellectual disability or schizophrenia.

80 THE PHARMA WORLD REMEDYFood: A medicine when you’re dealing with endometriosis Heavy periods, pain, and nausea. The symptoms of endometriosis aren’t just distressing, they interfere with day-to-day life. Inflammation due to  endometriosis lead to pain, fatigue and digestive problems, as well as, in some cases, infertility. But an antiinflammatory endometriosis diet could be the key to relief from the agony. How does food affect endometriosis? Inflammation and high estrogen levels can make endometriosis symptoms worse. And your diet can influence both factors. Fiber helps remove excess estrogen Too much oestrogen can aggravate endometriosis symptoms like cramping and pain. That’s where food and fiber can come to the rescue. “Your body gets rid of excess oestrogen in the stool,” explains Courtney Barth, a registered dietitian at Cleveland Clinic. “You should have a healthy bowel movement every day. If you don’t, you probably have constipation, and your estrogen levels could be too high.” You can boost your fiber by eating more: l Fruits and vegetables, but eat the whole food and avoid juice. l Ground flaxseed, Ispaghula husk l Legumes, like beans, lentils and chickpeas. l Whole grains, like whole-wheat atta, wholegrain bread and brown rice. Good fats fight inflammation Endometriosis is an inflammatory condition, so inflammation makes symptoms worse. Omega-3 fats can calm inflammation from endometriosis. Good food sources of omega3s include: l Fatty fish, such as Hilsa, pomfret, rohu, salmon, sardines and tuna. l Nuts and seeds, like walnuts, chia seeds, pumpkin seeds and flaxseed. l Plant oils, such as flaxseed oil and canola oil. l Monounsaturated fats also have antiinflammatory power. They’re found in: l Avocadoes. l Nuts and seeds. l Olive oil. l Peanut butter. l Safflower oil.

THE PHARMA WORLD 81 Foods to avoid with endometriosis Certain foods can worsen endometriosis pain by boosting inflammation or oestrogen levels. Limit or avoid: l Alcohol: Wine, beer and spirits can make endometriosis symptoms worse. l Caffeine: Limit your daily caffeine to 400 milligrams or less. One cup of coffee can have over 100 milligrams, depending on how it’s brewed. l Fatty meat: Limit your overall saturated fat intake to 10% of your daily calories. l Processed foods: Many packaged foods contain proinflammatory ingredients like added sugar, saturated fat and trans fat. l Sugary drinks: Fruit juices, sodas and energy drinks are often high in sugar, which makes inflammation worse. Aim for less than 26 grams of sugar each day. Does gluten or dairy make endometriosis worse? Some people with endometriosis find that a gluten-free or dairyfree diet helps them feel better. But it depends on the person. According to Barth, the low-FODMAP diet (designed for people with irritable bowel syndrome) can work with endometriosis, too. Minerals that can help relax muscles and regulate your cycle Calcium gets a lot of attention as an important mineral. But if you have endometriosis, make sure you’re also getting magnesium and zinc as magnesium helps with menstrual cramps and Zinc regulates your menstrual cycles, which is important for hormonal balance. Magnesium-rich foods include: l Dark chocolate (but stick to small amounts, as it usually contains added sugar). l Leafy greens, like arugula, dark lettuce, kale and spinach. l Legumes, like black beans and edamame. l Nuts and seeds, especially almonds and pumpkin seeds. The highest sources of zinc are animal sources. Good sources of zinc include: l Poultry, like chicken or turkey. l Red meat, but limit this to two low-fat servings per week. WHAT’S NEW? New Protein that hinders Covid-19 discovered Australian Researchers have announced the discovery of a new protein in the lung that can hinder Covid-19 infection. The leucine-rich repeat-containing protein l5 (LRRC15) also forms a natural protective barrier in the body of human beings. It is an inbuilt receptor that attaches to the SARS CoV- 2 virus and drags it away from the target cells. Published in the PLOS Biology journal, the study was done at the Charles Perkins Centre and the School of Life and Environment Sciences. The authors are developing two Covid-19 strategies with the help of LRRC 15 that is expected to work across several variants. New protein for sepsis treatment Researchers at the Feinstein institutes for Medical Research have discovered a new protein that can be a potential therapeutic target for lethal sepsis. The new study focuses on the detecting protein mediators that might contribute to uncontrolled immune responses to lethal infections. It explores the monoclonal antibody detection that may work against procathepsin-L (pCTS-L), a pro-inflammatory protein mediator, a the potential remedy. These antipCTS monoclonal antibodies may help in providing effective treatments for human sepsis as well as other infectious diseases, such as Covid-19. The research team created a pCTS-L neutralizing monoclonal anti-bodies panel, which effectively lowered the pCTS-L pro-inflammatory actitivites in human immune cell cultures and saved mice from lethal sepsis. Sepsis affects approximately 50 million people globally and occurs when he immune system of the body triggers too much inflammation to help fight against infections. It is noted that septic patients frequently show simultaneous pro and antiinflammatory pathways occurrence, which may make them suffer from immunosuppression. Source: Cleveland Clinic

DRUG SAFETY Amlodipi ne, nifedipi n e Removal of contraindication for use in pregnant women PMDA have announced that the product informa - tion for amlodipine and nifedipine should be re - vised to remove the contraindication in pregnant women and replace it with a precaution for use during pregnancy. The contraindications of these calcium channel blockers were based on toxicity studies in rats and mice. The MHLW and PMDA reviewed case reports of adverse events, results of observational studies and other publications and concludes. There were no domestic ICSRs reporting the prolongation of gestational period and duration of delivery with amlodipine or limb anomalies with nifedipine use. In domestic and international clinical guidelines, the benefit of strict blood pressure control throughout pregnancy using calcium channel blockers is recognized while any safety concerns for use in pregnancy has not been identified. CO VID-19 vacci ne Astraze neca Potential risks of acute disseminated encephalomyelitis (ADEM) The Therapeutic Goods Administration (TGA) has announced that the product information for COVID-19 vaccine As - trazeneca (ChAdOx1-S, Vaxzevria®) has been updated to include the potential risk of acute disseminated encephalomy - elitis (ADEM). The updated warning states that: very rare events of demyelinating disorders, including acute disseminated encephalomyelitis, have been reported following vaccination; health-care pro - fessionals should be alert of signs and symptoms of demyelinating disorders to ensure correct diagnosis, in order to initiate adequate supportive care and treatment, and to rule out other causes. Ja nus ki nase (JAK) i nhi bitors Risks of cardiovascular conditions, blood clots, cancer, serious infections The PRAC has recommended meas - ures following a review of clinical tri - als of tofacitinib and an observational study involving baricitinib. The review confirmed tofacitinib increases the risk of major cardiovascular problems, cancer, venous thromboembolism (VTE), serious infections and death due to any cause when compared with TNF-alpha inhibitors. The PRAC recommended that these medicines should be used in the following patients only if no suitable treatment alternatives are available: those aged 65 years or above, those at increased risk of major cardiovascular problems, those who smoke or have done so for a long time in the past, and those at increased risk of cancer. The Committee also recommended using JAK inhibitors with caution in patients with risk factors for VTE and with reduced doses in some patient groups. Bupropio n Potential risk of cardiac arrest or sudden death through unmasking of Brugada syndrome The HPRA has announced that the product informa - tion for bupropion which is indicated for major depres - sive disorder, for will be updated to advise that its use may unmask Brugada syndrome, a rare hereditary disease that can lead to car - diac arrest or sudden death. Patients are advised to talk to their doctor before taking bupropion if they have preexisting Brugada syndrome or if there is a family history of cardiac arrest or sudden death. Cephalospori ns Risk of fixed drug eruption The Central Drugs Stand - ard Control Organization (CDSCO) has approved the recommendation from the National Coordination Cen - tre – Pharmacovigilance Pro - gramme of India (NCC-PvPI), Indian Pharmacopoeia Commission (IPC) to revise the prescribing informa - tion leaflet (PIL) for cepha - losporins to include fixed drug eruption as an adverse drug reaction. The NCC-PvPI, IPC reviewed 203 Individual Case Safety Reports (ICSRs) of cephalosporin associated fixed drug eruption and a causal relationship between them was found. 82 THE PHARMA WORLD

THE PHARMA WORLD 83RED ALERT Codeine with ibuprofen Risks of serious renal and gastrointestinal harms The Pharmacovigilance Risk Assessment Committee (PRAC) of the European Medicines Agency (EMA) has recommended for codeine with ibuprofen combination medicines to include a warning of serious harms, including death. The PRAC reviewed several cases of renal, astrointestinal and metabolic toxicities that have been reported in association with cases of abuse of and dependence from codeine with ibuprofen combinations, some of which have been fatal. The PRAC found that, when taken at higher than recommended doses or for a prolonged period of time, codeine with ibuprofen can cause renal tubular acidosis. Kidney malfunction can also cause hypokalaemia. Therefore, renal tubular acidosis and hypokalaemia will be added to the product information as new adverse effects. Amoxicillin Risk of drug-induced enterocolitis syndrome (DIES) The Health Products Regulatory Authority (HPRA) has announced that the product information for amoxicillin will be updated to include the risk of drug-induced enterocolitis syndrome (DIES). On the basis of a recent review of the available safety data by the EMA PRAC, DIES is an allergic reaction with the leading symptom of protracted vomiting (1-4 hours after drug administration) in the absence of allergic, skin or respiratory symptoms. There have been severe cases of DIES which have progressed to shock. DIES has been reported mainly in children receiving amoxicillin. Remdesivir Risk of sinus bradycardia The CDSCO has approved the recommendation from the NCC-PvPI, IPC to revise the PIL for remdesivir to include sinus bradycardia as an adverse drug reaction. The NCC-PvPI, IPC reviewed 11 ICSRs of remdesivir associated sinus bradycardia and a causal relationship between them was found. Hydrochlorothiazide Risk of acute respiratory distress syndrome (ARDS) The MHLW and PMDA have announced that the product information for hydrochlorothiazide should be revised to include the risk of acute respiratory distress syndrome (ARDS). In internationally reported cases, a causal relationship between the drug and ARDS was reasonably possible. Considering the severity of ARDS and following the product information revision in the EU, the MHLW and PMDA concluded that ARDS should be added as a clinically significant adverse reaction. Vitamin B6 (pyridoxine) Risk of peripheral neuropathy The TGA has strengthened labelling requirements for products containing daily doses of 10mg of vitamin B6 (pyridoxine) to include a warning about peripheral neuropathy. The TGA had received 32 adverse event reports with sufficient information to establish a possible causal association between peripheral neuropathy and products containing vitamin B6. The TGA found that peripheral neuropathy can occur at doses less than 50 mg, and when people are taking multiple products containing vitamin B6. A review of the patient’s vitamin B6 intake is recommended paying close attention to potential sources such as multivitamins, magnesium and zinc products, particularly when taken in combination.

THE PHARMA WORLD 85 INTERVIEW l Fibroids l Endometriosis l Painful sexual intercourse l Pelvic inflammatory disease l Amenorrhea or absence of period which may be secondary to other or primary l Vaginitis l Menopause l Though urinary tract infection (UTI) is not gynaecological condition, it is found in newly married women. Is an IVF pregnancy considered high-risk? What are the risks and success rate of the procedure? Yes. Pregnancies that occur after infertility treatment, particularly after assisted reproduction, constitute highrisk pregnancies. Occurrences of conditions such as high blood pressure, preeclampsia, growth retardation and bleeding are higher in comparison with the norm of spontaneously entered pregnancies. The rate of premature births and the frequency of intrauterine deaths are also much higher than the average for all pregnancies. Furthermore, pregnancies resulting from in-vitro fertilisation (IVF) have significantly higher rates of requiring induced labour or caesarean section. However, it is to be assumed that these complications and unfortunate developments are not caused by in vitro fertilisation (IVF) itself, but rather, due to the frequency of multiple pregnancy and the risk factors of the women involved. In comparison to other pregnancies combined, these women are often older and frequently have more issues with obesity, uterine malformations, and irregular menstrual cycles. Approximately 16% of pregnancies result in miscarriage, induced abortion (1.0%), stillbirth (0.7%), or an ectopic pregnancy (0.5%). 25-30% chances of multiple pregnancy when >1 embryo is transferred. The offspring resulting from IVF have raised concerns that the children may be at increased risk for prematurity, low birth weight, birth defects, genetic and epigenetic abnormalities, vascular and metabolic abnormalities, delayed neurologic development, and cancer. The average overall IVF live birth rate per cycle is approximately 24% for all women, success rates vary, to some extent, with the cause of infertility. The success rates for women with tubal factor infertility, ovulatory dysfunction, Dr. Farzana Deeba Associate Professor Dept. of Obs & Gynae Reproductive Endocrinology and Infertility, BSMMU, Dhaka “Pregnancies that occur after infertility treatment, particularly after assisted reproduction, constitute high-risk pregnancies” As an eminent Gynaecologist of the country, what in your opinion, are the most common Gynaecological disorders prevalent among our women? Gynaecological disorders are those disorders that affect the reproductive system. The organs included in the reproductive system are breasts, uterus, fallopian tube, ovaries, and external genitalia. The most common gynaecological problems prevalent among our women are: l Leucorrhea (excess white vaginal discharge) or other forms of vaginal discharge l Pain or heaviness in the breast and lump in the breast. l Abnormal uterine bleeding due to any cause i.e. PCOS, fibroids, adenomyosis, polyp, malignancy l Polycystic ovarian syndrome (PCOS) l Dysmenorrhoea or painful menstruation

THE PHARMA WORLD 87 endometriosis, male factor, and unexplained infertility were above average, and those for women with multiple infertility factors, a uterine factor, and DOR were below average. Disorders like polycystic ovary syndrome (PCOS) and anovulation due to hormonal imbalances are the leading cause of infertility in women. How are they treated? Anovulation is very common among infertile women and is the most common cause of female infertility. Conditions causing hormonal imbalances like PCOS, thyroid disorder, hyperprolactinaemia, low ovarian reserve etc. are frequently seen in women having anovulatory infertility. As infertility is a couple’s problem, and despite the female partner’s diagnosis, the evaluation must rule out other factors in addition to ovulatory disturbance as a cause for the couple’s infertility. Semen analysis of the husband is mandatory prior to starting any infertility treatment. To treat all these causes of infertility, ovulation induction (either oral or injectable) is the treatment of choice. Optimization of health and lifestyle modifications should also be done to gain a maximum pregnancy rate. Some adjuvant drugs are also being used along with ovulation induction to enhance the success of ovulation induction. In some circumstances, laparoscopy may also be required. What is your advice to patients who are having trouble in conceiving? What are ways to improve reproductive health and increase fertility? Some simple changes can boost reproductive health who faced trouble in conceiving: l Have frequent intercourse, especially 5 days before and after ovulation (usually 10th to 20th days of menstrual cylce). l Don’t smoke. l Limit alcohol if one has a habit of alcohol consumption. l Cut back on caffeine, especially for females. l Stay at a healthy weight. Women who are too heavy or too thin may have reduced fertility. l Heat exposure can lower sperm count in men, so wear loose underwear, avoid hot tubs, and don’t rest your laptop computer near your scrotum. l Get plenty of sleep. l Try to avoid night shift work, which can disrupt hormone production. l Exercise regularly, but don’t overdo it. Excess exercise can interfere with ovulation. Limit vigorous exercise to 5 hours or less per week if you’re trying to get pregnant. l Take folic acid supplements to improve ovulation and, if you conceive, prevent birth defects. l Limit meat in your diet. Eat more fish rich in omega-3 fatty acids or plant-based proteins, which may improve ovulation. To improve reproductive health and fertility, follow the advice that I mentioned previously. If a couple failed to get pregnant by 1 year or a couple had a known cause of infertility, some medications (ovulation induction) and surgeries (laparoscopic evaluation & treatment) are advised to enhance fertility. Even some may require assisted reproductive techniques when other measure fails. Could you please tell us, in brief, about the role of laparoscopic surgery in infertility? Laparoscopy is regarded generally as the definitive test for the evaluation of tubal factors & is a better predictor of future fertility. Laparoscopy provides both a panoramic view of the pelvic reproductive anatomy and a magnified view of the uterine, ovarian, tubal, and peritoneal surfaces. Consequently, it can identify milder degrees of distal tubal occlusive disease, pelvic or adnexal adhesions, and endometriosis that adversely affect fertility but escape detection by other tests. Most importantly, laparoscopy offers the opportunity to treat disease at the time of diagnosis. Lysis of filmy or focal adhesions and excision or ablation of superficial endometriosis are relatively simple procedures well within the capabilities of most surgeons. Excision of ovarian endometriomas, lysis of dense or extensive adhesions involving the cul-de-sac or bowel, excision or ablation of widely disseminated or deeply invasive endometriosis, and fimbrioplasty or salpingoneostomy procedures require greater technical skill and experience. Where does Bangladesh stand regarding prevention, diagnosis and treatment of gynaecological disorders, compared to the advanced countries? Bangladesh stands in the middle regarding prevention, diagnosis and treatment of gynaecological disorder in comparison to advanced countries. But we are getting better day by day. Mass awareness has been created against breast and cervical cancers. Vaccines are available for young girls to prevent cervical cancer. The cervical cancer screening programme strategy has been developed by the Ministry of Health and Family Welfare (MoHFW) with technical support from the Bangabandhu Sheikh Mujib Medical University (BSMMU), the World Health Organization (WHO) and the United Nations Population Fund (UNFPA). Adolescent health has also got prioritized. Voices are raised regarding awareness about PCOS and endometriosis. Menopausal women’s well-being & health are also taken into account by gynaecologists. Various societies are founded, and they are working very hard about it by raising awareness and involving people and also the media. What can be done to increase the affordability and equitability of assisted reproduction technologies (ART) in our country? To increase the affordability and equitability of assisted reproduction technologies in our country, participation from the government and insurance agencies is required. Otherwise, it is quite impossible to make IVF equitable and affordable. n

Analysis and Developments Forecast 2030 The obstetrics and gynaecology drugs market size was USD 13,089.39 Million in 2021 and is expected to register a revenue CAGR of 7.5% during the forecast period. Growth is primarily driven by factors such as increase in awareness and use of contraceptives and Hormone Replacement Therapy (HRT), age-related increase in gynaecological and ovarian cancer, prevalence of gynaecological diseases, rise in healthcare expenditure, and rising investments to understand mechanisms of endometriosis and its treatment Obstetrics and gynaecology drugs are used for treatment of various medical conditions, such as gynaecological cancers, contraception, postmenopausal disorders, Polycystic Ovary Syndrome (PCOS), and infertility in females, among others, which are often required during pregnancy to treat specific disorders. Drug treatment for disorders during pregnancy is generally an option when the potential benefit outweighs known risks. In addition, increasing incidences of gynaecological cancers is a key factor expected to significantly drive revenue growth of the market between 2022 and 2030. According to estimates of American Cancer Society (ACS), over 113,520 individuals were diagnosed with cancers of reproductive organs in the U.S. in 2020. A range of drugs have been listed by National Cancer Institute (NCI), including Cervarix (Recombinant HPV Bivalent Vaccine), Gardasil (Recombinant HPV quadrivalent) and Gardasil 9 (Recombinant HPV nonavalent vaccine) for prevention of cervical cancer. In addition to treatment of cancers of reproductive system, obstetrics and gynaecology drugs are also used for treatment of menstrual OBGYN MARKET FORECAST Obstetrics and Gynaecology Drugs Market disorders such as cramps, pre-menstrual syndrome, metrorrhagia, and menorrhagia. Drugs, such as Acetaminophen (Tylenol) or NonSteroidal Anti-Inflammatory Drugs (NSAIDs) including ibuprofen (Advil, Motrin) and naproxen (Aleve), are used for relieving cramp pains. Oral contraceptives are used for regulating menstrual periods and reduce heavy bleeding. According to a 2020 study published in National Center for Biotechnology Information (NCBI), polycystic ovary syndrome has a global prevalence between 4% to 20%. The World Health Organization (WHO) further suggests that over 116 million women are affected by the disorder on a global level. Furthermore, increasing awareness regarding treatment of menstrual disorders is anticipated to rise demand for obstetrics and gynaecological drugs, thereby driving revenue growth of the market between 2022 and 2030. Therapeutic insights Hormonal therapy and non-hormonal therapy are the two main therapeutic subtypes used in gynaecological medications. In order to delay or stop the growth of cancer cells, which depend on hormones for growth, hormone therapy adds, blocks, or removes certain hormones from the body. Anti-infective, anti-inflammatory, lubricants, moistures, antidepressants, gabapentin, clonidine, and other medications are used in non-hormonal therapy. Gynaecology medications are sold in hospital pharmacies, retail pharmacies, and internet pharmacies for conditions such polycystic ovarian syndrome, menopausal disorders, contraception, and others. Some key highlights from the report In the market for obstetrics and  gynaecology  medicines, the non-hormonal therapy category is anticipated to grow at a high revenue  CAGR  during the forecast period. Any method of birth control that uses other preventative measures rather than interfering with the body’s natural hormonal processes is referred to as non-hormonal. Paroxetine (found in Paxil  and other  SSRIs), a drug also used to treat depression, is the only non-hormonal medica88 THE PHARMA WORLD

THE PHARMA WORLD 89 tion approved by the Food and Drug Administration to treat hot flashes. Other comparable antidepressants, such as SSRIs like fluoxetine (Prozac), and norepinephrine reuptake inhibitors like  venlafaxine  (Effexor), have also been shown to be unsuccessful in treating hot flashes. Additionally,  randomised  trials have shown that FDA-approved drugs like  alendronate  (Fosamax),  raloxifene  (Evista), and  risedronate  (Actonel) help halt bone loss. Major players  l Pfizer Inc., l AbbVie Inc., l TherapeuticsMD, Inc. l Amgen Inc., l Johnson & Johnson, l Ferring B.V., l Lupin, l Merck KGaA, l Novartis AG, l GlaxoSmithKline plc. l Abbott, l Eli Lilly and Company. Strategic development l In August 2022, Lupin entered into an exclusive licensing agreement with Japanese company l’rom Group Co., Ltd. for conducting clinical trials on biosimilar Denosumab in Japan. Denosumab is indicated for treatment of postmenopausal women with osteoporosis at high risk of fracture and prevention of skeletal-related events in patients with bone metastases from solid tumors among other indications. l In March 2022, GlaxoSmithKline plc. presented new findings in support of advancing treatment for certain gynaecologic cancers, including data evaluating Zejula (niraparib) and Jemperli (dostarlimab) at the upcoming Society of Gynaecologic Oncology (SGO) Annual Meeting on Women’s Cancer. l In February 2022, Merck KGaA announced in a European worksharing procedure an extension to the approval for metformin products in EU - Glucophage (metformin hydrochloride [HCL] immediate release), Glucophage XR (metformin HCL extended release) and Stagid (metformin embonate immediate release) - for use throughout pregnancy. n Source: Emergen Research In the market for obstetrics and gynaecology medicines, the non-hormonal therapy category is anticipated to grow at a high revenue CAGR during the forecast period. Any method of birth control that uses other preventative measures rather than interfering with the body’s natural hormonal processes is referred to as nonhormonal.

THE PHARMA WORLD 91 INTERVIEW Dr. Ummey Nazmin Islam Consultant Dhaka Medical College “In comparison to developed countries, our caesarean section rate is increasing, the cause is a lack of manpower and logistics round the clock” What in your opinion, are the most common Gynaecological disorders prevalent among our women? The most common gynaecological disorders we face in daily practice related to Abnormal Uterine Bleeding (AUB), could be in the form of Fibroid Uterus, Endometriosis, Adenomyosis, Anovulatory (commonly PCOS), Polyp, and malignancy of genital organs, etc. Another common problem we have to counteract is Pelvic infection. Last but not the least, all of us are dealing with the increasing prevalence of Infertility, male or female. Endometriosis can often lead to infertility and is itself a very serious condition. What are the causes and management thereof? Is there any way to reduce the chances of delveloping it? Although the exact cause of endometriosis is not certain, possible explanations include: l Retrograde menstruation l Transformation of peritoneal cells l Embryonic cell transformation l Surgical scar implantation l Endometrial cell transport l Immune system disorder There are some risk factors for developing Endometriosis also described in different studies. They are: l Newborn child with a history of per-vaginal bleeding l Adolescent girl with severe painful menstruation. l Women who have a family history of the such disease (mother, maternal aunt or sister) l Nulliparous women or women who gave birth for the first time after age 30 l Women with an abnormal uterus (Mullerian duct abnormality) Management depends on some factors: l Age of the patient l Severity of the symptoms l Desire for fertility l Ovarian reserve l Previous treatment Options of treatment are: l Medical management l NSAID l Progesterone (oral, injectable or Intrauterine device) l Oral Contraceptive Pills containing both estrogen and progestine

THE PHARMA WORLD 93 l GnRH analogues (Agonist or antagonist) Surgical management l Conservative (appropriate for a patient who desires fertility). l Cystectomy: complete or partial l Electrocautery l Aspiration and Sclerotherapy Definitive that includes Total Hysterectomy with bilateral oophorectomy. This is the appropriate option for the parous women who suffer severely. Treatment becomes more difficult when women with symptomatic endometriosis desire pregnancy. It reduces ovarian reserve drastically, even in younger women and thus needs ART sometimes. Regarding prevention, it is our message to the community that this is actually not an absolutely preventable disease but rather progressive. Some authors suggest having a healthy diet, adopting an active lifestyle, and avoiding excessive caffeine and alcohol may reduce the chance of developing endometriosis. We can rather halt endometriosis than prevent and ‘ Halt Endometriosis’ was the slogan of last year, 2022. Severe dysmenorrhea and a history of neonatal per-vaginal bleeding should not be overlooked. What is your advice to patients who are having trouble conceiving? What are ways to improve reproductive health and increase fertility? Actually almost 80% of couples conceive within one year of having the appropriate opportunity. During this period the couples should know clearly about the fertile period and use that time in the right way. Those couples who are struggling with infertility should consult with a gynaecologist whom they trust. I used this criterion here because infertility treatment needs time and consistency. If a couple switch doctor frequently treatment hampers and this may cause delayed treatment response. Equal access to fertility care remains a challenge for low and middle income countries. What can be done to increase the affordability and equitability of assisted reproduction technologies (ART) in our country? Fertility care always does not mean ART. Only 1- 2% of infertile couples need ART. Our present Government has ensured qualified Gynaecologists in almost every Upozela Health Complex who are competent to serve those people initially. The majority conceive with medical treatment and counseling only. Yes, ART service till date is limited to only Dhaka Medical College in the government sector and certainly, this is cost-effective. To increase the affordability and equitability of assisted reproduction Technologies (ART), the medicines and equipment that are the pivotal logistics of ART should be made available and affordable. Many competent doctors are already ready to serve and more are in the pipeline. Other staff including embryologists and lab staff should be trained. Local companies should produce quality drugs and equipment for ART. The government may consider the development of low-cost IVF centers in selected medical college hospitals. Caesaran section rates continue to rise. What, in your opinion, is the number one reason for choosing C-Sections over vaginal birth? Are there any long-term effects of C- sections on the mother? Yes, undoubtedly Caesarean section rates are rising in Bangladesh, but this scenario is almost the same in other developing or underdeveloped countries too like, other countries of this subcontinent, South America and Africa. I am not justifying by giving an example of other countries but it needs to be understood by the people. Many of the general population blame the doctor community for increasing the caesarean section rate. But grossly this is not right. In my view, nowadays, a group of women having a child at in older age which becomes high risk by default. They need caesarean section. Previously women used to give birth to many more children, and some of them may die during delivery or a few hours to days after birth. But nowadays the scenario has changed. People come to health care facilities, Government or private, and expect everything will go uneventful. They never try to understand that even after the highest level of cautions of the doctors’, situations may go critical for the mother or child. And then they blame the doctor only. That is why doctors sometimes don’t want to take chance. Many times, we find that patient party insists on a caesarean section. Sometimes whenever the labor pain starts woman insists on a caesarean section. The efficiency of the surgeons and the availability of the regional anesthesia made this more popular too. Most importantly, in comparison to developed countries, our caesarean section rate is increasing, the cause is a lack of manpower and logistics round the clock. An adequate number of midwives, nurses, electronic monitoring systems, and emergency caesarean section facilities with available competent surgeons and anesthesiologists must be ensured in every sector to reduce caesarean section rate. In Bangladesh, in the 1980’s maternal mortality ratio (MMR) was as high as 580 per lac live birth; the caesarean section was very low. But in 2017 MMR was 173 per lac live birth with an increasing rate of caesarean section. It substantially reduces birth-related complications like urinary incontinence and uterine prolapse. Caesarean section, in a passive way, reduces high order childbirth which restricts undue population growth. Yet, every procedure must have some short- and long-term effects. Due to caesarean section mother may face an increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and sometimes, preterm birth. n

THE PHARMA WORLD 95 Dr. Sonia Nasrin (MBBS, DGO, MCPS, FCPS) Junior Consultant (Gynae and Obs) OGSB & IRCH Mirpur 13- Dhaka “Consulting with a qualified healthcare provider is essential for developing a personalised treatment plan that is right for each patient’s need” IN CONVERSATION ian syndrome, abortion, ectopic pregnancy, fibroid uterus, utero vaginal prolapse, PID, adenomyosis, endometriosis, subfertility, cervical pathology, ovarian tumour etc. Most 80-90% of women suffer at their reproductive age and usually, complications are related to pregnancy. Symptoms may occur in the form of vaginal discharge, vaginal itching, menstrual disturbances, painful menstruation, coital problems, post-coital bleeding, low back pain, chronic lower abdominal pain, abdominal mass, infertility etc. Investigations are necessary for proper screening, diagnosis, treatment response, and follow-up in order to manage gynaecological conditions. A patient may need to undergo some investigations, such as ultrasonogram for pelvic pathology, VIA, PAP smear for cervical cancer screening, tumor markers to identify specific tumors and follow up, endometrial and cervical sampling, biopsy, histopathology, hormone levels, CT scan, MRI, etc. prior to receiving any therapy. However, a lack of information and assistance, illiteracy, reluctance to seek treatment, poverty, an absence of and restrictions on healthcare providers and facilities, etc. remain as major obstacles. Treatment of gynaecological diseases depend on specific condition and its severity. Treatment options may include lifestyle modifications, hormonal and nonhormonal medication, surgery, combination therapy, sometimes chemotherapy, radiotherapy, etc. Still, there are some general practices that can help in the management of these diseases, such asl Regular check-ups: Important for early detection and prevention of gynaecological diseases. Women should have regular pelvic and breast exams, pap test to monitor any changes. l Lifestyle modification: Regular exercise, a healthy diet, stress management, yoga and meditation can assist to minimise symptoms of endometriosis, PCOS, premenstrual syndrome, and other conditions. l Education, support and counseling: sometimes diseases can be complex and difficult to understand and manage by the patients. Counseling and education are the first steps to patient empowerment. The best practices for managing gynaecological diseases depend on the specific condition and the individual patient. Consulting with a qualified healthcare provider is essential for developing a personalised treatment plan that is right for each patient’s need. n What is your opinion about types of gynaecological diseases and their management? A disorder that affects the female reproductive system is referred to as a gynaecological ailment. Women’s health is a fundamental aspect of primary healthcare. All health sectors in Bangladesh are working tirelessly to enhance services for women. The most significant barrier, however, is the traditional beliefs of women and their families. In many cases, a woman’s problems begin while she’s a teenager or soon after giving birth, but they don’t seek medical help until much later in life, sometimes even beyond menopause. Gynaecological problems that patients commonly seek healthcare for include vaginitis, menstrual disorders, polycystic ovar-

FDA UPDATE 96 THE PHARMA WORLD Cidara Therapeutics, Inc. (Nasdaq: CDTX) and Melinta Therapeutics, LLC announced that USFDA approved Rezzayo (rezafungin for injection) for the treatment of candidemia and invasive candidiasis in adults with limited or no alternative treatment options. Rezzayo is the first new treatment option approved for patients with candidemia and invasive candidiasis in over a decade. The FDA approval was based on clinical data from Cidara’s global ReSTORE Phase 3 trial where Rezzayo, dosed once-weekly, met the FDA and EMA primary endpoints, demonstrating statistical non-inferiority versus caspofungin, a current once-daily standard of care. In addition, overall rates of adverse events and serious adverse events were comparable in patients receiving Rezzayo. Novel Treatment of Candidemia and Invasive Candidiasis FDA Approves Zavzpret Nasal Spray for Migraine The USFDA has approved Pfizer’s Zavzpret (zavegepant), the first and only calcitonin gene-related peptide (CGRP) receptor antagonist nasal spray for the acute treatment of migraine with or without aura in adults. In its pivotal Phase 3 study, Zavzpret was statistically superior to placebo on the co-primary endpoints of pain freedom and freedom from most bothersome symptom at two hours post-dose. The pivotal study also demonstrated pain relief as early as 15 minutes in a prespecified secondary endpoint versus placebo. The most common adverse reactions reported in at least 2% of patients treated with Zavzpret and at a frequency greater than placebo were taste disorders (includes dysgeusia and ageusia), nausea, nasal discomfort and vomiting. Reata’s Skyclarys for Friedreich’s Ataxia Reata Pharmaceuticals announced that the USFDA has approved Skyclarys™ (omaveloxolone) for the treatment of Friedreich’s ataxia in adults and adolescents aged 16 years and older. With this approval, the FDA granted a rare paediatric disease priority review voucher. Friedreich’s ataxia is an ultra-rare, inherited neurodegenerative disorder that is typically diagnosed during adolescence. Patients with Friedreich’s ataxia experience progressive loss of coordination, muscle weakness, and fatigue, which commonly progresses to motor incapacitation and wheelchair reliance by their teens or early twenties, and eventually death. The approval of Skyclarys is supported by the efficacy and safety data from the MOXIe Part 2 trial and a post hoc Propensity-Matched Analysis of the open-label MOXIe Extension trial. New Once-Weekly Therapy for Hemophilia A The USFDA has approved Sanofi’s Altuviiio [Antihemophilic Factor (Recombinant), Fc-VWF-XTEN Fusion Protein-ehtl], a first-inclass, high-sustained factor VIII replacement therapy. Altuviiio is indicated for routine prophylaxis and on-demand treatment to control bleeding episodes, as well as perioperative management (surgery) for adults and children with hemophilia A. Altuviiio is the first and only hemophilia A treatment that delivers normal to near-normal factor activity levels (over 40%) for most of the week with once-weekly dosing, and significantly reduces bleeds compared to prior factor VIII prophylaxis. Accelerated Approval for Filspari (sparsentan) Travere Therapeutics announced that the USFDA has granted accelerated approval to Filspari™ (sparsentan) to reduce proteinuria in adults with primary IgAN at risk of rapid disease progression, generally a urine protein-to-creatinine ratio (UPCR) ≥1.5 g/g. It has not been established whether Filspari slows kidney function decline in patients with IgAN. The continued approval of Filspari may be contingent upon confirmation of a clinical benefit in the ongoing Phase 3 PROTECT Study, which is designed to demonstrate whether Filspari slows kidney function decline. Topline results from the two-year confirmatory endpoints in the PROTECT Study are expected in the fourth quarter of 2023 and are intended to support traditional approval of Filspari.

THE PHARMA WORLD 97 FDA APPROVALS BRAND NAME GENERIC NAME MANUFACTURER DATE OF APPROVAL TREATMENT Joenja Tablets Leniolisib Pharming Group N.V. Mar 24, 2023 Treatment for Activated Phosphoinositide 3-Kinase Delta Syndrome Zynyz Injection Retifanlimab-dlwr Incyte Corporation Mar 22, 2023 Treatment for Merkel Cell Carcinoma Rezzayo Powder for Injection Rezafungin Cidara Therapeutics, Inc. Mar 22, 2023 Treatment for Candidemia, Systemic Candidiasis Daybue Oral Solution Trofinetide Acadia Pharmaceuticals, Inc. Mar 10, 2023 Treatment of Rett syndrome. Zavzpret Nasal Spray Zavegepant Pfizer Inc. Mar 09, 2023 Antagonist nasal spray for the acute treatment of migraine. Skyclarys  Capsules Omaveloxolone Reata Pharmaceuticals, Inc. Feb 28, 2023 Treatment for Friedreich’s Ataxia Altuviiio Lyophilized Powder for Injection Antihemophilic factor recombinant, Fc-VWFXTEN fusion protein-ehtl Sanofi Feb 22, 2023 Treatment for Hemophilia A Altuviiio for use in people with hemophilia A. Syfovre Injection Pegcetacoplan Apellis Pharmaceuticals, Inc. Feb 17, 2023 Treatment for Macular Degeneration Syfovre Filspari Tablets Sparsentan Travere Therapeutics, Inc Feb 17, 2023 Treatment for IgA Nephropathy Doxepin Zonalon Teva Pharmaceuticals Feb 17, 2023 Treatment Hydrochloride Topical Cream Lamzede Lyophilized Powder for Injection Velmanase alfa-tycv Chiesi Global Rare Diseases Feb 16, 2023 Treatment of non-central nervous system manifestations of alphamannosidosis. Jesduvroq Daprodustat GlaxoSmithKline Feb 01, 2023 Treatment of patients with anemia of chronic kidney disease (CKD). Jaypirca  Tablets Pirtobrutinib Eli Lilly and Company Jan 27, 2023 Treatment for Mantle Cell Lymphoma Jaypirca Orserdu  Tablets Elacestrant Menarini Group Jan 27, 2023 Treatment for Breast Cancer Brenzavvy  Tablets Bexagliflozin TheracosBio, LLC Jan 20, 2023 Treatment for Diabetes, Type 2 Rykindo for Extended-Release Injectable Suspension Risperidone Luye Pharma Group Jan 13, 2023 Treatment for Schizophrenia, Bipolar Disorder Airsupra Inhalation Aerosol Albuterol and Budesonide AstraZeneca Jan 10, 2023 Treatment for Asthma Leqembi  Injection Lecanemab-irmb Biogen Inc. and Eisai Co., Ltd. Jan. 06, 2023 Treatment for Alzheimer’s Disease NexoBrid Topical Gel Anacaulase-bcdb MediWound Ltd. Dec 28, 2022 Treatment for Burns, External Briumvi Injection Ublituximab-xiiy TG Therapeutics, Inc Dec 28, 2022 Treatment for Multiple Sclerosis. Xenoview for Oral Inhalation Xenon Xe 129 hyperpolarized Polarean Imaging plc Dec 23, 2022 Treatment for Diagnosis and Investigation Sunlenca Lenacapavir Gilead Sciences, Inc. Dec 22, 2022 Treatment-experienced (HTE) people with multi-drug resistant (MDR) HIV-1 infection. Lunsumio Injection Mosunetuzumab-axgb Genentech, Inc. Dec 22, 2022 Treatment of relapsed or refractory follicular lymphoma. Olpruva for Oral Suspension - formerly ACER-001  Sodium Phenylbutyrate Acer Therapeutics Inc. Dec 22, 2022 Treatment for: Urea Cycle Disorders

THE PHARMA WORLD 99 FACTS on FINGER TIPS GLOSSARY OF TERMS OBGYN THE PHARMA WORLD 99 Postpartum anxiety a condition marked by irrational fears that go well beyond the natural concerns parents have for their children’s health and well-being. For example, having unfounded, repetitive thoughts that someone or something is going to harm the newborn. Causes and risk factors l Shifts in hormones l Added life stressors, such as difficulty breastfeeding or issues during pregnancy and delivery l Being overwhelmed Acceleration of labour: The speeding up of labour by the use of drugs, usually via a Syntocinon drip. Active labour: Also known as the first stage of labour. This is the period after the latent (early) stage of labour when a woman is experiencing strong, regular contractions and her cervix continues to dilate from 4cms until she is fully dilated (10cms). Alpha fetoprotein (AFP): A substance present in the blood of pregnant women. This is tested as part of the Down’s syndrome screening tests. Breech presentation (BR): This means your baby is lying bottom or feet down in the uterus. Caesarean section: Delivery of an infant through an incision in the abdominal and uterine walls. Cephalic (Ceph): This means the baby is lying with its head in the lower part of the uterus. Chorionic villi sampling: A prenatal test that scans for genetic abnormalities. Crowning: The point in labour when the head of the baby can be seen at the vagina. Diamorphine: This is an injection like pethidine sometimes given for pain relief in labour. Like pethidine, it can cause drowsiness and nausea. Fetal distress: Persistently abnormal heartbeat or an irregular rhythm of the baby due to labour contractions can reduce the baby’s oxygen supply, causing the baby to become distressed. Induction: Starting the labour artificially. Lithotomy position: A position used for assisted deliveries, where the mother lies flat on her back with her legs raised and apart, supported by stirrups. Lochia: For a couple of weeks or more after the birth the woman loses a mixture of blood and mucus through the vagina. Multigravida: A woman who has been pregnant before. Multipara: a woman who has given birth at least once before. Oxytocin: The hormone secreted by women when they are in labour which stimulates labour contractions. Placenta Praevia: When the placenta is low down. Sometimes it covers the cervix and blocks the baby’s exit, in which case you would need a Caesarean section. Polyhydramnios: An excessive amount of amniotic fluid. Primigravida: A woman pregnant for the first time. Primipara: A woman giving birth for the first time. Syntometrine: This contains two drugs (syntocinon and ergomerine) that help the womb contract after the baby is born. It is sometimes used to speed up the delivery of the placenta or to stop bleeding after birth. Vernix: A white, waxy substance that covers the fetus in the uterus. due to the responsibilities of caring for a newborn l A lack of sleep, which is common for new parents l Certain health conditions, such as a history of eating disorders, anxiety or depression l Life events that increase risk for developing anxiety, such as a previous miscarriage or loss of a child l Lifestyle factors, such as caring for multiple children at once or having a child with health issues Symptoms According to Harvard Health, postpartum anxiety shares some symptoms in common with postpartum depression, including: l irritability l issues with relaxing l trouble falling or staying asleep l Shortness of breath l Heart palpitations or increased heart rate l Restlessness l Nausea and decreased appetite l Racing or irrational thoughts, particularly fearful ones l Poor focus l Social avoidance l Control issues l Overly cautious behaviour Treatments and medications Luckily, there is help for postpartum anxiety. These include: l Therapy: Cognitive behavioral therapy l Medication to improve the physical, behavioral and emotional symptoms: These include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and the antidepressant mirtazapine. l Social support: clinics and social support groups Harvard Health also suggests: l Cuddle your child to release moodenhancing oxytocin l yoga or meditation which offer calming breathwork l Weaning your child from breastfeeding slowly l getting more sleep. POSTPARTUM ANXIETY