6. Boucher C, Dorion D, Fisch C.

Retropharyngeal abscesses : a clinicl and

Acknowledgement radiologic correlation. J Otolaryngol 1999;28:134-7.
We would like to thank Ms. Reyminda R. Grageda 7. Sethi DS, Chew CT. Retropharyngeal abscess - the foreign body connection.
Ann Acad Med Singapore 1991;20:581-8.
for typing this manuscript meticulously.
8. Rauf A, Rafiq AP, Asef AW, et al. Transcervical foreign body. J Laryngol Otol
References 2000;114 :471- 2.
9. Uchigasaki S, Takahashi H, Matsuda T, et al. A sudden death case from
1. Jonathan P, Gady Har-El , Frank EL. Retropharyngeal Absecess: clinical retropharyngeal abscess. Nippon Moigaku Zasshi, 1997;51:442 - 5.
review. ENT J 1995; 74:701-4.
10. Matsuki M, Matsuo M, Kaji Y, et al. An adult case of retropharyngeal
2. Tannebaum RD. Adult retropharyngeal abscess: a case report and review of cellulitis; diagnosis by magnetic resonance imaging. Radiat Med
the literature. J Emerg Med 1996;14:147-58. 1998;16:289-91.
3. Joseph E, Shimshon B, Issac G. Retropharyngeal Abscess caused by a 11. Conessa C, Sissokho B, Faye M. Hypopharyngeal foreign body migration.
traumatic perforation of the hypoharynx by a fishbone. Ann Otol Rhinol Apropos of 2 pedia cases. Rev Laryngol Otol Rhinol (Bord),
Laryngol 1990; 99: 927-8. 2002;121:267-70.
4. Gupta KR, Kakar PK, Saharia PS. Impacted foreign body of retropahryngeal 12. Ngan JH, Fok PJ, Lai EC, et al. A prospective study on fish bone ingestion.
space. J Laryngol Otol 1972;86:519-21. Experience of 358 patients. Ann Surg 1990;211:459-62.
5. Neil Weir. Anatomy of the larynx and tracheobronchial tree. In: Kerr AG (ed). 13. Latifi A, Fadl AF, Khalid MH. Retropharyngeal abscess secondary to cervical
Scott - Brown's Otolaryngology, 6th Ed. London:Butterworths, 1997, pp. 1- spine brucellosis: a case report. Saudi J Oto-Rhino-Laryngol Head & Neck
28. Surgery 2000;2:29-30.

Students' Corner
Protocols for Exercise during Pregnancy
S.A. Fazlani
4th year Medical Student, Ziauddin Medical University, Karachi.

Background function tests during pregnancy have shown that women

who were engaged in daily exercise program developed
Most pregnant women restrict their mobility and
adaptive changes in lung functions in the antenatal period.13
their participation in routine activities, but studies have
Lesser weight gain and fat retention; improved attitude and
proved that daily exercises program can reduce chances of
mental state; easier and less complicated labor and quick
miscarriage by 40%.1,2 US researcher, James Clapp and co-
recovery are among the other advantages of exercise during
workers have observed that moderate exercises such as pregnancy.8
walking or cycling can prevent pregnancy induced
hypertension. Women who started exercise early in Fetal Benefits
pregnancy, their placenta grew almost a third faster in mid- Fetal benefits include improved stress tolerance and
pregnancy and had about 15% more blood vessels and advanced neurobehavioral maturation. 14,15 The offspring of
surface area at term. 3,4 An observational study in Punjab has the exercising women were significantly heavier (corrected
shown the incidence of Pre-term premature rupture of birth weight: 3.75 ± 0.08 kg vs. 3.49 ± 0.07 kg) and longer
membrane of about 5.4% which is higher than the incidence (51.8 ± 0.3 cm vs. 50.6 ± 0.3 cm) than those born to women
in United Kingdom, America and France etc, where it is in control group but there were no significant differences in
around 1-2%.5 Exercise can also prevent early onset of neonatal percentage body fat, head circumference, ponderal
labor, premature rupture of membrane, and can even help to index, or maternal weight gain.9,16 Consequently the
shorten the duration of labor.6 offspring of those mothers who started exercise early in
their gestation are leaner at 5 years of age and have a
Maternal Benefits
slightly better neurodevelopmental outcome.8,17 One review
A study has shown that women who exercised during concluded that "current evidence appears to indicate
pregnancy felt better during the first trimester than those participation in moderate to vigorous activity throughout
who did not exercise in pregnancy.7 Exercise acts in concert pregnancy may enhance birth weight", with a caution that
with pregnancy to increase the heart rate, stroke volume and vigorous exercises could result in lighter offspring.18 A
cardiac output. 8 It has also been observed that exercise help prospective study of more than 800 pregnant women found
mothers to loose pregnancy weight faster; it decreases aches that the babies of those who expended a mean of 2,000
and pains associated with pregnancy; reduces likelihood of kcal/wk in leisure time physical activity (a level that does
severe trauma from episiotomies and also reduces the not necessarily reflect intense activity) were significantly
number of caesarean sections.9-12 A study of changes in lung heavier at birth than those of non-exercisers.2

Vol. 54, No. 4, April 2004 226

Recommendations by as much as 25% percent and allows for the greatest degree
A few exercises recommended during pregnancy are of pelvic adaptation as the baby descends.20,24 Squatting
explained briefly as follows: should be avoided after 32 weeks of gestation if the baby is
For beginners: For women who have previously been a breech or the mother has a cervical stitch (cerclage),
sedentary, non-weight-bearing activities such as swimming, hemorrhoids, vulvar varicosities, or painful varicosities in
stationary cycling pose the least risk of injury and moderate the legs; however, a supported squat can be practiced safely
walking is also safe for most. A schedule of 20 to 30 minute as long as it does not cause any discomfort.25
exercise sessions daily at a comfortable pace is a reasonable Pelvic floor muscle training: Stress incontinence is a
goal. Because of the increased risk of injury to joints, a disturbing problem during pregnancy. The protocol has
jogging program should not be initiated at this time.19 been published previously26 and recommendations for
For previously active women: In the absence of obstetric general training to increase strength of skeletal muscle were
or medical complications, most active women can continue made.27,28 Participants were asked to conduct 8-12
to exercise in accustomed ways. Studies have proved that contractions of pelvic floor muscles three times a day at
exercises involving strenuous, prolonged physical activity home with additional training in groups once a week for 45
such as aerobics, circuit training, stair climbing, swimming, minutes with a physical therapist. The prevalence of urinary
biking, and running remains a way of life for at least 25% of incontinence was significantly lower in the training group
all women planning pregnancy. 20 than in the control group at 36 weeks of pregnancy, (32%
versus 48%) and at three months after delivery (20% versus
Activities that can be started Activities that can be continued 32%).7,22,27-29
during pregnancy, even by those during pregnancy by those currently Relaxation in the side lying position: Relaxation provides
not currently participating in an participating are:21,22 important benefits to a women's body and mind. Taking
exercise program are: 21,22
time each day to relieve stress can renew energy as well as
enhance experience of pregnancy and the growing life with
Low impact aerobics Backpacking (only if in good
in her. Relaxing on a side not only produces physical and
Cycling/stationary biking physical condition)
mental benefits for mother, but also maximizes blood flow
golf Ballet
to the uterus, providing benefits for the baby.
Rowing machine Stairmaster Basketball
/stair climbing Swimming Body building (only for experienced) Some Easy Exercises
Walking Cross country skiing (only if in There are quite few ways to get some easy exercise
Water aerobics good physical condition) into pregnant mother's daily schedule:
Tennis/racquetball (only if you Running (only if in good physical Take the stair whenever possible.
are in good physical condition) condition)
Park the car further away from stores.
Weight training Softball
Volleyball. Walk to do short errands.
Use a video if she can't get to the gym.
Walk around the house or up and down stairs while
Kegels maneuver: In this maneuver alternate contraction
and relaxation of the muscles of pelvic outlet and birth canal commercials are on television.
is done.23 Strengthening of these muscles supports the Schedule her workout like any other appointment.
contents of the abdomen preventing uterus or bladder from Get up to change the television channels.
falling through these muscles, especially after having
Use a push mower.
children. Relaxing these muscles teaches her how to let go
so the baby can pass through the birth canal. Exercise under Supervision
Running: It is recommended that most habitual runners can · A specialist can modify activities of women who happen
continue to participate until late pregnancy; those who are to be involved in the aerobic activities.
simply trying to maintain fitness (as opposed to competing)
· Lifting of weights should be avoided, except under
are well advised to reduce their running time to lesser than
proper prescription and supervision.
45 minutes.20
· Mothers with multiple gestations are at risk for
Squatting: Squatting during pregnancy helps increase the premature labor, and if they have additional risk factors, the
mobility of the pelvic joints and strengthens the legs. A aggregate risk is even higher so exercise program for these women
squatting position during birth can increase the pelvic outlet should therefore be individualized and medically supervised.

227 J Pak Med Assoc

· Women who are excessively obese or significantly Discussion
underweight should exercise under supervision and with
Continuing much higher levels of exercise are not
extreme caution if at all, as should those who have type
associated with an increased incidence of infertility,
1diabetes, pregnancy-induced hypertension, seizure
abortion, congenital malformation, premature labor,
disorder or anemia.19
premature rupture of membranes, cord entanglement, fetal
General Precautions distress, abnormal labor, significant growth restriction or
It is recommended that all pregnant women, maternal injury. 1-4,7,18,32-34 Like wise follow up studies for
regardless of their activity or fitness level, should take the first 5 years after delivery have revealed no evidence of
precautions against dehydration and hyperthermia. They abnormalities in postnatal growth or neurodevelopment in
should avoid exertion in hot, humid environments and these offspring and no evidence of structural defects, injury
should drink adequate fluids before, during, and after or other health abnormalities in women. 4 These
exercise. Appropriate clothing and other strategies (e.g. observational results led to a series of three prospective,
using a small fan while using an exercise cycle) will randomized studies on weight-bearing (treadmill, aerobics,
facilitate heat dissipation. This is especially important in the and stair-stepping) exercise training during pregnancy. 3,27,35
first trimester. To avoid compromising fetal growth, caloric High volume of moderate-intensity, weight-bearing exercise
intake must be adequate to meet the combined demands of in mid and late pregnancy symmetrically reduces
pregnancy (an additional 300kcal/day) and exercise, except fetoplacental growth with a proportionally greater increase
in the case of competitive athletes who are determined to in fat mass than that in lean body mass. 9 Investigators have
maintain high performance for as long as possible. Studies cited come theoretic reasons for concern about premature
reveal that there are no known added benefits, and more labor in women who exercise in late pregnancy. Exercise is
potential complications, with vigorous exertion. 20 Oxygen known to increase circulating levels of nor epinephrine and
consumption during pregnancy is higher, limiting the ability epinephrine. Nor epinephrine has been shown to increase
to perform high-intensity tasks. Regular exercises need to both strength and frequency of uterine contractions.35 In
be advised to heed signs of fatigue and curtail workouts contrast; epinephrine has an inhibiting effect on uterine
short of exhaustions to reduce the potential risk of activity. Runners often complain of contractions during
hypoglycemia. exercise, but actual measurement with tokodynamometry
has not demonstrated consistent changes in uterine
Contraindications contractility. Tokodynamometry is, of course, logistically
According to American College of Gynecology difficult in this situation and may not be reliable. The study
guidelines, careful evaluation should be done to determine did not find any evidence of an increase in preterm labor,
if exercise is appropriate for pregnant women who have premature rupture of the membranes or fetal distress.3
Weight loss of approximately 0.5 kg per week between 4
cardiac disease or restrictive lung disease. Second or third
and 14 weeks post partum in overweight women who are
trimester bleeding, pregnancy induced hypertension,
exclusively breast-feeding does not affect the growth of
preterm labor with present or previous pregnancies,
their infants.11 There is no data that suggest exercise is
intrauterine growth retardation, incompetent cervix,
related to abortions.
placenta previa and premature rupture of membrane are
absolute contraindications to exercise. 24 Participation in a Acknowledgements
full range of sports such as volleyball and tennis, as well as I am grateful to my fellow students, Ali S. M. Akhtar
any activity with the potential for causing abdominal trauma and Sadaf Shaheen for their continuous support and
should be avoided. Exercise during the first few days of cooperation in writing this review article.
exposure to high altitude is also not recommended because
of the reduced oxygen availability.
References
1. Clapp JF 3rd. The effects of maternal exercise on early pregnancy outcome.
Am J Obstet Gynecol 1989;161:14.
Warning Signs 2. Hatch MC, Stein ZA. Work and exercise during pregnancy: epidemiological
studies, in Artal R, Wiswell RA, Drinkwater BL (eds). Exercise in pregnancy,
Pregnant women should be alerted to signs that ed 2. Baltimore: Williams & Wilkins 1991, pp. 279-86.
should prompt them to stop exercising and seek medical 3. Clapp JF 3rd. The course of labor after endurance exercise during pregnancy.
Am J Obstet Gynecol 1990;163:1799-805.
attention. In addition to excessive fatigue, these include
4. Clapp JF 3rd. Exercising Through Your Pregnancy. Champaign, Ill: Human
pain (particularly in the back or pubic area), dizziness, Kinetics Publishers Inc; 1998, pp. 145-51.
shortness of breath, palpitation, decreased fetal movement, 5. Tahir S, Aleem M, Aziz R. Incidence and outcome of preterm-premature
rupture of membranes. Pak J Med Sci 2002;18:26-32.
persistent contractions, rupture of membranes, and vaginal
6. Beckmann CR, Beckmann CA. Effect of a structured antepartum exercise
bleeding. 31 program on pregnancy and labor outcome in primiparas. J Reprod Med

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 1990;35:704-9. Fam Physician 1999;48:2165-74.
7. Sternfeld B, Quesenberry CP Jr, Eskenazi B, et al. Exercise during pregnancy 22. Clapp JF 3rd, Simonian S, Lopez B, et al. The one year morphometric and
and pregnancy outcome. Med Sci Sports Exerc 1995;27:634-40. neurodevelopmental outcome of the offspring of women who continued to
8. Pivarnik JM, Lee W, Clark SL, et al. Cardiac output responses of primigravid exercise regularly throughout pregnancy. Am J Gynecol 1998;178:594-99.
women during exercise determined by the direct Fick technique. Obstet 23. Cowlin A, Shelley S. Exercises to ease pregnancy, birth and recovery.
Gynecol 1990;75:954-9. Washington: parent articles 1994; 352:9707-10.
9. Clapp JF 3rd. Exercise during pregnancy. A clinical update. Clin Sports Med
24. Davies GA, Wolfe LA, Mottola MF, et al. Exercise during pregnancy and the
2000;19:273-86.
postpartum period. ACOG Technical Bulletin number 189- February 1994. Int
10. Clapp JF 3rd, Little KD, Appleby-Wineberg SK, et al. The effect of regular J Gynaecol Obstet 1994;45:65-70.
maternal exercise on erythropoietin in cord blood and amniotic fluid. Am J
25. Teasdill W. Step-by-step yoga for pregnancy: essential exercises for the
Obstet Gynecol 1995;172:1445-51.
childbearing year. Chicago: Contemporary Books, 1999, pp.178-85.
11. Clapp JF 3rd. Guiding the athlete during pregnancy and lactation.
26. Clapp JF 3rd. The effect of maternal exercise on early pregnancy outcome.
Contemporary. Obstet Gynaecol 1996;41(sports medicine suppl):20-26.
Am J Obstet Gynecol 1989;161:14.
12. Crane SS, Wojtowycz MA, Dye TD, et al. Association between pre-pregnancy
27. Veille JC, Hohimer AR, Burry K, et al. The effect of exercise on uterine
obesity and risk of cesarean delivery. Obstet Gynecol 1997;89:213-6.
activity in the last eight weeks of pregnancy. Am J Obstet Gynecol
13. Phatak MS, Kurhade GA. A longitudinal study of antenatal changes in lung 1985;151:727-30.
function tests and importance of postpartum exercises in their recovery. Indian
J Physiol Pharmacol. 2003;47:352-6. 28. Bø K, Hagen RH, Kvarstein B, et al. Pelvic floor muscle exercise for the
treatment of female stress urinary incontinence. III: Effects of two different
14. Clapp JF 3rd, Lopez B, Harcar-Sevcik R. Neonatal behavioral profile of the
degrees of pelvic floor muscle exercise. Neurourol Urodyn 1990;9:489-502.
offspring of women who continued to exercise regularly throughout
pregnancy. Am J Obstet Gynecol. 1999;180:91-4. 29. Bø K, Talseth T, Holme I. Single blind, randomised controlled trial of
pelvic floor exercises, electrical stimulation, vaginal cones, and treatment
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1990;2:89-101. in management of genuine stress incontinence in women. BMJ
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16. Clapp JF 3rd, Kim H, Burciu B, et al. Beginning regular exercise in early
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18. Pivarnik J. Potential effects of maternal physical activity on birth weight: brief
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19. Clap JF 3rd. Cover story: recommending exercise during pregnancy. fetal activity late in gestation. J Matern Fetal Med 1997;6:134-139.
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21. Thomas W, Wang Y, MacNeal KE, et al. Exercise during pregnancy. Am Acad responses in normal pregnancy. Am J Obstet Gynecol 1981;140:123-7.

The Hippocratic oath: Has it ceased to be relevant?

W. Qidwai
Department of Family Medicine, The Aga Khan University, Karachi.

The Greek physician Hippocrates (460-377 B.C) is its precepts are as valid today as they were in Hippocrates'
traditionally regarded as the founder of medicine, scientific time. This can be best understood through an historical
discipline and medical ethics. 1 The Hippocratic Oath, taken review of the oath's transmission and acceptance in different
by ancient and medieval doctors, requires high ethical eras of western history. The longevity of the oath, however,
standards from medical doctors. Its principles are is clearly attributable to its intrinsic merit, its high moral
considered important in professional and ethical education reverent tone, and a literary eloquence that placed
of medical doctors even today. 2 Hippocrates among the best writers of antiquity.4
The Hippocratic Oath has survived, with over-riding Historically, the ethics of a professional were the
power, the test of time since it addresses the intrinsic nature ethics of a gentleman. Since the industrial revolution in the
of medicine. Even those who know little of it or reject parts 19th century, it has been argued that it has become
of it acknowledge it to be a symbol of the values of imperative to apply the principle of autonomy to issues in
medicine. It has been argued that it is its drive to the heart the ethics of health care.5
of medicine that makes the Hippocratic Oath inspiring even The social changes in the 1960s, where citizens
today.3 asked for a greater voice in all affairs that affected them
The moral and ethical message of the Hippocratic gave rise to formal approaches to ethics in the health fields.6
Oath has exhibited remarkable resiliency through the ages, The increasing incorporation of medical technology
in varied cultures. Although its language may appear odd, coupled with social demands (including those for health

229 J Pak Med Assoc