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She was inconsolably distressed and started crying when the tissue biopsy report of her cervix showed that she had a high grade precancer. J, 30, a mother of two came from an island of a neighboring country. She complained of excessive yellowish vaginal discharge for the last few months. It was not smelly and was not associated with itchiness or soreness. She had regular Pap smears in her country and was told they were normal. However, no HPV test was done. Vaginal examination revealed a small amount of yellowish discharge. The cervix appeared red and inflamed. Its surface bled slightly when it was swiped with a plastic brush to obtain cells for the pap smear. Pelvic examination and ultrasound scans of other pelvic organs were normal. Pap smear showed some abnormal cells suggestive of precancer of the cervix. HPV test was positive for types 16 and 18 which are high-risk HPV strains. She was advised to have a colposcopy examination with laser treatment. This was done by using a special telescope, called a colposcope, to examine abnormal areas in the cervix and a sample of tissue was collected for laboratory testing (biopsy). What is High-risk HPV? HPV is a group of more than 200 related viruses, some of which are spread through vaginal, anal, or oral sex. For the sexually transmitted HPVs, there are two groups: the low-risk and the high-risk strains. Low-risk HPVs usually do not cause disease. But a few can cause warts on or around the genitals, anus, mouth, or throat. High-risk HPVs can cause several types of cancer. There are about 14 high-risk HPV types including HPV 16 and 18. These two strains are responsible for 70 % of cervical cancer. (See also the article “Caught in Time: Cancer of Cervix” in the website) How Common is High-risk HPV? According to a local study of 2364 healthy women, one in four had been infected with high-risk HPV. The prevalence rate for women between 20 and 24 years old peaked at 49.1% but declined to 23% among women aged 30 to 49 years as most of the infections were cleared naturally. A small second peak of prevalence rate of 30% was observed among women above the age of 50 years old. This could be due to reinfection. What Is The Natural Progression of High-risk HPV Infection? HPV virus infects the cells of the cervix without much symptoms and approximately 90% of infections are cleared within two years by the immune system of the body. However, for some women, the infection lingers on and it is the persistent infection that causes cells to undergo precancerous changes. Studies have shown that only 5% of high-risk HPV infections will progress to high grade precancer within three years. Of these lesions, 80 % will regress and the remainder will go on to invasive cancer within five years if no treatment is done. J was more settled after I explained to her that her precancer had been treated and she did not have to have her uterus removed. She was still puzzled why previous pap smears could have missed her medical condition. I explained to her that the pap smear test was a screening test for abnormal cells on the cervix and the accuracy was only 60%. She was more reassured after that. On her review one year later, she remained well. She did not complain of vaginal discharge and the high-risk HPV strains were eventually cleared.

S,30, would like to forget the harrowing experience of her first delivery two years ago. She was at 39 weeks of gestation then. Early in the morning, she was woken up with labour pain which occurred every 10 minutes. While on her way to the hospital in the car, the pain became so frequent and intense that she felt there was no break in between the contractions. As soon as she reached the hospital, she had the sensation of bearing down with an urge to push. She was attended by the midwife immediately and a girl weighing 2.5 kg was delivered on the trolley during the transfer from the car. As she sustained multiple tears at her perineum and required many stitches, she had a more prolonged recovery than usual. S was a case of precipitous labour in which the baby was delivered within a very short period of time. What is precipitous labour? Precipitous labour is a condition in which labour and delivery occur within 3 hours after regular contractions. It is not a common occurrence and is estimated to happen in 1 to 3 per cent of deliveries. By comparison, a regular labour for mums who’ve never given birth before would last between 6 and 12 hours after regular contractions start and between 4 and 10 hours in those who have delivered a baby previously. What are the cause and risk factors for precipitous labour? The exact cause is not well understood. Risk factors include: History of precipitous labour Small baby with low birth weights e.g., prematurity or intrauterine growth restriction (IUGR) Mums who have delivered more than 5 babies before. Teenage pregnancy ·Hypertensive disorders of pregnancy (pre-eclampsia) or chronic hypertension Placenta abruption in which the placenta detaches too early from the uterus before the baby is delivered What are the signs of precipitous labour? Sudden onset of intense contractions Strong uterine contractions and pain Feeling of continuous uterine contractions with no break in between. Intense sensation of bearing down and the urge to defecate What are the complications of precipitous labor? There are no serious complications with precipitous labour most of the time. Occasionally, complications may develop. They include: Maternal complications: Retained placenta Lacerations of the cervix, vagina and perineum with heavy bleeding Postpartum hemorrhage from the vaginal tears or the failure of the uterus to contract (uterine atony) Shock from postpartum hemorrhage requiring blood transfusion Neonatal complications: Increased risk for infection if delivery happens in an unsterile environment Breathing difficulties from aspiration of amniotic fluid. Hemorrhage in the brain from a sudden change in pressure on the baby’s head during rapid expulsion During her subsequent pregnancy, S was seen at 8 weeks of gestion. Her antenatal course was uneventful. The length of her cervix was monitored regularly. It started to soften up around 36 weeks of gestation and began to dilate one week later. I suggested that she should have a planned delivery at 38 weeks when her cervix was open at 2 cm. She had an easy and normal delivery of her second daughter who weighed 3.2 kg.

S was in her second trimester of pregnancy. She was worried when she noticed that her baby was moving less and less. Her baby’s heart had stopped when she came for antenatal review at 26 weeks of gestation. S, 30, was diagnosed as an alpha thalassemia carrier when she was found to be anemic at the age of 18. Her husband,32, also suffered from the same medical condition. During the preconception check, she was forewarned that there was a 25 percent chance that her baby could end up as a stillborn if the baby inherited both their genes. What is thalassemia? Thalassemia is an inherited blood disorder that causes the body to produce a reduced amount of hemoglobin, a protein in the red blood cells that carries oxygen and nutrients to the cells in the body. Hemoglobin molecules are made of two components called alpha and beta chains. The production of these chains is determined by the genes. Any genetic mutations or changes will affect their production. In thalassemia, the production of either the alpha or beta chains are affected, resulting in either alpha-thalassemia (AT) or beta-thalassemia (BT). Depending on the severity, thalassemia is further classified in two forms: minor and major. How common is thalassemia in Singapore? In Singapore, about 3 to 9% of the population are carriers of the thalassemia gene. This means the risk of the child being born with thalassemia is much higher if both parents are carriers of the gene. What is alpha thalassemia (AT)? Four genes are involved in making the alpha hemoglobin chain, two from each of the parents. Severity of AT depends on how many genetic changes occur. In the severe form, all the 4 genes undergo mutation. This will result in stillbirth as in the case of S. What is beta-thalassemia (BT) Two genes are involved in making the beta hemoglobin chain. As in AT, if two genes undergo changes, symptoms of anemia will be severe. What could be the fetal and maternal complications of alpha thalassemia major (ATM)? Foetal complications: Alpha Thalassemia Major (ATM) is the most severe form of AT, in which both parents pass the defective genes to the fetus. The fetus will suffer from severe anemia and die from heart failure with accumulation of excessive fluid around the heart, lungs, intestines, abdomen as well as the skin and placenta. The baby appears swollen all over and is called hydrops fetalis. Maternal complications In severe ATM with hydrops fetalis, the mother may be at risk of maternal mirror syndrome, where the mother's condition mimics that of the sick fetus. The mother develops symptoms such as vomiting, hypertension, swelling of the hands and feet, passing protein in the urine and pulmonary edema (fluid in the lungs). The condition, though uncommon, may require delivering the fetus immediately. Can ATM be diagnosed by prenatal tests? If both parents are carriers of AT, prenatal tests can be done during early pregnancy. They are: 1. Chorionic villus sampling (CVS): The placental tissues are sampled at 10 to 13 weeks of pregnancy for molecular testing. 2. Amniocentesis: Cells in the amniotic fluid are taken at 14 to 20 weeks of pregnancy for analysis. S and her husband were referred for genetic counselling before conception. They were aware of the possibility of a negative pregnancy outcome. However, because of religious reasons, they opted not to do the prenatal test. After she was informed of her foetal demise, she decided to have the labour induced and delivered the hydropic baby weighing 1 kg.

R, 29, had just recovered from a mild Covid infection with a scratchy throat and cough 2 weeks ago. She was shocked to experience severe abdominal pain during the first and second days of her first menstrual period after recovering from the illness. She was also passing out lots of blood clots. Prior to her Covid infection, her periods had been very regular, occurring every 28 to 30 days, without any symptoms. During the past 2 years, some women have reported changes in their menstrual cycles for months after the infection. Others have also noticed disruptions in their menses following Covid vaccination. What are some of the changes to women’s periods following covid infection? They include: Heavy bleeding Reduced amount of bleeding Intermenstrual bleeding(bleeding between periods) No menstruation Shorter or longer cycle Acute abdominal pain How does Covid virus affect menstrual cycle? The menstrual cycle is controlled by a number of hormones regulated by the hypothalamus and pituitary gland in the brain together with the ovaries. In severe illness, such as Covid, the body would temporarily stop ovulation and channel the energy towards fighting off the infection. The menses will thus stop for a while and return to normal after the patient recovers. Covid can also cause massive inflammatory responses in the body, which in turn will cause disturbances in menses. It has also been suggested that the virus may enter the ovarian cells directly and affect the production of sex hormones. A study published in 2021 comparing the menstrual cycles of 237 patients with COVID to their cycles from beforehand found that 18% of mildly ill and 21% of severely ill patients had longer cycles with reduced amounts of menstrual flow. The suppression of ovarian function however is only transient and menses quickly returns to normal within 2 months after recovery. Can Covid vaccination affect menstrual cycle? Women vaccinated against COVID-19 have reported disruption of their menstrual cycle. An earlier study published in the British Medical Journal (BMJ) was unable to find a conclusive connection. A recent study, however, looked at two groups of women (about 2,400 women who received vaccines and about 1,600 who remained unvaccinated) over six menstrual cycles to see how vaccination changed cycle length. Overall, vaccination was associated with an increase of about one day in the cycle length. Emerging data also suggest that patients with endometriosis and PCOS are more likely to have the cycles disrupted by the vaccines though the effects may be temporary. Conclusion It appears that COVID infection and vaccines can cause disruption in the menstrual cycle. Stress caused by the pandemic may possibly also play an important role in causing such disturbances. Fortunately, studies so far have suggested that these changes appear to be transient and menstrual cycles seemingly return to normal after a few months for many women.

She was pleasantly surprised when her eczema, a skin condition with periodic outbreaks of red and itchy rashes, improved remarkably after she was given probiotics. Q, 30, a first-time mum was in her first trimester of pregnancy. She noticed that the frequency of flare-ups was reduced and the intensity of itchiness was much less. She had since cut down the usage of moisturizer and steroid creams prescribed by her dermatologist. What are probiotics? Our body contains trillions of microorganisms or microbes. These microbes are composed of bacteria, fungi (yeasts), viruses and protozoa. Probiotics are good microbes that reside mainly in the gut (mostly large intestines). Other locations include: mouth, urinary tract, skin, vagina and milk. They keep our body healthy by fighting off bad microbes and supporting our immune system. They also help digest food, destroy disease-causing cells and produce vitamins. Common probiotics are two groups of bacteria called Lactobacillus and Bifidobacterium and fungi, Saccharomyces boulardii. Probiotics can also be found in foods like yogurt, kefir, tempeh, and kombucha. They can thus be taken as nutritional supplements. According to the National Center for Complementary and Integrative Health of the USA, probiotics are one of the most commonly consumed dietary supplements for adults. What are the benefits of taking probiotics in pregnancy? Studies have shown that probiotics confer considerable health benefits to pregnant mothers and the newborn by reducing the incidence of some obstetrical complications. These include: Eczema: Probiotic supplements have been found to significantly reduce the incidence of eczema during pregnancy in mothers as well as babies. The World Allergy Organization recommends probiotic use in pregnancy and infants with a family history of allergic disease. Gut health: Taking probiotics during pregnancy may improve gut bacteria composition and digestive health and may help reduce symptoms of nausea, vomiting and constipation. Gestational obesity: Maternal obesity and excessive weight gain during pregnancy, are related to increased obstetrical complications. Studies have shown that in obese mums and in those who put on a lot of weight during pregnancy, there is an imbalance of the microbes in the intestine with a reduction of good bacteria. Probiotics may correct the imbalance and help rectify the metabolic disorder. Gestational Diabetes: Research studies have found that the use of probiotics during pregnancy reduced blood sugar and insulin levels. Treatment with probiotics during pregnancy may reduce the risk of development of gestational diabetes, especially in women over the age of 35 years and those who previously had the condition. Premature birth: A 2020 review found that the length of pregnancy was significantly longer in those taking probiotic supplements, compared with those receiving placebo treatments. Scientists also found that those who took probiotics had a significantly reduced risk of death from necrotizing fasciitis, a rare but life-threatening infection that can occur during pregnancy. Pre-eclampsia: Imbalance of gut microbe has been implicated in pre-eclampsia with dominance of bad bacteria. Administration of probiotics may reduce the risk. Mental health: There is limited evidence that probiotics may reduce depression and anxiety during pregnancy and after delivery. Are probiotics safe? Recent studies have found that probiotics are safe when given during pregnancy and breastfeeding. There have been no adverse outcomes to both the mother and the baby. Q was happy to continue consuming the probiotics and is waiting for the new arrival in a few months’ time.

N,31, was slightly taken aback when I showed her the ultrasound image of the moving foetus inside her womb. She had just delivered a girl seven months ago and was still breastfeeding. “Doc, how can it be?” she asked. “My mum told me that I would not get pregnant if I am breastfeeding.” Myths concerning fertility after delivery are common: from old wives’ tales that it is impossible to get pregnant while breastfeeding to beliefs that the body will not get pregnant until it is “ready.” When would ovulation occur after delivery? Ovulation is a prerequisite for pregnancy. Research studies have found that women ovulate for the first time between 45 to 94 days after giving birth. Most women do so around 6 weeks after childbirth. However, if they breastfeed, ovulation will be delayed as the elevated levels of milk producing hormone, prolactin, will suppress another pituitary hormone, follicular stimulating hormone (FSH), which will then inhibit the development of eggs in the ovaries. Breastfeeding thus has a contraceptive effect. How effective is breastfeeding as a contraceptive method? Using breastfeeding as a method for birth control is known as lactational amenorrhea method (LAM). Its effectiveness depends on the intensity and frequency of infant suckling and the extent to which supplemental food is added to the infant's diet. If the mother breastfeeds exclusively at regular intervals, the method is 98% effective for the first 6 months after delivery. To achieve such high effectiveness, certain criteria must be met. They are: Supplemental food to the infant should not exceed 5% to 10% of total feedings. Breastfeeding must be done every four hours during the day and every six hours at night. Supplementing with other forms of nutrition, expressing the breast milk by hand or by pump will reduce the effectiveness of LAM as prolactin levels may not be high enough to suppress ovulation. After 6 months or with the resumption of menstruation, the contraceptive efficacy of LAM is lower and is estimated to be around 94% at one year after birth. With weaning, prolactin levels decline and ovulation resumes within 14 to 30 days. How useful is LAM? LAM is useful as a temporary method of contraception and for child-spacing. It is most appropriate for women who plan to fully breastfeed for at least 6 months. Women who choose to use this method require proper counseling during pregnancy to improve efficacy. If the mother decides to supplement breastfeeding or if she begins menstruating before 6 months postpartum, other methods for contraception should be used. N decided to continue with the pregnancy but was apprehensive whether breastfeeding would cause her to have a miscarriage or premature birth. I reassured her that it would not be a problem to continue doing so. With the support of her husband, N continued to breastfeed her daughter and is awaiting the arrival of her new baby in a few months’ time.

Tearing with joy and looking slightly exhausted, she hugged her husband tightly and exclaimed happily, “I have done it finally!” M, 30, had just delivered her second child normally. Looking slightly dazed, her husband kissed her repeatedly and congratulated her for achieving a natural birth, which she had desperately wanted to. Two years ago, M delivered her first child in another hospital by an emergency Cesarean section (C- section) because of fetal distress. Her baby had pooped inside the womb during the early stages of labour. “Doc, would you let me try for a vaginal delivery?” she pleaded with me at her first consultation. M’s antenatal course was uncomplicated. She was of average height with a roomy pelvis. The fetus was assessed to be about 3 kg at term with a head-down position. After discussing the pros and cons of VBAC with the couple, I gave her the go-ahead for vaginal delivery which she believed would heal her emotional wounds from having undergone a C-section for her previous pregnancy. Prevalence of VBAC According to the 2018 data from the Centers of Disease Control and Prevention (CDC) of USA, 13 % of pregnant mums had VBAC. There is no local statistics. Advantages and Risks of VBAC Advantages Relatively safe in selected cases Avoidance of surgical and anaesthetic complications of C-section Shorter recovery time Option to have another vaginal delivery in subsequent pregnancies Reduction of the risks of multiple Cesarean deliveries, the most serious of which is placenta accreta spectrum disorder (PAS) Positive impact on the emotional wellbeing of the couple Risks Uterine rupture The most serious risk of VBAC is uterine rupture in which the scar from a previous C-section gives way under the pressure of contractions. The incidence of uterine rupture is about 0.5% -1% after one previous lower segment C-section, and 4–9% after a previous classical cesarean section. The resulting tear, if it rips through all layers of the uterus, can be life threatening for both the mother and the baby. Up to 30% of babies may die or suffer permanent brain damage. What are the warning signs and symptoms of imminent uterine rupture? These include: Severe abdominal pain Vaginal bleeding Rapid and rising maternal pulse Sudden nausea and vomiting A drop in the fetal heart rate by electronic monitoring Assessing the suitability of VBAC VBAC is not for everyone. The following conditions may not be suitable for VBAC Classical C-section where the scar is in the upper part of the uterus Previous uterine surgery e.g., fibroid removal. This may result in weakening of the muscle wall of the uterus History of prior uterine rupture Obstetric complications: e.g., severe pre-eclampsia Medical conditions Chance of a successful VBAC? If there are no contraindications, the chance of a successful VBAC resulting in a natural delivery may be up to 60–70%. M had spontaneous labour at 39 weeks of gestation. Labour commenced with a “show” and regular contractions. Her labour progressed smoothly and she delivered a healthy baby boy 5 hours after admission with the help of a vacuum cup.

In the last few months, the Omicron variant of the coronavirus has spread across the world and caused a rapid increase in the number of new infections. According to the Straits Times (Jan 26, 2022) about 70 percent of daily cases are now of that strain, which has become the dominant variant in place of Delta. The proportion could actually be closer to 90 percent. The Omicron peak may exceed that of Delta and hit 20,00 to 25,000 cases a day. What are the symptoms of Omicron in pregnant patients? Omicron is highly contagious, spreads very easily, and could evade vaccines as well. It has an incubation period of roughly three days, according to a recent study. For most people, Omicron appears to cause milder illness. Symptoms are similar in pregnant as well as non-pregnant patients. They include: Sore throat Fever Body pain Running nose Fatigue Cough Sneezing Loss of smell or taste is less common with Omicron Can Omicron cause more severe disease in pregnant women? Scientists found that Omicron replicates more rapidly in the upper respiratory tract than in the lungs and thus produces milder infection. Nonetheless, pregnant mothers, being in a “low immunity” state, are more vulnerable to get severe disease. Unvaccinated pregnant mothers have three times the risk of being hospitalised or needing ICU-level care and twice the risk of needing ECMO [major organ support] or dying if they contract Covid-19. A recently published study in Scotland found that 98 percent of pregnant patients who were admitted to the ICU for critical care were unvaccinated. Locally, Health Minister Ong Ye Kung, in a Facebook post on Sept 29, said that more than 85 percent of pregnant women hospitalised with Covid-19 were not fully vaccinated. Among them, about 20 per cent needed oxygen supplementation, and another 10 per cent needed high dependency care or care in the intensive care unit (ICU). With vaccination, researchers found that mothers with Omicron infections were less likely to have medical intervention than those with Delta infections. What are the maternal and foetal complications of omicron infection? Regardless of variant, pregnant mothers with Covid-19 are at increased risk of getting complications. They include： Preeclampsia: The high blood pressure usually develops after 20 weeks of pregnancy Eclampsia: A life-threatening condition when convulsions occur in a pregnant woman suffering from high blood pressure, often followed by coma HELLP syndrome: A medical emergency that affects the blood and liver. ICU admission especially if patient has shortness of breath, chest pain, and cough with fever Infections Maternal death Foetal complications include: Premature birth Foetal growth restriction Stillbirth Neonatal death How can pregnant women protect themselves from the Omicron variant? Besides wearing masks, practising good personal hygiene and restricting social interactions, the most important way for pregnant mums to reduce chances of getting serious illness from Omicron is to get vaccinations and booster shots. There is robust data to show that the vaccines are safe and effective in all stages of pregnancy and have been endorsed by major medical institutions worldwide. Over 170,000 pregnant women in the US have received an mRNA vaccination (either Pfizer BioNTech or Moderna) and there have not been any safety concerns raised. Booster shots of mRNA vaccines are 90 percent effective against hospitalisation with Omicron, according to the Centres for Disease Control and Prevention (CDC) of the USA. In summary, though Omicron is messaged globally as a mild variant, it is still a dangerous virus. Pregnant mums, being a vulnerable group, are encouraged to get vaccinated and have booster shots, both to protect themselves and others. Let us not be complacent and let our guards down.

She was breathless when she shuffled her way slowly into the consultation room. Her feet were swollen from ankles up to the legs. After climbing up the examination couch with some difficulty and pointing at her huge tummy, she asked, “Doc, can I deliver my baby soon?” N,32 and a first-time mum was at her 36 weeks of gestation. There was no history suggesting viral infection during her antenatal period. She was not a carrier of thalassemia and her blood group was O Rh+ve. Glucose tolerance test was normal and blood tests for rubella( German Measle), syphilis and toxoplasma were negative Non-invasive prenatal test (NIPT) was normal. Ultrasound scan for foetal anomalies at 22 weeks gestation did not reveal any obvious structural defects. Foetal weight was average and the amniotic fluid index (AFI) was normal. However, during the growth scan at 32 weeks of gestation, the amniotic fluid was noted to be excessive with an AFI of 28. N was suffering from a condition called polyhydramnios. What is polyhydramnios? Amniotic fluid is a clear liquid that surrounds the foetus inside the womb. It promotes foetal growth, helps develop its lungs, keeps a constant temperature around the baby and acts as a protective cushion for the baby. The amount of amniotic fluid is greatest at about 34 weeks of gestation when it averages 800ml. At 40 weeks of gestation, the level drops down to about 600ml. Polyhydramnios occurs when the volume of amniotic fluid exceeds normal levels. It is present in about 1 to 2 percent of pregnancies. Most cases are usually mild and result from a gradual buildup of amniotic fluid during the second half of pregnancy. But in severe cases, major complications to the mother and baby can appear. What are the causes of polyhydramnios? In 50-60% of severe cases, the cause is unclear. Some of the known causes include: · A birth defect that affects the baby's digestive or central nervous system · Maternal diabetes before or during pregnancy · Big baby · Twin pregnancy · Foetal anaemia: A lack of red blood cells in the baby · Blood incompatibilities between mother and baby · Infection during pregnancy What are the symptoms of polyhydramnios? Mild polyhydramnios is generally innocuous. In severe case, the symptoms include · Shortness of breath or discomfort in breathing · Swelling in the lower extremities and abdominal wall · Uterine discomfort or contractions · Difficulties or discomfort in urination · Swollen vulva How is polyhydramnios diagnosed? Polyhydramnios is diagnosed by ultrasound examination. There are two ways of measuring amniotic fluid: amniotic fluid index (AFI) or maximum pool depth (MPD). They have fairly similar diagnostic accuracy. However, AFI is more commonly used. AFI is calculated by measuring the maximum vertical pocket of fluid in four quadrants of the uterus and adding them together. An AFI of 25 cm or more indicates polyhydramnios. Complications of polyhydramnios Polyhydramnios is associated with the following complications: Prematurity: excess amniotic fluid can trigger preterm labour or premature rupture of membranes and increase the chances of a baby being born prematurely. Big baby: Polyhydramnios is commonly associated with big babies. This may lead to increased incidence of caesarean section and /or birth trauma during vaginal delivery. Placental Abruption: The placenta prematurely separates from the wall of the uterus before delivery resulting in foetal asphyxia Foetal Malposition: With too much fluid in the womb the baby may assume various positions instead of the normal head-down position during delivery. Umbilical Cord Prolapse: This is the most dangerous complication when the umbilical cord drops into the vagina ahead of the baby. Postpartum haemorrhage: Heavy bleeding can occur from lack of uterine muscle tone after delivery How is polyhydramnios managed? In the majority of cases, no medical intervention is required. If the mother feels breathless, drainage of the amniotic fluid or amnioreduction can be considered. However, this may cause infection and placental abruption. Medications like indomethacin may be used to reduce foetal urine output. But due to the risk of foetal heart problems, it is not recommended after 32 weeks of gestation. Timing and mode of delivery will depend on the stage of pregnancy, foetal position and presence of complications. As the foetus was lying horizontally across the mother’s abdomen (transverse lie) N was advised to have a caesarean section. A healthy baby boy weighing 3 kg was delivered. A nasogastric tube was passed down the baby's food passage to ensure there was no blockage before feeding. Both the mother and child were discharged well 3 days after the operation.

Her eyes were red and tears were rolling down her cheeks when I told her that her blood level of B-HCG, (pregnancy hormone), was declining. A week ago, she was elated and thrilled when she discovered that she was pregnant after she underwent intra-uterine insemination of sperm (IUI) for the first time. N, 39, a housewife was married for 5 years and had been trying actively to conceive since marriage. She had failed IVF 3 times in the past 2 years. It was a roller coaster ride and she was emotionally spent and went into a period of depression. Encouraged by her spouse, she came for a consultation to find out more about IUI. Physical and ultrasound examination revealed that her reproductive system was normal. Semen analysis of her spouse was also normal. The couple was suffering from unexplained infertility, a condition in which no identifiable cause can be found with normal fertility tests. Superovulation and IUI were discussed and N was counselled on the risks and success rate of the procedure. (Please refer to SO-IUI on the website). Her blood level of B-HCG was 450 IU/L sixteen days after IUI. This was increased to 920IU/L two days later. On her next review after a week, the level dropped to 864 IU/L which was further reduced to 439 IU/L the next day. Vaginal ultrasound examination did not reveal any gestational sac. N was having a very early miscarriage, otherwise known as a chemical pregnancy. What is a chemical pregnancy? A chemical pregnancy is a very early miscarriage. The fertilised egg is able to produce enough B-HCG to cause a positive pregnancy test but fails to implant completely into the womb. This usually takes place around 5 weeks of gestation and the pregnancy sac cannot be seen by ultrasound examination. How common is a chemical pregnancy? Chemical pregnancy is fairly common. The reported incidence varies between 8% to 75 % of all conceptions. The wide variation is due to the fact that the exact number of chemical pregnancies is difficult to estimate because many of these pregnancies end without any symptoms. Most women who have a chemical pregnancy would never know that they had been pregnant and treat it as “delayed periods”. What could be the symptoms of chemical pregnancy if any? Delayed period Spotting a few days before period is due More menstrual cramps than usual Heavier menses with clots than usual What are the causes of a chemical pregnancy? The causes of a chemical pregnancy are about the same as those of other miscarriage (please refer to “losing a baby” in the website). But in most cases, the miscarriage is due to problems with the embryo, possibly caused by a defective sperm or egg. What is the treatment of a chemical pregnancy? As chemical pregnancy occurs very early after conception, no medical treatment is required. However, emotional support by the spouse, family and friends is important in the grieving process of the patient. N felt a sense of grief and loss. I told her that these feelings were normal. She was advised to allow herself to grieve at her own pace and in her own way. She was encouraged to communicate her feelings openly with her husband, who was very supportive to her emotional needs. N decided to take a break before deciding her next move on fertility management.

She was woken up in the morning by a sharp pain in her left breast. She was shocked to see a large, red and tender swelling in the upper half of her breast. She felt slightly feverish and had chills. K, 30, a first-time mum, had delivered her baby normally a month ago. Breast feeding was relatively easy. Her baby latched to her breasts well. Milk started flowing on the third day with ample supply and smooth flow. On examination, there was a red, hot, tender fan-shaped swelling spreading from the nipple to the upper part of her left breast. The surrounding skin was tight and thickened. Her temperature was elevated at 38 degrees Celsius. K had inflammation of the breast-a condition known as lactation mastitis. What causes lactation mastitis? Mastitis is fairly common during the first 6 months of breastfeeding. It often happens when bacteria from the skin surface or baby’s mouth enters the breast through the nipple. This occurs more frequently if the mother has a cracked or sore nipple. Mastitis can also result from a clogged milk duct due to incomplete emptying. The blockage causes the milk to get trapped and stagnated. This provides a good fertile ground for bacteria to breed. What are the signs and symptoms? As in the case of K, symptoms of mastitis can appear suddenly. They include: Hot, tender swelling of breast, Skin redness, often with an inverted triangular pattern with the lowest angle pointing towards the nipple, A breast lump may appear if pus starts to collect, Fever, chills and body aches, Painful lymph nodes in the armpit next to the infected breast. What are the risk factors? They include: Sore or cracked nipples, Too long an interval between breastfeeding, Wrong or improper breastfeeding techniques, Incomplete emptying of the breast from anxiety, being stressed or overly tired, Poor nutrition, Previous history of mastitis. What could be the consequences? Mastitis that is not adequately treated can lead to breast abscess when pus starts to collect. Surgical drainage may be necessary. Lactation mastitis also makes the mother feel tired and run down. This may make it difficult for her to care for her baby. She may quit breastfeeding altogether or wean her baby off prematurely. How is mastitis treated? Mastitis usually responds to antibiotics, which will not harm the baby. A full course has to be taken. If initial treatment doesn't work, a sample of the milk may be sent to the laboratory for culture and sensitivity testing so that appropriate medication can be given. Other measures include: Encouraging the mother to drink plenty of fluid, Applying hot or cold compress to the affected breast just before breastfeeding and hand-expressing or pumping of milk if necessary, Giving pain killers before massage, Massaging the affected breast from the periphery of the breast towards the nipple after placing a hot wet towel over the affected area for 10-15 minutes, Breastfeeding from the affected breast first so as to move the milk through the breast faster, Having ample rest between feeds. K was treated with antibiotics and some anti-inflammatory drugs. Fortunately, her mastitis which was due to blocked ducts responded. The lactation consultant helped her to clear the blockage by doing deep massage using the knuckles while she was breastfeeding. K was also encouraged to feed the baby more frequently. Cold cabbage leaves were used to cover the affected breast between feeds to relieve inflammation and pain. The mastitis gradually subsided after two days. K was able to continue breastfeeding her baby for over 12 months.

I am 52 years old and have been menopausal for 2 years. Recently, I had indigestion and experienced a bloated feeling in my tummy. I had little appetite and lost some weight. In addition, I also had a little vaginal bleeding. I have not had any history of gastric discomfort in the past. My friend suggested that these symptoms could be attributed to those of ovarian cancer. Could you tell me what are the symptoms of ovarian cancer? What should I do? Ovarian cancer is a silent killer. In its early stage it rarely has any symptoms while at the advanced stage it may cause a number of nonspecific symptoms that are often mistaken for more common benign conditions, such as gastric discomfort, constipation or “sensitive” irritable bowel. Symptoms of ovarian cancer include: Fullness or swelling of the tummy Stomach upset or indigestion Weight loss · Discomfort or pain in the lower tummy Changes in bowel habits, e.g. constipation Frequency and urgency in urination Menstrual irregularity or abnormal vaginal bleeding These symptoms are also commonly caused by non-cancerous conditions as well as by cancers of other abdominal organs. When they are caused by ovarian cancer, they tend to be persistent and represent a change from the norm. The symptoms usually become more severe as the tumour grows. By then, the cancer is usually spread outside the ovaries and make it much harder to treat. It is easy to overlook the symptoms of ovarian cancer. If your symptoms persist for a while, you should consult your gynaecologist early.