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H welcomed the recent announcement by the Singapore government that social egg freezing is allowed for women aged 21 to 37. Previously, the procedure was only reserved for women with medical conditions, such as cancer, who wanted to preserve their fertility. H, aged 34, and single, had no plans for marriage for the next few years. “At least I have a backup plan for fertility when I find my Mr. Right,” she said. Like most women, she was mindful about her ticking biological clock. She knew that biologically, a woman is born with a finite number of eggs, the quality and quantity of which will decline over time. She also read about another fertility preservation option- ovarian tissue freezing. In this procedure, part of the ovary is taken out of the body, stored and frozen for future use. She wanted to know which option would suit her best. What is Egg Freezing? Egg freezing or oocyte cryopreservation (OC), is an assisted reproduction technology that freezes and stores a woman’s unfertilized eggs for conception at a later stage of her life. The patient has to undergo daily injections of hormones to stimulate the growth of eggs in both ovaries. When these eggs reach a mature stage, they are retrieved by needle aspiration through the vagina under ultrasound guidance. The procedure is done under sedation or general anesthesia. The retrieved eggs are examined under microscope to determine their suitability for storage. These eggs are then frozen through a process called vitrification and stored in tanks filled with liquid nitrogen until the woman is ready for conception. What is Ovarian Tissue Freezing? Ovarian tissue freezing is also known as ovarian tissue cryopreservation (OTC). Under general anesthesia, part or whole of the ovarian cortex, the egg-producing portion of the ovary is resected through a key-hole (laparoscopy) surgery. The ovarian tissue is dissected into smaller pieces in the laboratory. These are frozen and stored under liquid nitrogen. When the patient is ready for conception, the ovarian tissues are reimplanted back into the patient’s pelvic cavity by laparoscopy. The patient has to wait for a short while for the return of ovarian function of these reimplanted tissues. Reasons for doing OC or OTC? There are two main reasons for fertility preservation: Medical: Women with medical conditions that threaten fertility: Certain medical conditions such as cancer or its treatment, such as chemotherapy or radiotherapy, may damage the growth and development of eggs. Fertility is thus impaired and irreversible sterility may result. Social: Women who are not ready to have a baby for personal reasons or professional ambitions or the lack of a suitable partner to begin a family with and who would like to start the family at the later stage of life. Marrying late and postponing childbearing are on the rising trend in most developed countries. Comparison between the 2 options of fertility preservation: OC: Can be done under sedation or general anaesthesia. Invasive surgery is not required. The chances of successful live birth are dependent on the age at the time of cryopreservation and the number of eggs retrieved. Successful pregnancy, live birth and perinatal outcomes have been reported. More than one cycle may be required to retrieve adequate numbers of eggs to improve chances of successful live birth. It is estimated that in order to achieve a 70–80% chance of one live birth, 2 to 3 treatment cycles may be required to harvest between15 to 20 mature eggs. IVF is the only way to achieve pregnancy. Requires daily hormonal stimulation for about 2 weeks. This may disrupt the everyday activities of the patient. Ovarian stimulation increases the risk (albeit minimal) of thrombotic events (blood clots forming in the circulation) and ovarian hyperstimulation syndrome. Ovarian stimulation increases the risk of borderline ovarian tumours or gynaecological malignancy. Ovarian stimulation is associated with short and long-term psychological and/or hormonal side effects. The preserved eggs may not end up being used, due to spontaneous conception, or through choice. Only 3 –12% of women have utilised their eggs. Not suitable for children, adolescents, and young adult cancer patients who require immediate chemotherapy and do not have enough time for ovulation induction. OTC: Can only be done under general anaesthesia. 2 surgeries required, one for resection, and the other for re-implantation. There is a slight increased risk of surgery and anaesthesia. Suitable for children, adolescents, and young adult cancer patients who require immediate chemotherapy and do not have enough time for ovulation induction. Successful outcomes have been reported regarding hormonal function, live birth, pregnancy rates and perinatal outcomes. Women can use cryopreserved tissue later in life to improve their hormonal status. Thousands of egg can be preserved at one time, without the need for hormonal stimulation. Long-term surgical risks such as adhesions, could impair the ability to achieve spontaneous pregnancy in future. Spontaneous pregnancy is possible. Based on recent research studies, about 4 out of every 10 females who tried to get pregnant using frozen ovarian tissue were successful. Half of the females got pregnant naturally, and half after IVF. Tissue may not end up being used, due to spontaneous conception, or through choice. After thinking through the 2 options, H decided to have OTC which was successfully done recently.

K, 56, was taken aback when she noticed brown vaginal discharge on her underwear. She knew she had to have a gynaecological consultation immediately, as advised by her oncologist. She had breast cancer 2 years ago and had a mastectomy done. The tumor was hormone sensitive and she was given tamoxifen soon after the surgery. Gynaecological examination did not reveal any pelvic masses. The uterus and cervix appeared normal. Stale blood was seen at the cervical opening. Ultrasound examination showed that the uterine lining (endometrium) appeared thickened and measured 14mm. What is tamoxifen? Tamoxifen belongs to a group of medications called selective oestrogen receptor modulator (SERM). It can act like oestrogen on some tissues and block the effects of oestrogen on other tissues in the body. It is thus known as a Janus-headed drug. What is tamoxifen used for? Tamoxifen was originally developed as a contraceptive morning-after pill but was found to be ineffective. However, its anti-oestrogenic properties were soon discovered to be effective in the treatment of hormone dependent breast cancer. Because of the low toxicity and wide availability, it has become one of the most frequently prescribed anticancer drugs worldwide in the last decades. The drug has been approved by the U.S. Food and Drug Administration for the following indications: In women at high risk of breast cancer, it helps lower the risk of developing breast cancer. For women with breast cancer treated with surgery, it can help lower the chances of the cancer recurring and improve the chances of survival. It can also lower the risk of a new cancer developing in the other breast. For women with breast cancer that has spread to other parts of the body, What is the relationship between Tamoxifen and uterine cancer? While Tamoxifen is efficacious in the treatment of breast cancer, it can increase the risk of uterine cancer (endometrial cancer) especially in postmenopausal women with preexisting pathologies in the uterus. Most studies have found that the increased risk is about two to three times higher than that of the general population. Besides endometrial cancer, tamoxifen can cause a group of cancers of the uterine muscle (sarcoma). But these cancers are very rare. Paradoxically, tamoxifen can also be used to treat certain forms of advanced endometrial cancer. This is another indication of this Janus-headed drug. The molecular mechanisms for the Janus-headed activity of tamoxifen remain elusive. What are the things to look out for while taking tamoxifen? It is recommended that any abnormal vaginal bleeding, bloody vaginal discharge, staining, or spotting while the patient is under the medication should be investigated straightaway. This is to rule out endometrial cancer as well as other non-cancerous uterine lesions that the drug may cause. K underwent a hysteroscopy and endometrial curetting. Pathology report revealed uterine polyps with no cancer detected. She was very relieved with the result and continued with tamoxifen therapy.

For about 5 days every month, R, a 20-year-old undergraduate, would experience breast tenderness, headaches, indigestion and bloating. She would have certain food cravings and would sometimes gain one to two kilograms in weight prior to her menstrual period. She often felt exhausted, listless and irritable. These symptoms rapidly subsided soon after her menstruation began. R is suffering from premenstrual syndrome or PMS. Diet and PMS Premenstrual syndrome (PMS) is a common disorder in women of childbearing age. It has a negative impact on the mental and physical health of women. Despite much research, the exact cause of PMS is still not known. However, studies have shown that healthy food choices and a balanced diet can help relieve some of the symptoms. Vitamins The following vitamins have been found to be helpful in easing PMS: Vitamin B-6: It helps the body use serotonin, a brain hormone, which may ease depression. Vitamin B-6 is found in chicken, fish, potatoes, eggs, and carrots. Vitamin D: Research studies have shown that increased intake of vitamin D helps PMS symptoms by reducing tissue inflammation. Vitamin D is found naturally in foods like sardines and salmon. Vitamin E: This may reduce headache and breast tenderness. It is found in nuts such as almonds, peanuts and hazelnuts and in green leafy vegetables. Minerals The following minerals have been found to be helpful in easing PMS: Calcium: This may ease mood swings, headache, bloating, and irritability. It is found in dairy products such as milk, cheese, and yogurt. Almonds, beans, soymilk and tofu are also good sources of calcium. Magnesium: This may relieve bloating and breast tenderness, and is found in many foods, including fresh fruits and vegetables. Iron: An increase in iron intake before and during menstrual period will replace the iron lost in the menstrual blood . Iron-rich foods include red meats e.g. beef. Carbohydrates Complex carbohydrates like whole-grain bread, brown rice, whole-wheat pasta and buckwheat noodles are good choices. They raise blood serotonin levels and help manage mood swings. As these foods enter the bloodstream gradually, they cause only a moderate rise in insulin levels, which then keep food cravings under control. Water Increasing water intake of 1.5 to 2 liters a day helps reduce bloating and aid in digestion. Foods to avoid Some foods can make PMS symptoms worse. These include Salt: Fast food or processed food, including canned foods, are often high in salt. A study in Taiwan has shown that excess consumption of junk food was associated with higher incidence of PMS. Refined sugar: Sweets and candies can aggravate PMS symptoms. Caffeine: Caffeine can disrupt sleep, which makes PMS symptoms harder to cope with. It can also cause breast tenderness. Limiting chocolate and caffeinated drinks, such as coffee or soda can help. Alcohol can induce depression and disrupt sleep. Many kinds of alcohol are also high in sugar. The severity of PMS symptoms appears to be reduced if one limits the intake of alcohol. With diet modulation and lifestyle changes, R’s PMS symptoms improved though they did not disappear completely. She feels happier as she is able to cope with PMS better now.

“The very thought of childbirth makes me nervous and anxious. My heart rate would go up and I would feel clammy. I actually avoid watching labour and delivery scenes in movies as I have been traumatized mentally by many negative birth stories I heard....I could imagine the day I delivered my baby, there would be chaos and panic in the delivery suite." These were shared with me by G, a 30-year-old first-time mum when she came for her first antenatal visit at 8 weeks of pregnancy. G is not alone. According to research studies, about one in three mums is traumatized by childbirth. It is normal for pregnant mums to feel anxious about giving birth. This is especially so for first time mums. Many women worry about the health of their baby, the labour pain and /or whether they may need an epidural or a C-section for the delivery. Studies have also found that women with anxiety during pregnancy have a longer labour than women who are not anxious. These women are also more likely to develop postpartum mental issues such as depression and mood disorders. Fear-Tension-Pain Cycle The “Fear-Tension-Pain” cycle was described by a British obstetrician in the 1920s. Fear causes women to become tense which in turn increases their pain. The increased pain then causes women to become more fearful, and the vicious cycle continues. Mental preparedness Mindset plays an important role in the birth experience. Even though birthing is unpredictable and medical emergencies do happen along the way, mental preparedness will help the mum to focus on the goal and calm her mind. This will usually result in a positive outcome. Tips to allay birth anxiety 1. Positive affirmations by the partner and health professionals. Listening to and learning from positive labour stories may help. 2. Empower patients with knowledge of the physiology and anatomy of the birth process. Meditation and massaging the back can help reduce pain during early stage of labour 3. Encourage the patient to share her concerns with her obstetrician, including pain management during labour and the indications of a C-section. Information and awareness can help alleviate anxiety. 4. Calm the nerves by: · Getting quality sleep every night. Lack of sleep can worsen your anxiety. · Eating a healthy, balanced diet helps regulate gut bacteria, which researchers have linked to lessened anxiety. · Regular exercise helps reduce anxiety and stress. · A childbirth class and various breathing techniques can minimize stress · Build a support system. Friends, supportive family members and uplifting social media groups can help ease anxiety by sharing the patient's feelings. With positive affirmation from her spouse, G gradually changed her mindset on childbirth. She also attended childbirth classes which helped her understand the labour process better. Her antenatal course was uneventful. She went into spontaneous labour at 39 weeks of gestation. Under epidural anesthesia, G had a smooth vaginal delivery.

B, 32, had severe endometriosis. She had deep infiltrative endometriosis involving the large intestine or DIE of the bowel. As a teenager, B had occasional menstrual cramps with a sensation of “heavy pulling in my womb”. This was temporarily relieved with Chinese herbal medication. However, the menstrual discomfort recurred around the age of 28 and was accompanied with abdominal bloating, nausea, constipation, diarrhoea and pain during defecation. She was initially diagnosed as irritable bowel syndrome (IBS) by her family doctor. The gastro-intestinal symptoms improved with medicine but not the menstrual pain. The intensity of the pain gradually increased and was only relieved with painkillers. She had to take frequent leave from work during the first few days of menstruation. She was then referred for gynaecological evaluation. As B was not married, clinical evaluation had to be done by examination through the anus. This revealed an immobile normal-sized uterus with a tender and nodular mass about 1.5 cm at the space between vagina and rectum behind the uterus (fig 1). Ultrasound examination of the ovaries were normal. MRI of the pelvis confirmed the pelvic mass. Colonoscopy was normal. DIE of the Bowel DIE of the bowel is a chronic disease and is difficult to diagnose because the symptoms are usually non-specific, often mimicking IBS. Management is also challenging and complex as the lesion is invasive, infiltrating more than 5 millimeters into the tissues surrounding the bowel. This causes extensive scarring (adhesions) among the pelvic organs which are often stuck together (frozen pelvis) with a deranged anatomy. Bowel endometriosis typically presents as a single nodule, with a diameter larger than 1 cm. It accounts for 5% to 12% of women presenting with endometriosis. The lower part of large intestines (rectum and sigmoid) accounts for up to 90% of all intestinal lesions. Symptoms of DIE Symptoms include: · Chronic pelvic pain · Menstrual cramps · Infertility · Pain during sex · Painful bowel movements · Pain with urination Occasionally, some patients may have minimal symptoms. Diagnosis of DIE Vaginal examination may reveal nodules along the back of the uterus. Sometimes bluish nodules may be seen at the upper part (vault) of the back of the vagina. Imaging techniques using vaginal ultrasound and MRI will outline the size and the extent of the lesion. This is important in the surgical planning before operation. Treatment of DIE Medical treatment: Progestogen hormones orally or via intrauterine device (Mirena) and GnRH agonist injection may be used to relieve the symptoms. But DIE is unlikely to resolve. There is a high chance of symptoms relapsing after stopping the medicine. Side effects following prolonged medication may not be suitable in patients who wish to conceive as ovulation is being suppressed. Surgical treatment: As DIE may progress and block the digestive tract, surgical removal of the lesion may be done at some stage. The ideal is a complete resection of all visible lesions whilst preserving pelvic organ function. This may not be achieved in some patients. Assisted reproductive techniques for conception may be required in patients post-surgery. B was treated medically with oral progestogens for 6 months. The symptoms subsided somewhat as she did not have menses while on the therapy. However, she suffered from side effects like acne, weight gain and mood swings. As the DIE lesion did not decrease in size in subsequent MRI, B requested surgical intervention. This was done laparoscopically with the colorectal surgeon. At the operation, the DIE had encircled more than half of the circumference of the rectum. Part of the rectum had to be resected together with the lesion. The surgery was uneventful and B was discharged well 4 days after operation. She remained pain free at the last review 6 months after surgery.

G, a 28-year-old first-time mum, requested caesarean section as a mode of delivery for her baby. She was concerned that natural birth might “permanently tear” her birth canal and cause a “loose” vagina which could affect her sex life subsequently. She was told that a laxed vagina could reduce sensation during intercourse which could lead to diminished sexual satisfaction, decreased sexual self-esteem and may cause a drift in her marital relationship. Caesarean sections (C-section) appeared to be a better option. Incidence of C-section in Singapore is on the rise C-section has become a common method for giving birth in countries around the world and Singapore is no exception. In the early 1990s , 10-15% of total births were delivered by C-section. Now, the procedure accounts for an estimated 40-45% of all births and many of these are performed on patient’s request. How Common IS “Loose Vagina” (Vaginal Laxity)? Vaginal looseness is considered a form of sexual dysfunction and is a subjective and self-reported sexual health concern. There are no objective measures. How Could Vaginal Birth Cause Vaginal Laxity? The vaginal walls contain elastic muscles that normally fold up and hold the vagina closed tightly. During childbirth, pregnancy hormones cause these muscles to relax. The vagina is designed to be able to relax and re-tighten repeatedly, without any loss of tone or tissue elasticity. However, there are limits to the elasticity of the muscles and associated tissues. A few risk factors are known to contribute to chronic feelings of vaginal looseness. They include: Trauma: Pelvic floor muscles which surround and help maintain the position and shape of the vagina are damaged to varying degrees during childbirth. Age: With aging, there is gradual weakening of the vaginal muscles and tissues. Multiple vaginal births: With multiple deliveries, there is incomplete recovery of pre-pregnancy vaginal tightness. Does Vaginal Laxity Affect Long Term Sexual Enjoyment? Sexual enjoyment is important in maintaining a healthy marital relationship. Many factors can influence sexual satisfaction in women. They include interpersonal relationship, mental and physical health of the couples. It is generally perceived that normal childbirth resulting in vaginal laxity may have a negative impact on sexual function. Short-term studies have suggested that there is little difference in sexual outcomes at 6 months postpartum when comparing caesarean section with vaginal deliveries. A recent long-term study published in 2022 also had the same conclusion. Researchers in the UK and Sweden looked at the sexual health of women for up to 18 years after giving birth. The study found that sexual enjoyment and sexual frequency are unaffected by the mode of delivery. So, whether patients give birth vaginally or by C-section, there was no difference in the long-term sex life. Both groups had sex equally as often, and were equally sexually satisfied. I spent some time explaining to G the advantages of normal vaginal birth including better development of the immune system of her baby and less chances of the baby developing early life infections and non-communicable diseases, including inflammatory diseases, allergies, metabolic diseases and obesity later in life. With strong emotional support from her husband, G finally decided to have a vaginal delivery and had a healthy baby boy weighing 3kg.

G, 45, had heavy menses with cramps for the past five years. She was married with two grown up children. In her late 30s, she noticed that her menstrual periods were getting heavier with clots. The bleeding was getting worse when she was 40. At times, her clothes were soiled. She became light headed and felt very tired during menses in spite of taking oral iron tablets regularly. She began to experience menstrual cramps after about a year. It was accompanied by backache a day before and during the first 2 days of her menses. Initially, the pain was bearable but the intensity gradually increased so that it could only be relieved with a pain killer, hot pad and rest. G was diagnosed with multiple fibroids at the age of 39. She was offered surgical management which she was not mentally prepared for. She was then treated conservatively with tranexamic acid, a medication that blocks the breakdown of blood clots, which prevents bleeding, Ponstan, a pain killer as well as oral iron therapy. As G’s symptoms did not respond well to conservative treatment and her quality of life was severely affected, she decided to have her uterus removed after suffering for the past 5 years. “I am too old to have another baby and the uterus has caused me so much suffering,” she said. Types of hysterectomy To remove uterine fibroids, there are two types of hysterectomy. · Total hysterectomy – the womb and cervix (neck of the womb) are removed. · Subtotal hysterectomy – the main body of the womb is removed, leaving the cervix in place. Choice of total or partial (subtotal) hysterectomy Total hysterectomy (TH) involves removal of the body and the neck (cervix) of the womb, while partial or subtotal hysterectomy (SubTH) concerns the removal of only the body of the womb, leaving the cervix behind. The cervix is the lowest portion of the uterus. It contains lots of glands that produce mucus forming clear vaginal discharge. The mucus is secreted under the influence of the hormonal changes of the menstrual cycle, becoming more profuse at the time of ovulation. Hysterectomy disrupts the intimate anatomical relationship between the uterus, bowel, bladder and vagina Bladder function: Hysterectomy involves separation of the bladder from the womb. This is more extensive in TH than in subTH. It has been reported that symptoms of incomplete emptying of bladder, urinary incontinence and frequency of passing urine improve better with subTH than TH. Urinary tract infections are less common following a subTH. Bowel function There has been no significant difference in bowel symptoms following either subTH or TH. Sexual function: Studies have shown an improvement in sexual activity following either type of hysterectomy as the symptoms which patients have previously suffered from have been removed and there is no worry of becoming pregnant. However, hysterectomy may interfere with lubrication and orgasm. With subTH, patients will not experience vaginal dryness or have a shortened vagina and sexual satisfaction may be better than post TH. With subTH, the duration of operation, bleeding and injuries to the bladder and ureters are less. There are also fewer wound infections and haematomas (collections of blood under the wound).Thus, hospital stay and recovery are shorter. After discussing the pros and cons of both types of hysterectomy, G opted for subTH which was carried out successfully via laparoscope. She was discharged well the next day. She was reminded to have regular checks with pap smear on her cervix for early detection of cancer.

After eating some salads and cheese at a farewell party for a colleague a few days ago, T, a 32-year-old mum-to-be began to feel unwell. She had lost her appetite the next day and started to have diarrhea 2 to 3 times a day. She took some medications for food poisoning from her family physician. The symptoms did not subside, Instead, she started to have fever with chills and rigor. She was then admitted to the hospital for further investigation. T was in her second trimester of pregnancy. Other than the slight dehydration and a raised temperature of 38 deg C, her vital signs were normal. The fetus was active and well with a heart rate of 160 beats per minute. There was no stiff neck or severe headache to suggest infection of her nervous system. Blood culture was positive for Listeria. Listeria infection (Listeriosis) Listeriosis is an infection caused by eating food contaminated with the germ called Listeria monocytogenes. Pregnant women are much more susceptible to listeria infections than are healthy adults. During pregnancy, it usually causes mild symptoms in the mother. The consequences for the foetus however, can be serious. It can end up with miscarriage, stillborn, premature birth or severe life-threatening infection soon after birth. Symptoms of Listeriosis Symptoms usually appear a few days after consuming the contaminated food. Occasionally, it can take 30 days or more before symptoms of infection begin. Fever and muscle aches are common; sometimes preceded by diarrhea or other gastrointestinal symptoms. In severe infection, inflammation of the membranes covering the brain and spinal cord called meningitis may occur. The symptoms include Severe headache Stiff neck Confusion or sensitivity to light Convulsion Diagnosis and treatment Listeria bacteria can be diagnosed by blood culture. In some cases, samples of urine or spinal fluid can be tested for the bacteria as well. During pregnancy, antibiotic treatment should be given to prevent the infection from affecting the baby. Prevention Listeria bacteria can be found in moist environments, soil, water, decaying vegetation and animal feces. It can survive and even grow under refrigeration, freezing and other food preservation measures. People can get infected by eating contaminated raw vegetables, deli meat, unpasteurized milk, cheese, hot dogs and smoked seafood To prevent Listeriosis, simple food safety guidelines should be followed: Avoid uncooked food Keeps things clean: including refrigerator, cooking utensils, cutting board and hands. Wash raw vegetables thoroughly and cook the food to a safe temperature. T was given antibiotics and probiotics promptly and was hydrated with fluid intravenously. Fever and diarrhea subsided on the 3rd day after admission. She was discharged well. Her antenatal course remained uneventful. The fetus grew satisfactorily without complications. She is in her last trimester now.

T, 26, a first-time-mum was taken aback when I told her that her blood pressure had shot up from around 110/70 mm Hg in the first trimester to 140/ 95 mm Hg in the second trimester. She did not have symptoms like nausea and dizziness. There was no swelling around her ankles but her urine sample contained a small amount of protein. T had developed an obstetrical complication in pregnancy called pre-eclampsia. What is Pre-eclampsia (PE)? Pre-eclampsia is a complication of pregnancy that causes the mother to have high blood pressure and protein in the urine. It affects between 5 to 10 in 100 pregnant women and is diagnosed in the second half of pregnancy, during labour or soon after birth. What is the cause of PE? The exact cause of pre-eclampsia is not fully understood. Research studies have suggested that PE begins in the placenta — the organ that nourishes the fetus throughout pregnancy. Early in a pregnancy, the fertilised egg implants itself into the womb by producing root-like growths called villi. These villi are fed nutrients through blood vessels in the womb and eventually grow into the placenta. In women with preeclampsia, these blood vessels do not appear to develop or work properly. This may lead to the irregular regulation of blood pressure in the mother. It is still unclear why the blood vessels do not work well as they should. It is likely that genetic factors may play a role, as the condition often runs in families. But this only explains some cases of PE. Oftentimes, there is no contributing factor What are the signs of PE? Most cases are usually asymptomatic. High blood pressure (hypertension) and protein in the urine (proteinuria) are usually picked up at routine antenatal checkups. Weight gain and swelling of legs are quite common in pregnancy. But PE may be suspected if there is a sudden weight gain or a sudden swelling particularly in the face and hands. In severe cases (0.5 % of pregnancy), PE can lead to serious, sometimes life- threatening, complications affecting both the mother and the foetus. The symptoms of severe PE include: · Severe headaches · Blurring of vision or other visual disturbances · Severe abdominal pain · Nausea and vomiting · Shortness of breath, caused by fluid in the lungs Also read the article in the website High blood pressure put baby’s life at risk What are the complications of severe PE? Complications in the mother include: · Seizures or convulsions (eclamptic fits) before or just after the baby’s birth · Liver or kidney failure · Problems with blood clotting as the number of platelets in blood are reduced · Placental abruption: Premature separation of placenta before birth Complications in the foetus include: Intrauterine growth restriction (IUGR):As the placenta is affected, the foetus receives inadequate blood and oxygen and fewer nutrients. Foetal distress: Foetus may become asphyxiated before or during birth Prematurity Stillbirth Can PE be predicted early? As PE is a potentially serious problem, many methods have been tried to detect it early. These include the use of ultrasound measurement of the uterine blood flow and the measurement of blood levels of biomarkers from the placenta. They are still not widely accepted in clinical practice. New research published this year in the journal Nature may show promise. Researchers showed that RNA molecules sequenced from a single blood sample could predict preeclampsia early in pregnancy, months before symptoms appear. T was monitored closely. She was treated with antihypertensive medication and her blood pressure was well controlled. Her foetal growth was normal. Labour was induced at 38 weeks gestation and she delivered a healthy baby girl weighing 3 kg normally.

Inside the cubicle, the midwife cautiously handed over the tiny infant to K’s husband and instructed him on how to start skin-to-skin contact with the newborn. K, 30, a first-time mum had just delivered the baby prematurely at 35 weeks gestation by Caesarean section. She had profuse vaginal bleeding from premature separation of the placenta. The baby boy weighed 2.4kg and was crying well at birth, with a good Apgar score of 9. Thankfully, he was in a stable condition. What is premature birth? Premature or preterm birth is defined as a live birth before 37 weeks of gestation. Depending on the gestational age, it is further subdivided into the following: extremely premature (less than 28 weeks of gestation) very premature (28 to 32 weeks of gestation) moderate to late premature (32 to 37 weeks of gestation). The younger the preemies, the lesser the chances of survival. For those who survive, the majority go on to live a relatively normal life. However, some may have long term health issues such as hearing and sight problems, delayed development and cerebral palsy. How common is premature birth in Singapore? In Singapore, about 1 in 11 babies are born prematurely. This is similar to the worldwide incidence of 10%. What is Kangaroo Maternal Care (KMC)? KMC is the care of a premature baby with continuous and prolonged skin-to-skin contact between the mother and the infant immediately after birth. It is an easy-to-use method, first proposed by doctors in Bogotá, Colombia in 1983. It has the following advantages: It is evidence-based. Survival rates for preterm and low birthweight babies have been noted to improve. It helps regulate a baby's temperature, breathing and blood sugar levels. It helps babies gently adjust to life outside the womb. It helps initiate and establish breastfeeding. With improved bonding, mothers would feel more confident with better self-esteem and would have a sense of fulfilment. It leads to less anxiety and depression for the mothers. If the mother is not available (e.g., after a C-section), fathers, partners and other family members can also provide KMC. There is less incubator care for premature baby Baby can be discharged earlier from the hospital. What are the prerequisites of KMC? According to the new guidelines released by WHO this November, KMC should start immediately after birth, without any initial period in an incubator. Research has now shown that starting immediate KMC saves many more lives, reduces infections and hypothermia, and improves feeding. Breastfeeding should be exclusive and initiated immediately. The infant should be clinically stable, able to breathe spontaneously after resuscitation and is not in shock or needs mechanical ventilation. The infant’s clinical condition (including heart rate, breathing, colour, temperature and oxygen saturation) must be monitored. K’s baby thrived well and was discharged with the mother on the third day after delivery.

M brought her 13-year-old daughter to see me theother day. “Doc, my daughter started her periods about 2 years ago. Initially, her period was not regular every month. It may be delayed for two to three weeks. Her periods also vary in amount and duration in different months. She will bleed for 3-7 days and may need to change pads 3-4 times a day. But for this month, she has been bleeding for more than two weeks. The flow for the first week was so heavy that she stained her bed sheets twice at night. The bleeding is less now. She uses only one or two pads a day. My mother-in-law wants to give her some Chinese herbs but I prefer to seek your advice,” she said. M's daughter looked pale and worried. She did not have other medical issues. Her BMI was normal. An abdominal ultrasound examination with a full bladder revealed that her reproductive organs were normal. Blood hormone tests of thyroid gland, pituitary gland and ovary were normal. Full blood count revealed that she was slightly anemic. Irregular Periods in Adolescents Most girls will get their first period between the ages of 10 and 15. Some girls will get their period earlier whilst some will get theirs later. The menses can be irregular in frequency, duration and the amount of flow. It usually takes about 2 years before they become regular. Having an irregular period during puberty is normal. Parents need not be too anxious unless their daughters have other signs of health problems. What Causes Irregular Periods in Teenagers? A girl’s menstrual cycle is the number of days from the beginning of her period to the start of the next period. During a menstrual cycle, one of the ovaries releases an egg in a process called ovulation. At the same time, hormone changes prepare the lining of the uterus to become thick in preparation for pregnancy. When the egg is not fertilized, the lining of the uterus sheds through the vagina resulting in a menstrual period. Irregular menses in teenagers is due to anovulatory cycles in which the body does not ovulate monthly. This is because the brain centers that regulate menstrual periods have not yet attained maturity. Illness, rapid weight change and stress can aggravate the situation and make the cycles more unpredictable. When should irregular periods be a concern? Teenagers should seek medical advice if her: • Regular menses becomes irregular • Menses suddenly stops for more than 3 months • Menstrual cycle is longer than 35 days • Menstrual cycle is shorter than 21 days • Menses lasts more than seven days • Bleeding between periods • Excess hair growth on the abdomen, face, or chin • Severe menstrual cramps, pain, or clots M thought the cause of her daughter’s problem was due to a recent bout of viral fever coupled with the stress from her studies. I treated her daughter with hormone and iron tablets. The bleeding stopped after 2 days. The menstrual cycle was regulated with medications for another 3 months. Her periods had returned to normal since then.

She kept spitting saliva into a plastic cup almost every 10 to 15 minutes with occasional belching. “Doc, I feel so miserable that I keep spitting the excess saliva. If I don’t spit it out, I feel choked in my throat, If I swallow it, I feel very nauseated. Is there any solution?” T, 30, a first-time mum, was 8 weeks pregnant. She had morning sickness earlier on which was aggravated by the excessive production of saliva a week ago. T was suffering from ptyalism, a rare condition in which there is increased salivation during pregnancy. Ptyalism in Pregnancy Ptyalism is an uncommon condition in pregnancy. The incidence varies significantly worldwide, from 0.08% of pregnancies , reported in the United States, to up to 0.3%, reported in Japan. Cause of Ptyalism Ptyalism usually occurs in women who are suffering from severe morning sickness called hyperemesis gravidarum. The exact cause remains unclear. It is speculated that changes in various pregnancy hormones may play a role. Some researchers believe there may be a psychological component as ptyalism is more common in psychotic women. Also, women who feel nauseous tend to swallow less, which allows saliva to build up in the mouth. The frequent vomiting may stimulate the salivary glands to produce more saliva to protect the irritation by the gastric juice on the mouth and throat. Symptoms of Ptyalism Symptoms include · Massive saliva volumes (up to 2 litre per day) · Swollen salivary glands · Sleep deprivation · Emotional distress · Social embarrassment Ptyalism usually resolves during the second trimester. But in some cases, it persists throughout the pregnancy. Treatment of Ptyalism There is no definitive treatment for ptyalism. Treatment modalities ranging from medications, hypnosis to dietary and lifestyle changes have not been successful. However, the following strategies aimed at helping patients swallow might help. These include: · Eating frequent small meals · Avoiding starchy foods · Frequent sips of water · Maintain good oral hygiene I reassured T that this disorder did not have any negative impact on the development of the baby and the obstetric outcome. She was able to cope with the inconvenience of frequent spitting as the pregnancy progressed. Fortunately, the symptoms stopped at 30 weeks and she delivered a healthy baby boy at term.