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G, 43, had a rude shock and felt devastated a year ago when she was diagnosed with ovarian cancer. She was unaware that the bloated feeling in her tummy was associated with the disease. “I had nausea and a bloated feeling in my tummy for a week. My family doctor diagnosed me as having tummy upset and treated me with gastric medications” G recalled, "but the symptoms persisted and I began to lose my appetite. She then arranged for me to have an ultrasound examination of the pelvis which showed a 5 cm tumour in my left ovary.” When I examined G, the abdomen was distended with fluid. The left lower abdomen was slightly tender.  MRI (Magnetic Resonance Imaging) scan confirmed the left ovarian cyst with solid areas in its wall.  There was ascitic fluid in the abdominal cavity with a suggestion of tumour spreading to the peritoneum, the inner lining of the abdominal cavity. The blood level of ovarian tumour marker, CA125, was raised many times above normal. She had an extensive surgery a week later with removal of the left ovarian tumour together with the uterus, the right ovary and the omentum, the fatty tissue apron covering the intestines. Microscopic examination of the tumour confirmed ovarian cancer with spread to the omentum and peritoneum. The cancer was classified as stage III and chemotherapy was soon administered after she recovered from the surgery. Ovarian cancer is the second most common gynaecological cancer and the 5th commonest cancer in Singapore. There are 359 cases diagnosed yearly based on the Singapore Cancer Registry 2011-2015. It is a very silent disease with minimal or no symptoms in early stage. It often goes undetected until it has spread to the abdomen. When this happens, the following symptoms may be present. They include: · Bloatedness of the tummy · Indigestion and loss of appetite · Weight loss · Abdominal pain · Change of bowel and urinary habits Many of these symptoms are non-specific and can also be the symptoms of other less serious condition such as irritable bowel syndrome. Depending on the extent, the disease is classified into four stages. · Stage I: cancer is confined to the ovaries. · Stage II: cancer has spread to the surrounding pelvic organs, such as the fallopian tubes or uterus. · Stage III: cancer has spread beyond pelvis into other parts of the abdomen. · Stage IV: cancer has disseminated to distant sites outside the abdomen such as the  lungs and brain. It has been estimated that more than 60% of ovarian cancers are in the advanced stages (stage III and IV) when the patient is first diagnosed. Till now, there is no reliable, effective screening method to detect the disease early. Because of the late diagnosis, patients with ovarian cancer have a poor outlook despite treatment which usually involves a combination of surgery and chemotherapy. Surgery is usually the initial step. It is done to remove the cancer mass as much as possible and also helps confirm the stage of the disease. How much surgery to be done would depend on how far the cancer has spread. For very early stage, the surgery may involve removing the affected ovary and its fallopian tube. This procedure is for fertility preservation. In advanced stages, as in G’s case, the ovaries, uterus, cervix, or fallopian tubes have to be removed together   with lymph nodes, the omentum and all visible cancer masses. Chemotherapy may be necessary to kill cancer cells that might remain. These powerful medications are usually given through the vein (intravenous). But sometimes they may work better if they are injected directly into the abdomen. G had side effects from the chemotherapy. She looked slightly pale and tired on her last review. She had to wear a wig from the hair loss. But she was in good spirits. “I am a fighter” she said.

P,45, felt a lump in her right breast during her shower one day. She quickly made an appointment with a surgeon and had an urgent mammogram and ultrasound examination done. The lump was biopsied and confirmed to be cancerous. She subsequently had her right breast removed together with the lymph nodes in the right armpit. Luckily, the cancer had not spread and was classified as stage 1. She was then put on hormonal therapy to reduce the chances of the cancer recurrence. She saw me a few months after the surgery. She felt tired, listless and weak. “Doc, what should I eat to improve my health?” she asked. “I have had so many well meaning friends giving me advice about my diet that I am confused. They tell me that soy foods and sugar will feed the cancer cells and should be avoided. Is there any truth?” I told her that soy foods, such as tofu and soya milk are rich in proteins and should be good for the body. But people are worried that they also contain the chemicals called phytoestrogens, which are similar to the female hormones in our body. These chemicals may stimulate breast cancer cells to grow. But latest studies have shown that they do not adversely affect breast cancer and may even reduce the risks of recurrence.  However, there is no conclusive evidence regarding the safety of soy supplements. Concerning sugar intake, I told her that excessive intake may lead to obesity which may increase chances of cancer relapse. I  gave her the following pointers in her food choices. · Eat protein-rich foods. Protein helps the body to repair cells and tissues. It also helps the immune system. Good sources of protein include lean meat, fish, eggs, milk, yogurt, nuts, beans and soy. · Embrace whole grains. Whole grains provide a good source of carbohydrate and fibre, which help keep the energy levels up. Good sources of whole grains include oatmeal and brown rice. · Consume colourful fruits and vegetables daily. Besides vitamins and minerals, these foods contain antioxidants, which are important in the fight against cancer. · Choose healthy fat. Avoid fried and greasy foods. Healthy fats include olive oil. omega-3 fatty acids, nut and seeds · Stay hydrated by drinking plenty of water. Avoid drinking large amounts of caffeinated beverages. · Avoid alcohol: There is a link between regular alcohol consumption and an increased risk of breast cancer. P was attentive and jotted down these dietary tips. She looked more cheerful  as she left my room.

He had noticed a slight swelling on the left side of his scrotum for a year. It happened insidiously and he had not thought much about it. He felt an occasional dull pulling pain which was aggravated when he carried a heavy load. Lying flat relieved the pain. C, a 35-year-old engineer, had been married for five years. He and his wife had been trying for a baby without success. Abnormal sperm count was the cause. His sperm count was low (less than 10 million per ml) and they were mainly defective and unable to move and swim effectively. Normal sperm count should be at least 20 million per ml with more than 50 per cent of the sperm swimming actively and 15 per cent having a normal shape. When I examined C, the swelling on his scrotum felt like a bag of worms with dilated veins on the skin. The testes were soft and slightly small. Ultrasound examination with Doppler colour flow confirmed the presence of dilated veins which were more prominent when C was asked to bear down (Valsalva manoeuvre). I told C he had varicocoeles of the testes. For normal sperm production, the testes require a temperature a few degrees lower than the core body temperature. This is done by a network of veins that surrounds the testes and drains blood back to the heart – effectively cooling that area. When the valves within these veins are incompetent or defective, blood accumulates and the veins expand and become dilated, forming a venous lump in the scrotum. The pooling of blood around the area raises the testes’ temperature, resulting in poor and abnormal sperm production. Metabolic waste products may also accumulate in the testes. This diminishes the amount of oxygen and nutrients required for sperm development. In addition, the abnormal blood flow interferes with testosterone (male hormone) concentration, which in turn causes a reduction in sperm production. Over time, such compromised circulation may result in a disruption of normal male hormone production. Varicocoele is more common on the left side of the scrotum, as in C’s case. This is related to the anatomical position of the veins. Someone who has varicocoele will usually have it from early childhood but it only becomes larger and more noticeable during adolescence when there is increased blood flow to the testes. It is also more common in tall and thin men and can run in families. Occasionally, a varicocoele can develop suddenly due to a cancerous growth in the kidney which obstructs the veins. This usually happens in elderly men. Many patients do not have symptoms. It tends to be found in infertile men – accounting for about 40 per cent of men with primary infertility (never fathered a child) and about 40 to 70 per cent with secondary infertility (have fathered children in the past but are now unable to do so). The occasional pulling pain that C felt is not common and is usually due to prolonged physical exertion. “What should I do to improve the quality of my sperm? Could it be cured by taking medicine?” C asked. Medication does not improve the quality of the sperm as it does not remove the cause. However, a painkiller may be prescribed if there is discomfort. For some patients, wearing snug, supportive underpants may help ease any discomfort. As for treatment, there are two approaches: surgical repair and percutaneous embolisation. In surgical correction (varicocoelectomy), all the abnormal veins are tied off (ligation). Two different surgical techniques have been used. They are open incision on the groin or scrotum and laparoscopic (key-hole) surgery using a telescope through the abdominal wall. These can be done on a day-stay basis under general anaesthesia. Post- operative pain and complications are few. In percutaneous embolisation, which is performed by a specialist X-ray doctor (radiologist), a special tube (catheter) is inserted into a vein in the groin. Under X-ray guidance, a small metal coil is threaded through the tube into the affected vein. It is then released to block the blood flow to the affected vein and to redirect it to healthy ones. C opted for the surgical repair as he was afraid of having metallic coils in his body. His sperm count and quality recovered dramatically. Six months after surgery, his wife conceived. He is now the proud father of three children.

He was extremely distressed when he rushed his wife, E, to the hospital. She was groaning in pain at the backseat of his car and was in an advanced stage of labour.  He almost freaked out in the delivery suite when he witnessed his baby being delivered in a breech position: butt first, rather than head first. E, a 35-year-old mum had 2 previous normal deliveries. Her babies weighed around 3.3 kg each at birth. She was from a neighbouring country and came for her first consult only at 32 weeks of gestation.  Her prior visits to the obstetrician in her native country were apparently uneventful. Ultrasound examination revealed that her baby was in a breech (butt- first) position.  External cephalic version (ECV) without general anaesthesia was attempted to correct the breech position on her second visit 2 weeks later. But it failed. E began to try all sorts of methods, including acupuncture, yoga and eating a spicy meal, to get her baby to change its position. At her subsequent visit at 35 weeks gestation, the baby was still in a breech presentation. As ECV again failed, I advised her to deliver the baby by lower segment caesarean section (LSCS) to avoid complications to the baby. She agreed. This was scheduled at 38 weeks of gestation. However, she started to have labour pains a week before the scheduled operation. By the time she was admitted to the labour ward, her cervix was fully dilated and the water bag had burst. The baby’s butt could be seen emerging from the birth passage. With further contractions, the baby’s legs emerged and part of the body was hanging outside the mother. It was too late for Caesarean section. I immediately performed an assisted vaginal breech delivery which went on smoothly. A  baby girl weighing 3kg  was finally delivered in a healthy condition. About 3 -4% of all births present as breech at term.  Many studies have demonstrated that planned Caesarean delivery is safer than planned vaginal delivery in terms of infant deaths and injuries. This is because in a breech presentation, the baby’s head comes out last. His or her body may not stretch the cervix enough to allow room for the head to come out easily. As a result, the head or shoulders may be jammed against the bones of the mother’s pelvis. Delivery under such situations may result in serious injuries such as cerebral palsy or nerve injuries to the baby. Another risk is that the umbilical cord may slip into the vagina before the baby is delivered. If this happens, suffocation and death to the baby may occur. As Caesarean section itself also carries risks like infection and bleeding, the obstetrician may perform a manoeuvre called ECV in the antenatal period to turn the baby to the head down position. This procedure is usually done without anaesthesia after 32 weeks and involves applying gradual pressure to the abdomen to turn the baby from the outside. The baby’s heart rate is monitored closely before and after the procedure. In E’s case, ECV failed. Vaginal birth was imminent as she was admitted to the labour ward in the late stage of birth. Fortunately, the baby was not too big and the delivery went well without complications. I saw E and her husband the next day.  They had just recovered from the “shock” the day before. “Doc, we are amazed by the calmness you showed at delivery. Kudos to you.” E exclaimed.

Breech pregnancy means the baby is positioned head up. This means the buttocks and feet will come out first, instead of the head during delivery. During pregnancy, the baby is surrounded by the amniotic fluid in the amniotic sac. It moves freely in a weightless condition inside the womb. At the early stages of pregnancy, the volume of the amniotic fluid is relatively large in relation to the baby and breech position is quite common. As pregnancy progresses and in the last trimester, about 97 percent of babies turn spontaneously to the head-down position. Thus, only about three to four percent of babies will remain in a breech position. Types of Breech Pregnancy Positions A breech baby may be lying in one of the following positions: Breech with extended legs or frank breech: This is the most common position where the baby’s legs are straight up against the body in a V shape with legs pointing towards the face. Breech with flexed legs or complete breech: In this position, the baby is in a sitting position with the legs crossed in front of the body and the feet near the bottom Footling breech: In this position, one or both of the baby’s feet are hanging below its bottom, so the foot or feet are coming out first during vaginal delivery. Causes In most cases, there is no obvious reason why the baby remains in a breech position. But some conditions may make the baby easier to poise in a bottom-down position. These include: · Premature birth: In this situation, the baby does not have enough time to turn head down. · Distorted shape of the womb : Normally, the cavity of the womb is shaped like an inverted triangle with a flat top. But some mothers may be born with a womb that has a dip or indentation at the top (arcuate uterus) or the cavity may be divided by a muscular wall (septate uterus) (see fig 1&2) These conditions will make the baby difficult to turn to a head down position. · Uterine fibroids: These muscle growths may distort the shape of the womb. · Low-lying placenta (placenta previa). This condition may prevent the baby from having enough space to position itself correctly. · Excessive or scanty amniotic fluid: Too much amniotic fluid allows the baby to assume any position it likes; reduced amount of amniotic fluid, on the other hand, makes it difficult for the baby to move around. · Multiple pregnancies: When there are more than one baby, foetal movements may be limited, · Short umbilical cord. When the cord wraps around the baby, its movement is limited. · Birth orders: Some first-time mums with a tight abdomen are more likely to have a breech pregnancy. On the other hand, mothers who have delivered five or more babies may have loose abdominal muscles. They have increased chances of a breech birth. · Studies have shown that women with previous Caesarean section have a higher chance of breech birth than that of women with previous vaginal deliveries

N ,40, was very reluctant to talk about his problems on his first visit. He had been married for 3 years and had tried for a baby for the past one year. “How often do you have intimacy with your wife?” I asked. “Not often” was his short answer. He did not wish to elaborate further citing tiredness as being the reason. As we established a closer rapport, he was more relaxed and more willing to open up during his subsequent visits. “Doc, my sexual desire and libido have taken a beating during the last 6 months. I used to be intimate with my wife two to three times a week,” he recalled,” but now, it is down to once a month and sometimes even longer. Erection difficulties have surfaced more often in the past 2 months. This has made the situation worse and I am becoming depressed. I feel tired most of the time after work. I would even sleep watching television. I used to play basketball once or twice a week but now my strength is gone. I could not even aim at the hoop properly. Now, I really appreciate the lyrics in Beatles’ song “Suddenly, I’m not half the man I used to be”...." he sighed. N was suffering from symptoms of low testosterone, the male hormone in our body. This was confirmed by a blood test. After investigations, I found the low testosterone was due to a tiny growth in his pituitary gland, a small pea-size gland at the base of the brain. That tiny growth is called a prolactinoma which produces an abnormally high amount of prolactin, the milk producing hormone. It is noncancerous and occurs infrequently. They usually remain small, less than 1 cm in diameter, and are called microadenomas. Very rarely, they may grow bigger and become macroadenomas. Elevated levels of prolactin reduce testosterone and sperm production. Low testosterone will cause decreased energy, sex drive, erection difficulty, reduced muscle mass and strength, the symptoms manifested in N’s case. If left untreated, low blood count (anaemia) and brittle bone disease (osteoporosis)may result. Breast tenderness and enlargement may also be present. If the prolactinoma gets bigger, visual impairment may occur and hormones produced by thyroid and adrenal glands may be affected. Prolactinoma is diagnosed by an elevated blood level of prolactin and the demonstration of the tumour in the pituitary gland by magnetic resonance imaging (MRI) Most prolactinomas respond well to treatment with medications. Surgery is seldom necessary unless the tumour gets bigger and cause visual disturbances. N was treated with medication promptly. His blood levels of prolactin returned to normal within a month and the testosterones levels gradually rose. He began to feel more energetic and his sexual drive reverted to normal. He was beaming with joy when I confirmed that his wife was pregnant 5 months after his treatment. However, I warned him that he should continue with the medication and monitor the prolactin levels as recurrence of prolactinoma occurs frequently.

N, a first-time mum, felt much relief when her child had the vaccination for hepatitis B (Hep B) soon after birth.  She was found to be a Hep B carrier during a blood screening test in the first trimester. Hep B is a common infectious disease affecting about 6% of Singaporeans. It is due to a virus which infects the liver, causing inflammatory changes. If the inflammation persists, liver hardening(cirrhosis), liver failure and cancer may develop. The virus is usually transmitted from the mother to the new-born during childbirth. It can also spread by direct contact with bodily fluids such as blood, semen, or vaginal secretions of an infected person. This can happen during sexual intercourse or blood transfusions. It does not transmit by coughing, sneezing, casual contact or breastfeeding. Hep B may be either short-lived (acute) or long lasting (chronic). An acute infection lasts less than six months. The immune system can clear the virus and the patient usually recovers completely without treatment. A small number of patients—usually newborns or children younger than 5 years of age -- cannot get rid of the virus due to a poorer immune response. They become carriers with chronic infection. They usually do not have symptoms until years later when they become seriously ill from liver malfunction. To prevent the newborn from getting hep B infection, all pregnant mothers should have their blood tested. Testing is especially important for health care workers and those whose spouses or partners are carriers. This group of women has a higher risk of getting the infection. If the mother is a carrier, the baby should be vaccinated preferably within 12 hours after the baby is born. In this way, the baby has a more than 90% chance of being protected against the chronic infection. As for N, I told her that it was safe to breastfeed her baby. I advised her to refrain from taking alcohol and herbal supplements which are toxic to the liver.  After her confinement, she should be seen by a hepatologist for follow up so that her liver functions can be checked and her liver scanned regularly. Her husband should also have his blood tested and vaccination done according to the test results. Two months after delivery, N was happy to inform me that her baby  had developed immunity against the virus via the blood test.

She walked slowly and reluctantly into my consultation room with her parents. She looked thin and listless. H, a 17-year-old teenager came to see me because her mother had noticed that she had drastic weight loss and her menses had stopped for the past 4 months. She was the youngest of 3 children. She was bright academically and had been of normal body weight. Eight months ago, she started to get conscious about her body image after her cousin commented that she had put on weight during a social gathering. Thereafter, she started comparing her body weight with her peers. She tried to lose weight by becoming a vegetarian and began to eat less and exercise more. She felt good about herself only when she lost weight. She weighed herself almost daily. She spent most of her time worrying about her weight. As a result, she spent less time on the social activities she used to enjoy. She became very quiet and withdrawn, often keeping to herself in her room. H was undernourished with sunken eyes. Her BMI was way below normal  and her skin was dry with soft downy hairs. Her nails were brittle. Her blood pressure was low and her heart rates were slow and sometimes irregular. H was diagnosed with anorexia nervosa, an eating disorder characterized by · An abnormally low body weight · Extreme restriction of food intake · Intense fear of gaining weight or becoming fat · Distorted perception of weight How does anorexia affect the reproductive health? With severe reduction of food intake, our body does not have enough “energy” to function properly It has to prioritize which bodily functions are not essential. Reproductive function gets the least priority.  As a result, the control centre in our brain which regulates menstruation becomes suppressed, resulting in prolonged cessation of menses (amenorrhea). With amenorrhea, the levels of female hormone (oestrogen) are low and hormonal imbalances occur. These imbalances may lead to symptoms such as loss of sleep, night sweats and irritable moods which may further aggravate anorexia Oestrogen is also important in maintaining the levels of calcium in the bones. With amenorrhea, depletion of calcium in the bones (osteopenia) can occur. This may lead to osteoporosis or brittle bone disease if left untreated. Amenorrhea may result in infertility too. For many young women, the idea of not being able to have children in the future may be alarming. The sooner the menstrual period is restored, the higher the chances of resuming fertility, but the longer a woman goes without having her period, the less likely it is for her to become pregnant on her own. To treat H, I had to seek help from my psychiatrist colleague, a psychologist, nutritionist and nurse therapist. With the support of the family, H was finally able to start eating normally  by this multidisciplinary approach. Her physical health gradually improved and her menses returned after about 6 months of intense therapy.

T was devastated when she was diagnosed to have cervical cancer. T,42, woke up one day and saw red blobs of blood staining the bed sheets. She had had sexual intercourse with her husband the night before. She was frightened and looked worried when I saw her the next day. “I had been spotting on and off for the past 3 months but had never experienced so much bleeding. Could it be something serious?” she asked anxiously. A pelvic examination revealed that her cervix (neck of the womb) was totally replaced by a huge ulcer which had extended to the upper part of the vagina (birth passage). The ulcer was oozing with blood.  Biopsy of the ulcer was performed and confirmed that the it was cancerous. Further imaging procedures including MRI and PET scan indicated that the cervical cancer had spread to distant lymph nodes. Cervical cancer is the 10th most common female cancer in Singapore with about 190 cases diagnosed every year. It is highly preventable as it is usually slow growing. There is a progression through precancerous changes which usually occur in women in their 20s and 30s. The invasive stage of the cancer appears most often in women who are in their 50s. Cervical cancer is usually associated with human papillomavirus (HPV) infection. Early sexual contact (before age 16), multiple sexual partners, and taking oral contraceptives (birth control pills) increase the risk of cervical cancer. A history of sexually transmitted infections or other co-infections e.g. HIV, and cigarette smoking are additional risk factors. Cervical cancer may have no signs or symptoms in early stage. In later stages, the patient may experience: o             Abnormal vaginal bleeding between periods o             Post-coital bleeding (bleeding after sexual intercourse) o             Post-menopausal bleeding o             Abnormal smelly or bloody vaginal discharge o             Pelvic pain or pain during sexual intercourse o             Kidney failure due to a urinary tract blockage and bowel obstruction, when the cancer is advanced Cervical cancer is staged depending on its size as well as the degree of spread. It ranges from stage 1 (early) to stage 4 (advanced). Staging is important, as it helps the gynaecologist decide the most appropriate and effective way of treatment. As T had an advanced stage of cervical cancer, radiotherapy with chemotherapy was the option. She was warned of the side effects of the treatment such as loss of appetite, nausea, vomiting or frequent bowel movements.  She should avoid alcohol and engage in mild physical activity. She should also get enough rest at night. Emotional support from the family and friends would help in alleviating her depression and anxiety. She was in good spirits during her last review. “Doc, I have been redefining my life on what is best for me going forward, ” she said. I was moved by her positive attitude towards this deadly disease. I had been seeing T for follow up for the past 5 years. She remained well with no signs of relapse.

The delivery suite was dimly lit. The air was still and the room appallingly quiet. She was sitting on the edge of the bed weeping. Her eyes were red and puffy. Her husband, standing next to her, was holding and hugging her tightly. They were gazing attentively at their baby boy who was lying motionless in a little white crib He was a stillborn. E, a first-time mum was at her 32 weeks of gestation. She was admitted to the hospital because her water bag had burst and the umbilical cord had slipped out into the birth canal. Oxygen to the baby was cut off abruptly. Her baby’s heart had stopped beating on arrival to the hospital. Following my advice, labour was induced with her consent and a stillborn delivered the next day. Every year across the world, there are more than three million babies who are delivered as stillborn. In Singapore, the number is around 80 to 120. Stillbirth refers to foetal death occurring during pregnancy or delivery. Majority happen before labour and in 30 to 40 percent of cases, no cause can be found. Common causes of stillbirths include: 1. An abnormal baby due to: Chromosomal, genetic or metabolic abnormalities Structural abnormalities 2. Placental malfunction: Placental abruption or premature separation of the placenta can result in foetal death by cutting off the oxygen supply to the foetus. Preeclampsia or pregnancy induced hypertension increases the risk of abruption by twofold. IUGR (intrauterine growth restriction), preeclampsia, gestational diabetes, or postdates pregnancy are more liable to placental malfunction 3. Umbilical cord accident: Cord prolapse as in E’s case Cord round the baby's neck (nuchal cord) which becomes too tight and cuts off the oxygen supply to the baby 4 Maternal conditions and lifestyle: Bacterial or viral infection of the mother may cause foetal death Alcohol and cigarette consumption by the mother There are some risk factors which predispose the mother to deliver a stillborn. They include Age: teenage and older mums (35 years and above) are more prone to have stillbirths Obesity: Women who are overweight are more prone to having stillbirth Multiple pregnancies History of previous pregnancy loss To help E cope emotionally with the loss of her baby, I advised her to consult a professional counsellor as grieving is a vital step in the recovery process. Her friend also invited her to join a support group of child bereavement in her church. Three months had passed. I received a letter from E. ” Dear Doc, let me share with you my feelings soon after I lost my baby. I was confused, sad, frustrated and bewildered. My nights were long. I could not sleep well, often waking up in the middle of the night staring at the cot I had prepared for him and searching desperately for him. These were the darkest hours of my life. I was in a bottomless abyss. Thanks for your help in getting me the professional counsellor. I am slowly but gradually coming out of my grief. I am feeling much better now."

G looked tense. Her face was creased with anxiety. “Doc, I am a coffee addict. I can’t work without drinking three to four mugs of coffee a day. I am in my first trimester now and my friend told me that I may have premature birth if I continue drinking the beverage. Is it true?” She said apprehensively. "I am also in a dilemma. I will have terrible migraines when I stop drinking coffee. What should I do? " Like G, many pregnant mums are in a quandary regarding the negative effects of coffee on their health as well as the developing foetus. Coffee contains caffeine which is a well-known stimulant that can cause an increase in maternal blood pressure and heart rate. Caffeine can reduce iron absorption from food. It is also a diuretic that may induce loss of body fluid leading to dehydration. All these negative effects on health have led obstetricians to advise pregnant mum to reduce the consumption of coffee. Caffeine has a negative influence on foetal growth too. Studies have shown that it can enter foetal circulation via the placenta. Its levels remain longer and higher in the foetus due to immaturity of the foetal liver which cannot break down caffeine as quickly as in the adult. A number of animal studies have shown that caffeine can cause birth defects, premature labour, preterm delivery, and increase the risk of having low-birth weight offsprings. However, no conclusive evidence has been found in the human. Whether caffeine causes miscarriage remains controversial. In one study, women who consume 200mg or more of caffeine a day are twice as likely to have a miscarriage compared to those who do not drink coffee. In another study, no such increased risk has been found. With regards to migraine, I told G that it was due to caffeine withdrawal. She should gradually wean herself off coffee, by sipping smaller amounts of the beverage slowly throughout the day. If the headache still persists and complete abstinence is not possible, a small cup of coffee with less than 200mg of caffeine a day is permissible. G tried to wean off coffee slowly by drinking decaffeinated coffee and tea. She succeeded in stopping drinking coffee after a few weeks. A healthy baby girl weighing 3 kg was delivered normally at term. “Doc. Thanks for helping me kick the habit of drinking coffee,” she smiled as she told me during her postnatal visit. “I also save a lot of money from buying expensive coffee,” quipped her husband.

In the course of my clinical practice, I have come across many patients who are confused between side effect and allergy of the medication.  Very often, the symptoms experienced by the patients in response to the drug are actually its side effects, and not an allergic reaction. Why is it important to differentiate the two? This is because it helps the healthcare provider make decisions on whether the patient should continue taking the medication. An allergic reaction means that the drug should not be given to the patient as some of the drug reactions may be fatal. On the other hand, side effects are usually mild and less severe and they may even go away with time as the body makes adjustments.  The patient may not have to stop taking the medication if the side effects can be tolerated and continue to derive its beneficial effects. Take the example of the common antibiotic, penicillin. The patient may experience diarrhoea or have a bloated feeling in the tummy after taking the drug. These are side effects. In some patients, however, swollen eyes and lips with rashes all over the body may develop. These reactions are due to an allergy. They can be life-threatening if breathlessness or respiratory distress occurs. What is Allergy? Allergy occurs when our body “sees” the drug as “foreign”. In order to get rid of this alien substance, special cells in our immune system are gathered to launch a reaction. At times, this reaction can be mild such as skin rashes or hives but occasionally, it may be severe as in an anaphylactic shock. Signs and symptoms of allergy are: · Hives · Red and itchy rashes · Breathing difficulties · Swelling in the face, tongue, lips, and throat According to the American Academy of Allergy, Asthma, and Immunology (AAAAI), allergic reactions account for 5-10% of adverse drug reactions. Some may occur immediately, while others may take hours or days to develop. What are Side Effects? Unlike drug allergy, side effects have nothing to do with the immune system. They are caused by the way the medication works. For example, when penicillin is consumed, it destroys many good bacteria in the intestines. This may result in diarrhoea or experiencing a bloated feeling in the abdomen. Side effects occur much more frequently than allergic reactions. Common signs and symptoms include: · Nausea · Dizziness · Palpitations Certain groups of people are more prone to side effects. They include: · Elderly patients · Pregnant women · Children · Patients with chronic illnesses e.g. diabetes What should you do? · Good communication is essential. Tell your healthcare provider as much information as possible regarding the symptoms you experience. Be as specific as you can. Your doctor may be able to differentiate whether you are truly allergic to the medication. · Ask your healthcare provider what could be the common side effects of the drug you are going to receive especially if it is a new medication. · Apply to the Singapore Medical Association for a Medik Awas Card, which aims to prevent medical mishaps by alerting medical and dental personnel to the drug/s you are allergic to. The more you know about the differences between side effects and allergies, the more empowered you will be to make the right choices when it comes to taking medicine.