WRITE UPS - MISCELLANEOUS: (GYN) - Obstetrics & Gynecology In 21st Century



 In an article like this, the position of the author is similar to an actor who plays the role of a mad person. Such an actor has a precarious possibility of overacting in his role, In the same way the author of such an article is precariously placed to trip into unscientific and share market like speculations. This is more so in one of the fastest developing branches like obstetric and gynecology. Extensive reading and research go in before such articles are actually penned. However, it is always the responsibility of the authors of such articles to have a sound scientific footing on which they can base their predictions lest they can reduce their words to those of science fiction or fantasy.


 This is an area that deals with stark practice of obstetrics & gynecology rather than pure academics and scientific research. India is probably the only country that provides completely free health care to any of her citizens who want it and we are indeed proud about it. However, with open economy becoming a reality, very soon market forces will also influence health care. Teeming millions of poor Indian mothers who will continue to be kept poor by a corrupt, inefficient, morally debased and refractory politicobureauratic system, managed care will soon take over the thought processes of those sensible planners who would like to channelize these scant resources for the health care of such mothers. A revolution can sweep the economy in such a way that the Indian health care system which a badly beaten by traditional economic guidelines will find itself forced into managed care system.s A cost plus based pricing structure, without any real incentive to direct funds to the poor, powerless and pregnant mothers of this century will move towards a price competent, cost controlled and therefore a really meaningful budget distribution towards the young and most needy clientage of our health system the pregnant mothers. This is where a really managed care system will work.

 This is relatively a new health care delivery system. This system stresses a quality of care by appropriate providers at each level of the society. It identifies and reduces the use of less effective investigations and treatment modalities. This will improve access to better treatment modalities without  increasing the costs. Greater emphasis on preventive care and wellness, decline in availability of grants for useless research and changes in technology for better outcome will be the hallmark of such managed care in the entire health planning of the society without increasing the costs.


 In the first half of this century, new knowledge of biological sciences dramatically improved the teaching and practice of this specialty. As the century closes O. & G. teaching and practice are striving to adopt a more rigorous form of clinical science. With the first randomized clinical trial in 1940, quantitative science and logic began to replace experience and opinion in the education of medical students and in the practice of obstetrics & gynecology. This evolved approach has taken a firm grip over this science. Two decades ago a survey showed that this science had least evidence to support most of its practices and decisions. Science than an explosion of well devised studies have taken place shattering some of the over publicized norms. It also helped to establish the rationality and importance of newer practice. Classic example of the latter is the use of corticosteroids in improving lung maturity of an unborn preterm child. In the century to follow, this welcome trend is likely to snowball. The biggest handicap for obstetricians as scientific investigators has admittedly been a risk of disturbing normal physiology. Evaluating a treatment modality of myocardial infraction is totally different from evaluating a management modality of pregnancy. This handicap has been excellently taken care of in the last quarter of this century. This was done by influx of modern technology the fore-bearer being ultrasonography Now, in this new century, the obstetric scientist is much better equipped to generate evidences for a or against “ the facts” in his science. Evidence based medicine is therefore going to be very important in the next century.


 This is an alternative to prenatal diagnosis that is likely to become very popular in the next century. It consists of genetic analysis of one or two blastomeres removed by micromanipulation from four to eight cell stage embryos obtained by in-vitro fertilization. Such an embryo biopsy at the eight-cell stage has been shown to be non-detrimental to the biopsied embryo. In fact it may be beneficial to the embryo hatching. When a women is a carrier of genetic disease, polar bodies. Small cells which accompany the oocyte but are not involved in embryo development can also be removed for analysis.
 Such a preconception genetic diagnosis has an obvious advantage of diagnosing a genetic defect even before implantation and hence termination of such a pregnancy would indeed be very easy. At present , this technique is available in a mere handful of centers and specifically for IVF babies. But with turn of the century , it may soon be available to other pregnancies as well.


For years scientists have contemplated the enigma of why a fetus with its unique antigens is not rejected by the immune cells from the mother. The resulting advances from studies in this area of reproductive immunology have greatly contributed to our understanding of the mechanisms involved in normal and abnormal pregnancies. These advances came in the last decades of this century. Better understanding of maternal fetal immune interactions is now on the cards. The nature and implications of immunological cross talk between the decidua and trophoblast will be studied in larger details in the 21” century. The observation that chronic violates of unexplained etiology occurs when maternal T cells invade fetal tissue and the hypothesis that this entity might be a result of graft versus host allegoric recognition will become more and more clear in 21” century, This for a clinical in the 21” century, pre-implantation genetic diagnosis combined with a better understanding of reproductive immunology would successfully reduce the incidence of miscarriages. “ Human pregnancy is an incompetent process” will no more hold true.


 The birth of first test tube baby was a landmark event in the current century. Assisted Reproduction Clinics opened worldwide. India was no exception. Our country soon got filled with a horde of such clinics. As this century bids adieu the situation on this front has become pathetic with the need for quality control becoming more pertinent. With a pot full of money involved and emotions of infertile couples at stake, fly by night operators, clandestine clinics and untrained or scantily trained “ experts” have started making their rounds. With the local press being more than ready to give them publicity, patients throng.

 The society has started realizing that such technique offer only a 10% carry home baby rate. It has also realized that inspite of a huge amount of money being pumped in, one is likely of fail more often then not. In the next century, there will soon be an added responsibility for doctors in this field. It will soon be necessary to open up such ARC to the scrutiny of peer groups who will have to be honest and just. If all those involved will not respond quickly and responsibly , a situation akin to Cosumber Protection ACT will step in. It will be necessary to look at all steps along the way to reduce the costs without compromising with the quality. This will be major trend in 21” century.


 Blood cells recovered from the umbilical cord are to become an increasingly viable alternative to the bone marrow. The latter is conventionally used for transplantation in the current century. The structural and functional integrity of the hematopoietic system is maintained by relatively small hematopoietic stem cells that undergo either a self-renewal or differentiation into lineage-the progeny are unable to self renew. Instead they are irreversibly committed to one of the hematopoietic lineage. These progenitor cells have been found in the bone marrow and even in peripheral blood. Recently they have also been found in umbilical cord blood ( UCB.)

 Ontogenetically hematopoiesis appears to be a migratory phenomenon during embryonic and fetal development. Recently umbilical and placental blood sampled immediately prior to delivery has been shown to contain a large number of hematopoietic progenitor cells. The normally discarded UCB is now being evaluated as a potential source of hematopoietic stem cells. UCB can easily be collected and can serve as an alternative to bone marrow for clinical transplantation in diseases such as Fanconi’s anemia, aplastic anemia, leukemia and other congenital disorders. This is an area to be watched in 21” century.


 In clinical infertility practice, male factors in infertility continue to be stubborn and difficult to treat even at the turn of the century. However, advances in the treatment of these problems have slowly opened up. Treatment modalities like Intracytoplasmic Sperm Injections ( ICSI) HAVE OPEND SOME WINDOWS IN THESE AREAS. In the next century, besides more easy availability of such treatment modalities, there will be other techniques coming up for these hitherto stubborn problems.


 This is indeed an area where tons of research is currently going on throughout the globe. The ideal contraceptive has still evaded us. Next century is likely to throw up a male contraceptive as close as possible to the ideal. It has to be cheap, safe, easily available, least toxic, producing least adverse drug reactions and is acceptable to the couple. Above all, for the males, the contraceptive should be such that it should affect spermatogenesis without affecting the libido. Immunology and newer hormones are incessantly trying their best to break this hitherto unyielding wall.


 An impressive session on this subjects was recently held in Kualalampur during the Asian Congress of Obstetric & Gynecology. The deliberations of the congress showed great promise it holds for 21st Century. With operative techniques and international consultations being possible trans satellite, the obstetrics and gynecology world is going to shrink all the more, in the next century.

 Neuronal network simplistically speaking is an array of accumulated comprehensive clinical pictures of the obstetric and gynec. Diseases. It might mean upto 1 million pictures and images. These are continuously upgraded by feeding centers. At the same time these centers feed in their cases and comprehensive clinical investigative picture to get the precise diagnosis in seconds. This network can plan upto date treatment of the cases as well. These two areas show the days to follow in satellite medicine for obstetrics and gynecology.


 Endoscopic surgery gynec oncology, antepartum fetal surveillance, assisted reproductive techniques, fetal medicine and surgery etc are areas which already took giant strides in this century. Obviously they are going to develop all the more in the decades to follow. Also those that are misadventures in them will fade out and scientifically correct will with stand the scrutiny of time. Accordingly, maturity ethical balancing and understanding of limitations will be added on the these advances in the century to follow.


 All in all, the next century will still continue to keep the pregnant mother at the central focus for the entire obstetric & gynec world. All efforts will be for her benefit. The obstetricians and gynecologists will continue to toil for her survival and health in the century to follow. The teachers in the subject will continue to encourage and teach the latest in the subject and The Lord will continue to help and bless both of them in the 21st century.



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