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S, a 29-year-old nurse was both excited and worried when she was pregnant. Excited, because this was the first time she was on her way to motherhood. Worried, as she knew that she might encounter many potential complications during her pregnancy. S was married for about a year. She was diagnosed as having lupus 3 years ago when she was admitted to the hospital because of fever, joint pains and “butterfly” rashes over her face. She was treated with medications by the rheumatologist. Except for a few episodes of “flares”, she was in remission for the past six months. What is lupus? Lupus, medically known as Systemic lupus erythematosus (SLE), is a chronic autoimmune disease in which the immune system cannot distinguish the difference between healthy cells and foreign invaders, causing it to attack its own tissues and resulting in widespread inflammation and tissue damage in the affected organs. The organs affected are usually the joints, skin, brain, lungs, kidneys, and blood vessels. Causes of Lupus The causes of SLE are unknown, but are believed to be linked to environmental, genetic, and hormonal factors. Complications during pregnancy Because of improved treatment of SLE over the past decades, more women are getting pregnant during the remission stage. However, pregnancy complications are much higher compared with healthy women. Complications in the mother include: Disease flares Flares (exacerbation of symptoms) of SLE can occur during pregnancy in about 10 to 30 % of cases. They are more common in younger patients and often present during the first or second trimester or during the first few months after delivery. Most flares are mild and can be easily treated with small doses of steroids. Preeclampsia (hypertensive disease in pregnancy) Occurs in about 15 to 30 % of patients. It may occur more frequently among women with “flares” or in women with kidney disease. A daily low-dose aspirin during pregnancy may reduce the risk of preeclampsia. Kidney impairment Kidney damage caused by SLE may cause further deterioration of kidney function. Premature delivery There is an increased risk of premature birth and is related to the severity of the disease Foetal loss Miscarriage and stillbirth rates are higher with SLE especially if the mother has preeclampsia, active lupus or kidney damage. Low birth weight baby Kidney complications, high blood pressure, premature birth or "premature rupture of membranes" (when the water breaks before contractions begin) all contribute to this complication. Complications in the new-borns: The most serious complication of neonatal lupus is complete heart block in which the baby is born with an abnormally slow heart rate. Sometimes, the baby may have neonatal lupus with rashes on the scalp and around the eyes. The rash almost always resolves by six to eight months of age. Most of these infants do not develop SLE in later years. S and her husband were aware of the complications. She decided to take sabbatical leave. Working together with the rheumatologist, her pregnancy was monitored closely with blood and urine tests and regular ultrasound examination. Her kidney function remained normal. At about 34 weeks of gestation, her blood pressure started to get elevated. Labour was induced at 37 weeks of gestation and she delivered a healthy girl normally.

Soya milk and tofu were the staple food for G, a 34-year-old teacher and a vegetarian. She was getting married soon and came for a preconception check. She was keen to get pregnant after marriage because of her age. But she was confused and in a dilemma as her friend advised her to cut off soy completely in her diet as it might affect her chances of conception. She was not totally convinced until she read some negative reports of the effects of soy on fertility in some female magazines. “Will taking soy products make it difficult for me to conceive?” she asked. G appeared healthy on examination. Her BMI was normal at 22. Her menstrual cycles were regular, occurring once every 30 days and lasting 4-5 days. There was no menstrual pain or abnormal vaginal discharge. Examination of the reproductive organs was normal. This was confirmed by an ultrasound scan. Her husband, 36, was an accountant. He did not smoke or drink and exercised regularly with G at the gym about two to three times a week. His semen analysis was normal with good sperm count, normal sperm motility and morphology. What is soy? Soy is a popular food in Asia. It belongs to the pea family and is rich in protein, polyunsaturated fats, fibre, vitamins, and minerals. Soy products such as tofu and soya milk have been consumed by vegetarians as a main source of protein all over the world Soy and female fertility There is a controversy regarding the effect of soy on the fertility of both men and women. This arises because soy contains compounds called isoflavones which are plant-derived female hormones. They can exert a weak effect on human body and have been shown to reduce fertility in experimental animal studies. In humans, a few clinical studies have shown that taking isoflavones can reduce the levels of pituitary hormones which may then affect the growth of the egg and ovulation. But the quantity of soy taken in those studies is very large and many times more than the normal dietary consumption. Other studies, however, suggest the exact opposite, that soy consumption may have a positive effect on fertility. A large study of more than 116,000 female nurses aged 25-42 years old, called the Nurses Health Study II, has shown that excessive animal protein intake was associated with decreased fertility. Addition of tofu improved the fertility outcome, thus supporting the benefits of soy. Another recent study (2015) of 315 women presenting in an infertility clinic in Massachusetts also found that intake of soy foods was positively related to the probability of having a live birth during in vitro fertilization treatment. General consensus among the clinicians is that eating a moderate amount of soya does not affect female fertility and is safe for women trying to conceive. Soy and male fertility The worry that soya products reduce male fertility arose in 2008 when researchers from the Harvard School of Public Health in Boston found that regular consumption of these foods may lower the sperm count. They studied 99 men from infertile couples. They found that the men who ate soy foods had, on average, 41 million fewer sperm per ml than men who didn’t eat these foods. But there were no changes observed in other parameters. The conclusions from this study are not definitive. On the other hand, a number of studies, in which controlled amounts of isoflavones from soy were fed to human subjects, have found that the compounds have no effect on the quantity, quality or motility of sperm. All in all, there is not enough evidence to suggest that soy influences sperm count and reduces male fertility. G and her husband listened attentively and appeared satisfied with my explanation. She continued to eat her normal diet and came back to see me with a positive pregnancy test 3 months after her marriage. She is currently awaiting the arrival of her baby in a few weeks’ time.

M, a 16-year-old student was shocked when she found a small amount of whitish discharge oozing out from her nipples when she accidentally pressed on them while bathing. Upset and disturbed, she went and told her mother who brought her to see me the next day. M had her first menstruation at the age of 12. Since then, it had been irregular, occurring every two to three months. For the past six months, she had had no “proper” menses except for some spotting on and off. She did not pay much attention and did not inform her mother. Physical examination revealed a small amount of milky discharge from her nipples on squeezing. Gynaecological examination did not show any abnormalities. Examination of the eyes was normal. The blood prolactin (milk hormone) level was elevated about two times that of the normal. MRI of the pituitary gland showed a small tumor about 3mm in size. M was suffering from a prolactin-secreting tumor of the pituitary gland called prolactinoma. The pituitary gland is a pea-sized hormone-secreting organ attached to the base of the brain. It controls the growth, the development and the functioning of other hormone-secreting glands in our body including the ovaries. Prolactinoma is noncancerous. Based on the size of the tumors, those that are less than 10mm are known as microprolactinoma and those beyond 10mm, macroprolactinoma. The tumor causes the pituitary gland to produce excessive prolactin which stimulates breast milk production and suppresses ovulation. How common is prolactinoma? Prolactinoma is the most common benign hormone-producing tumor of the pituitary gland, making up to 40% of the total number. Studies have estimated that it occurs in about 3 per 10,000 women and is most often seen in the age group 25 to 34 years. Cause of prolactinoma The exact cause of prolactinoma is poorly understood. Symptoms and signs of prolactinoma Prolactinoma may not cause any noticeable signs or symptoms when small. However, excessive prolactin in the blood may result in the following symptoms: Irregular menstrual periods or no menstrual periods Milky discharge from the breasts when not pregnant or breast-feeding Painful intercourse due to vaginal dryness Loss of interest in sexual activity Infertility When the tumor gets larger, it may press on the surrounding structures in the brain, resulting in symptoms that include: Headaches Vision changes-visual field deficits, blurred vision, decreased visual acuity Seizure Diagnosis and Management of prolactinoma Diagnosis of prolactinoma is by the elevated blood levels of prolactin and is confirmed by the MRI image of the pituitary gland. Treatment is by using oral medications such as dopamine agonists. Cabergoline and bromocriptine are the two commonly used drugs. M was put on bromocriptine. She tolerated the medication well. The milk secretion stopped after a month and her menstruation returned to normal after about 3 months of medication. She had been on the medication since and was being monitored periodically for her blood prolactin levels which had remained normal since.

D, a 37 year-old nurse, was surprised and puzzled when I prescribed aspirin for her present pregnancy. She was at 13 weeks of gestation. “Doc,” she asked, “isn’t aspirin used for headache and for patients recovering from a stroke or heart attack? Why is it given during pregnancy?” In her first pregnancy 2 years ago, she had severe pre-eclampsia at the last trimester of pregnancy. An emergency Caesarean section was performed at 34 weeks gestation to prevent serious life-threatening complications to the mother and the foetus. Fortunately, her baby weighing 1.2 kg survived albeit staying in the neonatal intensive care unit for a while. I explained to her that low-dose aspirin was given for two reasons. It relaxes the uterine blood vessels and keeps the flow of nutrients and oxygen to the baby. It also delays and prevents the onset of pre-eclampsia. What is Pre-eclampsia? Pre-eclampsia is a pregnancy complication characterized by high blood pressure, protein in the urine and swelling in the legs, face and hands. It affects about 10 per cent of first pregnancies and the symptoms and signs usually begin after 20 weeks of pregnancy. Left untreated, pre-eclampsia can lead to serious and even fatal maternal consequences such as stroke, seizure, as well as kidney, liver and heart failure. The baby may die from premature birth, early separation from the placenta and asphyxia. The growth of the baby is also affected from malfunction of the placenta. The cause of pre-eclampsia is still unknown. Medical conditions such as hypertension, kidney disease and diabetes are associated with a higher risk of developing pre-eclampsia. How does aspirin help in pre-eclampsia? Research studies have suggested that low-dose aspirin helps prevent or delay the onset of pre-eclampsia in 2 ways: 1. It inhibits thromboxane, a hormone that raises blood pressure and is elevated in women with pre-eclampsia. 2. Aspirin also improves blood flow across the placenta, by dilating the uterine arteries. Inadequate placental blood supply plays a key role in initiating pre-eclampsia. According to a comprehensive review of the scientific evidence by the USPSTF(U.S. Preventive Services Task Force) in 2014, prenatal aspirin has been shown to reduce the risk of pre-eclampsia by 24%. Risks of taking low-dose aspirin in pregnancy Maternal Risks: Scientific studies have shown that consumption of low-dose aspirin during pregnancy does not increase the risk of bleeding complications such as early placental separation and postpartum hemorrhage. Fetal Risks: Several systematic reviews have shown intake of aspirin does not increase the risk of congenital anomalies. There have been no adverse fetal or neonatal outcomes. Recommended use of prenatal use of low-dose aspirin According to the USPSTF guidelines for the prevention of preeclampsia which is supported by the American College of Obstetricians and Gynecologists, low-dose aspirin (81 mg/day) as prophylaxis is recommended in women at high risk of preeclampsia and should be initiated between 12 weeks and 28 weeks of gestation (optimally before 16 weeks) and continued daily until delivery. The criteria for high-risk patients include: History of severe pre-eclampsia Multiple pregnancy Chronic hypertension Type 1 and 2 Diabetes Kidney disease Autoimmune diseases e.g. SLE D understood the benefits of taking low-dose aspirin to reduce the risk of pre-eclampsia, premature birth and intrauterine growth restriction in her present pregnancy. She took the medication with good compliance. Her antenatal course remained uneventful with normal blood pressure. She opted for a repeat cesarean section at 38 weeks gestation and delivered a healthy normal baby boy weighing 3 Kg.

N gazed worriedly at the monitor screen while I searched intensely for the foetal heart beat by moving the ultrasound transducer around on her lower abdomen. This was her second antenatal visit at 12 weeks of gestation. My heart sank when I could not see any flickering on the screen. After 15 minutes of search, I finally told N and her husband the bad news. Her baby had passed on. “Doc, I can’t understand this. I didn’t bleed. I didn’t feel any pain. I still have the sore breasts and morning sickness,” she started to sob uncontrollably. “Could it be that I went cycling and jogging the last few days? Could that have caused the miscarriage?” she asked.  During her first antenatal visit 3 weeks ago, her baby’s heart was flashing clearly on the screen and N could hear and see her baby’s heart beating. N was suffering from a silent miscarriage, known medically as “missed abortion” or “missed miscarriage”, in which the body fails to recognize that the fetus is dead or has not developed. The body also fails to expel the pregnancy tissue, which continues to produce the pregnancy hormones. As a result, some of the pregnancy symptoms and signs may persist for a while. How common is missed miscarriage? About 1-5% of all pregnancies will result in a missed miscarriage. What are the causes and risk factors of missed miscarriage? Causes of missed miscarriage are not fully understood. About 70 to 80 percent of miscarriages are the result of faulty genes. It is nature’s way of cutting down the number of malformed babies. Other risk factors include: Obesity Infections, including sexually transmitted infections Diabetes or thyroid disease Malformations of the womb Smoking tobacco or drinking alcohol Autoimmune disorder such as Systemic lupus erythematosus (SLE) Miscarriage is not caused by physical exertion. A recent research review published in 2019 concluded that "prenatal exercise is not associated with increased odds of miscarriage.” What are the symptoms of a missed miscarriage? Missed miscarriage usually has no symptoms. Occasionally, there may be a brownish or pinkish discharge. Early pregnancy symptoms, such as nausea and breast soreness may persist for a while, lessen or disappear. This is different from a typical miscarriage, which usually presents with heavier bleeding and abdominal cramps. How is a missed abortion diagnosed? A missed abortion is usually diagnosed by the absence of foetal heartbeat on ultrasound examination. Blood levels of the pregnancy hormone B-hCG may not rise at a typical rate seen in normal pregnancy. What are the treatment options? There are several treatment options in managing missed abortion including: Expectant management: This is a wait-and-see approach. Usually if a missed miscarriage is left untreated, the foetal tissue may pass out within three or four weeks. This may be emotionally difficult for the patient. Sometimes, the expulsion may not be complete and evacuation of the uterus may be needed. Medical treatment: Medication is used to hasten the process of expelling the foetal tissue. It can be taken in oral form or by insertion of a pessary in the vagina. Again, the process may be incomplete and surgical treatment may be necessary. Surgical treatment: The minor procedure is called evacuation of the uterus using vacuum suction. During this procedure, the cervix is dilated and foetal tissue is removed via suction by a plastic tube. I reassured N that her physical exertion had no relation to the foetal demise. After explaining the various treatment options, N chose to have the surgical treatment, which was done successfully. I also told her husband that her emotional recovery may take longer than her physical recovery. He should be around to listen and support her in her grieving process.

K was visibly shocked and upset when I told him the result of his semen analysis. His sperm count was low at 10 million per ml compared to the normal of more than 20 million per ml. The qualities of the sperm including the swimming ability (motility) and shape (morphology) of the sperm were also below normal. “Doc,” K looked at me in disbelief. “Can I repeat the test?” he requested. A week later, the repeat test showed a similar result. K, 32, a sales executive had been married for the past 3 years. He had been trying actively to impregnate his wife without success for the past 2 years. He did not smoke, drink, or had past exposure to sexually transmitted diseases. He exercised regularly. But he had a craving for fast food since young. He would indulge in sausages, chips, pizza, processed and red meats almost every other day. Despite regular exercise, he had been putting on weight over the years. Male infertility In Singapore, it has been estimated that one in 5 to 6 couples of reproductive age has problems with getting pregnant. About half of the cases are due to male factors and over 90% are due to low sperm count (oligospermia), decreased motility (asthenozoospermia), and reduced number of sperm of normal shape (teratozoospermia). Sperm and fast food Scientific reviews have revealed that sperm counts in developed countries have plummeted by nearly 60 percent in the past 40 years. The decline has been attributed to many factors. Among these factors, diet is increasingly being recognised as a major one. In recent years, scientists have found that eating too much fast food with processed meat and large amounts of saturated fat is associated with lower sperm counts. This is confirmed by a new study in 2019 which showed the negative impact of fast food on sperm counts and testicular function. The researchers studied the diet and semen quality of nearly 3,000 healthy young Danish men who underwent a compulsory military-readiness medical exam between 2008 and 2017. They categorised the diet into four patterns: "Prudent": Lots of fish, chicken, vegetables, fruit, and water "Vegetarian": mainly vegetables, soy milk and eggs "Scandinavian": cold processed meats, whole grains, mayonnaise, cold fish, condiments and dairy "Western": pizza, chips, processed and red meats, snacks, refined grains, energy drinks, and sweets The results: Men who ate the prudent diet had the highest sperm count, followed by those who took vegetarian and traditional Danish diet. Those who had the Western diet had the lowest sperm count. It has been suggested that the trans fatty acid and saturated fat in fast food can affect sperm production, damage sperm DNA and reduce the production of male hormones. Environmental toxins such as phthalates and pesticides can also enter our body via food. These chemicals can further disrupt the hormonal system in our body and affect sperm health. K began to understand the negative impact of fast food on sperm. He cut down the frequency of eating fast food gradually. Instead, he started to eat more vegetables, fruits, nuts and fish. He tried to eat at least one healthy home-cooked meal a day instead of eating out. He also stopped taking drinks with high sugar content, such as soda, and replacing it with water. "Doc, I even buy a recipe book for cooking healthy dishes and learn how to cook on weekends. I am confident that my sperm count will improve," he said positively.

When sex is a pain! Many months ago, a women’s magazine article on the non-consummation of marriage examined the sexual experiences of Singapore’s brides and grooms. A small proportion of married couples were still fumbling lovers, it said. Annulment statistics indicate some truth in this observation. In 1996, there were 178 cases and the figure soared to 412 in 2006, according to the Statistics Singapore website. Many cases were attributed to women being unable to have intercourse or who did so with difficulty, a condition medically known as vaginismus. Many such marriages could have been saved through medical intervention and sexual counselling. Unfortunately, these couples may be too shy or believe there is no solution. Below is an abstract from the journal of my patient, Ms. G, a 30-year-old housewife who was successfully treated for vaginismus within two months. “My husband and I had decided not to have sex until we got married. We approached our wedding night with excitement. But this was shattered when we tried to consummate it. A beautiful wedding gave way to a painful honeymoon. We failed miserably every time we tried. I ended up weeping uncontrollably every night. No matter how much I wanted to have sex, it was just too painful. I felt like a failure as a woman. Shameful. Guilty. Alone. “What was wrong with me? I was well educated. Although I was raised in a traditional Chinese family, my Mum was comfortable talking about sex. ‘Sex is painful, in the first few months.’ she used to tell me. “I started to read voraciously on vaginismus. We tried several methods but failed. My hubby was always very supportive, encouraging and patient. After a few months of futile attempts, he suggested seeing a gynaecologist.‘ “How humiliating if other people found out,’ I thought. The gynae’s clinic was rather intimidating. I could not even allow the doctor to examine me. When I was introduced to the dilators, I almost freaked out as I had to insert those plastic ‘tools’ into my vagina. I cried. The gynae recommended that we see a sex counselor. It proved fruitful. I realized that my ‘problem’ was fear of pain. Initially, I just could not bring myself to use the dilator. Conjugal union was meant to be beautiful. The use of the dilator was so barbaric, crude and degrading. I felt that if I were to use it, I would be an animal of sorts. I looked at my hubby and I knew I had to do it for him. He had waited for me all this while, never demanding anything from me and loving me with all my ‘defects’. After much coaxing and encouragement, we finally had our first marital union. It was happy and emotional. And we are expecting our first child this year. Vaginismus is the involuntary muscle tightening around the vaginal opening in anticipation of penetration. The muscles go into spasms because of pain or fear of pain. Penile penetration becomes difficult or impossible. We don’t know the exact number of women suffering from vaginismus, but it is estimated that for every woman who seeks help, 10 suffer in silence. We also don’t fully understand the causes. The majority are linked to fear of pain or dislike of sex. For some, it may be the result of being sexually abused, assaulted or raped. One physical cause is an inflammation of the vagina. A very strict upbringing where sex was never discussed or unhelpful messages leading to feelings of guilt and shame can be the causes. Religious or cultural taboos or the fear of getting pregnant are other possibilities. Psychosexual counselling using behaviour therapy is the preferred treatment. Couples also benefit by solving their interpersonal problems through communication. Surgery is seldom suggested. It cannot cure a psychological condition and it may inflict further trauma. Recently, botulinum toxin (Botox) has been used to paralyse the vaginal muscles allowing almost immediate penetration. But this does not deal with any of the psychological issues. With psychosexual therapy and the use of a dilator, success is almost 100 per cent if the couple is motivated and committed to resolving their problem.

She came for her annual gynecological checkup. There was a plaster cast over her right arm. “What happened to your arm?” I asked. “I slipped and fell in the bathroom and fractured my wrist. After investigations, the doctor told me that I suffered from osteoporosis,” she answered. L, a 52-year-old teacher had been menopausal for the past 2 years. She was thin and petite. Her mum also had a hip fracture when she was in her 50s. Osteoporosis is a serious bone-thinning disorder. The bones become so weak and brittle that a slight fall or mild trauma may cause a fracture. It is often referred to as the 'silent disease' because the patient usually has no symptoms until he or she has a fracture. How does osteoporosis happen? Bone is a living tissue that is constantly in the stage of renewal. New bone is formed and old bone is broken down and replaced. When we are young, the process of bone building is faster than that of bone loss and our skeleton remains healthy and strong. Bone mass peaks by the age of 30. Thereafter, the mass declines gradually with age as new bone formation cannot keep up with the loss of old bone. Bones thus get thinner and osteoporosis results. Osteoporosis may develop depending partly on how much bone mass we attained in our youth. Peak bone mass is also somewhat inherited. The higher the peak bone mass, the less likely osteoporosis will develop as we age. What are the symptoms of osteoporosis? Typically, there are no symptoms. Sometimes, backache may occur from a minor fracture or collapse of the vertebrae. A “dowager hump” or a stooped posture may be obvious and the patient may notice getting shorter with time. What are the risk factors?. There are many risk factors. They include: Gender. Women are much more likely to develop osteoporosis than men. Age. The older you are, the greater your risk of osteoporosis. Race.  Asian women are more prone to osteoporosis. There are also some ethnic variations Family history of osteoporosis Body frame size. Small body frames have a higher risk of osteoporosis Hormonal factors: post-menopausal women and patients with an overactive thyroid gland are more likely to develop osteoporosis. Diet: A diet low in calcium Medications: Long-term use of oral or injected steroid medications Medical conditions: chronic kidney or liver diseases. Excessive alcohol consumption and smoking. How is osteoporosis diagnosed? The bone density is usually measured by running a scanning machine using low levels of X-rays over the body of the patient. The proportion of mineral in the hip and spine bones is then calculated. Complications of osteoporosis Serious complications such as hip or spine fractures may be life threatening. Prevention and treatment Good nutrition especially calcium and vitamin D intake and regular weight bearing exercise are essential in keeping the bones healthy throughout life. Treatment using oral medications such as bisphosphonates and injection such as Monoclonal antibody are effective in improving the bone density and reducing the chances of bone fractures. L was prescribed oral medication for her condition. She told me that she was lucky to have had only a wrist fracture and not a hip or spine fracture. “I am more aware of my bone health now,” she said as she was leaving my consultation room.

She was glad that her symptoms of morning sickness were over. Her husband suggested that they go for celebration with a good meal. Halfway through the lunch, she suddenly felt dizzy  blacked out for a few seconds. She was perspiring profusely when her panicky husband brought her to my clinic. N, 30, was a first-time mum at 15 weeks of gestation. She looked pale on examination. Her blood pressure and heart rates were normal. Obstetrical examination was normal. There was no vaginal bleeding. Blood tests revealed that her hemoglobin was 9.2gm/dl and the blood level of iron was low. N was suffering from pregnancy anemia due to iron deficiency. Anemia is a condition in which there is not enough red blood cells to carry adequate oxygen to the tissues in the body. How common is iron deficiency anemia during pregnancy? According to a recent study (GUSTO study 2019), about one in five Singaporean women aged 15 to 49 years had anemia while pregnant. 91% of these women were found to be iron deficient. What causes iron deficiency anemia during pregnancy? The body uses iron to make hemoglobin, a protein in the red blood cells that carries oxygen to the tissues. During pregnancy, the body needs more iron to make more blood to supply oxygen to the baby. If the pregnant mum does not have enough iron reserve or gets enough iron during pregnancy, she will develop iron deficiency anemia. How does iron deficiency anemia during pregnancy affect mother and baby? Currently, there is no study to show that anemia per se increases the risk of maternal death. Anemic mothers are more vulnerable to getting infection. But there is also a dearth of information on the frequency and severity of infection in these women. During pregnancy or labour, should the mother have excessive bleeding, she is more vulnerable to shock. With regards to the foetus, severe anemia increases the risk of premature birth, The baby’s birth weight may be low and the risks of intellectual disability, autism or attention deficit hyperactivity disorder (ADHD) are increased. Some studies also show an increased risk of infant death immediately before or after birth. What are the risk factors for iron deficiency anemia during pregnancy? Risks factors include: Age: Adolescent girls and women over 35 Race: In Singapore, iron deficiency is more common in Malays and Indians Educational levels: Gusto study revealed that pregnant mothers who attained university qualification are more likely to be iron depleted A closely spaced pregnancy Multiple pregnancy Frequent vomiting due to morning sickness Inadequate intake of iron from diet and prenatal supplements Anemia before getting pregnant What are the symptoms of iron deficiency anemia during pregnancy? The signs and symptoms include: Fatigue Weakness, shortness of breath Pale skin, brittle hair and nails Irregular heartbeats Dizziness or lightheadedness Cold hands and feet As symptoms of anemia often mimic those of normal pregnancy, most women often disregard them. It is important, therefore, to routinely test women for anemia and check their haemoglobin levels at regular intervals throughout pregnancy. How can iron deficiency anemia during pregnancy be prevented and treated? Good nutrition and balanced diet can prevent iron deficiency anemia during pregnancy. Dietary sources of iron include lean red meat, poultry, fish and green leafy vegetables and fruits. A high content of vitamin C in vegetables and fruits will enhance iron absorption. Taking a prenatal vitamin that contains iron can help prevent and treat iron deficiency anemia during pregnancy. The daily requirement of iron is 27 milligrams a day. If the hemoglobin levels remain low despite dietary and prenatal iron treatment, iron transfusion through intravenous route may be considered. Blood transfusion is rarely necessary. N’s condition improved with increased intake of iron-rich food and prenatal supplements. Her haemoglobin level was restored to normal after 4 weeks. There was no further episode of dizziness.

She looked dejected. Her menstruation came again. Her hope of attaining motherhood was dashed once more. She had been using ovulation prediction kit (OPK) to time sexual intercourse for the past 8 months with no result.” Why is it so?” she asked. Y,30, had been married for the past 2 years. She had been actively trying to conceive for the past one year. Her menstrual periods were regular and her husband’s semen analysis was normal. She was advised by her friend to use OPK to help improve her chances of conception. What is OPK? OPK is a home test kit used to track ovulation by measuring the levels of Luteinizing hormone (LH) in the urine. LH is a hormone produced by the pituitary gland of the brain and is involved in triggering ovulation, the release of egg from the ovary. Its levels are usually low in the urine but there is a surge 24-48 hours prior to ovulation, the most fertile time for conception. By identifying the LH surge, couples can time sexual intercourse to maximize their chances of getting pregnant. When to use OPK? In women with regular monthly menstrual cycles, the LH surge usually occurs between days 12 to 16. The day of the LH surge may vary from cycle to cycle. It should be noted that the surge may not be observed in every cycle. In women with irregular cycles, it may be difficult to determine when to start using the kit. Daily LH testing can be tedious, costly and impractical especially if the cycle length is long. How to use OPK? Testing is done in the morning. When the LH surge occurs, a color change will be seen on the test strip. There are many brands available in the market. Each brand may have its own instructions of testing. Many manufacturers advise testing with the first morning urine sample while some may advise the test to be done with the second urine or late morning sample. Instructions by the manufacturer should be followed to attain optimal result. One should also limit the fluid intake before testing as drinking large amount of liquids before testing can dilute the LH concentration in the urine and make detection of the surge difficult. Why does OPK fail in helping couples achieving pregnancy? Although OPK, if done correctly, is accurate in detecting the LH surge, it is not full proof that true ovulation would occur a day or two later. In a study of 43 women in which urinary LH was recorded and analyzed daily, it was found that LH surges consist of many variable and unpredictable patterns and ovulation may not actually happen with each pattern. In some women, a surge may happen without an egg being released, a condition known as Luteinized Unruptured Follicle Syndrome (LUFS). Women with this syndrome have a normal LH surge and menstruation but no ovulation. In women with polycystic ovarian syndrome (PCOS), there are false small surges in the urinary LH. This could mislead patient to time sexual intercourse wrongly. Similarly, patients with irregular cycles may end up testing the surge too early or too late and missing the ovulation window altogether. In women near the perimenopausal age, urinary LH could also be elevated without ovulation. Conception I explained to Y that even if timing of sexual intercourse using OPK is done at the most fertile period, only one out of four or five women will get pregnant during that menstrual cycle. In other words, the natural rate of conception per cycle is 20- 25 %. There are many other factors that can affect the ability to become pregnant. Further investigations revealed that Y had endometriosis which was treated accordingly. Subsequently, after another 4 cycles using OPKs, Y finally conceived. “Getting pregnant is not easy!” she exclaimed.

I was called to see T at the emergency room in the hospital one night. She was a 28-year-old teacher and had been married for the past 2 months. T was seen by me 2 years ago for severe menstrual pain. She had endometriosis which was confirmed by a laparoscopic examination. She declined medical treatment. Instead, she chose alternative therapy. When I saw her, she was in distressed. “Doc, I should have listened to your advice and have my condition treated. I know that endometriosis is going to affect my sexual life but I did not imagine that it could hurt me so badly,” she said. “My husband and I could not enjoy ourselves on our wedding night because of my pelvic pain. But the pain has gotten worse every time we have sex.” T is suffering from dyspareunia or pain during sexual intercourse. Studies have shown that about two out of three women with endometriosis have this sexual issue. The pain varies from mild discomfort, sharp or stabbing pain to deep pelvic ache. It occurs not at the entrance of the vagina but on the deeper part of the pelvis during thrusting. It may last for hours or even up to a few days after sexual intercourse. Why should Endometriosis cause Painful Sex? Endometriosis is a chronic disease where there is a backflow of the inner lining of the uterus (endometrial tissues) into the pelvic cavity. These tissues cause irritation to the surrounding organs. As a result, scars are formed around the back of the uterus and vagina. The vagina may even get stuck to the rectum (Figure 1). Sexual penetration will pull or stretch the scarred tissues causing deep seated pain. Figure 1 What may be the consequences? Dyspareunia will take away the joy and fun of sexual intimacy. This may lead to a gradual reduction in the desire to have sex. Consequently, couples may have less and less sexual activity. This can cause tension and turmoil in their relationship. There will be additional emotional stress if couples are planning to conceive. Some men may feel anxious about having sex. Erection and/or ejaculation problems may ensue. How to cope with the sexual issues? - Treat the disease: Besides surgery, hormone impregnated Intrauterine device (Mirena) and medications such as GnRH agonist, Visanne and oral contraceptive pills have been used to treat endometriosis with varying degrees of success. - Communication: Sexual intimacy is a very personal matter. Couples should have open discussions on the various sexual issues. This may allay anxiety and help in reducing the pain. Communication between couples may help the men understand the physical and emotional impact of dyspareunia better. - Vaginal lubricant: As dyspareunia reduces sexual arousal and vaginal secretions, water based lubricants may be useful. - Timing. The pain may be worse around menses. Avoiding sex during that time may help. - Sexual positions: Sexual positions that cause less pain such as shallow penetration or one that the couple can control over the depth of penetration may reduce the pain. - Other forms of sexual stimulation: Penetrative sex is not the only way for bonding between couple. Foreplay or other forms of sexual stimulation may help. After I explained the pros and cons of various modalities of treatment, T opted to have the Mirena IUCD inserted. Other than some irregular spotting in the initial months, T had no other side effects. The dyspareunia had improved further with counselling and the use of vaginal lubricant.

Because of bodily changes, it is generally advised that the pregnant mother should not carry heavy objects especially repetitive lifting as this may have negative impact on maternal and foetal health. Abdominal aches and cramps are common during pregnancy. This is due to the enlarging womb stretching the surrounding supporting ligaments and abdominal muscles. Lifting heavy object will cause more cramps and stitches. Hormonal changes may loosen the joints and muscles around the pelvic girdle. Increase in the abdominal pressure during heavy lifting may result in involuntary leaking of urine (stress incontinence) and a dull aching sensation around the back and pelvic area. The centre of gravity of the body is also shifted forward during pregnancy. It is easy for the mother to lose her balance and fall during lifting. A serious fall may be risky to both the mother and the foetus as it may lead to premature labour or premature separation of the placenta. Besides, lifting may cause more strain to her spine and may aggravate the low backache which may be already present. Impact of Heavy Lifting During Pregnancy Although it is uncertain whether heavy lifting would affect foetal health, some research studies have suggested that it may increase the risk of miscarriage, premature birth, smaller baby at birth (intrauterine growth restriction) and high blood pressure slightly. It is assumed that increased abdominal pressure and reduced blood flow to the womb during lifting may be the reasons. A potentially severe complication to the mother is a hernia which may require a surgical repair later on in life. According to the guidelines by American Medical Association (see fig 1): For repetitive lifting beginning in the 24th week or intermittent lifting beginning in the 30th week of pregnancy, up to 51 pounds (around 23Kg) is permitted. In the final week of pregnancy, less than 24 pounds(10.8Kg) is allowed for repetitive and less than 31 pounds (14 Kg) for intermittent lifting If it is necessary for the mother to lift or carry anything, she should · Hold the object close to her body. · Bend your knees, rather than the back, Keep the back straight. · Try not to twist or make jerking or sudden movements while lifting · Wear non-slippery shoes · Avoid lifting things from the floor or things overhead. · Avoid lifting with one hand or while sitting or kneeling