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INTRODUCTION:-
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.
MANAGED CARE :-
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.
EVIDENCE BASES OBST. & GYN. PRACTICE:-
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.
PRE-IMPLANTATION GENETIC DIAGNOSIS ( PGD):
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.
REPRODUCTIVE IMMUNOLLGY :-
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.
QUALITY CONTORL IN ASSISTED REPRODUCTION:-
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.
A NEW CANDIDATE FOR TRANSPLANTS IN 21ST 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.
DEFEATING THE MALE FACTOR IN INFERTILITY :-
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.
CONTRACEPTIVE TECHNOLOGY:-
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.
TELEMEDICINE & NEURONAL NETWORK:-
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.
MISCELLANY :-
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.
EPILOGUE:-
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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