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M almost freaked out when she saw a patch of fresh blood staining her panty in the morning. She had had sexual intercourse with her husband the night before. She woke him up straightaway and rushed to my clinic. M, 28, a first-time mum, was in her 12 weeks of pregnancy. She related the incident with some embarrassment. "Doc, will I have miscarriage?” she asked. Ultrasound examination revealed that the baby was active with a normal heart rate of 150 beats per minute. The placenta was at the normal site with no sign of detachment. Vaginal examination showed that she had a 1cm polyp protruding from the cervix (the neck of the womb), with a small amount of blood on its surface. I reassured M that there was no cause for alarm and that I would watch the bleeding closely. M was happy to find that the spotting stopped 2 days later. Her pregnancy progressed normally albeit with an increase in yellowish vaginal discharge. At around 21 weeks of pregnancy, the discharge turned pinkish with a slight smelly odour. Her cervical polyp had bled again. I advised her to have it removed and this was done under sedation the next day. Microscopic examination of the polyp revealed that it was non-cancerous. Cervical polyps are growths that appear like bulbs on thin stems on the cervix (fig 1). They are usually cherry-red to reddish-purple in appearance but may appear greyish-white. They are usually small, varying in size from 1 cm to 2cm, and can occur alone or in groups. The cause of cervical polyps is not well understood, but they are associated with chronic inflammation of the cervix or local congestion of cervical blood vessels. They may also result from an abnormal response to the female hormone, oestrogen. Figure 1 They are usually non-cancerous. Very rarely (less than 2%), cancerous lesions may present as polyps and thus it is recommended that all symptomatic polyps should be removed and examined for signs of cancer. Cervical polyps can be found in women at any stage of pregnancy. Most of the time, patients have symptoms of vaginal bleeding, bleeding after sexual intercourse or vaginal discharge. Occasionally, the polys do not have any symptoms and are only discovered during vaginal examination. It is difficult to establish whether the polyp is a pre-existing condition or one that has developed during pregnancy. Bleeding in pregnancy from a cervical polyp poses a quandary to the mother. Can the polyp cause miscarriage or premature birth? Can it be cancerous? Would the procedure of its removal have a negative impact on the pregnancy? Currently, if the polyp is asymptomatic, conservative management is preferred. If symptoms are present, the polyp should be removed as infection may set in and premature birth may result. Removal of cervical polyps can be done under sedation with antibiotic cover.  The polyp should preferably be assessed with a colposcope to ascertain its appearance, location, form and length. It is then removed by a polyp forceps. The risk of miscarriage is minimal. M recovered from the polyp removal satisfactorily other than a slight vaginal bleeding for a few days. Her pregnancy progressed well. She is now awaiting delivery in a week’s time.

K,38, would never forget the experience soon after her delivery. She had a massive bleed and had to be resuscitated in the intensive care unit (ICU). This was her third pregnancy. Her two previous pregnancies were normal and the deliveries were smooth and uncomplicated. For this pregnancy, she had mild gestational diabetes and the amniotic fluid was found to be excessive during the last trimester. Her water bag burst at about 37 weeks and she delivered a baby girl weighing 3.2 kg normally after 6 hours of labour. Soon after the placenta(afterbirth) was delivered, there was a sudden gush of blood flowing out of her uterus. The uterus was massaged instantaneously to make it contracted like a hard ball. Intravenous medication was also given to help sustain the uterine contractions. All these measures were done to cause occlusion of the blood vessels in the placental bed to stop the bleeding. But within seconds, her uterus began to relax again. With rapid loss of blood, K was soon in a state of shock. Her blood pressure dropped from 120/70 mm Hg to 80/40 mm Hg. Her pulse rate went up from 78/ min to 110/min. Her skin was cold and clammy and the breathing was shallow and fast. She was also feeling weak and confused. She was immediately transferred to the ICU for resuscitation with intravenous infusion and blood transfusion.  Blood loss was estimated to be around 1000ml. K was having a massive postpartum haemorrhage (PPH), a condition in which heavy bleeding occurs after giving birth. It is a serious life-threatening condition and is ranked among the major causes of maternal mortality. Fortunately, it is not common locally, with an incidence varying between one to five per 100 deliveries. When it occurs within 24 hours after delivery it is called primary PPH. Less often, it may happen within 6 weeks after delivery and is termed secondary PPH. The amount of blood loss is often difficult to estimate. Arbitrarily, for vaginal delivery, PPH is said to occur if 500 ml of blood is lost. There are many causes of PPH, the most common being uterine atony in which the uterine muscles do not contract well after birth. This can happen if the uterus is overstretched when the mother gives birth to twins or a big baby or if excessive amniotic fluid is present. Poor uterine contraction can also result from fatigue due to prolonged labour or from a uterine infection. Other common causes of PPH include; Retained placenta, in which part or whole of the placenta is not expelled from the uterus after birth. This would prevent the uterus from contracting and occluding the blood vessels. Lacerations of the vagina and cervix. K continued to bleed in spite of resuscitation efforts with 1200ml of blood transfused and medications to contract the uterus. Her blood pressure remained low. She was put under general anaesthesia and the uterus, cervix and vagina were gently explored to ensure there was no lacerations or retained placenta. A Bakri intrauterine balloon was then inserted into the uterine cavity under ultrasound guidance (fig 1). Figure 1 This device acts as a tamponade by exerting pressure on the blood vessels against the uterine wall. K responded well to the treatment and the bleeding gradually stopped 6 hours after the delivery. The balloon was taken out the next day as she recovered from the shock. At the post-natal review 6 weeks later, K’s husband cheekily declared, "Doc, thanks for your help, her application for admission to heaven had been rejected!”

Never did she expect that starting a family was such a challenge. She had had 3 miscarriages for the past 4 years. Y, aged  35, came from a neighboring country. For her first pregnancy, she conceived within  6 months of her marriage. She thought that everything would be smooth-sailing. Unfortunately, she had a miscarriage at about 10 weeks of gestation. She felt upset and grieved over her loss  for a while. It took her another year to conceive the second time. The pregnancy progressed smoothly until the fetal heart stopped beating at 12 weeks of gestation. She was  devastated  and suffered a short spell of depression. She had some blood tests done by her local gynecologist, who told her that all the results were normal and the miscarriage was due to “bad luck”. She moved with her husband to another town due to his work commitments. She was pregnant soon after. Again, mishap happened at around 16 weeks of gestation. This time, she was told that the miscarriage was due to an abnormal wedge of tissue which was found to divide the upper part of her uterine cavity. “Doc, can you please confirm this anomaly and help me solve the problem?” she asked. Y had a uterine septum which was confirmed by a magnetic resonance imaging (MRI). A uterine septum occurs when a full or partial wall separates the uterus. It is a structural abnormality and is formed during Y’s development as a fetus. Cause of the septum: During embryonic development, the uterus starts out as two small tubular structures. As the fetus develops, each structure moves downwards and towards the middle of the body where they fuse together to form a single organ. Normally, the wall where the two tubes join in the middle will break down completely resulting in a single triangular shaped uterine cavity (fig 1). If the wall between the two tubes does not disintegrate completely, a septum will form (fig 2). Figure 1 Figure 2 Prevalence: About one in 10 to 15  women with repeated miscarriages has a uterine septum. Symptoms: Uterine septums increase the risk of a miscarriage by two to four times. It is suggested that if the foetus is implanted on the septum, the blood supply to the foetus may be compromised resulting in pregnancy loss. Besides miscarriages, uterine septum may increase the risk for: · Preterm birth · Abnormal foetal position e.g. breech · Intrauterine growth restriction · Premature detachment of placenta: Placenta abruption · Stillbirths and neonatal deaths in the first week of life Diagnosis: Uterine septums are usually detected during an ultrasound examination, hysterosalpingogram (HSG) or magnetic resonance imaging (MRI). More recently, a modified ultrasound procedure, called sonohysterogram is used to provide better images and measurements of the septum. It involves instilling saline into the uterus and then looking at it with an ultrasound. Treatment: The septum can be removed with a simple surgical procedure using a hysteroscope. The uterus is distended with saline solution. The lighted telescope is inserted into the vagina, through the cervix and into the uterus. The septum is then incised. The procedure  is  usually done under general anesthesia. Outcome: After removal of the septum, the patient is advised to wait for two to three menstrual cycles for healing to take place before trying to conceive. About 50 to 80 percent of women will go on to have an uneventful pregnancy. Y had a successful removal of the septum. She returned for review six months after surgery and was pregnant the following month. The antenatal period went smoothly without complication and she delivered a healthy male baby weighing 3.2 kg by Caesarean section. When I saw her the next day after delivery, she looked at her baby in her arms and said “ Doc, it’s so surreal. I still can't believe that I have a baby! I  look at him in wonder and will never forget the long and tough path I have travelled to bring him safely into the world. I am so lucky to have my little miracle baby”.

M, a 28-year-old mum was taken aback when she saw traces of blood in her urine. She was at her 15th week of gestation and this was her first pregnancy. She also noticed that she peed more often than usual for the past few days and there was a slight burning sensation during urination. Her urine appeared cloudy with a pungent smell. Microscopic examination of the urine revealed a large number of white and red blood cells. Urine culture grew the bacteria, E. coli. M was suffering from urinary tract infection (UTI). What is UTI? UTI is a bacterial infection of the urinary tract, which comprises the kidneys, where urine is produced; the ureters, which carry urine to the bladder, the reservoir for the urine; and the urethra, the final passage that sends the urine out of the body. How common is UTI during pregnancy? UTI is not uncommon, occurring in about one in 20 pregnant mums. The recurrence rate in those who have had the infection once is about 30%. Most UTIs occur in the bladder and urethra. They are usually mild. But occasionally, the infection may spread along the ureter to the kidney and the results can be more severe. In about 2 to 7% pregnancies, UTI has no symptoms. It is known as asymptomatic bacteriuria (ASB). The infection is only discovered by urine culture where more than 100,000 organisms/mL on a clean catch urine are found. Untreated asymptomatic bacteriuria can lead to the development of symptomatic bladder infection(cystitis) in approximately 30 percent of patients and the development of kidney infection (pyelonephritis) in up to 50 percent. Why is UTI More Common During Pregnancy? Several factors can contribute to UTI during pregnancy. They include: Changes in the body during pregnancy: The growing uterus can compress the ureters and bladder, making urine more difficult to empty completely. This will give bacteria an opportunity to grow in the urinary tract. Changes in hormones: The rising levels of the pregnancy hormones would relax the muscles in the urinary tract which again cause slow emptying of the urine. Proximity to the bowel. The most common bacteria in UTI is E. coli, which comes from the bowel. Because the urethra is close to the anus, the bacteria can invade the urinary tract easily, especially when the perineal region is not easy to clean thoroughly during pregnancy. Sexual intercourse during pregnancy may lead to UTI, as bacteria in the perineum may be driven into the urethra. What are the symptoms? Typical symptoms include: Frequency and urgency of urination Burning sensation during urination Cloudy, dark, bloody or foul-smelling urine Fever with chills and rigors Lower abdominal pain or discomfort Pain on one or both sides of the upper abdomen or at the back How will UTI affect the pregnancy? UTI during pregnancy can cause serious problems to the mother and the foetus. For the mother, the risks of developing high blood pressure (preeclampsia), anemia and life-threatening sepsis and shock are increased. For the foetus, premature birth, intrauterine growth restriction and low birth weight babies are more common. Risks of infection and pneumonia in the newborn are also raised. How is UTI diagnosed? The gold standard for the diagnosis is a urine culture. This is done by collecting the midstream urine after the mother has carefully cleaned the perineal area. In patients with recurrent UTI or when there is blood in the urine, an ultrasound of the kidneys and bladder should be done to rule out tumors or stones. How is UTI treated? UTI should be treated with appropriate antibiotics after the urine culture and sensitivity test. The antibiotic should not have any adverse effect to the foetus. It is usually given over 7 to 14 days. A repeat urine culture should be done to make sure that the bacteria is eliminated. In severe cases involving the kidneys, intravenous antibiotics may be given. For M, an oral antibiotic was given promptly. She was asked to drink plenty of water as this will dilute the urine and help flush bacteria out of the urinary tract. Besides water, she also drank cranberry juice frequently. Cranberries are known to contain compounds that may help prevent bacteria from attaching to the lining of the urinary tract. Every time she used the toilet, she was advised to wipe her perineum from front to back This would help keep bacteria away from this area. She was told not to wear tight fitting pants. With all these measures, M did not have recurrent UTI and she delivered  a healthy boy at full term without complications.

M ,aged 60, came to see me because she had noticed fresh stains of blood on her underwear for the past 3 days. “ I have been menopausal since the age of 52. I thought my periods would be a thing of the past. But I am alarmed to see fresh vaginal bleeding again.There was no abdominal pain or backache. I did not have any abnormal vaginal discharge. My husband and I have not had any sexual intercourse for few years,” she said. Examination with a speculum, a metal instrument used to expose the vagina, revealed a small amount of fresh blood at the opening in the cervix (neck of the womb). A pelvic ultrasound examination showed that the uterus(womb) was small with a thin lining. The ovaries were small and appeared normal. M was advised to have further investigations. What is postmenopausal bleeding? Menopause, the end of menstruation, is usually confirmed in women over 45 years of age who have not had menses for more than a year. Bleeding after this point is known as postmenopausal bleeding (PMB). It occurs in about 10% of women after menopause It is abnormal and should be evaluated thoroughly because about 10 per cent of PMB is linked to cancer of the cervix or uterus. What are the causes of PMB? PMB can be caused by: Cancer of the uterus, cervix or vagina Polyps: These are usually non-cancerous growths inside the uterus or on the cervix. Endometrial atrophy (thinning of the uterine lining) or vaginal atrophy: Low hormone levels after menopause cause the tissues of these organs to become thin and bleeding may sometimes occur. Endometrial hyperplasia: This is due to excessive overgrowth of the uterine lining from hormonal imbalance after menopause. Sometimes, the cells can become overactive and turn cancerous. Infection of the uterine lining (endometritis) Medications such as hormone therapy, tamoxifen (anti-breast cancer drug) and blood thinners. How Is It Diagnosed? Besides reviewing the medical history and clinical examination, the following tests are usually helpful: Vaginal ultrasound examination: This imaging technique looks for growths in the uterus and ovaries and also evaluates the thickness of the uterine lining. Hysteroscopy and endometrial biopsy: The hysteroscope is a thin, lighted tube with a camera attached at one end. Using this instrument, the uterine cavity is explored and abnormal tissues taken for microscopic examination. How Is It Treated? Treatment will depend on the cause of the bleeding. If the bleeding is due to cancer, treatment will depend on the type of cancer and its stage. Common treatment modalities for endometrial or cervical cancer include surgery, chemotherapy and radiation therapy. If it is due to benign polyps, removal by the hysteroscope will suffice. In endometrial atrophy, oestrogen hormone or alternative medications may be given. In endometrial hyperplasia, progesterone hormone medications may be prescibed. Prevention PMB may be benign but could be a result of a more serious condition such as cancer. A regular gynaecological checkup after menopause can help detect conditions before they become more problematic or result in PMB. When cancers are diagnosed early, the chances of survival are higher. M had a hysteroscopy and biopsy done. She was much relieved when the biopsy result showed that the bleeding was due to endometrial atrophy. She declined hormonal treatment as she was afraid of the side effects. She remained well with no further bleeding when she was reviewed six months after the minor surgery.

H, 29, was at 32 weeks of gestation. She was counting down the weeks for her first child to be born. One morning, she was woken up by a severe piercing pain in her stomach. “The pain felt like I was going into labor. It was a consistent, stabbing pain on my right side," she said. She was then rushed to the emergency room of the hospital by her panicky husband straight away. On examination, H was crying in pain. Her body temperature, blood pressure and pulse rate were normal. Her uterus was soft with no signs of labour. Her right upper abdomen was very tender to touch especially when I suddenly released the pressure of my examining hand (rebound tenderness). Her right abdominal wall was very rigid and guarded as well. The diagnosis of appendicitis was immediately suspected. Ultrasound examination showed an enlarged thickened appendix. This was confirmed by an MRI scan. She was referred immediately to the surgeon who was able to locate the inflamed appendix with laparoscope and remove it successfully without any complication to the mother and the foetus. How common is appendicitis in pregnancy? Appendicitis is the inflammation of appendix, which is a finger-shaped pouch that projects from the large intestine on the lower right side of the abdomen. It is the most common, non-obstetric emergency that requires surgery during pregnancy. It is seen in approximately one out of 1,500 pregnancies and commonly happens during the second or third trimester. What are the symptoms and signs? In the "classic" presentation of appendicitis in the non-pregnant patient, the onset of abdominal pain is the first symptom. The pain is around the umbilicus (belly-button) initially which then migrates to the right lower quadrant as the inflammatory process progresses. Nausea and vomiting, if present, follow the onset of pain. Fever may develop later. During pregnancy, the symptoms and signs may be slightly deviated from the classic presentation especially in late pregnancy. This is because some of the symptoms like nausea and vomiting may also be present in early pregnancy. In the last trimester, the pain from appendicitis is located higher up in the upper, rather than in the lower abdomen, as the appendix is being pushed up by the enlarging uterus. How is it diagnosed? Besides the medical history and physical examination, blood investigations may reveal a raised white cell count and an elevated inflammation marker, C-reactive protein. Ultrasound scan may show a swollen, thickened non-mobile appendix. An MRI should be done to confirm the diagnosis to avoid an unnecessary surgery. Early diagnosis is also important as the longer the delay, the more likely the patient may have complications, especially if the appendix ruptures. If this happens, the mother may have blood poisoning (septicemia) which can be life threatening. Premature birth and foetal demise may occur. What is the treatment? Surgery is the treatment of choice. If appendicitis happens in the first or second trimester, laparoscopic removal is usually done. In the last trimester, the size of the enlarged uterus may make the laparoscopic surgery difficult and conventional laparotomy may be performed. Postoperatively, the mother must be monitored carefully for premature birth. H was lucky that the appendicitis was diagnosed early. She felt better after the surgery and was discharged 3 days after the operation. Her antenatal course remained uncomplicated and she delivered vaginally a healthy baby boy at 39 weeks of gestation. “I feel so lucky that we have caught it(appendicitis) in time,” she said. The thought of the painful episode, however, had lingered in her mind for quite a while.

HPV stands for Human Papilloma Virus. It is a very common virus and consists of a group of 200 types of related viruses. More than 40 HPV types can infect the genital areas of males and females. They are spread through intimate contact during vaginal, oral or anal sex. The infection is very common and nearly all sexually active men and women will get it at some point in their lives. It happens more often in those who have many sexual partners or in those who have sex with an infected partner. But a person with only one sexual partner can also get HPV infection. HPV vaccine has significantly reduced precancerous lesions and genital warts among young people according to research studies published in 2019. This means fewer people in the future will develop cancers linked to HPV, including cervical cancer, anal cancer, and some mouth and throat cancers. However, many women are still unclear about the types of vaccine, their efficacy and risks of vaccination as well as who and when should the vaccine be given. I have collated them in the following Q&A format. What are the vaccines available? There were 3 different vaccines available (Cervarix®, Gardisil®, Gardisil9®) Cervarix® vaccine protects against HPV types 16 and 18 (responsible for 70% of cervical cancer). Gardasil® vaccine protects against HPV types 6,11 (responsible for warts) and types 16, 18 Gardasil®9 vaccine protects against HPV types 6, 11, (responsible for warts) 16, 18, 31, 33, 45, 52 and 58(responsible for 90% cervical cancer) These vaccines do not contain a live virus and thus they are noninfectious and cannot give a person HPV. What are the risks of a vaccine reaction? Most people vaccinated do not have serious reactions. Common reactions include: Soreness, redness or swelling at the site of injection Mild fever Headache Fainting spell after vaccination Severe allergic reaction is very rare, estimated at about one in a million doses. Anyone allergic to the ingredients in the HPV vaccine should not get the vaccine, including severe allergy to yeast. It may happen within a few minutes to a few hours after the vaccination. Can the vaccine help prevent HPV? HPV vaccines are extremely effective in preventing infection by the HPV types they cover. It reduces a woman’s risk of cervical cancer and precancerous growths substantially. In men, the vaccine may prevent genital warts, penile cancer, anal cancer, and the spread of HPV to sexual partners. Since they do not protect against all HPV infection, it does not prevent all cases of cervical cancer. It does not treat or cure an HPV infection in women or men who are already infected by one of these HPV types. Who should be vaccinated against HPV and when? HPV vaccine produces the strongest immune response in preteens. According to the Advisory Committee on Immunization of USA, routine vaccination for girls and boys should start at age 11 up to 26 years old. From 11 to 15 years old, two doses are given at 0 and at 6 to 12 months. From 16 to 26 years old, 3 doses are administered at 0, 1 or 2 and 6 months. Recently, Gardasil®9 vaccine had been expanded to include people between the ages of 27 and 45. Research has suggested there may still be benefits to getting the vaccine at a later age. How long will the vaccines last? HPV vaccines have been shown to provide excellent duration of protection for the periods through which they have been studied. Continued protection has been observed at least 10 years following vaccination. Further data will become available in the future as female and male participants in vaccine studies are followed over time. If a woman has had HPV infection, can she still be vaccinated? Women who have evidence of present or past HPV infection may be vaccinated. Studies have shown that the vaccines may have some therapeutic effects as the recurrence of cervical pre-cancerous lesions may be reduced. Can pregnant women receive HPV vaccine? The HPV vaccine is not known to be harmful to pregnant women or their babies. However, until more information is known, pregnant women are advised not to receive the HPV vaccine. Women who are breastfeeding can safely receive the HPV vaccine.

Holding her newborn baby who was soundly asleep in her arms, C recounted the dramatic events that happened during labour a week ago. She was still in a daze as to how her boy, at the verge of death, could defy all odds and survive. “You are truly a warrior,” she said. C, a 36-year-old teacher was in her third pregnancy. At 22 weeks of gestation, she was diagnosed to have gestational diabetes with a slight increase in the amniotic fluid. During the last trimester, her blood pressure was raised and she was admitted for induction of labour at 39 weeks of gestation. A rare complication occurred during the induced birth. An hour after the foetal membranes were ruptured artificially, the electronic recording of the foetal heart rate (Cardiotocograph CTG) showed a sudden and rapid deceleration to a dangerous level. A vaginal examination revealed that a loop of cord had slipped out of the cervix into the vagina with the foetal head compressing it. She was immediately put on the head-down-bottom-up (Trendelenburg) position to keep the baby's weight off the cord and was rushed to the operation theatre where an emergency caesarean section was performed. C had a dangerous obstetric complication called umbilical cord prolapse, which occurs in about 0.5% of births. What is umbilical cord prolapse? The umbilical cord is a flexible tube-like structure that connects an unborn baby with the mother. It is the lifeline for the baby as it transports nutrients and oxygen to the baby and carries away the baby's waste products. During pregnancy or delivery, an umbilical cord can prolapse when it drops through the opening of the womb ahead of the baby. The cord would be trapped and get compressed against the baby's body during delivery. This would deprive the baby of the oxygen resulting in grave consequences. What are the risk factors for umbilical cord prolapse? Cord prolapse is more likely to occur if the following risk factors are present. They include: Premature rupture of membranes Polyhydramnios: excessive amniotic fluid surrounding the foetus Premature birth Breech Multiple pregnancy What are the signs of umbilical cord prolapse? If the cord prolapses outside the vagina, the patient may be able to feel or see the cord. Otherwise, the condition is detected during a vaginal examination. If the baby’s heart rate is being monitored when cord prolapse happens, there would be a rapid and sudden drop in the heart rate. What are the consequences of umbilical cord prolapse? Cord prolapse presents a great danger to the foetus. Deprivation of oxygen to the baby may cause brain damage and even result in a stillbirth. It is an obstetric emergency and the baby must be delivered immediately. How should umbilical cord prolapse be managed? To reduce the risk of the cord becoming compressed, the patient should be put in the Trendelenburg position. The midwife may insert a hand in to the vagina to lift the baby’s head to stop it compressing the cord and the baby should be delivered urgently, either by assisted delivery or by emergency caesarean section. When C’s baby was delivered by caesarean section, he was pale, floppy with little response to stimulation.  His heart beat was 90 beats per minutes. His breathing was shallow and irregular. After resuscitation for 5 minutes with oxygen, his condition improved with a good Apgar score. He was sent to the neonatal intensive care unit (NICU) for further observation. Much to C’s relief, her baby was discharged from the NICU 2 days later and has recovered well since.

She sighed a big sigh of relief when her COVID-19 tests were negative. M, 29, pregnant with a pair of twins was at 30 weeks of gestation. She had been having fever and cough for 2 days before she was admitted to the ward for observation. For expectant mothers, the deadly virus has caused much stress and anxiety. It also raised many unanswered questions. Effects on the mother: Current data indicates that pregnant mums do not have a greater chance of getting sick from COVID-19 than the general public. There is also no evidence to suggest that infected expecting mums have more serious complications than non-pregnant women. In an analysis of 147 women, only 8 percent had severe disease and 1 percent were in critical condition, according to a report published on February 28 by the World Health Organization. At present, there is no data to show an increased risk of miscarriage. Though there have been some babies born prematurely, it is unclear whether it is due to the virus. Effects on the baby: Available evidence has suggested that the virus is unlikely to cross the placenta and infect the fetus. Babies born to women with the infection seemed to be free from the virus and appeared healthy at birth according to a study published in Lancet in February 2020. After birth, the newborn is susceptible to person-to-person spread. Researchers have reported 33 babies with COVID-19 infection shortly after birth; only three had mild symptoms and signs of the illness. Breast feeding: Current evidence suggests that breast milk does not contain the virus. The Royal College of Obstetricians and Gynaecologists (RCOG) advises that breast feeding is permissible if the baby is well. The concern is whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding. American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine have the following suggestions: · Mothers with confirmed COVID-19 should take all possible precautions including washing her hands before touching the infant and wearing a face mask, if possible, while breastfeeding. · If breast milk is expressed with a manual or electric breast pump, the mother should wash her hands before touching any pump or bottle parts and follow recommendations for proper pump cleaning after each use. If possible, consider having someone who is well feed the expressed breast milk to the infant. As very little is known about COVID-19, there are currently no recommendations specific to pregnant women regarding the evaluation or management of COVID-19 according to obstetrics fraternities (ACOG and RCOG). Prevention: As the immune system in the body does change during pregnancy and expectant mums infected with viruses from the same family as COVID-19 (e.g. SARS) can become more seriously ill, it is important for expectant mums to try to protect themselves by: · Avoiding people who are sick or who have been exposed to the virus · Cleaning their hands often using soap and water or alcohol-based hand sanitizer · Cleaning and disinfecting frequently touched surfaces daily · Wearing a facemask and avoid touching the face and eyes · Social distancing · Any other measures recommended by the local government

M was upset and looked at me in disbelief when I told her the not-so-sweet news. She had failed her glucose tolerance test (GTT) and had been suffering from gestational diabetes. M, aged 34, and a first-time mum was at 24 weeks of gestation. “Doc, I have a sweet tooth.” She confessed. “I would indulge in cakes and ice-cream after my morning sickness was over. Would the high blood sugar affect my baby?” She then revealed that her mum was also diagnosed to have diabetes recently. Gestational Diabetes Mellitus (GDM) is a condition in which a woman develops high blood sugar levels during pregnancy. It happens when the body does not produce enough insulin to effectively convert glucose to stored energy resulting in its build-up in the blood. It can affect any pregnant mother, but the following are the risk factors: Obesity: BMI more than 25kg/m2 History of delivering a big baby (4kg and above) Previous history of GDM Aged 35 and above Family history of diabetes History of delivering stillborn It is quite common in Singapore. According to a study published in 2018 by the Agency for Care Effectiveness at the Ministry of Health, one in five pregnant women tested had GDM, more than double the 9.2 per cent in the United States. Indian and Chinese mothers have a higher incidence than the Malay mums. GDM can negatively impact a woman’s pregnancy and the health of the baby. If the diabetes is not well controlled, the mother can run the risk of having miscarriage, stillbirth and premature birth. After delivery, the diabetes usually goes away by itself. But in 10 % of the women who do not watch their diet and weight carefully, full-blown diabetes may occur within 5 years after childbirth. GDM may affect the growth of the baby, who tends to be heavier than normal. The amniotic fluid that surrounds the baby may also be excessive. As a result, the baby could lie in an unusual position. Difficult delivery may be encountered and chances of caesarean section and instrumental delivery using forceps or vacuum are increased. The newborns are also more prone to breathing difficulties (respiratory distress syndrome) and may suffer from low blood sugar (hypoglycemia) immediately after birth. They may develop obesity and diabetes later in life. I advised M to exercise regularly, engaging in activities such as walking, yoga, Pilates or swimming. I also referred her to the dietician who would advise her on how to plan her meals and the right types of food to eat. She was also referred to the endocrinologist, a specialist doctor who treats disorders of the endocrine glands and hormones. Her blood sugar levels before and after meals were monitored regularly. With diet control, M’s blood sugar levels remained normal. Her pregnancy progressed well with normal foetal growth. The amniotic fluid level was not excessive. Labour started spontaneously at 39 weeks of gestation and a healthy boy weighing 3.2kg was born by normal vaginal delivery. Both M and her child had an uncomplicated postnatal course. At 6 weeks after birth, M had a repeat glucose tolerance test, which was normal. I emphasized to M the importance of living a healthy life style so that the chances of GDM in subsequent pregnancies would be mitigated.

Y was perplexed and confused when the biopsy result of her neck of the womb (cervix) showed that she had the precancerous condition known as Cervical squamous Intraepithelial Neoplasia (CIN). “Doc, I can’t understand this,” she said. "I have gone for my pap smears regularly and they have all been normal." Y, 38, had been married for 10 years and had 3 children. She saw me recently because of vaginal discharge which was mixed with occasional streaks of blood after sexual intercourse. On examination, her cervix looked inflamed and red. It bled slightly when it was gently touched with a brush. Her pap smear done elsewhere a year ago was reported as normal. Pap smear or pap test has been widely used as a simple, noninvasive, low-cost screening test for early detection of pre-cancers and cancers in the cervix for the past 80 years. In fact, its use is largely responsible for a reduction of cervical cancer in Singapore. In the early days, the test involved scraping and collecting cells from the cervix by a wooden spatula and smearing them on a glass slide. Abnormal cells detected on the slide may suggest pre-cancer or cancer of the cervix. But like any other screening test, there are false negative and positive results. In the former, the result indicates no abnormal cells while in fact it does. In the latter, the reverse is true and this may result in unnecessary surgery and anxiety to the patient. Up till the late 1990s, the false negative rate was reported in approximately 20 to 45 percent of patients screened.  This was confirmed by studies that showed that as many as 30% to 50% of women with cervical cancer had had a prior normal pap smear. To reduce the false negative rate, pap tests are now performed using a liquid-based technology. The entire sample collected is placed inside a vial of liquid and no other substances, such as fixatives, are mixed with the sample. This method of collecting samples has allowed abnormal cells to be identified in about 80 to 90 percent of Pap tests thus reducing the false negative results significantly. Factors causing a false-negative result include: An inadequate collection of cells The number of abnormal cells is too low Blood or inflammatory cells obscuring the abnormal cells Collection of cells at the wrong location For pap tests with false positive results, they are less common. The number ranges from approximately one to ten percent of all Pap tests screened. I repeated the pap test for Y. It showed some inflammatory cells with reactive changes. High risk HPV (human papilloma virus) DNA test was negative. As the cervix looked inflamed  with contact bleeding, I advised her to have a colposcopy. In this procedure, her cervix was stained with chemicals and examined under the microscope(colposcope). Abnormal looking tissue was excised and sent to the laboratory for testing(biopsy). She consented straightaway. The abnormal tissues excised showed the precancerous condition CIN3. After discussing with her husband, Y decided on conservative treatment with continuous surveillance and regular follow-up. The take-home message in Y ‘s case is that, if the cervix looks abnormal, it should be biopsied to obtain a diagnosis. Though the accuracy of Pap test has improved over the years, it is still not diagnostic. Relying on its result may occasionally lead to false reassurance and underestimation of the severity of disease.

She was distraught when her blood tests confirmed that she had been infected with CMV- the cytomegalovirus. K, a 28-year-old kindergarten teacher and a first-time mum was at her 18 weeks of pregnancy. She had a mild fever and sore throat about 2 weeks ago. There were some swollen lymph nodes on her neck. “Doc, will CMV affect my baby?” She asked.” I read in the internet that it can cause blindness, hearing loss and mental retardation in my child.” I told her that she had about a 40 % chance of transmitting CMV to the baby. Of the babies that become infected, only 10% will show signs of congenital CMV with multiple disabilities. Cytomegalovirus (CMV) is a very common virus that can infect almost everyone. The primary (first time) infection usually occurs in children and less often, in adults, as in K’s case. It is estimated that between 60 to 90 percent of all adults would have had the infection. It belongs to the same family of viruses that causes chickenpox and herpes. Once infected, the virus stays in the body for life. Most people do not know they have had CMV because it rarely causes symptoms. If symptoms do occur, they include sore throat, swollen tender lymph nodes, mild fever, fatigue and feeling unwell. CMV is transmitted through infected bodily fluids such as blood, saliva, urine, semen and breast milk. Pregnant mothers can get the primary infection via sexual intercourse or through contact with children. CMV is the most common virus that passes from mothers to babies during pregnancy. About 1 to 4 in 100 women have CMV during pregnancy. Majority (85-95%) of the babies born with CMV do not have health issues. But in the remainder, serious birth defects can occur. They include: Microcephaly, in which the baby’s head is smaller than normal. This may result in mental retardation. Enlargement of the liver and spleen. Problems with the vision and hearing. Seizures. In some babies who have no symptoms at birth, varying degrees of hearing, mental or coordination problems may develop later in life. Thus, long term follow-up of the baby is of utmost importance. K asked me in what way she could find out whether her baby was affected with the virus. The only way, I said was by a procedure called amniocentesis in which a long needle is introduced into the uterus to withdraw some amniotic fluid which surrounds the baby. Virus could then be cultured from the fluid. After prolonged discussion with her spouse and family, K decided to continue with the pregnancy without any intervention. A fetal anomaly scan at 20 weeks showed that the brain, heart and abdominal organs were normal. The pregnancy progressed smoothly and the baby’s brain MRI scan at 36 weeks gestation did not show any abnormality. K finally delivered a healthy baby boy at 39 weeks of gestation. She had a sigh of relief when the urine and blood of the baby were tested negative for CMV. “What a close encounter with CMV!” she exclaimed.