Conservative Management of Eclampsia and Severe Pre-eclampsia -- A
Bangladesh Experience

Mosammat Rashida Begum, MBBS, FCPS, MS; Sayeba Akhter, MBBS, FCPS; Anowara
Begum, MBBS, FCPS; Mahmuda Khatun, MBBS, FCPS; Ehsan Quadir, MBBS, DCH;
Saleha Begum Choudhury, MBBS, FCPS
[Medscape Women's Health 7(1), 2002. © 2002 Medscape, Inc.]

Abstract and Introduction


Abstract

Objective: To observe whether the pregnancy can be safely continued for a
reasonable period to gain fetal maturity in cases of eclampsia and severe
pre-eclampsia.
Methods: Fifty-one patients were followed up in a specialized care
(eclampsia) unit in Dhaka Medical College and Hospital between January 1998
and October 2000. Twenty-one patients with complaints of headache and
blurred vision, and 30 patients with history of convulsion, all at
gestational age < 36 weeks, were enrolled for this study. Magnesium sulfate
was used to prevent convulsion in severe pre-eclampsia and to control
convulsion in eclampsia. After conducting a baseline assessment, pregnancy
was continued to gain fetal maturity. Patients were monitored closely.
Diastolic blood pressure, 24-hour urinary total protein (UTP), and serum
uric acid were chosen as the main parameters to detect the deterioration of
a patient's condition. Pregnancy was terminated when deterioration occurred,
as determined clinically or by 1 or more of the above parameters.
Dexamethasone was used during the waiting period for fetal lung maturity.
Patient outcomes were analyzed.
Results: At admission, the patients' mean gestational age (± SD) was 30.65 ±
2.38 weeks, and the range was 24-34 weeks. Mean diastolic blood pressure was
109.06 ± 11.61 mm Hg, 24-hour UTP was 2.25 ± 1.73 g/24 h , and serum uric
acid level was 5.5 ± 1.12 mg/dL. Pregnancy was continued for a mean of 13.27
± 8.26 days (range, 3-35 days). Thirty-two babies (62.75%) with birth weight
1.0-2.5 kg (2.02 ± 0.45) were born alive. Six of them (18.75%) weighing
between 1.0 and 1.5 kg at birth were referred to the intensive care unit,
and 1 (3.13%) weighing 1 kg at birth died within 5 minutes after birth.
Among live-born babies, 93.75% were in good condition at the time of
discharge from the hospital. Intrauterine death occurred in 19
(37.25%).cases. Twelve of them delivered spontaneously within 7 days of
death and 7 required induction. In all cases, maternal condition was
satisfactory.
Conclusion: In carefully selected cases and with close supervision,
pregnancy may be continued in women with eclampsia and severe pre-eclampsia
to increase fetal maturity without increasing the risk to the mother.

Introduction

Eclampsia and severe pre-eclampsia that develop long before term are
associated with increased rates of perinatal mortality and morbidity.
The progression from severe pre-eclampsia to eclampsia is a continuous
process; patients with severe pre-eclampsia who remain untreated may develop
eclampsia. Occurrence of a seizure that is not attributable to other causes
in a pre-eclamptic patient is known as eclampsia. It is conventionally
considered to be the end stage of the disorder, but this is an
oversimplification. Some patients have only systemic disturbances and the
problem can be controlled easily with rapid recovery after delivery. Other
patients may become desperately ill with progressive renal failure,
disseminated intravascular coagulation (DIC), microangiopathic hemolysis,
and liver dysfunction. Thus, convulsions are a marker for severe illness but
not always a reliable one. Some patients with pre-eclampsia are more
dangerously ill than others with eclampsia.[1] If convulsion can be
controlled and all other parameters remain indicative of a state of severe
pre-eclampsia, women with eclampsia can be treated as if they had severe
pre-eclampsia.
The clinical course of these conditions may lead to progressive
deterioration of both mother and fetus . Because the only cure for these
conditions is delivery, there is universal agreement that patients should be
delivered if severe pre-eclampsia develops after 34 weeks of gestation or if
development of convulsion occurs anytime during the gestational period.[2,3]
Aggressive management with immediate delivery leads to high neonatal
mortality and morbidity resulting from prematurity. Thus, prolonged
hospitalization in a neonatal intensive care unit (ICU) is necessary for the
majority of surviving newborn infants.[4-7] Moreover, a significant
proportion of surviving infants have long-term disability.[8] Conversely,
attempts to prolong pregnancy with expectant management may result in fetal
death or asphyxial damage in utero as well as increased maternal
morbidity.[5,7,9]
It is recognized that termination of pregnancy is the only definitive cure
of the pathophysiologic events of pre-eclampsia and eclampsia. So, an
arbitrary time period for delivery of all patients with these complications
has not been thought to be in the best interest of either the mother or the
fetus. But there is considerable disagreement about management of patients
with severe pre-eclampsia before 34 weeks' gestation. Some institutions
consider delivery to be the definitive therapy for all cases, regardless of
gestational age, whereas others recommend prolonging pregnancy in all
severely premature pre-eclamptic gestations until 1 of the following occurs:
development of fetal lung maturity, development of fetal or maternal
distress, or achievement of gestational age of 34 to 36 weeks.[4,9-11]
Eclampsia is a grave condition, and as there is a constant threat of
eclampsia in cases of severe pre-eclampsia, maternal well-being should
always receive priority. However, if convulsive fits can be controlled and
the features promptly stabilized with treatment before fetal maturity has
been attained , continuation of the pregnancy for a few weeks may be
considered.[12] Continuation of pregnancy for a few more weeks with the hope
of delivering a more mature baby should be weighed against the potential
risk conferred by such a procedure. Not only may the underlying disease
process flare up at any moment, but there is a considerable risk that the
baby will die in utero or become undernourished and that spontaneous
premature labor will occur. Thus, only in selected cases is one justified to
continue the pregnancy; this requires keeping the patient in the hospital
with close monitoring of maternal and fetal condition and strictly following
the management protocol recommended for severe pre-eclampsia.[13]
We observed, after controlling convulsion, that some patients were unwilling
to immediately terminate their pregnancy; this resulted in a 3- to 4-day
delay in termination. Although the perinatal death rate was very high,
patients were discharged in good condition. On the basis of this experience,
we sought to determine whether pregnancy can be continued in cases of
eclampsia and severe pre-eclampsia in order to improve neonatal outcome --
without causing any harm to the mother.

Materials and Methods

This descriptive study was conducted at Dhaka Medical College and Hospital
between January 1998 and October 2000 and included 21 patients with severe
pre-eclampsia (with premonitory signs and symptoms of eclampsia, ie,
headache, blurred vision, and restlessness) and 30 patients with eclampsia,
all of whom were at < 36 weeks' gestation. We selected a 36-week cutoff
point for gestational age because of the high neonatal morbidity and
mortality among babies born before this cutoff point in our country. Poor
neonatal care facilities are the primary reason for this. At our
institution, 9352 babies were born in 1999. Of these, 4478 were high-risk
pregnancies (unpublished Dhaka Medical College Hospital statistics). The
neonatal care unit has only 8 beds with 1 incubator and 2 phototherapy
machines. The unit does not admit a baby if a bed is not available. Outside
the hospital, there are a few private well-equipped institutions with ICUs.
But the cost for care in these units is about 4000Taka (BSD), or about $70
USD, per day; this cost exceeds most patients' monthly income!
All patients had a live fetus at the time of inclusion and all had
documented evidence of the disease -- ie, proteinuria, edema. high blood
pressure, convulsion -- before management started. Patients with maternal
and fetal indications necessitating immediate delivery on admission were not
included. Exclusion criteria were as follows: Glasgow Coma Scale < 15, heart
failure, severe oliguria, anuria, pulmonary edema, renal failure, HELLP
(hemolysis, elevated liver enzymes, and low platelet count) syndrome, DIC,
hepatic failure, recurrent convulsion after magnesium sulfate, gross
intrauterine growth retardation, fetal distress (nonreassuring fetal
status), and patient unwillingness to stay in the hospital.
All patients were admitted into the Eclampsia Unit of the Obstetrics and
Gynecology Department. They came from in and around Dhaka; some of them were
referred from other hospitals and health centers, and some came directly to
this institution. Those who were referred from other hospitals or health
centers had received at least 1 injection of diazepam. Initial management at
this institution included the following: intravenous injection of magnesium
sulfate, 4 g, administered slowly; magnesium sulfate, 3 g intramuscularly
(IM), in each buttock as a loading dose, followed by 2.5 g IM in each
alternate buttock every 4 hours for 24 hours; bed rest; oral phenobarbitone,
and an antihypertensive (eg, methyldopa, hydralazine, nifedipine) as
required. Oral methyldopa, with or without nifedipine, was administered to
maintain diastolic blood pressure at a level between 90 and 100 mm Hg. If
diastolic blood pressure increased to above 110 mm Hg after magnesium
sulfate therapy or despite adequate oral antihypertensive medications,
intravenous bolus doses of hydralazine, 5-7 mg, or a continuous intravenous
infusion of hydralazine was administered.
All patients underwent 24-hour urine collection for measurement of urinary
total protein (UTP). Serum urea, creatinine, uric acid, SGOT, SGPT, and
platelet count were determined in all cases. Ultrasonography was performed
for estimation of gestational age of the fetus; for this, the last menstrual
period and height of the uterus were correlated. During the initial 24-hour
observation, all patients received dexamethasone, 12 mg IM, every 12 hours
for 48 hours.
Before starting conservative management, patients and their relatives were
informed about the management plan and risks and benefits of conservative
management. If the patient agreed to continue conservative management of
eclampsia, she signed a consent form. After the initial 24-hour observation
period, patients were again counseled regarding maternal and perinatal risks
and benefits of conservative management.
The goal of the conservative management was to prolong pregnancy until 36
completed weeks or until the onset of either maternal or fetal complications
(fetal death, fetal distress, or static growth). Patients were monitored by
staff specially trained in eclampsia management. Monitoring included inquiry
about any complaints, blood pressure measurement 4 times daily, fetal heart
sound auscultation 2 times daily, fetal growth monitoring by ultrasonography
every 2 weeks, and repetition of other tests whenever necessary. Patients
were instructed to report the development of features such as persistent
headaches, insomnia, visual disturbances, epigastric pain, and such other
features as uterine contractions, cramps, vaginal bleeding, ruptured
membrane, or decreased fetal movement.
Blood pressure was controlled by administering methyldopa and oral
nifedipine. The initial dose of methyldopa was 250 mg every 8 hours up to a
maximum dose of 500 mg every 6 hours. Nifedipine, 10 mg, was administered
every 8 hours up to a maximum dose of 10 mg every 6 hours. The aim of
therapy was to keep systolic blood pressure at a level between 140 and 150
mm Hg and diastolic blood pressure at a level between 90 and 100 mm Hg. If
diastolic blood pressure rose to 110 mm Hg or above, hydralazine was
administered in 1 of 2 ways: 20 mg diluted in 10 cc distilled water,
administered by IV directly in 5-mg boluses or 20 mg in 200 cc normal
saline, administered by IV drip at the rate of 10 drops per minute and
increased as necessary. Dexamethasone therapy was repeated weekly until
delivery.
Laboratory evaluations of UTP, urea, uric acid, platelet count, SGOT, and
SGPT were repeated weekly whenever initial parameters were higher than
normal levels. Otherwise, tests were not repeated because of limited
facilities. Fetal evaluation included kick count, auscultation of fetal
heart sound, measurement of fundal height, and ultrasonography performed
every 2 weeks.
Termination of pregnancy was based on both maternal and fetal indications.
Maternal indications for delivery were the following: uncontrolled severe
hypertension in spite of the adequate antihypertensive therapy, onset of
persistent headache, epigastric pain, vaginal bleeding (abruptio placentae),
and ruptured membranes. Fetal indications for delivery included fetal
distress (or, nonreassuring fetal status, [as determined by auscultating
fetal heart sound and, in some cases, by biophysical profile) fetal death,
static growth, and attainment of 36 weeks pregnancy. All patients were
discharged with stable blood pressure levels and 1+ or absent urinary
albumin.
Analysis of data included assessment of maternal complications, laboratory
findings, days gained during management, and perinatal outcome. Perinatal
outcome parameters included mortality, gestational age at delivery, birth
weight, birth condition, neonatal complications, and number of days spent in
neonatal intensive care. Results were expressed as mean ± SD and relative
risk.

Results

Of 51 patients, 21 were diagnosed with severe pre-eclampsia, and 30 were
diagnosed with eclampsia. The average age of the patients was 25.21 ± 4.64
years (range, 17-35 years). Most of the patients were primigravid (68.63%),
and no patients had antenatal check-up before admission to the hospital.
Average gestational age was 30.65 ±2.38 weeks (range, 24-34 weeks) (Table
1).
Table 2 shows the patients' conditions at admission. Patients had diastolic
blood pressure levels ranging from 90-140 mm Hg with a mean value of 109.05
± 11.61 mm Hg. Most of the patients (90.2%) had 2+ to 4+ proteinuria, and
74.51% had moderate leg edema. All patients were fully conscious at
admission.
Laboratory investigations are shown in Table 3. Urea, SGOT, SGPT, and
platelet count were within normal limits. The mean UTP was 2.25g/24 hours
(range, 0.12-6.53 g/24 h; serum uric acid was 5.5 mg/dL (range, 3.6-8.7
mg/dL; and serum creatinine was 1.31 mg/dL (range, 0.7-3.6 mg/dL).
Table 4 summarizes pregnancy outcomes. The average pregnancy prolongation
was 13.27 ± 8.26 days, with a range of 3-35 days.
Twelve patients reached 36 weeks of gestation. Of these, 5 were at 32 weeks,
3 were at 33 weeks, and 4 were at 34 weeks at the time of recruitment. One
of the babies weighed 2.3 kg at birth, 7 weighed 2.4 kg, and 4 weighed 2.5
kg at birth. Prognosis was unsatisfactory for those patients whose
gestational age was < 30 weeks (see Discussion, below). Of the 16 patients
with gestational age < 30 weeks, only 1 baby survived. The patient came into
the study at a gestational age of 28 weeks and pregnancy was continued for
another 2 weeks. The baby's birth weight was 1 kg. Lower segment cesarean
section was performed because the mother's 24-hour UTP rose from 1.5 g to 3
g and blood pressure could not be controlled satisfactorily.
Intrauterine death occurred in 19 (37.25%) cases. Only 1 patient (1.96%)
developed a maternal complication (abruptio placentae) 3 weeks after
development of convulsion. Table 5 shows the indication for termination of
pregnancy. Eighteen patients, including 12 with intrauterine death, went
into spontaneous labor at different ages of gestation. Other pregnancies
were terminated for the following reasons (1) no improvement after treatment
(n = 7 [13.73%]; although none of these patients had recurrent or persistent
seizure, they all had uncontrolled blood pressure and increasing uric acid
and total protein values), (2) patient's desire (n = 2 [3.92%]); (3) fetal
compromise (n = 15 [29.41%]); (4) attainment of 36 weeks (n = 7 [13.72%]; 12
patients attained 36 weeks gestation, but 5 went into spontaneous labor);
(5) premature rupture of membrane (n = 1 [1.96%]); and (6) abruptio
placentae (n = 1 [1.96%]).
For the 32 live-born babies, the average birth weight was 2.02 kg ± 0.45
(range, 1.0-2.5 kg). Six babies weighing 1.0-1.5 kg at birth were referred
to the ICU; 1 of them died 2 days after birth, 1 died 3 days after birth,
and 4 were discharged from hospital after 3 weeks.
Table 6 shows the perinatal outcomes before and after 30 weeks of gestation.
Live birth occurred in only 12.5% of those whose gestational age was 24-29
weeks and in 85.71% of those whose gestational age was >= 30 weeks at
recruitment. Relative risk of intrauterine death was 6.13 times higher for
infants of gestational age < 30 weeks than for those of gestational age >=
30 weeks (95% CI, 2.66-14.08).

Discussion

The first goal of management of severe pre-eclampsia and eclampsia is
prevention or control of convulsions and stabilization of the patient's
basic cardiovascular status. Administration of magnesium sulfate by an
established protocol[14] is considered to be the most rapid, efficient, and
safe pharmacologic approach for accomplishing this goal.
Hospitalization is an essential part of this management because it is
necessary to evaluate the full extent of the effects of the disease process
on the mother and fetus. Only in this way can the patient experience minimal
physiologic stress while undergoing the laboratory procedures needed to
assess maternal conditions, especially renal and hepatic function.
Finally, the aim should be to designate the time of delivery in such a
fashion that both the mother and fetus are best able to tolerate delivery
while providing the fetus with the maximum chance of extrauterine survival.
Most clinical centers have limited experience in managing such patients. As
a result, there are no recommended protocols for conservative management of
patients with severe pre-eclampsia and eclampsia. Thus, management has been
based on retrospective observations and empiric clinical experience, with an
aim to secure safety of the mother first and a secondary goal of safe
delivery and survival of the newborn.
We wish to emphasize that the group of patients included in this study were
carefully selected. First, they were judged suitable for expectant
management if they had no other medical obstetric complications or
complications of eclampsia and if they remained stable during the initial
24-hour observation period.
We found that it was possible to prolong pregnancy by an average of 13.27 ±
8.26 days (range, 3-35 days) in our study population. Platelet count, SGOT,
SGPT, and serum urea of all patients were within normal limits. Only 24-hour
UTP, uric acid, and creatinine values were higher than normal in most of the
patients.
Schiff and colleagues[15] concluded that the level of proteinuria and the
rate of increase in proteinuria during conservative management are not
important predictors of maternal or perinatal outcome. In their study,
patients whose protein excretion reached 10-20 g/24 h had outcomes and
admission-to-delivery intervals similar to those seen in women who had mild
proteinuria (< 5 g/24 h).
In our study, the maximum protein excretion was 6.53 g/24 h in a patient
whose pregnancy could be continued for only 3 days, and she gave birth to a
stillborn baby. The uric acid level of that patient was within the normal
limit (4.30 mg/dL). On the other hand, for a patient whose protein excretion
was 0.37 g/24 h, pregnancy could be continued for 15 days longer, and she
gave birth to a baby weighing 2.5 kg. The uric acid level of this patient
was 7.8 mg/dL.
The maximum uric acid level, 8.7 mg/dL, was observed in a patient whose
pregnancy could be continued for only 3 days (spontaneous delivery
occurred); . the birth weight of her baby, who died 24 hours after birth,
was only 1 kg. Surprisingly, the 24-hour protein excretion of this patient
was only 0.70 g. Thus, it is difficult to say whether uric acid or protein
excretion has a more predictive value of pregnancy outcome. Lim and
associates[16] found only a weak correlation between serum uric acid levels
and the severity of disease. They showed a weak correlation between serum
uric acid levels and maternal blood pressure and birth weight of the baby.
It is important to note that delivery was delayed until 36 weeks' gestation
in 12 patients, and none of those infants required admission to the neonatal
ICU. The patients whose gestational age was far away from term (< 30 weeks)
during enrollment showed poor prognosis. Sixteen patients had a gestational
age between 24 and 29 weeks. Of these, intrauterine death occurred in 14
cases; 2 patients did not respond to treatment, and cesarean section was
performed 2 weeks after admission at 30 and 31 weeks, respectively. Both of
these babies were transferred to the ICU; their birth weights were 1 kg and
1.2 kg, respectively. One survived and the other died 2 days after birth.
Lin and coworkers[17] reported the outcome of perinatal death in 95
pre-eclamptic pregnancies at < 30 weeks' gestation. Their study was
conducted at the Chicago Lying-In-Hospital between 1958 and 1976; the
patients were diagnosed with hypertensive disorder of pregnancy.
Martin and Tupper[9] reported on 55 patients with severe pre-eclampsia who
were treated conservatively; 9 were between 24 and 30 weeks' gestation. Two
of the 9 pregnancies resulted in stillbirths, and 1 ended in neonatal death.
Goodlin and colleagues[18] reported on 11 patients with severe pre-eclampsia
who were treated conservatively; 4 were at 24-27 weeks' gestation. Two of
these 4 gave birth to stillborn babies, and 1 died during the neonatal
period; 2 survived. Moore and Redman[19] reported on 24 patients with severe
pre-eclampsia before 34 weeks' gestation who were treated conservatively. Of
these, 4 patients had onset of symptoms during midtrimester that resulted in
2 stillbirths and 2 neonatal deaths. On the basis of these data, it is clear
that if severe pre-eclampsia develops before 30 weeks of gestation, the
result of conservative management is not satisfactory, which is consistent
with the findings of the current study.
Maternal morbidity was not high in our study. Only 1 patient developed
abruptio placentae 3 weeks after her admission; her convulsions had occurred
at 28 weeks of gestation. Sibai and colleagues[20] found high maternal
morbidity in patients with severe pre-eclampsia who were conservatively
managed, which is not consistent with the results of our study. Conservative
management did not significantly improve perinatal outcome in this series,
as intrauterine death occurred in almost all cases of midtrimester
pregnancy. However, the maternal condition was quite stable in the majority
of cases during continuation of pregnancy.
No death or major complication developed in this series. During discharge,
all patients had stable blood pressure and 1+ or absent urinary albumin. The
mean time interval between delivery and discharge was similar to that of
other patients who were not enrolled in this series. Because of cultural and
socioeconomic conditions, almost all patients were lost to follow-up after
discharge. Even though counseling was offered, no patient came for
follow-up. The limitation of this study, then, is that we are not able to
follow up on the long-term effects of conservative treatment of these
patients.

Conclusion

We conclude that in selected cases, with close monitoring and supervision,
conservative management can be attempted in cases of severe pre-eclampsia
and eclampsia after 30 weeks of gestation. This is especially important in
developing countries, where neonatal intensive care is either nonexistent or
beyond the reach of many patients. Further controlled trials involving a
larger number of patients are needed to establish the safety of the
protocol.

Table 1. Patient Characteristics


Range
Mean ± SD
Age (Yrs)
17-35
25.21 ± 4.69
Gestational age at admission (weeks)
24-34
30.27 ± 2.59
Parity
Number
Percentage
Nil
35
68.63
1-2
11
21.57
3-4
5
9.80
Severe pre-eclampsia
21
41.18
Eclampsia
30
58.82

Table 2. Condition at Admission

Diastolic BP (mm Hg)
Range
90 - 140
Mean ± SD
109.05 ± 11.61
Number
Percentage
Proteinuria
   +
5
9.80
   ++
10
19.61
   +++
33
64.70
   ++++
3
5.88
Edema
   Nil
5
9.80
   +
8
15.69
   ++
27
52.94
   +++
11
21.57
Glasgow Coma Scale
   15
51
100

Table 3. Laboratory Investigations

Specimen
Range
Mean ± SD
24-hour UTP (g/24 h)
0.12 - 6.53
2.25 ± 1.73
Urea (mg/dL)
22 - 65
41.25 ± 7.32
Creatinine (mg/dL)
0.7 - 3.6
1.31 ± .56
Uric acid (mg/dL)
3.0 - 8.7
5.5 ± 1.12
SGOT (IU/L)
7 - 42
17.85 ± 8.06
SGPT (IU/L)
10 - 42
20.0 ± 11.57
Platelet count (n/mm3)
100 - 300
202.81 ± 49.82
UTP = urinary total protein

Table 4. Pregnancy Outcomes

Outcome
Range
Mean ± SD
Pregnancy continued (days)
3 - 35
13.27 ± 8.26
Birth weight (kg)
1.0 - 2.5
2.02 ± 0.45

Number
Percentage
Complications
   Abruptio placentae
1
1.96
   Intrauterine death
19
37.25
Mode of delivery
   Vaginal
25
49.02
   Spontaneous labor
14
56
   Induction
11
44
   Cesarean section
26
50.98
   Elective
22
84.62
   Emergency
4
15.38

Table 5. Indications of Delivery

Indications
Number
Percentage
Resistant to treatment
7
13.73
   Unstable blood pressure
5
71.43
   Increasing UTP
1
14.28
   Increasing uric acid
1
14.28
Patient desire
2
3.92
Fetal compromise
15
29.41
Attainment of 36 weeks
7
13.73
Premature rupture membrane
1
1.96
Abruptio placentae
1
1.96
Spontaneous labor
18
35.29
UTP = urinary total protein

Table 6. Perinatal Outcome

Gestational age at recruitment
Still born
n (%)
Live born
n (%)
RR (95% CI)
24-29 weeks' gestation
14 (87.5%)
2 (12.5%)
6.13 (2.66-14.08)
30-34 weeks' gestation
5 (14.28%)
30 (85.71%)
Total
19 (37.25%)
32 (62.75%)

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Funding Information

Mosammat Rashida Begum, MBBS, FCPS, has no significant financial interests
to disclose.
Dr. Mosammat Rashida Begum, Prof. Sayeba Akhter, Prof. Anowara Begum, and
Prof. Mahmuda Khatun are with the Dhaka Medical College and Hospital, Dhaka,
Bangladesh. Dr. Ehsan Quadir is with Sir Salimullah Medical College and
Mitford Hospital, Dhaka, and Dr. Saleha Begum Choudhury is with BSMMU
(Bangabandhu Sheik Mujib Medical University), Dhaka. Email-
[log in to unmask] <mailto:[log in to unmask]> .


Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.