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In this issue...

• IN BRIEF
• Tea strengthens bones
• Wanted Non-epidural options for painless childbirth
• Blood test to reveal low birth weight
• EMERGENCY CONTRACEPTION
• ABOUT CAESAREAN SECTION
• Gag Bag
• Next Issue

IN BRIEF

Fulvestrant for stubborn breast cancer

The US FDA approved the drug fulvestrant as supplementary therapy for patients with advanced breast cancer not responding to other treatment.

The drug is approved for use in post-menopausal women with hormone receptor positive metastatic breast cancer. Fulvestrant is to be used where the cancer continues to progress despite anti-estrogen therapy.

The drug is administered by injection, once a month.

Breast-fed babies make smarter adults

Want your baby to turn out to be a smart adult ? Make sure you breast-feed the child for at least nine months.

A study involving over 3253 Danish men and women revealed that more the babies were breast fed, the higher their intelligence scores in their late teens and 20s. However, breast - feeding 1st nine months did not indicate any additional effect.

Researchers point out that this could be due to the impact of the nutrients in mother's milk on the developing brain. The intimate physical and psychological relationship associated with breast feeding could be an additional factor. Again, mothers who breast-feed tend to spend more time with their little ones right through childhood, positively affecting the development of intelligence.

Have son, live shorter?

Old church records appear to substantiate what many a modern exasperated mother may already know: sons shorten the life span of mothers while daughters lengthen it.

A recent study scrutinized church family records kept in Finland for a nomadic people called the Sami during the period 1640 to 1870. Researchers who concentrated on mothers, who lived past 50, found that a son typically reduced a mother's life span by about 34 weeks. Daughters countered the effect. It took three daughters to negate the effect of one son.

Apparently, baby boys made greater demands on the mother's body than the smaller girls.

Of course, the finding may not apply to the modern era, which boasts of superior medical care. However, some mothers may beg to differ!

Tea strengthens bones

A Taiwanese study has found increased bone density in people who have been drinking tea for long.

The study involved over 1037 men and women, 30 are older. After considering other factors affecting bone density, researchers found that those who drank two cups of tea a day for at least six years had the highest bone mineral density. Higher the bone density, lower the risk of fractures due to osteoporosis.
The hipbone density of those who drank tea for 10 years or more is six percent higher than those who were not devoted to the daily cup. Those who
had taken to tea for less than six years had no advantage. Those sipping tea for six to 10 years had more than two percent bone density advantage.

Experts point out that tea may not be directly related to bone strength, as the secret could be some characteristics of tea drinkers. The study also did not explore the link between tea and osteoporosis. All the same, for fans of chai the motivation could run deep as the bones!

Wanted Non-epidural options for painless childbirth

New research information shows that even in America with its advanced medical facilities, very few people are able to take advantage of epidurals and other sophisticated methods of relieving pain during childbirth. This underlines the need for more options to counter labour pain.

While medications have improved fears remain about the possible effects of the drugs on the child. Options available vary from laughing gas to birth in warm water. Experts say that the best option may be to combine natural methods with medications. This could mean an experienced midwife lending a hand during the early stages followed by a possible epidural when the pain gets intense. Other suggested non-drug methods include Lamaze breathing techniques and staying upright or squatting during labour.

Epidurals may not increase Caesarean sections but can lengthen labour by 30 minutes or so. The drugs also raise the temperature of the mother leading to increased use of forceps and testing of the newborn for infections. However, it is not easy to establish the risk as women with more prolonged and more difficult labour are more likely to use painkillers.

Blood test to reveal low birth weight

Researchers have found that women, who had low levels of a certain protein in their first trimester, were more likely to have babies five-and-a-half pounds or less.

The study involved more than 4250 women whose blood samples were tested during the first trimester. The findings indicated a link between low level of pregnancy-associated plasma protein A and underweight babies.

It is hoped that this could lead to the development of a blood test that could help women take adequate precautions in time.

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MEETING THE CHALLENGE

The problem

Unintended pregnancy is a major, though unrecognised, public health problem in India. The National Family Health Survey (NFHS-2) 1998-99 showed that 21% of the reported births in the previous three years had been unwanted at the time of pregnancy - 12% were wanted later and 9% were not wanted at all. Indeed, it is estimated that more than 50% of pregnancies occurring every year are unplanned.

Unintended pregnancy can result from:

• Non-use of contraception
   

• Contraceptive failure

Contraceptive failure accounts for about half of all unintended pregnancies.

What unintended pregnancy means to women and families

While it is certainly true that even a "surprise" pregnancy can
result in healthy children and happy families, unintended pregnancy can have significant consequences. Approximately half of all unintended pregnancies end in abortion. Even when an unintended pregnancy is carried to term, the child is at a higher risk of negative outcomes such as low birth weight, death in infancy, not receiving the resources necessary for healthy development and neglect or abuse. The mother is at greater risk of depression, physical abuse and not achieving her educational, financial and career goals.

Institute of Medicine recommendations to reduce unintended pregnancy

The Institute of Medicines 1995 landmark report. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families documents unintended pregnancy as a frequent and widespread problem with serious consequences, imposing burdens on children, women, men and families. The report specifically advocates an aggressive approach to increasing access to contraceptive services and recommends "broadening the range of health professionals and institutions that promote and provide methods of birth control".

The role of emergency contraceptive pills
[ECPs] in reducing unintended pregnancy

Emergency contraceptive pills can contribute to reducing unintended pregnancy by providing women with a method of preventing pregnancy after intercourse. ECPs (also called post-coital contraception) are a safe and effective way of preventing accidental pregnancy after unprotected intercourse.

How do ECPs work?

ECPs work the same way as regular birth control pills. The pills-

• Inhibit or delay ovulation
   
• Stop fertilisation
   
• Prevent implantation

The primary mechanism of action is inhibiting ovulation, but statistical evidence suggests that ECPs have more than one mechanism of action.

Methods of Emergency Contraception

Efficacy of emergency contraceptive methods

The overall risk of pregnancy after a single act of unprotected sex on any day in the menstrual cycle is 2% to 4%. The pregnancy risk from a single act of intercourse is highest (between 20% to 30%) in the days before and just after ovulation. Counting the first day of menstrual bleeding as Day 1, the pregnancy risk is low before Day 7 and after Day 17 inclusive in a 28-day cycle. Adjusting for shorter and longer cycles displaces these estimated fertile days earlier and later, respectively, within the cycle.

The efficacy of emergency contraceptive methods, as demonstrated in clinical trials, can be described in two ways:

• Expressed as a failure rate, i.e. citing the proportion of women who
  become pregnant despite using the method. This approach includes, as
  treatment successes, all women who had treatment and did not become
  pregnant in that cycle. It is possible that many of them would not have
  become pregnant even without treatment.
  
   

• Expressed as the ratio of observed to expected pregnancies, i.e. estimating
  the number of pregnancies expected without treatment from the
  menstrual and coital histories of all women in the trial, and comparing this
  number with the actual numbers of pregnancies occurring after treatment.

Both of these approaches obviously rely on accurate recollection of date of last menstrual period and coital history.

Indications for use of Emergency Contraception

• Intercourse without contraceptive protection, including unsuccessful
  withdrawal before ejaculation or ejaculation on external genitalia
   

• Condom used incorrectly, dislodged, torn during intercourse or
  removed too early
   

• Inadvertent expulsion or partial expulsion of intrauterine device
   

• Failure to take birth control pills (three or more) in the two weeks
  preceding intercourse
   

• Exposure to possible teratogen, such as live vaccine, cytotoxic drug,
  extensive radiographic studies
   

• Sexual assault

Screening questions for prescribing ECPs by phone

1. Have you had unprotected sex or a problem with your birth
   control method during the past 3 days?
   If yes, give date(s) __________________ and
   time(s) _______________

2. Did your last menstrual period begin less than 4 weeks
   ago?
   Yes __________ No __________

3. Was this period normal in length and timing?
   Yes ________ No _________

If the response is "yes" to all three questions, patient qualifies for telephone
prescription of ECPs.

If the response to any of these questions is "no" or it is suspected that the sexual history may be inaccurate, patient requires pregnancy test before receiving ECP prescription.

Safety

Studies have identified no absolute contraindications to ECP use other than known pregnancy against which it is ineffective. Likewise, no ECP regimen has been linked to any teratogenic effects.

Side effects

Approximately 50% of women using the ECP regimen experience nausea and 20% vomiting. Using antiemetics 1 hour before ECP use can decrease the incidence of vomiting, but such medication is not effective when used after symptom onset. A WHO multinational study showed that the rate of emesis was 33%. This was lower in woman who used the levonorgestrel alone regimen than in those who used the combination regimen.

Conclusions

Indian women now have at their disposal a powerful tool for reducing the country's unacceptably high rates of unintended pregnancy and abortion - a "second chance" at pregnancy prevention. Although hormonal post-coital contraception regimens have a long record of clinical safety and efficacy, ECPs remain woefully underutilised. In addition to direct prevention of pregnancy, ECPs can provide a back-up in the event of condom failure and can offer an alternative for women who would not consider abortion. Now the challenge is for physicians to educate patients and increase everyone's access to this safe and convenient method.

Further Reading
1. Asian J of Obs and Gynae Pract 2001; 6(No: 1): 19-24
2. Int J of Gynecology, and Obs India, Nov-Dec 2001; 4: 6; 101-104
3. The Female Patient 2001; 26: 15-27
4. Faculty of Family Planning and Reproductive Health Care RCOG, 2000; Apr: 93-106
5. Am Fam Phys 2000; 62: 2287-92
 

ABOUT CAESAREAN SECTION

PATIENT INFORMATION

What is a caesarean section?

When is a caesarean section necessary?

A caesarean section may be planned in advance based on the doctor's assessment of the condition of the mother and the unborn child. Or, after labour starts, the doctor may assess the risk to the mother and the child under certain conditions and opt for an emergency caesarean section.

When is a caesarean section planned in advance?

The gynaecologist regularly monitors the condition of the mother and the foetus right from the time pregnancy is established. This may reveal certain conditions calling for a caesarean section. These include:

• Instead of the normal head-first position, the baby
  is in a feet-first, buttocks-first position (called
  "breech"). Or the baby may be in a crosswise
  ("transverse") position.
   

• The mother has undergone a previous caesarean
  section or another surgery that required opening of the uterus.
   

• The baby is too large to pass through the pelvis.
   

• The placenta is placed over the cervix. This can
  cause severe bleeding during a normal birth.
   

• The mother has active genital herpes, large genital
  warts, is HIV positive or has AIDS.
   

• The baby has some abnormality that requires delicate handling.
   

• The uterus has some malformation or scarring.
   

What are the circumstances that may call for a caesarean section?

An emergency caesarean section may become necessary if:

• The baby has irregular heartbeat indicating possible
  stress and inability to withstand continued labour.
   

• The baby is not receiving enough blood and oxygen
  through the umbilical cord.
   

• The placenta begins to detach from the uterine wall too early.
   

• The baby is too large to move through the birth
  passage or there is some obstruction.
   

• The cervix has stopped dilating.
   

How is caesarean section done?

• The mother is first given medications to dry the
  secretions in the mouth and upper airways.
   

• The lower abdomen is washed and shaved.
   

• A catheter is placed in the bladder to drain off urine.
   

• An intravenous needle is inserted into the arm for
  fluids and necessary medicines.
   

• Usually the mother receives spinal or epidural
  anaesthesia so that she can remain awake during the
  procedure. However, some may require general anaesthesia.
   

• The surgeon makes an incision through the
  abdomen wall and the uterine wall. Usually a
  "bikini" incision is made along the pubic hairline,
  unless it is necessary to make a vertical incision
  down the middle of the abdomen.
   

• The amniotic sac is opened and the fluid released.
   

• The baby is removed through the incision.
   

Is it against nature to have a caesarean section?

As with every body function, the best course would be the "normal" way. In the case of childbirth, the normal way would be to give birth vaginally. However, what is important is to deliver a healthy baby safely while preserving the mother's health. Doctors usually recommend a caesarean section when they think a normal delivery may put the mother, the baby or both at risk.
 

What are the likely complications after a caesarean section?

Modern surgical techniques and medicines have made caesarean sections relatively risk-free compared to olden times. However, it remains riskier compared to normal delivery. Doctors weigh the risks against benefits before recommending the procedure.
These are some of the possible complications:

• Post-operative infection
   

• Excessive bleeding
   

• Adverse effects of anaesthesia
   

• Blood clot formation
   

• Surgical injuries to organs like the bowel and the bladder
   

• Failure of the uterus to contract after delivery. This
  may cause severe bleeding.
   

Once a caesarean section is done is it never possible to give birth normally?

This used to be the case. However, now it is estimated that vaginal birth after a caesarean section succeeds in 60 to 80 percent of cases. In such cases doctors normally allow labour to proceed for a while before deciding on the right course of action. The circumstances that led to the previous caesarean section and the nature of the incision have a bearing on the possibility of a subsequent vaginal birth.

The Female Patient May 2002

Gag Bag

A wife one evening, drew her husband's attention to the couple next door
and said, "Do you see that couple ? How devoted they are ?
He kisses her every time they meet. Why don't you do that"
"I would love to," replied the husband, "but I don't know her well enough.

Two men were in a pub.
One man said, "Did you know that beer contains female hormones?"
The other man said, "No! Is it true ?" " Yes," said the first man.
"If you drink too much, you start talking crap and you drive terribly."

 

Intelligent man + Intelligent woman = Romance
Intelligent man + Stupid woman = Pregnancy
Stupid man + Intelligent woman = Affair
Stupid man + Stupid woman = Marriage