AL SHIFA CLINIC KARACHI

Syed Intisar Hussain

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

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Time For Men To Share The Burden Of Pregnancy

Introduction

A fast-growing population is one of the greatest challenges currently faced by Pakistan. Increasing poverty, food shortage, health challenges, depletion of natural resources, and overcrowding are just some of the problems associated with overpopulation. According to the 2017 Census of Pakistan, with a population of more than 207 million, the country is the fifth most populated country in the world<a href="#accordion">[1]</a>. Therefore, effective birth control methods are a need of the hour to prevent the risks associated with overpopulation.

However, the use of contraception is largely stigmatized in Pakistan due to various reasons. As per the Pakistan Demographic and Health Survey (PDHS), the current contraceptive prevalence rate (CPR) is only 34%<a href="#accordion">[2]</a>. Moreover, the use of contraceptive methods among men is extremely low. Thus, resulting in the burden of pregnancy and contraception lying largely with women. This could probably be due to a lack of awareness among men regarding various contraceptive methods that are readily available. Raising awareness about these methods is the first step in ensuring that the financial and emotional burden of <a href="https://merisehat.pk/article/how-to-practice-safe-sex">safe sex</a> is shared among both partners in a couple.&nbsp;

Almost 200 years ago, humans invented the world&#39;s first condom, and for a long time that was the greatest discovery in the world of contraception. However, scientists soon discovered methods specifically designed for women that could aid further in population control. Several female contraceptive options ranging from hormonal pills to invasive tubal ligation were introduced. However, each of the proposed methods comes with its side effects. Contraception methods have been widely politicized and various speculations exist regarding the reasons behind the disparity among male and female contraceptives. However, it is important to mention that male contraceptive methods are generally safer than their female counterparts, which is why in recent years significant work has been done to search for effective male contraceptive options. This shift in tide is also perpetuated in part by the increasing awareness among men and their willingness to use contraceptives.&nbsp;&nbsp;

&nbsp;

Understanding Male Contraceptives

Currently, two widely acceptable male contraceptive methods exist: condoms and the invasive vasectomy.

&nbsp;

<h5 dir="ltr">Condoms</h5>

These are a form of barrier method and stop the sperm from entering and fertilizing the egg. Along with being an effective and inexpensive birth control, condoms also prevent sexually transmitted infections (STIs). However, incorrect use is associated with a high failure rate, and they can easily break or get damaged. In Pakistan, condoms are the most used form of contraceptive method, with a frequency of 65.5%<a href="#accordion">[3]</a>.&nbsp;

In recent years, the Pakistani government has stepped up its social media campaigns in a bid to educate the public regarding the use of condoms and other effective family planning methods. This is aimed at controlling the growing population by promoting birth spacing and awareness of women&#39;s fertility. Doorstep availability and affordable prices have significantly increased the use of condoms among the general population.&nbsp;

Unfortunately, misconceptions about condoms and other family planning methods still need to be overcome.&nbsp;

&nbsp;

<h5 dir="ltr">Vasectomy</h5>

Also called male sterilization, the surgical procedure has been in use since the 1970s. The procedure involves cutting or blocking the vas deferens that carry sperm to the urethra. As a result, the semen is devoid of sperm and the egg cannot be fertilized. It is not easily reversed; therefore, it is mostly advised to men who are sure of not wanting children or who believe their family is complete.&nbsp;

With a success rate of 99.85%, it is the most reliable contraceptive option. Moreover, compared to tubal ligation in women, it is less invasive, has fewer risks, and has a quicker recovery time. However, only 2.4% of men around the world have undergone the procedure<a href="#accordion">[4]</a>. In Pakistan, the prevalence is only 0.4%<a href="#accordion">[3]</a>.&nbsp;

The lack of knowledge regarding vasectomy plays a major role in its low acceptance. Moreover, a majority of men hold the view that it leads to impotency or reduces sex drive. However, a recent study has found that men in Pakistan are becoming more accepting of vasectomy and recognizing their role in sharing the responsibility of family planning<a href="#accordion">[5]</a>.&nbsp;

&nbsp;

While female birth control pills have been around for more than 50 years, researchers have only recently started looking into pills for men.&nbsp;

In 2019, a team of scientists conducted a clinical trial for a male birth control pill among 82 healthy men<a href="#accordion">[6]</a>.&nbsp;They administered dimethandrolone undecanoate (DMAU) in varying doses over a period of 28 days. The two active hormones, progestin, and modified testosterone, helped suppress levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in the study participants. Thus, suppressing sperm production without causing symptoms of low testosterone levels.&nbsp;

Although the study did not measure sperm count, the pill was found to be safe, even in high dosages. The team is currently conducting a longer trial to assess the drug&#39;s effect on sperm production and any long-term effects on the body.&nbsp;

However, men are often hesitant to use hormonal options due to the presence of adverse effects. Therefore, a team at the University of Minnesota have developed a non-hormonal male contraceptive pill. According to early results from a trial in mice, the contraceptive was 99% effective at preventing pregnancy<a href="#accordion">[7]</a>. Moreover, it had no obvious side effects in the mice.

Called YCT529, the non-hormonal pill works by targeting a protein called the retinoic acid receptor alpha (RAR-&alpha;). Through inhibition of this receptor, the retinoic acid in the body is unable to cause cell growth and differentiation, both of which contribute to sperm formation. As a result, the contraceptive helped cause reversible sterility in male mice.&nbsp;

Researchers now plan to conduct human trials for the compound. However, it is too early to tell whether the results in mice will also translate to humans.&nbsp;

&nbsp;

Conclusion

Pakistan faces several challenges to the acceptability of various family planning methods. These range from religious and cultural beliefs, low literacy levels, misconceptions about side effects, lack of knowledge regarding various options for men and women, and reluctance to adopt a method. According to a study from Karachi, fear of side effects was the most common reason for low prevalence among users<a href="#accordion">[8]</a>.&nbsp;

Several trials are currently underway to look for safe and effective male contraceptive pills. However, it can take years till a pill is available in store. Even then, its availability will not matter until there is a change in beliefs regarding family planning.

Despite the safety and availability of male contraception, men are reluctant to use the contraception methods due to various reasons ranging from misconceptions about side effects to a lack of knowledge about safe sexual practices.&nbsp;

Therefore, there is a need for campaigns aimed at educating men about the importance of adopting contraception methods.&nbsp;

&nbsp;

Key Points

<ul>
</ul>

<ul>
	<li>A growing population poses several challenges to a country&#39;s health and economic stability.</li>
	<li>Effective implementation of family planning measures can help control overpopulation.</li>
	<li>In Pakistan, use of contraceptives is highly stigmatized due to various reasons.</li>
	<li>While several advances have been made in the search for female contraception, men have only been presented with two options: condoms and vasectomy.</li>
	<li>Condoms are the most commonly used form of contraception; however, there is a need to raise awareness on its correct usage.</li>
	<li>Vasectomy is the most effective male contraceptive method, but the lack of education and widespread myths regarding its side effects has resulted in a low frequency (0.4%) of the procedure in Pakistan.</li>
	<li>Recently, scientists have begun testing various hormonal and non-hormonal compounds as male contraceptive pills.&nbsp;</li>
	<li>In 2019, a team of scientists tested varying doses of dimethandrolone undecanoate (DMAU) among healthy males and found it was well-tolerated. They are now planning long-term clinical trials to test the compound&#39;s effect on sperm production.</li>
	<li>Recently, a team at the University of Minnesota developed a non-hormonal contraceptive pill. They tested the compound in mice and found it to be 99% effective, with no observable side effects. The team now plans to conduct human trials of the compound.</li>
	<li>The development of male contraceptive pills can help men share some of the burden of contraception and pregnancy.</li>
</ul>

&nbsp;

[1] Statistics, P. B. o., 2021. Brief on Census - 2017. [Online].

[2] Meherali, S., Ali, A., Khaliq, A. & Lassi, Z. S., 2021. Prevalence and determinants of contraception use in Pakistan: trend analysis from the Pakistan Demographic and Health Surveys (PDHS) dataset from 1990 to 2018. F1000 Research, Volume 10.

[3] Shattuck, D., Perry, B., Packer, C. & Quee, D. C., 2016. A Review of 10 Years of Vasectomy Programming and Research in Low-Resource Settings. Global Health, Science and Practice, 4(4), pp. 647-660.

[4] Siddiqui, M. et al., 2020. Prevalence and Predictors of Contraception Usage in Karachi, Pakistan. Cureus, 12(10).

[5] Hatesh, H., Maheshwari, B. K., Shah, S. Q. & Kumar, D., 2020. Males’ perception and motivation for Vasectomy. Pakistan Journal of Public Health, 10(4).

[6] Thirumalai, A. et al., 2019. Effects of 28 Days of Oral Dimethandrolone Undecanoate in Healthy Men: A Prototype Male Pill. The Journal of Clinical Endocrinology & Metabolism, 104(2).

[7] Society, A. C., 2022. A non-hormonal pill could soon expand men’s birth control options. [Online].

[8] Bibi, S., Memon, A., Memon, Z. & Bibi, M., 2008. Contraceptive knowledge and practices in two districts of Sindh, Pakistan: A hospital based study. Journal of the Pakistan Medical Associatio, 58(5).

Nimrah H. Sattar

Madeeha Syed

Your Body After Giving Birth

Overview

Post-pregnancy or postpartum is a crucial period. It&rsquo;s also known as the fourth trimester. This is when your body is <a href="https://merisehat.pk/disease/chronic-fatigue-syndrome">recovering from the fatigue</a> of pregnancy.

During pregnancy, the body goes through a lot of changes to accommodate your baby. The body eventually goes back to normal, but this can take a while.&nbsp;

Continue reading to find out more about some common changes that take place in your body, after you give birth. 
&nbsp;

Post-pregnancy or postpartum

During pregnancy, hair growth gets better and the texture of hair gets thicker. This is all thanks to the hormones that are active during that phase. However, post-delivery, this phase settles down and enters into a resting phase for about one to five months. Normal hair growth pattern usually returns six to 15 months after delivery. 
&nbsp;

Shoe surprise is pretty common after pregnancy. It is not just the midsection that gets affected. After a baby is born, your shoe size changes permanently. That is because during pregnancy women gain an average of 25-35 pounds which puts extra pressure on the feet. This pressure flattens out the arch in your feet which is the reason for extra inches in your feet. 
&nbsp;

Belly bulge is common after pregnancy. A lot of women expect that the belly will return to its normal size after birth. The upper portion of the uterus is at the level of your navel. Post-pregnancy belly returns to its normal size in about six to eight weeks. A good diet and exercise are the key to toning down your belly. Workouts focused on the core can show quick results. 
&nbsp;

A common expectation of most women is that the breast size will go up after giving birth and breastfeeding. Once you stop breastfeeding, however, the size goes back to what it was. In fact, in some cases, it goes a cup down. The main reason for the size to increase is that fat tissue in the breast is replaced by functional tissue. Once a woman stops breastfeeding, functional tissue depletes as it is no longer needed. 
&nbsp;

The first six months of the post-partum period are the recovery period. No matter how easy or smooth your pregnancy is, your body has gone through a lot of stress and trauma. It needs time to recuperate. Remember that every mom goes through a different experience and symptoms; hence, the recovery rate also changes.

Most of the symptoms, like sore nipples, backache, pain in the thigh area, etc., continue for more than a week. Other symptoms, like leaky breasts, can linger on for months.

In vaginal delivery, recovery timelines vary depending upon the kind of delivery. The soreness and perennial pain go away in three weeks. However, in the case of vaginal tear or episiotomy (incision made on the vagina to ease the delivery process), recovery can take up to six weeks.

If you have been delivered through c-section, it will take around three to four days in the hospital to recover. In about four to six weeks you can recover completely. 
&nbsp;

For the first 24 hours after birth, ice your perineum region. Sit in warm baths for 20 minutes to ease pain and avoid long periods of standing or sitting.

Ease pain and aches by taking hot showers and massages.

Do your Kegel exercises, to strengthen your pelvic muscles.

Keep up with your doctor appointments. It will help you stay on track. Your doctor can also notify you about your emotional well-being and help you with your new journey.

Ask your doctor regarding your workout plan. They can guide you about how and when can you exercise. It is a good idea to start by walking into your house and then gradually into the neighbourhood. Walking helps in recovery by improving blood circulation and toning muscles. 
&nbsp;

Bottom Line

Your diet after pregnancy shouldn&rsquo;t be very different from what you eat during pregnancy. Avoid processed foods. Focus on eating whole grains, high fibre foods, Omega-3 fatty acid-rich food, nuts, and fish.&nbsp;

<ul>
	<li>Lean Meat: Milk, cheese, and yogurt are all crucial components of a breastfeeding mother&#39;s diet. Your infant receives calcium from breastmilk for the formation of bones. Consume foods high in calcium to replenish the calcium your body has lost. Include three cups of dairy in your diet each day.</li>
	<li>Pulses: These are a good source of protein and fibre. You can cook them with different seasonings to make them tasty and easy to eat. Pulses also prevent fat from accumulating in the body.</li>
	<li>Vegetables:&nbsp;These are low-calorie healthy food. They are rich in antioxidants and aid in losing weight. Spinach and broccoli are good sources of Vitamin A which is healthy for you and your baby.</li>
</ul>

Once the baby is born, you can resume most of the food you avoided during pregnancy. Include nutrient-rich foods like legumes, proteins, fibre, citrus fruits, and vegetables. Don&rsquo;t forget to keep yourself hydrated. You may consult a dietician and your doctor in designing your diet plan.

Namwer Rao

Humza Khizer

Baby Blues (Postpartum Depression): Is There A New Treatment?

The entire process of pregnancy is very rewarding, but what happens after you have delivered the baby? Your body that has gone through so many constant changes over the 9 months, reverses them all to get you back to normal. This process often leads to postpartum <a href="https://www.merisehat.pk/disease/depression">depression</a>.

About 11% of women in the United States suffer from postpartum depression (PPD).<a href="#accordion">[4]</a>&nbsp;PPD affects not just the life of the mother but also the infant. If left untreated, it can get worse and affect your spouse or other people close to you. So far, the treatment used for PPD has been very generic; similar to that of major depressive episode (MDE) consisting of conventional antidepressants like SSRIs, benzodiazepines, and tricyclic antidepressants. FDA has recently approved the first-ever drug targeted toward treating postpartum depression. 
&nbsp;

Understanding The Latest Treatment For Postpartum Depression

Postpartum depression is best explained as a worsened form of postpartum blues or baby blues. Baby blues are experienced a few days after delivery. Some new moms, however, experience a much more severe case of baby blues that can be classified as postpartum depression and it can go on for over a year.<a href="#accordion">[8]</a>&nbsp;PPD is characterized by:

<ul>
	<li>Feeling depressed and low</li>
	<li>Sleeping too little or too much</li>
	<li>Feeling tired all the time</li>
	<li>Doubting yourself as a mother</li>
	<li>Thinking that you do not want the baby</li>
	<li>Excessive crying</li>
	<li>Loss of appetite</li>
	<li>Anxiety and panic attacks&nbsp;</li>
	<li>Thoughts of harming yourself or the baby</li>
	<li>Unable to think clearly or make the right decisions</li>
	<li>Increased anger and irritability</li>
	<li>Overall reduced interest in everything</li>
</ul>

If you or anyone that you know are facing any of these symptoms, immediately contact your physician and get yourself screened through the Edinburg Postnatal Depression Scale (EPDS). It is one of the most common and quickest screening tools with high accuracy and allows your physician to assess the situation better through the score.&nbsp; 
&nbsp;

A lot of factors contribute to postpartum depression.The biggest factor that is not only responsible for PPD but also for the baby blues is the drastic change in hormones. During pregnancy, your estrogen and progesterone levels are very high. As soon as the baby is delivered, these levels are dropped drastically.

Since estrogen is directly linked to increasing serotonin levels in our brain&nbsp;and progesterone is known for stimulating dopamine release, the decrease in the production of these hormones coupled with some underlying mental issues or previous history of depression or anxiety becomes the most common and the biggest cause of PPD.<a href="#accordion">[2][3][7]</a> 
&nbsp;

While screening of postpartum depression can be done by several tools that are used for Major Depressive Episodes (MDE), the most universally acceptable tool targeted especially for PPD is Edinburgh Postnatal Depression Scale or EDPS. EDPS is a 10-item questionnaire with a response score of 0 to 3. If the total score is over 12, then there is a need for further in-depth assessment of the situation and severity of the condition.&nbsp;

PPD is best diagnosed by your medical practitioner through regular visits. Your doctor asks a series of questions every few days to assess your mental health and well-being. Another way to differentiate PPD from baby blues is to ensure that the patient has at least 3-5 of the symptoms that make up PPD. The generalized diagnostic criteria used for PPD are similar to the one used for Major Depressive Episode (MDE). Immediate attention is recommended to avoid any worsening of the symptoms and from transitioning of PPD to postpartum psychosis. 
&nbsp;

So far, the treatment of postpartum depression is similar to that of conventional major depressive disorder. Special attention is paid to the excretion of the drug and the concentration of the drug removed from the body through breast milk.

The following antidepressants are commonly used to treat postpartum depression due to their low levels of excretion in breast milk, making it safe for use if you are a breastfeeding mother:

<ul>
</ul>

<ul>
	<li>Fluoxetine</li>
	<li>Paroxetine</li>
	<li>Sertraline</li>
	<li>Bupropion</li>
	<li>Amitriptyline</li>
	<li>Doxepin</li>
	<li>Desipramine</li>
	<li>Tranylcypromine</li>
	<li>Trimipramine</li>
	<li>Desipramine</li>
	<li>Paroxetine</li>
	<li>Escitalopram</li>
</ul>

These antidepressants come with some common side effects that include nausea, vomiting, dizziness, sexual issues, diarrhea, blurry vision, weight gain, increased perspiration, etc.<a href="#accordion">[6]</a> 
&nbsp;

Brexanolone (under the brand name of Zulresso) got approved by the FDA as the first drug targeted toward PPD. Brexanolone is approved with a Risk Evaluation and Mitigation Strategy (REMS) which means that it is currently a controlled medicine available through a restricted distribution channel to carefully assess the conditions of the patients throughout the treatment. The program is currently known as Zulresso REMS Program.<a href="#accordion">[5]</a>&nbsp;Currently, to get Brexanolone administered to you for treating your PPD, you are required to enroll in the Zulresso REMS program.&nbsp; 
&nbsp;

<ul dir="ltr">
	<li>
	<h5>Mechanism Of Action</h5>
	</li>
</ul>

Brexanolone is a synthetic form of allopregnanolone. Allopregnanolone is a neurosteroid. Neuroactive steroids are a group of substances that change a receptor&rsquo;s response to a stimulus by binding to them.<a href="#accordion">[4]</a>&nbsp;Allopregnanolone is best understood as a metabolite of progesterone, which is a GABA-A receptor agonist. This means that progesterone is responsible for increasing GABA functions.

The exact mechanism of the drug and of allopregnanolone is still unknown. Their enhancement of the functions of GABA (Gamma-aminobutyric acid) means that it will inhibit neuronal excitability by blocking messages that are sent to our nervous system with the help of certain stimuli. This not only aids in dealing with depressive triggers but also helps with anxiety.<a href="#accordion">[1]</a> 
&nbsp;

<ul dir="ltr">
	<li>
	<h5>Dosage And Administration</h5>
	</li>
</ul>

Zulresso is administered intravenously. The dosage is determined by your doctor based on your weight and other factors. The drug is administered over a period of 2.5 days or 60 hours and requires constant monitoring due to the risk of unconsciousness.<a href="#accordion">[5]</a> 
&nbsp;

<ul dir="ltr">
	<li>
	<h5 dir="ltr">Adverse Effects</h5>
	</li>
</ul>

Since the drug is relatively new, there are a limited number of side effects reported so far. They include:

<ul>
	<li>Dry mouth</li>
	<li>Dizziness</li>
	<li>Flushed skin</li>
	<li>Losing consciousness</li>
</ul>

<h5 dir="ltr">Important!</h5>

FDA has advised to stop the treatment of Zulresso if more serious side effects occur that may include the worsening of PPD and suicidal thoughts especially in women under the age of 25. 
&nbsp;

Current research suggests that brexanolone may interact with other CNS depressants like opioids and benzodiazepines and increase the severity of the adverse effects with regard to sedation. Alcohol consumption is also not advised due to similar reasons.

During the clinical trials, patients who were taking antidepressants also showed a more severe case of sedation as compared to the ones who did not or were a part of the placebo studies. 
&nbsp;

Considering the rapid onset of action with brexanolone especially when compared to the long-term treatments offered by conventional antidepressants, it is believed that brexanolone can take over the go-to therapy for PPD. However, a much more convenient way of administration would be through oral pills instead of I/V. There are still many concerns left that can only be answered through long-term data in a lesser restricted environment as opposed to a clinical trial setting.&nbsp; 
&nbsp;

<ul>
</ul>

<ul>
	<li>Current antidepressant therapies employed for PPD are based on&nbsp;long-term treatment.</li>
	<li>Brexanolone&rsquo;s onset of action is fast and has shown significant improvement in women of all ages suffering from PPD.</li>
	<li>Some women under the age of 25 were observed to experience severe side effects that even led to the worsening of their PPD.</li>
	<li>The drug is still under strict observation with the help of the REMS program.</li>
	<li>Administration coupled with the duration over which it has to be administered can make it difficult to commercialize as compared to drugs that are available in the form of oral pills.&nbsp;</li>
</ul>

[1] Allen B, Vespa PM. Antiseizure medications in critical care: An update. Curr Opin Crit Care. 2019;25(2):117-125

[2] ATP Science, 2021. HOW DOES PROGESTERONE CREATE A DOPAMINERGIC RESPONSE?. [Online] .

[3] Debra Fulghum Bruce, P., 2020. Postpartum Depression. [Online].

[4] Fala, L., 2019. Approved by the FDA Specifically for Postpartum Depression in Adults. [Online]

[5] Federal Drug Administration, 2019. FDA approves first treatment for post-partum depression. [Online]

[6] Fields, L., 2021. Which Antidepressants Treat Postpartum Depression?. [Online]

[7] Matthew Hoffman, M., 2021. Estrogen and Women's Emotions. [Online]

[8] Mayo Clinic, 2022. Postpartum depression. [Online]

Umna Salah

Getting Back To Working Out After Giving Birth

The weeks after one&rsquo;s delivery can be as stressful as they are joyous. Newborn babies need constant attention and it&rsquo;s difficult to take out time to care for oneself. When the baby is down for a nap, it&rsquo;s our chance to get some sleep too or catch up on chores. Naturally, there&rsquo;s very little time or mental space for fitness and physical activity. Plus, there&rsquo;s the physical exhaustion that comes with long nights and breastfeeding. 
However, taking care of our bodies is essential to recovering quickly from pregnancy and childbirth. Taking time out for fitness enables us to better manage the stressors that come with a newborn baby, both physically and emotionally. This, in turn, ensures that we are able to enjoy the joys of new motherhood as well.

<div>&nbsp;</div>

time to recover body

As a new mother, it&rsquo;s important to ensure that you are consuming all of the nutrients that are essential to your health and recovery. If you are breastfeeding, it is even more important that you consume a nutritious diet.&nbsp;

Try to include a good amount of protein in your diet, as well as good fats and essential fatty acids. Eating a sufficient amount of carbs will give you the energy you need to keep up with your baby. Make sure to include fruits and nutrients in your diet as they are an important source of <a href="https://merisehat.pk/article/a-guide-to-essential-vitamins-and-micronutrients-and-should-you-be-taking-them">micronutrients and fibre</a>.&nbsp;

If you have a straightforward vaginal delivery, you can start with gentle movement in the form of short walks as soon as the day you deliver; however, you will have to wait till your epidural has been taken out. If you delivered via a caesarean or faced postpartum complications, you may have to wait a few extra days to give your body time to recover.&nbsp; 
&nbsp;

<h5>Moderate Walking</h5>

Easy to moderate walking is the best way to start moving after childbirth. You can start with just 20 minutes a day and gently build up to half an hour over the course of four to six weeks. Consider breaking up your walks into several walks a day to avoid tiring yourself out and being able to fit them in more easily into your newborn&rsquo;s routine. You could start with two 10-minute walks a day, build that up to two 12-minute walks after a few days and so on. Walking burns calories, while also strengthening muscles and joints, and improving blood circulation. 
&nbsp;

<h5>Postpartum Exercises</h5>

Incorporate gentle postpartum exercises and stretches into your routine in the first few weeks after a delivery. There is a lot of information online about safe postpartum exercises. You can look some up and aim to do them for five minutes a day. YouTube videos focused on postpartum exercises can also be easy to follow along, and if you&rsquo;d like the opportunity to get out of the house, a postpartum exercise or yoga class might just be the thing for you. As with walking, start with just a few minutes a day and slowly build up as your body adjusts.

Your pelvic floor and core tend to be particularly weak after childbirth. Before you move onto high-impact exercises, it is important to build some strength in these parts of the body. You can start doing gentle pelvic exercises, like kegels and pelvic tilts in the first week after your delivery. Aim to do them for about five minutes at a time, up to three times a day. Again, there&rsquo;s no need to do long sessions and tire yourself out. Fitting in smaller movement sessions throughout the day will ensure that you are able to be consistent and don&rsquo;t end up pushing yourself too much.

About a month after childbirth, you can start exercising core exercises into your routine. Again, this also depends on what kind of delivery you&rsquo;ve had and whether you faced any complications during or after. Once again, incorporate a few minutes of core work into your daily movement sessions and break it up into two to three sessions a day.&nbsp; 
&nbsp;

<h5>As A Rule Of Thumb</h5>

You should wait at least six weeks after childbirth to get into high-impact exercises. It&rsquo;s important to prepare your body in the preceding weeks and to also take it slow when you do start with higher impact movement. Make sure to consult your doctor and get their okay beforehand. Even at this stage, start slowly and listen to your body. There&rsquo;s no need to push forward from the get go. What&rsquo;s important is that you maintain consistency and build up in a manner that is doable for you. 
&nbsp;

It&rsquo;s easy to forget to take care of ourselves in the first few months after childbirth. But we need to remember that we need as much love and care as our newborn babies do. Being kind to yourself and patient with your body is especially important after a delivery. Remember, the healthier you feel, the better you&rsquo;ll be able to enjoy the time you get with your newborn!

Ayesha Binte Rashid

What To Do After Getting A Caesarean?

You&rsquo;ve had your baby, and you&rsquo;re ready to go home. But before you can leave the hospital, there&rsquo;s some post-delivery care that you should take care of. In this article, we&rsquo;ll cover caesarean section (C-section) aftercare, including when it&rsquo;s time to take your catheter out and when you&#39;re ready for discharge from the hospital.

&nbsp;

recovery after  a c-section

After you have a C-section, this is the most critical period. You might feel tired, emotional, or anxious about your baby or yourself. Be sure to:&nbsp; 
&nbsp;

Make Time For Yourself And Rest

<ul>
	<li>Drink water</li>
	<li>Eat healthy</li>
	<li>Do light exercises only (such <a href="https://merisehat.pk/article/how-walking-helps-you-think-bette">as walking</a>) 
	&nbsp;</li>
</ul>

Take Care Of Your Wound And Stitches (If Applicable). You Need To

<ul>
	<li>Keep your wound clean and dry</li>
	<li>Wear comfortable maternity clothes that make it easy to get in and out of bed easily. Think loose fitting tops with leggings</li>
	<li>Avoid tight clothing, such as jeans or elastic waistbands, etc.</li>
	<li>Avoid heavy lifting or carrying heavy objects, etc.</li>
	<li>Speak to your doctor if you feel there is an infection developing in your wound area (this can happen on rare occasions) 
	 
	Ask for help from friends and family members when needed 
	&nbsp;</li>
</ul>

You might feel weak and sore for a while after your surgery. Don&#39;t worry, it is normal! Moving around would help you feel better and get the blood flowing through your body again. You might want to ask someone to help with the lifting and carrying of heavy objects until you&#39;ve fully recovered from your surgery. 
&nbsp;

Here are some useful tips for moving around:

<ul>
	<li>Care For Your Incision: You&rsquo;ll likely be in the hospital for 2-3 days. During that time, your healthcare team would ask you to do a few things to help ensure you&rsquo;re on the right track.</li>
	<li>Keep Your Incision Clean And Dry. If needed, use pads or bandages.&nbsp;</li>
	<li>Avoid Placing Hot Water Bottles or heating pads over your incision area because they could increase swelling and cause pain.</li>
	<li>Do Not Lift Anything That&rsquo;s Heavy during the first six weeks following your surgery. And even after that, if there&rsquo;s something you need to move, keep it light or, better yet, ask for help!</li>
	<li>Avoid Sexual Intercourse for six weeks after having a c-section (or until advised otherwise). This is to allow your uterus and vagina to heal well before you have another child vaginally.&nbsp;</li>
	<li>After The Period Of Six Months, you might resume intercourse as normal, but again, keep it light.&nbsp; 
	&nbsp;</li>
</ul>

<ul>
	<li>Stretching. It&rsquo;s a good idea to stretch your abdominal muscles and any other muscles that have been affected by the surgery.</li>
	<li>Breathing exercises. Use diaphragmatic breathing (also called belly breathing) to help relax your body and calm down after surgery.</li>
	<li>Pelvic floor exercises. They help strengthen the pelvic floor muscles and support the uterus, bladder, and bowel function after pregnancy. They also improve sexuality for both men and women, increase energy levels (and thus productivity) and reduce lower back pain or sciatica symptoms by improving posture or alignment through strengthening these core muscles</li>
	<li>Walking is a great form of exercise during recovery time because it helps strengthen leg muscles while also building endurance, which is helpful if you have had stitches put in place during surgery! 
	&nbsp;</li>
</ul>

<ul>
	<li>If you notice any unusual bleeding, such as a sudden gush of blood, or if the flow of your postpartum discharge changes in colour or consistency</li>
	<li>If you experience pain or discomfort</li>
	<li>If you have a fever (above 100&deg;F) 
	&nbsp;</li>
</ul>

Note: If you have questions about your recovery that aren&rsquo;t covered here, please ask your obstetrician or midwife.&nbsp;

If you&rsquo;re concerned about anything at all whether it&rsquo;s the way your belly feels after surgery (which, by the way, should feel like it has been run over by a truck!), whether there&rsquo;s an abnormal amount of blood coming out of your vagina, whether there are signs of infection (fever, chills), etc., go see someone right away.

It&rsquo;s better to err on the side of caution than risk an infection setting in that could lead to more problems later on down the road. And even though C-sections carry risks themselves (mainly related with anaesthesia), they&rsquo;re still safer than vaginal births when it comes down to actually giving birth itself. 
&nbsp;

Just sitting back and waiting for your body to heal would get you there. But you could be up and running and taking care of your baby with the right care in no time.&nbsp;

<ul>
	<li>Take It Easy. It might be tempting to jump right back into your normal routine, but try to cut yourself some slack. Your body needs time to heal after having been through an invasive procedure like surgery.</li>
	<li>Don&rsquo;t Be Afraid of taking pain medication, if necessary. If soreness is keeping you from getting quality rest at night, talk with your caregiver about options for relieving this discomfort. 
	&nbsp;</li>
</ul>

C-section recovery is a process. You might not feel like doing much, but it&rsquo;s important that you get up and move around as soon as possible. The more your body moves around, the sooner it will heal!

How To Prepare For Giving Birth

If you&#39;re pregnant, you may be wondering what you can do to prepare for the big day. There are plenty of things that will help make your labour easier and keep your body healthy while it grows a baby. Here&rsquo;s my advice on how to boost your chances of having an easy and healthy childbirth experience. 
&nbsp;

prepare for the big day

One of the most important things you can do to prepare for childbirth is to get as much rest as possible. That&rsquo;s not just because it will make you feel better, but also because it will help your baby grow and develop.

Rest is especially important for pregnant women, who need plenty of sleep to meet their bodies&rsquo; demands for nutrients and energy during pregnancy. A baby needs that energy too! As long as there are no complications with your pregnancy or labour, it&rsquo;s a good idea to take lots of naps throughout the day, even if you don&#39;t feel tired. It will help keep both you and your little one happy and healthy in the long run. 
&nbsp;

Wear shoes that are comfortable and supportive, such as those that are flat or have very low heels. Good arch and ankle support is important for you to be able to walk in them. Your shoes should have a good grip on the floor so that you can walk safely while they are wet or slippery (e.g., when the floor is icy). 
&nbsp;

<ul dir="ltr">
	<li>Don&rsquo;t stand for long periods of time.</li>
	<li>Don&rsquo;t sit for too long.</li>
	<li>Don&rsquo;t cross your legs.</li>
	<li>Don&rsquo;t wear high heels. 
	&nbsp;</li>
</ul>

Exercise can help you sleep better and help you cope with stress. Being physically active can help you lose weight, which has many benefits including an improved outlook and higher self-esteem (both of which will be handy during labour). It will also help you glow! 
&nbsp;

Kegel exercises are a type of exercise that strengthen the pelvic muscles. The pelvic muscles include pubococcygeus (PC) muscles and the urethral sphincter, which are responsible for contracting during orgasm (both women and men) and ejaculation in males, as well as when urinating or having bowel movements in both sexes. They also help control the flow of urine from the bladder, helping to prevent leakage from an enlarged prostate gland or urinary tract infection (UTI). Kegel exercises can help some women who have trouble with bladder control after childbirth. 
&nbsp;

Lie down on your back with knees bent so that your feet are flat on the floor and close together; keep arms at sides if comfortable or place them above head with elbows bent so they rest comfortably against ears if desired; relax all body parts except buttocks. Focus on relaxing tense areas such as shoulders and thighs. You should feel like you&rsquo;re making yourself &ldquo;soft&rdquo; all over before starting any exercise involving these areas; this will help prevent injury later on because we don&rsquo;t want anyone getting injured during childbirth either! 
&nbsp;

You should eat a variety of foods from all of the food groups. Whole grains, fruits, and vegetables are good sources of fibre. Fruits and vegetables also have vitamins and minerals that nourish your body. Good sources of protein include lean meats such as fish or poultry, beans, eggs, nuts, seeds and low-fat dairy products. Limit processed foods such as chips, crackers, cakes and cookies because they lack the nutrients you need to stay healthy during pregnancy. High-fat foods can cause weight gain during pregnancy which increases your risk for developing certain pregnancy complications, such as preeclampsia (high blood pressure) or gestational diabetes (high blood sugar). 
&nbsp;

<ul>
	<li>Eat a <a href="https://merisehat.pk/article/what-are-the-common-components-that-constitute-a-healthy-diet">healthy diet</a></li>
	<li>Drink plenty of water</li>
	<li>Sleep as much as you can</li>
	<li>Sleep in a comfortable position, ideally on your side with a pillow under your tummy and another one between your legs to help keep baby from pushing on your bowel (if you are feeding him or her)</li>
	<li>Avoid too much caffeine or alcohol, which can cause contractions and make you feel jittery. Also avoid smoking because it restricts blood flow to the uterus and placenta, which could affect oxygen supply to the baby</li>
	<li>Avoid heavy lifting, working out too hard or going for long walks until after delivery because these things aren&rsquo;t good for either of you right now!</li>
	<li>Avoid too much stress &mdash; take some time each day just for yourself so that when the big day comes (and it will come) everything will go smoothly 
	&nbsp;</li>
</ul>

&nbsp;While it&rsquo;s important to be prepared for childbirth and know the basics of what to expect, don&rsquo;t worry if you&rsquo;re not sure about all of these things. The most important thing is that you feel comfortable during and after birth. So, get as much rest as possible and make sure your doctor knows how well rested you are.

Don’t Lose Heart!

<a href="https://www.merisehat.pk/disease/coronary-artery-disease">Coronary Artery Disease (CAD)</a> is a leading cause of death globally. While there are some factors, such as family history, age and sex, that cannot be modified to prevent heart diseases, many lifestyle changes can decrease your risk of heart disease.

&nbsp;

Understanding measures for better cardiac health

The chemicals in tobacco can often cause irreversible damage to the heart and blood vessels. In addition, because of the damaged vessels, your heart will work harder to supply oxygen to the body and brain, causing an increase in blood pressure and heart rate. However, the good news is that the risk of heart disease starts to drop a day after quitting. Moreover, the risk of heart disease drops to almost half, a year after quitting cigarettes.

A healthy diet is low-fat, high in fiber, and includes plenty of fish, fresh fruits, vegetables, and whole grains. Also, limit the amount of salt you are eating in a day to no more than 6g, which is about a teaspoonful. Too much salt in your diet can cause an unhealthy spike in blood pressure.

There are 2 types of fats: saturated and unsaturated. Avoid foods with saturated fats since they increase the levels of bad cholesterol in your blood.

Below is a list of foods that are high in saturated fats:&nbsp;

<ul>
	<li>Fatty-cut meat&nbsp;</li>
	<li>Butter&nbsp;</li>
	<li>Ghee&nbsp;</li>
	<li>Cream&nbsp;</li>
	<li>Cheese&nbsp;</li>
	<li>Biscuits and cakes&nbsp;</li>
</ul>

A balanced diet should include unsaturated fats since they increase the levels of good cholesterol in your blood, and reduce any blockages in the arteries. Below is a list of foods high in unsaturated fats:&nbsp;

<ul>
	<li>Oily fish&nbsp;</li>
	<li>Avocados&nbsp;</li>
	<li>Sunflower, vegetable, and olive oils&nbsp;</li>
	<li>Nuts&nbsp;</li>
</ul>

You should also eliminate sugar from your diet and have carbohydrates in moderation, as this puts you at a higher risk of developing diabetes. Furthermore, this has proven to increase your risk of developing heart disease.&nbsp;

&nbsp;

A healthy diet with regular exercise is the best way to reduce your chances of developing high blood pressure. Regularly exercise will lower your cholesterol and make your heart and blood circulatory system more efficient. Exercise will also keep your blood pressure at healthy levels.&nbsp;Exercising regularly reduces your risk of heart attacks because, like any other muscle, the heart muscle will also benefit from exercise. A strong heart will be able to pump blood around your body without much effort. Aerobic exercises, for example, walking, dancing, and swimming will also help keep your heart healthy. However, if you’ve not been active for a while, slowly work your way up from moderate-intensity to high-intensity exercises. You can start with:&nbsp;<ul><li>Regularly walking at a brisk pace, or 150 minutes of aerobic exercises every day.&nbsp;</li><li>75 minutes of more strenuous aerobic activity, for example, running.&nbsp;</li><li>You can also sign up for strength training sessions once a week.</li></ul>

Being overweight increases the risk of developing heart disease, high blood pressure, type 2 diabetes, and high cholesterol. A body mass index (BMI) of 25 or higher is overweight. Moreover, unhealthy weight gain is also associated with higher blood pressure and high cholesterol which increases the risk of heart disease and stroke. Excess weight around the middle of the body also increases the chances of developing heart disease.&nbsp;

However, a mere reduction in your weight by 3% to 5% can be beneficial in decreasing certain fats in the blood, lowering blood glucose, lowering blood cholesterol, and reducing the risk of diabetes type 2.&nbsp;

&nbsp;

People who don’t get enough sleep are at a higher risk of developing obesity, depression, diabetes, high blood pressure, and heart disease. Thus, make sleep a priority. You need to set a sleep schedule and prioritise it by going to bed and waking up at the same time every day. Keeping your bedroom dark and quiet will also help you get a good night’s sleep.

Some people tend to manage stress with unhealthy habits, such as drinking or smoking, and overeating. The key is to look for alternative ways to manage stress. For example, meditation, relaxation exercises, and physical activities are great ways to manage stress and improve your overall health.&nbsp; 
&nbsp;

<ul>
	<li>Coronary artery disease is a leading cause of death globally, and while there are some factors such as family history, age and sex that cannot be modified to prevent heart diseases, many lifestyle changes can decrease your risk of heart disease.&nbsp;</li>
	<li>Eating a healthy diet, regular physical activity, and managing stress can have a positive impact on your overall health.&nbsp;</li>
	<li>However, if you feel unwell after any physical activity, speak with your doctor and they will run some tests to rule out underlying health conditions.&nbsp;</li>
	<li>If you have a family history of heart diseases, you can always speak with your doctor about regular checkups to help pick on any health concerns early on.&nbsp;</li>
</ul>

&nbsp;

Staff Writer

Iqra Mazhar

Impact Of OCP On Mental Health

Oral contraceptive pills (OCPs) are popular among women of reproductive age due to their ease of use and high efficacy. However, sociodemographic disparities in its use persist around the world. Those with greater awareness and education, who are unmarried and from the upper class, are more likely to use it than others. In Pakistan, this figure is close to 8% of girls and women<a href="#accordion">[4]</a>. 
&nbsp;

Understanding OCP's Influence on Mental Health

The effects of OCPs vary depending on individual factors, the specific formulation of the pill, and how it is used. 
&nbsp;

<ul>
	<li>
	<h5>Mood Swings</h5>
	</li>
</ul>

OCPs change your body&#39;s hormone levels by preventing ovulation and thickening cervical mucus. These hormonal changes may have an impact on your brain&#39;s neurotransmitters and hormonal signaling pathways, which may have an impact on your mood and cognitive function. As a result, you go through emotional changes, such as increased feelings of irritability, sadness, or anxiety.

Some studies have pointed out a possible connection between OCP and depression. This might be brought on by pill-induced bloating, decreased sex desire, and weight gain. Headaches, fatigue, and nausea may also have an impact on mental health. 
&nbsp;

These fluctuations in mood and an increase in symptoms of depression are the most common reasons girls and women discontinue OCPs. In general, adolescent girls who use OCPs are more likely to experience hypersomnia, eating problems, and increased crying than their counterparts who do not use OCPs. According to one study, it may be related to the type and amount of progestin in these pills<a href="#accordion">[1]</a>.

Many older OCPs that contain ethinyl estradiol are linked to severe mood problems. In contrast, newer OCPs with physiological forms of estrogen are usually easier to tolerate and have a weak link to mood problems<a href="#accordion">[1]</a>.

A Danish study found an increased risk of the first diagnosis of depression and the first use of an antidepressant among users of various types of OCPs. They were highest among adolescents. However, more research is needed to fully understand this relationship.

On the plus side, studies show that OCPs improve mood and mental health while alleviating premenstrual symptoms. 
&nbsp;

<ul>
	<li>
	<h5>Cognitive Function</h5>
	</li>
</ul>

The impact of OCPs on cognitive function and brain health is complicated.

Estrogen, for example, is thought to be neuroprotective in the hippocampus, hypothalamus, amygdala, and brainstem. It helps to protect the brain from cognitive decline, neurodegenerative disease, and affective disorders. 
&nbsp;

Furthermore, estrogen can influence brain regions involved in emotional processing, such as the dorsolateral prefrontal cortex.

Progesterone, on the other hand, is not thought to be neuroprotective. It can also aggravate mood symptoms.

The clinical significance of these findings is still under investigation. 
&nbsp;

Note: It should be noted that scientific research on this topic is still ongoing, and the long-term effects of OCPs on brain health are not fully understood.

Any changes in mood or brain function associated with OCP use are likely to be temporary and reversible in many cases. When you stop using OCPs, your hormone levels will return to normal, and any negative effects on brain health will fade.

Some girls, however, may have specific sensitivities or reactions to the hormones in OCPs. In rare cases, stopping the use of OCPs may not immediately reverse certain effects on mood or brain function.

Decisions about the use of OCPs should be made in consultation with a healthcare professional who can take into account individual health needs and medical history. 
&nbsp;

This includes:

<ul>
	<li>
	<h5>Pre-Existing Mental Health Conditions</h5>
	</li>
</ul>

If you already have a mental health condition, such as depression or anxiety, OCPs may exacerbate your symptoms. Furthermore, OCPs may interact with your current medications.

Inform your doctor so that he or she can tailor your treatment to your specific needs, medical history, and potential risks and benefits of OCPs. 
&nbsp;

<ul>
	<li>
	<h5>Individual Response</h5>
	</li>
</ul>

Individual reactions to OCP use can differ greatly. Some girls tolerate OCPs well and experience no adverse effects on brain health.

At the same time, some girls may be more sensitive to the hormonal changes caused by OCPs, resulting in emotional or mental health issues. Or they may be predisposed to side effects due to risk factors. 
&nbsp;

Note: Please consult a professional doctor if you have any concerns about the effects of OCPs on your brain health or mood. They can offer personalized advice, consider alternative contraceptive options, or modify the prescription to reduce side effects. 
&nbsp;

Few studies have looked into the relationship between oral contraceptives and mental health, such as mood swings and cognitive function.

According to the Harvard Study of Moods and Cycles, 16.3% of people reported a decline in their mood, while 12.3% reported an improvement. However, the vast majority of people reported no change in their mood<a href="#accordion">[2]</a>. 
&nbsp;

32-60% of women discontinue the pill within 6 months for a variety of reasons, the most common of which are mood changes<a href="#accordion">[3]</a>.

It&rsquo;s important to talk to a doctor before starting a contraceptive pill, especially if you have known potential risks, like a history of depression.

It&rsquo;s also important for healthcare providers and adult supervisors to monitor depressive symptoms in adolescents using OCPs because it may put them at risk for nonadherence if the pill affects their quality of life. 
&nbsp;

Key Takeaways

<ul>
	<li>OCPs may have significant benefits, such as providing contraceptive protection, regulating menstrual cycles, and managing certain medical conditions like PCOS.</li>
	<li>The potential effects of OCPs on brain health in girls vary depending on the individual.</li>
	<li>According to the limited research available, it&#39;s been observed that not all girls will experience these symptoms, and those who do may have different degrees of severity.</li>
	<li>Some possible symptoms include mood swings, depression, anxiety, and changes in cognitive function like memory or concentration issues.</li>
	<li>Symptoms such as headaches, nausea, fatigue, and decreased libido can also have an impact on the overall well-being and brain health of girls who use OCPs.</li>
	<li>In most cases, these symptoms are transient and disappear once the pill is discontinued.</li>
	<li>It&#39;s crucial to weigh the potential benefits of OCP use (such as contraceptive protection, regulation of menstrual cycles, and management of certain medical conditions like PCOS) against potential risks. 
	&nbsp;</li>
</ul>

[1] Mu E, Kulkarni J. Hormonal contraception and mood disorders. Australian prescriber.

[2] MGH Center for Women’s Mental Health. Do oral contraceptives cause mood swings or depression? MGH Center for Women’s Mental Health.

[3] Anouk E. de Wit Bs. Association of use of oral contraceptives with depressive symptoms among adolescents and young women. JAMA Psychiatry.

[4] Meherali S, Ali A, Khaliq A, Lassi ZS. Prevalence and determinants of contraception use in Pakistan: trend analysis from the Pakistan Demographic and Health Surveys (PDHS) dataset from 1990 to 2018. F1000Res. 2021;10:790. Published 2021 Aug 11. doi:10.12688/f1000research.55204.1

Shermeen Zuberi

This article or video has been recorded by a subject / domain specialists with a proven track record of excellence in their area. 

Baby Loading

There&rsquo;s no doubt that pregnancy tests and ultrasounds are the only credible ways to determine whether or not you&#39;re pregnant. But urine or blood tests may give false positives and ultrasounds may take 17 days post ovulation to identify a healthy pregnancy.

&nbsp;

However, excited or anxious as you are at the mere idea of being pregnant, you&rsquo;re probably looking for additional indications and symptoms, too. A missed period (menses), smell sensitivity, weariness or fatigue, and of course, the infamous nausea and morning sickness all point towards pregnancy. In a recent study, 15.6% of participants even showed <a href="merisehat.pk/disease/anxiety">anxiety </a>symptoms during early pregnancy<a href="#accordion">[1]</a>.&nbsp;

&nbsp;

As new parents, you&rsquo;ll come across a lot of hearsay about the topic. You need to stop reading too much into signs and let&rsquo;s just keep the fiction separate from the facts to begin with.&nbsp; 
&nbsp;

Understanding The Early Pregnancy

Your first week of pregnancy is determined by the date of your last menstrual cycle. It may seem strange because technically you weren&#39;t even pregnant at that point of time.

&nbsp;

The date of your last menstruation would also determine the estimated delivery date. For this reason, the first few weeks of your 40-week pregnancy might be symptom-free. 
&nbsp;

If you are expecting, you may experience the following signs and symptoms in the first few weeks:

<ul>
	<li>Minimal cramps and spotting</li>
	<li>Missed period</li>
	<li>Fatigue and weariness&nbsp;</li>
	<li>Nausea</li>
	<li>Painful breasts&nbsp;</li>
	<li>Bloating</li>
	<li>Frequent urination</li>
	<li>Traveling sickness</li>
	<li>Fluctuations in the mood&nbsp;</li>
	<li>Fluctuations in body temperature&nbsp; 
	&nbsp;</li>
</ul>

Other indicators may include:

<ul>
	<li>Elevated blood pressure</li>
	<li>Severe exhaustion and heartburn&nbsp;</li>
	<li>Increased heartbeat</li>
	<li>Changes in the breast and nipple</li>
	<li>Bouts of acne</li>
	<li>Noticeable increase in weight</li>
	<li>Pregnancy glow 
	&nbsp;</li>
</ul>

<h5>Implantation Bleeding&nbsp;</h5>

During the first 4 weeks, everything happens on a cellular level. The fertilized egg produces a blastocyst (a fluid-filled collection of cells) that will develop into the organs and body parts of the fetus.

&nbsp;

The blastocyst stays in the endometrium (the uterine lining) for about 10-14 days (week 4) following fertilization. This may result in implantation bleeding, which could be misinterpreted as a light period. This does not happen to everyone. If you experience it, you&rsquo;ll note that it coincides with the time you expect your period to start. 
&nbsp;

Here are a few indicators of implantation bleeding:

<ul>
	<li>Color</li>
</ul>

Each occurrence may be pink or light brown.

&nbsp;

<ul>
	<li>Bleeding</li>
</ul>

Implantation bleeding is typically a few drops of blood. It&#39;s frequently described as very light bleeding that never becomes a flow or requires the use of a pad or tampon.

&nbsp;

<ul>
	<li>Pain and other symptoms </li>
</ul>

The pain is usually milder than with regular menstrual cramps. It may be accompanied by nausea and frequent urination.

&nbsp;

<ul>
	<li>Duration</li>
</ul>

Implantation bleeding usually lasts less than 3 days and does not necessitate treatment. Occasionally, it will last only a few hours.

&nbsp;

NOTE: Although implantation bleeding is not usually a cause for concern, you should talk with a doctor if you experience symptoms such as: persistent bleeding, vaginal blood clots or bleeding that saturates a pad every 30 minutes.&nbsp; 
&nbsp;

<h5>Missed Period&nbsp;</h5>

Your placenta begins synthesizing human chorionic gonadotropin (hCG) shortly after implantation. This hormone assists the body in maintaining pregnancy. It also instructs the ovaries to stop releasing mature eggs (ovum) once a month.

&nbsp;

You are likely to miss your periods starting from 4 weeks post fertilization. If you usually have an irregular period, you should get a pregnancy test to confirm. The majority of home tests are capable of detecting hCG levels in your urine as soon as 8 days following a missed period. 
&nbsp;

<h5>Raised Body Temperature&nbsp;</h5>

An elevated body temperature might also be an indicator. It is also possible that exercise and hot weather can also cause your core temperature to rise more easily. Take precaution and drink plenty of liquids to keep yourself hydrated and maintain your body temperature. 
&nbsp;

<h5>Fatigue&nbsp;</h5>

Throughout pregnancy, you may experience fatigue and weariness at any stage, but it&rsquo;s a typical sign of early pregnancy. This is because your progesterone levels rise, which makes you feel drowsy.&nbsp; 
&nbsp;

<h5>Increased Heart Rate&nbsp;</h5>

During weeks 8-10, your heart will beat harder and more frequently. Palpitations and arrhythmias are common during pregnancy due to hormones. According to a 2016 study review, blood flow increases by 30-50% during pregnancy. This puts more strain on your heart<a href="#accordion">[2]</a>.

&nbsp;

If it was a planned pregnancy, you may have discussed any underlying cardiac problems with your medical team prior to it, right? If not, now is the time to talk about any conditions or treatment that may be required. 
&nbsp;

<h5>Early Changes To Breasts: Tenderness and&nbsp; Swelling&nbsp;</h5>

Breast modifications are possible between weeks 4 and 6. Hormone fluctuations are likely to cause sensitive and sore breasts, which will likely subside within a few weeks as your body adjusts to the hormones.

&nbsp;

Changes in the nipple and breast are also possible around week 11. Hormones continue to cause breast growth. The areola may darken and get bigger. 
&nbsp;

<h5>Changes in Mood&nbsp;</h5>

During pregnancy, your estrogen and progesterone levels are elevated. This increase may affect your mood, making you more emotional or reactive than usual. Mood swings are frequent during pregnancy and you&rsquo;ll often feel sadness or despair, irritation, anxiety, and euphoria.&nbsp; 
&nbsp;

<h5>Frequent Urination &amp; Incontinence&nbsp;</h5>

The amount of blood in the body increases during pregnancy. As a result, your kidneys process more fluid than usual, resulting in extra fluid in your bladder.

&nbsp;

Besides, hormones influence bladder health as well. You may find yourself racing to the restroom more often or accidentally leaking during pregnancy. 
&nbsp;

<h5>Bloating &amp; Constipation&nbsp;</h5>

Comparable to the signs of a menstrual period, bloating is a possibility during early pregnancy. This could be related to hormonal changes, which can also cause your digestive system to slow down. As a result, you may feel constipated and obstructed. Constipation can also promote abdominal bloating. 
&nbsp;

<h5>Morning Sickness, Nausea, &amp; Maybe Vomiting&nbsp;</h5>

Nausea and morning sickness commonly appear between weeks 4 and 6, peaking around week 9. Although it is referred to as morning sickness, it may occur at any time of day or night. The exact cause of nausea and morning sickness is uncertain; however, it is believed that hormones may play a role.

&nbsp;

Many women have mild to severe morning sickness throughout the first trimester of pregnancy. So, you should be mentally prepared for it to get more acute near the end of the first trimester. But, don&rsquo;t worry; it usually subsides as you reach the second trimester. 
&nbsp;

<h5>Smell Sensitivity &amp; Food Intolerance&nbsp;</h5>

Smell sensitivity is a common early pregnancy symptom that is primarily self-reported and has minimal scientific support. However, it may be notable because smell sensitivity triggers nausea and vomiting. It may also induce a severe intolerance to particular meals. According to 2017 research, women have an enhanced or diminished sense of smell during pregnancy<a href="#accordion">[3]</a>.&nbsp;

&nbsp;

Smell sensitivity is very common during the first and third trimesters. Only rarely will you feel as if your sense of smell has diminished; otherwise, it will be sharper and more pronounced throughout the pregnancy. You may find some scents less appealing even though they had never bothered you in the past.

&nbsp;

The good news is that the sense of smell returns to normal within 6-12 weeks after delivery. 
&nbsp;

Weight gain is a normal phenomenon near the end of the first trimester. You may gain between 1 and 4 pounds in the first several months. Calorie guidelines for early pregnancy remain similar to your regular diet, but will increase as the pregnancy advances. 
&nbsp;

<ul>
	<li>Pregnancy weight is frequently visible in the following areas in the latter stages:</li>
	<li>Breasts (approximately 1-3 pounds)&nbsp;</li>
	<li>Uterus (approximately 2 pounds)&nbsp;&nbsp;</li>
	<li>Placenta (approximately 1.5 pounds)</li>
	<li>The amniotic fluid (approximately 2 pounds)</li>
	<li>Increased blood and fluid volume (approximately 5-7 pounds)</li>
	<li>Fat (approximately 6- 8 pounds) 
	&nbsp;</li>
</ul>

<h5>Heartburn&nbsp;</h5>

Hormones can relax the valve that connects your stomach and esophagus. This permits stomach acid to escape, resulting in heartburn. 
&nbsp;

<h5>Pregnancy Skin: Glow OR Acne&nbsp;</h5>

Some individuals may begin to say that you have the &quot;pregnancy glow.&quot; It&rsquo;s the combination of an increased volume of blood and elevated hormone. Your skin appears flushed and glossy due to the increased activity of your body&#39;s oil glands. Be prepared; there&rsquo;s also the possibility of acne.

&nbsp;

<h5>Backache</h5>

More than one-third of pregnant women experience back pain. This is frequently related to ligament relaxation and a shift in posture caused by the growing pregnancy.&nbsp;

&nbsp;

Wearing flat-heeled shoes, utilizing seats with good back support, avoiding carrying heavy objects, and practicing light exercise can all help prevent back pain during pregnancy. Similarly, exercising in water, physiotherapy, and acupuncture can all help reduce back pain during pregnancy. 
&nbsp;

Pregnancy tests detect a specific level of human chorionic gonadotropin (hCG) in your urine. You can take a pregnancy test to check whether or not you are pregnant as soon as you miss your period. You get the most reliable results if you take it at least 1 week after you&#39;ve missed your period.&nbsp;

&nbsp;

While some tests claim to provide accurate results prior to a missed period, taking a test too soon can result in a false negative (the test says you&#39;re not pregnant, but you are).

&nbsp;

Additionally, your healthcare professional can take a blood sample to screen for pregnancy as early as 1 week before a missing period. 
&nbsp;

<h5>Tips</h5>

<ul>
	<li>
	If you obtain a negative result on a home pregnancy test, then it&rsquo;s recommended that you take another one 7 days later to double-check.
	</li>
	<li>Home pregnancy tests are 97% more accurate when used correctly at the right time, according to the National Institute of Child Health and Human Development in 2017<a href="#reference">4</a>. Home pregnancy tests vary in accuracy. Choose one that is known to be accurate.</li>
	<li>A blood test can typically detect pregnancy much earlier, but it must be performed in a medical professional&#39;s office or clinical setting.</li>
</ul>

&nbsp;

During early pregnancy, your body will undergo major changes. You may notice symptoms like nausea, breast discomfort, and of course, the missed period. If you suspect you&#39;re pregnant, a home pregnancy test is a good first step to take. These tests are typically available without a prescription at pharmacies and other shops.&nbsp;

&nbsp;

If you get a positive result, make an appointment with a doctor. They will examine you and run more tests to confirm your pregnancy. You can then begin a prenatal regimen to protect your and your fetus&#39; health. 
&nbsp;

<ul>
	<li>During early pregnancy, your body will undergo major changes.</li>
	<li>Missed periods, nausea, throwing up, breast modifications, exhaustion, fatigue, and frequent urination are all symptoms of a pregnancy.</li>
	<li>If you suspect you&#39;re pregnant, a home pregnancy test is a good first step to take.</li>
	<li>If you get a positive result, make an appointment with a doctor.</li>
	<li>Once your pregnancy is confirmed , your healthcare professional will guide you on the appropriate prenatal regimen.&nbsp;</li>
</ul>

[1] Rubertsson C, Hellström J, Cross M, Sydsjö G. Anxiety in early pregnancy: prevalence and contributing factors. Arch Womens Ment Health. 2014;17(3):221–8.

[2] Soma-Pillay P, Nelson-Piercy C, Tolppanen H, Mebazaa A. Physiological changes in pregnancy: review articles. Cardiovasc J Afr. 2016;27(2):89–94.

[3] Dikici O, Muluk NB, \cSahin E, Altintoprak N. Effects of pregnancy on olfaction. ENT Updat. 2017;7(2):104–7.

[4] PAGE JP. How Do I Know If I’m Pregnant. JAMA. 2001;286(14).

Neelam Asad

Are You Really Eating For Two When You’re Pregnant?

You&rsquo;re pregnant! Congratulations! And now, naturally, there must be a lot of questions in your mind about what&#39;s going to happen to your body and how it&rsquo;s going to change.&nbsp;

It&rsquo;s an experience unique to each woman. But the statement should not make you throw caution to the wind. From what the doctors say to what&rsquo;s been tried and tested by pregnant women around the world, there&rsquo;s some good, genuine advice to help you. Especially, the general precautions related to your diet <a href="https://merisehat.pk/article/lets-talk-about-sex-during-pregnancy">during pregnancy</a> that you should adhere to religiously.&nbsp;&nbsp;

So, let&rsquo;s dig in! 
&nbsp;

Diet during Pregnency

You probably know how it feels when you&rsquo;re &ldquo;eating for two&rdquo;, instead of one.&nbsp;

To begin with, during your pregnancy, you only need about 300 extra calories per day.

There is a good chance that you have been told that you need to eat for two. Because of this advice, some expectant mothers worry about whether they have to eat twice as much as they normally would.

The truth is that while your body does require 300 extra calories per day during pregnancy, the equivalent of a slice of bread or a small apple, you should still be eating balanced meals like fruits, vegetables and whole grains along with lean protein sources like chicken or fish.&nbsp;

Staying hydrated is also important. A majority of doctors recommend drinking at least eight glasses (64 ounces) of water per day. 
&nbsp;

This is your time to eat for one.

This can be a challenging concept to grasp if you&rsquo;re used to going all out when it comes to food. Especially, if you&rsquo;re pregnant with your second or third child. It&rsquo;s important to remember that while your body is making a lot of changes during this time, it is still adapting to its new role and not yet fully prepared for what&rsquo;s ahead.

The best thing you can do right now is follow these guidelines:

<ul>
	<li>Eat healthy food. Choose fresh fruits and vegetables over processed ones whenever possible.&nbsp;</li>
	<li>If they are not organic, wash them thoroughly with soap and water before eating them raw (or cook them). Some foods are more likely than others to contain harmful bacteria like listeria. These include unpasteurised milk products (raw milk), undercooked chicken and meat products as well as raw shellfish such as oysters and mussels.</li>
	<li>Eat a variety of foods from each food group every day. Healthy eating during pregnancy is about getting the right amount of nutrients in the right balance for you and your baby</li>
	<li>Eat plenty of fruits and vegetables (at least five servings per day)</li>
	<li>Choose whole grains like brown rice, oats and whole wheat bread, instead of refined grains such as white rice and white bread. Whole grains provide fibre which supports colon health and regular bowel movements so say bye-bye to constipation. Some examples include barley, quinoa, bulgur (cracked wheat), oats, and popcorn without butter added.</li>
	<li>If you have any concerns about consuming gluten during pregnancy, contact your healthcare provider first before making changes to the food choices that you normally make at home. They may be able to recommend alternatives that in their opinion would work better with your unique situation.</li>
	<li>Eat lean meat, poultry fish eggs at least two times per week. This means trimming excess fat from meats before cooking them as well as choosing low-fat options like ground turkey breast instead of ground beef. 
	&nbsp;</li>
</ul>

If you&rsquo;re pregnant, you probably know that there&rsquo;s a difference between your first and third trimester cravings. Most women experience nausea in the first trimester (which is why it&rsquo;s called morning sickness), but by the second or third trimesters many cravings come along. These are often specific foods that provide nutrients like iron and protein.&nbsp;

By this point in the pregnancy, some women may have an aversion to certain foods they once loved, especially if they&rsquo;re in their second or third trimester. But others continue to eat pretty much anything they want throughout their pregnancies.

The first trimester is also when doctors generally recommend eating for one. Many women get morning sickness early on during this time and aren&rsquo;t able to keep much food down at all! 
&nbsp;

It&rsquo;s important not to deprive yourself of nutrition during this time because not eating enough could lead to low blood sugar levels that affect your baby as well as risk complications like preterm labour later on in pregnancy

In fact, the physical stress on your body during pregnancy could be as great as or greater than that experienced during any other time in your life. This is because you are making more blood than normal.

Your blood volume increases by 60-80 percent. This means that you need to make more oxygen-carrying red blood cells and platelets (cells in the blood that help with clotting) during pregnancy. Your heart has to work harder to pump this extra volume around your body and through the placenta, which carries oxygen and nutrients from mother to fetus through their bloodstreams an amazing feat of engineering! That&rsquo;s why it&rsquo;s called &ldquo;double trouble&rdquo;. 
&nbsp;

We&rsquo;re not saying that supplements are a panacea, but they could be an important part of a well-rounded pregnancy diet.&nbsp;

<ul>
	<li>Be sure to talk to your doctor about supplements before taking any.</li>
	<li>Supplements are most effective and safest when they&rsquo;re taken in conjunction with a healthy diet and lifestyle.&nbsp;</li>
</ul>

If you follow these guidelines, you&rsquo;ll be on your way toward having the healthiest baby possible.

&nbsp;

Fast food is not healthy, and it&rsquo;s certainly not good for your developing baby. You&rsquo;ll be consuming something that&rsquo;s high in calories and low in nutrition. It tends to be fried, over-processed, or processed with artificial ingredients.&nbsp;

A diet rich in fast food leads to weight gain and increases your risk of heart disease, diabetes, stroke and certain cancers.

To be fair, though, the occasional burger or burrito wouldn&rsquo;t harm you or your baby. However, that won&rsquo;t be the case if all you eat most days is a burger or burrito. So, if you think about it, an eating a salad occasionally, like once a week, won&#39;t hurt either! 
&nbsp;

Eating well is the key to good health and a long life. If you&rsquo;re eating for two, remember that it doesn&rsquo;t mean eating twice as much food. In fact, it means eating only about 300 extra calories each day.&nbsp;

Dialogues concerning sexuality, reproductive health, contraception, and sexually transmitted illnesses (STIs) are limited worldwide. One of the biggest reasons for these decreased dialogues is the fear of spreading indecency among the younger population. Unfortunately, the failure to discuss these topics has had a great impact on public health and led to an increase in the prevalence of abortions and STIs, such as HIV, in the country. The current abortion rate in Pakistan stands at 50 per 1,000 women aged 15-49 years; one of the highest in the world<a href="#accordion">[1]</a>.

The lack of education on such topics also means that both men and women are generally unaware of reproductive health issues. Moreover, the lack of knowledge and awareness of contraception increases the risk of teenage pregnancies, unplanned pregnancies, and unsafe abortions. Thus, resulting in poor health outcomes for both mother and child.&nbsp;

As per estimates, only 35% of married women of reproductive age in Pakistan, use some form of contraception<a href="#accordion">[1]</a>. Condoms are the most common method of contraception, followed by pills and withdrawal methods<a href="#accordion">[2]</a>. Although the use of oral contraceptive pills has increased over the years, there is still poor knowledge of the drug&#39;s effects. This lack of awareness can lead to the misuse of these medications, leading to adverse effects in at-risk individuals for e.g. women with existing cardiovascular disease (CVD) are often at a higher risk of these side effects.&nbsp;

Across Europe and the world, CVD accounts for a majority of deaths in women, while contrastingly in Pakistan, men and women are at an equal risk of coronary artery disease<a href="#accordion">[3]</a>. Due to the high prevalence, it is important that women are aware of the risks associated with using oral contraceptives with pre-existing heart conditions.&nbsp;

&nbsp;

Oral contraceptive pills (OCPs) are often the most popular option among users. They range in effectiveness from 89-99%. They are of two types: combined estrogen-progesterone and the progesterone-only pill. While both are a form of birth control, they can also be used for treating medical conditions such as endometriosis, <a href="https://www.merisehat.pk/disease/polycystic-ovary-syndrome-pcos">polycystic ovary syndrome (PCOS)</a>, and other menstrual disorders.

&nbsp;

1. Combined Oral Contraceptive (COC) - These contain a combination of the hormones, estrogen and progesterone that help prevent ovulation; thus, preventing pregnancy. The pills may contain the same dose of the hormones (monophasic), or varying weekly doses of both or either component (multiphasic). A single packet typically contains 21 pills that are taken over a 28-day period and 7 placebo pills for menstruating days. Although they have a generally safe profile, nausea, vomiting, weight gain, fluid retention, and bloating are common side effects of drug use. However, in some cases, they can also cause other severe side effects, such as:

<ul>
	<li>Increased risk of blood clots</li>
	<li>Hypertension</li>
	<li>Increased risk of stroke and myocardial infarction</li>
</ul>

These drugs are usually contraindicated in smokers and those older than 35 years of age.

&nbsp;

2. Progestin-Only Pill (POP) - Unlike COCs, these only contain a synthetic progestin. The lack of estrogen reduces the risk of adverse side effects such as thromboembolism, stroke, or cardiovascular diseases. However, it can cause breast tenderness, heavy bleeding, mood swings, anxiety, and weight gain among users. POPs are typically prescribed to women who cannot have COCs or estrogen-containing compounds.

3. Emergency Contraception Pill (ECP) - Also called the morning-after pill, it may contain higher doses of the hormone estrogen, progestin, or both. They help delay ovulation or fertilization and are commonly used following unprotected sexual intercourse or a condom breakage. However, they are not meant for regular birth control.

Understanding The Correct OCP For Heart Patients

Doctors usually prescribe contraceptive methods based on a patient&#39;s health and preference. As per current guidelines, doctors must weigh the risks and benefits for each patient prior to selection of contraception.&nbsp;

Women with cardiac disease are not only at a higher risk of maternal death during pregnancy, but also complications such as stillbirth, preterm delivery, or intrauterine growth restriction. Due to the high incidence of unplanned pregnancies, it is important that these women are counselled on effective and safe contraceptive options. Moreover, they are more likely to develop adverse effects to oral contraceptives. Therefore, caution is practiced when prescribing them pills or other contraceptive options.&nbsp;

OCP use among smokers older than 35 years of age is associated with a significantly higher risk of cardiovascular side effects such as deep vein thrombosis. As per estimates, such women have a ten-fold increased risk of myocardial infarction<a href="#accordion">[4]</a>. Therefore, women older than 35 are typically assessed for risk factors such as CVD, hypertension, diabetes, and kidney disease prior to use.&nbsp;

Compared to non-users, combined oral contraceptive users have a much higher risk of myocardial infarction and stroke. Moreover, women with pre-existing hypertension have a 9-16% chance of exacerbation when using OCPs<a href="#accordion">[4]</a>.

&nbsp;

Ideally, contraception is meant to be safe, effective, and protect against sexually transmitted infections. However, no one method can guarantee all three.&nbsp;

&nbsp;

<ul>
	<li>Barrier Methods - These methods are all safe for cardiac patients; however, they have a high failure rate. Therefore, should not be prescribed in cardiac patients to avoid pregnancies.&nbsp;</li>
	<li>Combined Oral Contraceptive Pill - Due to the estrogen component, COCs are associated with multiple risks to women with cardiovascular disease. Therefore, women with CVD risk factors and existing heart disease are not prescribed COCs.</li>
	<li>Progestin-Only Pill - In women with an increased risk of thromboembolism, POPs are usually the preferred option. They are generally considered safe for all CVD patients. However, they can interfere with warfarin metabolism and decrease its therapeutic role. Therefore, careful monitoring of INR is required in such patients.&nbsp;</li>
	<li>Depo-Provera Injection - These injectable contraceptives last 12 weeks and are very effective. However, discontinuation causes a rapid return to fertility. Moreover, it can put patients at risk of ischemic heart disease.</li>
	<li>Mirena Intra-uterine Device (IUD) - Although extremely effective, its insertion can induce a vasovagal reaction in 5% of patients, and lead to a cardiovascular collapse<a href="#accordion">[5]</a>. It is contraindicated in women with pulmonary vascular disease and those at high risk of endocarditis.&nbsp;</li>
	<li>Hormonal Implants - Subcutaneous progestogen implants are highly effective and work as a form of sterilization. Moreover, they have no cardiac contraindications.</li>
</ul>

&nbsp;

According to the Pakistan Demographic and Health Survey (PDHS), the current contraceptive prevalence rate (CPR) is only 34%<a href="#accordion">[6]</a>. There are several barriers to contraceptive use among Pakistani women of reproductive age. These range from religious factors, and lack of access to low socioeconomic status. Although oral contraceptive pills are commonly used as a form of birth control, there are a lot of misconceptions regarding infertility and weight gain that further limits their use.&nbsp;

The lack of dialogue around sexual and reproductive health has left a huge majority of Pakistani women unaware of their health condition and the best health options for their bodies. Moreover, in Pakistan, there is a high prevalence of cardiovascular diseases among women. This puts them at an even higher risk of pregnancy complications; thus, emphasizing the need for better contraceptive methods for these individuals.&nbsp;

Currently, progestin-only pills and hormonal implants are considered the most effective and safe contraceptive options for women with CVD. However, newer formulations of oral contraceptive pills with lower overall risk are being developed. These are expected to help lower blood pressure in users and prevent weight gain.&nbsp;

For now, the best method is to weigh all benefits and risks associated with a particular method before use. Moreover, women should be counseled on the various options available to them and the adverse effects associated with these options.&nbsp;

&nbsp;

<ul>
</ul>

<ul>
	<li>In Pakistan, only 35% of married women of reproductive age practice some form of contraception.</li>
	<li>The stigma surrounding sexual health has placed several barriers for women to access safe contraception methods in the country.</li>
	<li>The lack of awareness of various contraceptive methods has led to an increase in abortions and sexually transmitted infections among the younger population.</li>
	<li>Due to their overall safety profile, easy availability, and high effectiveness oral contraceptive pills are mostly prescribed to women. The two common oral contraceptives include the progestin-only pill and the combined oral pill.</li>
	<li>Despite the overall safety profile, OCPs can increase the risk of several side effects, especially among women with a cardiovascular disorder.</li>
	<li>Women with existing cardiac disease are at a higher risk of maternal death during pregnancy, and complications such as preterm birth, growth restriction, and stillbirth. Therefore, there is a greater need for safe and effective contraceptive methods for these high-risk individuals.&nbsp;</li>
	<li>COCs increase the risk of stroke, thromboembolism, and myocardial infarctions. Therefore, they are contraindicated in smokers above 35 years of age and women with CVD risk factors or existing cardiac disease.</li>
	<li>POPs and hormonal implants are generally considered safe and effective in cardiac patients.</li>
	<li>Newer contraceptive pills are being developed that are expected to have a lower overall risk for cardiac patients.</li>
</ul>

&nbsp;

[1] Siddiqui, M. et al., 2020. Prevalence and Predictors of Contraception Usage in Karachi, Pakistan. Cureus, 12(10).

[2] Mushtaq, K., Ashraf, M. & Thaver, I. H., 2020. Who are the women wishing to opt for contraception?. Journal of the Pakistan Medical Association, 70(12).

[3] Jafar, T. H., Jafary, F. H., Jessani, S. & Chaturvedi, N., 2005. Heart disease epidemic in Pakistan: women and men at equal risk. American Heart Journal.

[4] Cooper, D. B., Patel, P. & Mahdy, H., 2022. Oral Contraceptive Pills. s.l.:StatPearls Publishing.

[5] Kaminski, P., Szpotanska-Sikorska, M. & Wielgos, M., 2013. Cardiovascular risk and the use of oral contraceptives. Neuro Endicrinology Letters.

[6] Hudsmith, L. & Thorne, S., 2007. Contraception in women with cardiac disease. Women's Health, 3(6), pp. 711-717.

[7] Meherali, S., Ali, A., Khaliq, A. & Lassi, Z. S., 2021. Prevalence and determinants of contraception use in Pakistan: trend analysis from the Pakistan Demographic and Health Surveys (PDHS) dataset from 1990 to 2018. F1000 Research, Volume 10.