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Tuberculosis (TB) is a disease caused by the organism, Mycobacterium tuberculosis. The bacteria usually attack the lungs, but they can affect other parts of the body. The disease can be in an inactive phase (latent infection) when the patient remains asymptomatic or may progress to an active stage, when it can spread through the air. For women in the reproductive age, TB can present great challenges before, during and after pregnancy. TB can cause infertility in women. The bacteria can affect the fallopian tubes leading to inflammation and subsequent blockage. During pregnancy, TB may present a challenge in diagnosis. The initial symptoms may mimic those of viral “flu” with cough, fever and lethargy. As TB is relatively uncommon in Singapore, if the symptoms persist for more than 2 weeks, one should keep the diagnosis of TB in mind. The sputum should be sent for smear and culture. A chest X-ray may be done after putting a lead shield over the abdomen to prevent the harmful effects of radiation on the baby. Tuberculin skin test should be done as it is considered safe throughout pregnancy. Pregnant women who have active tuberculosis should be treated as TB is a deadly disease. For the baby, intrauterine growth restriction may occur if the mother is not treated. In rare cases, the baby may develop TB. The standard first line drugs are safe and do not harm the baby and patients. The pregnant woman should be monitored with liver function tests and visual fields at periodic intervals. After delivery, mothers may be worried whether they should breast feed their babies. Those who choose to breastfeed and are still undergoing TB treatment can safely do so. Very small amounts of the medication may pass to the baby through the breast milk but the amounts are too small to produce toxicity. It is Important that the mother should put a mask on while breast feeding. With increasing affluence and improved socio-economic status, the number of patients suffering from TB in Singapore is small. Following the launch of the Singapore Tuberculosis Elimination Programme (STEP) in 1997, the number of TB cases has declined and fluctuated between 35 to 45 cases per 100,000 population among Singapore residents. In 2016, there were 1,617 new cases of TB and majority were male aged 50 and above. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/.

Q. I had 3 caesarean sections, the last one was about 6 months ago. Recently I had lower abdominal pain on and off near the right side of my abdominal wound. My obstetrician told me that it is due to adhesions. What is adhesion? What are the causes? Is it serious? Do I require another surgery? What can I do to relieve the pain? A. Adhesions are bands of fibrous scar tissue formed on the surface of the abdominal organs such as intestines and the womb (see figure 1&2). Normally, these organs are lying freely in the abdominal cavity without sticking to one another. Their surfaces are smooth and are covered by a thin membrane. However, if this membrane is breached from handling by surgeon during abdominal operation, inflammation will occur with subsequent scar formation. The scar will bind the organs together and/or induce the organs to stick to the abdominal wall. It has been estimated that adhesion will develop in more than 90% of patients after an abdominal surgery. The more times the surgery is performed, the more extensive the adhesions. Another cause of adhesion is infection. It can be a result of a ruptured appendix or pelvic infection. In women with endometriosis, a chronic condition in which there is a backflow of menstrual blood into the pelvic cavity, the menstrual deposits may cause widespread scar formation resulting in the pelvic organs gumming together. Most adhesions do not cause symptoms except for occasional cramps. The abdominal pain is intermittent and usually resolves by itself without treatment. But in some patients, the adhesions can be severe and cause partial or complete blockage of the intestines. If the intestines are partially blocked, abdominal pain may become severe and the abdomen is bloated with gas. There may be nausea and occasional vomiting. With conservative treatment using medications and intravenous fluid therapy, the blockage is often settled If there is complete blockage, non-stop vomiting with abdominal distension can occur. The patient needs immediate medical attention. Otherwise, severe dehydration, fever, shock and death may occur. Urgent surgery to relieve the intestinal obstruction is required. Abdominal adhesions are permanent and there is no way to prevent their formation. Since you have mild abdominal cramps without nausea or vomiting, you probably do not have intestinal obstruction. Surgery is probably not necessary. Medications to relieve the intestinal spasms will help. A low-fibre diet, which is easier to digest and a regular bowel habit are important to prevent an intestinal blockage. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/

F was devastated when her doctor told her that her chance of conception was less than 5%. F, 36,had been married for 5 years and was infertile. She lived in a neighbouring country and had failed IVF twice over the past one year. She was told by the local fertility specialist that her ovarian reserve was low. “Doc, I have always assumed that I should have no problem with fertility and should be able to conceive whenever I want”, she said. During her first 2 years of marriage, her husband was not ready. So she waited. She only consulted the doctor after she tried unsuccessfully for about a year. Her fertility workout was normal. She ovulated regularly and her womb and tubes were normal. Her husband’s semen analysis was normal. The couple then tried IVF on the advice of the specialist. But it ended in failure. “I don’t want to attempt IVF again”, she confided, with tears in her eyes. "It was so traumatic emotionally and physically. I just want to know how low my ovarian reserve is. Is there any other way for me to conceive?” she asked. After blood tests and an ultrasound examination, I confirmed that her ovarian reserve was in the low normal range. I suggested intrauterine insemination(IUI) with superovulation(SO) as an alternative. On the third attempt, she was overjoyed when her urine pregnancy test was positive 3 weeks after the procedure. Her face was beaming with smiles when she saw her baby wriggling in the womb on the ultrasound examination. She finally delivered a healthy boy by Caesarean section. She sent me a thank you card in which she wrote “Doc, please tell your infertile patients not to give up hope. They are not numbers. They don't need a stockpile of eggs to have a successful pregnancy”. What is Low Ovarian Reserve? Ovarian reserve refers to the pool of eggs present in the ovaries at any given time. Low ovarian reserve is when the number of eggs is so depleted that there is an insufficient number to ensure a reasonable chance of pregnancy. Physiology of egg development A female foetus is born with a finite number of egg cells. In the first 3 months of pregnancy, the egg cells rapidly multiply. By the 5th month of pregnancy, the foetus has a peak of six to seven million eggs. After that, the eggs start to disintegrate and the number declines to one to two million eggs at birth, falling further to 250,000 to 500,000 eggs at puberty. At 37 years of age, a woman will only have about 25,000 eggs and at menopause the number is almost zero. There are three types of eggs in the ovary: immature eggs, eggs that are selected to mature and atrophic or dead eggs. These eggs are encased in sacs called follicles that support and nourish them until they mature. Every month, about 1000 immature eggs are selected for growth. One of these eggs will develop, mature and ovulate and the rest will degenerate, die and are reabsorbed into the ovary. Causes of Low Ovarian Reserve · Aging: Ovarian reserve is part of the female biological clock. The clock can vary from person to person. Some women continue to be fertile in their 40s, while others begin to lose their fertility in their 20s. But the reserve declines with age. · Genetic: low ovarian reserve can be due to chromosomal anomalies such as Turner Syndrome, where the woman does not have two X chromosomes, or gene abnormalities such as Fragile X syndrome. · Infection: Infection from STDs, TB or a ruptured appendix can deplete the egg numbers · Surgery: removal of part or all of the ovary due to ovarian cysts or cancer · Cigarette: Smoking can bring forth menopause earlier by 2 years · Destruction of ovarian tissue from radiotherapy, chemotherapy · Unknown cause. Diagnosis of low ovarian reserve Majority of women with low ovarian reserve have no symptoms though some may experience a change from normal to shortened menstrual cycle, e.g. from 30 days to 25 days. The diagnosis is usually made during investigations of infertility. Tests include transvaginal ultrasound and hormone evaluations for follicle stimulating hormone (FSH), oestrogen and the anti-Müllerian hormone (AMH). The levels of FSH and oestrogen are good indicators of fertility and AMH usually correlates well with fertility potential by reflecting the number of eggs left in the body. These tests can detect low ovarian reserve fairly accurately. Treatment of low ovarian reserve No treatment can slow down ovarian aging or prevent a low ovarian reserve. Pregnancy is usually achieved through assisted reproductive techniques, as in F's case. It is important that the couple should be counselled and be realistic about the chances of success so that they can make the appropriate decision. Other options include using donor eggs or adoption. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/.

Obesity is an “epidemic” in developed countries. It increases the risks of chronic diseases such as hypertension and diabetes and has a negative impact on reproductive health like erectile dysfunction and infertility. Dietary control is essential in the management of obesity. Many diet plans have been proposed for the reduction of body weight, sometimes in an unhealthy way. Fad crash dieting, for example, is potentially dangerous. Eat smart with a healthy balance diet is thus the most important thing in weight management.Below are some of the foods that may be helpful in weight management. Almond Almond is rich in nutrients, including magnesium, iron, calcium, vitamin E and fibre. It may help maintain healthy cholesterol levels.Almond is also a superior snack when compared to junky options such as pastries. Chewing the nut will make you feel as if you are eating something substantial.· Beans Beans are a great source of protein. They are also high in fibre and slow to digest. You would feel full longer, which may stop you from eating more. Oatmeal Oatmeal is made from rolled or ground oats which are rich in B vitamins, omega-3 fatty acids, and potassium. They also contain complex carbohydrates, as well as water-soluble fibre, which slow digestion down and stabilize levels of blood-glucose. Broccoli Broccoli is rich in calcium, potassium, Vitamin C, folate, fibre and phytonutrients. Phytonutrients are compounds that reduce the risk of developing heart disease, diabetes, and some cancers..It contains antioxidants , beta-carotene and sulforaphane, a chemical that is said to have anti-cancer and anti-inflammatory qualities.However, overcooking broccoli can destroy many of its nutrients. So, eat it raw or lightly steamed. Apple Besides vitamins, apple is an excellent source of antioxidants, which combat free radicals. A research in the Florida State University has found that older women who started a regime of eating apples daily experienced a 23 percent drop in levels of bad cholesterol (LDL) and a 4 percent increase in good cholesterol (HDL) after 6 months. Egg Egg is another source of protein that can easily be incorporated into a balanced diet. It contains vitamin B-2 and vitamin B-12, both of which are important for energy and red blood cells. It is also a good source of the essential amino acid leucine, which is important for stimulating the production of muscle protein.The yolk of the egg contains the majority of the vitamins and minerals. It also contains the fat and cholesterol. Research has shown that taking eggs in moderation do not increase the risk for heart disease. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/.

I am six months pregnant. Recently, I visited my friend in Shanghai. I saw her secretary wearing a suit which is supposed to protect her unborn foetus from irradiation. She told me that this type of garment is very popular in China and suggested that I should buy one before going back. I have my doubts. Is it necessary? Does it really protect the foetus from irradiation? The radiation you referred to is probably the background radiation, which is present in our environment and around us all the time. The radiation comes from the soil and cosmic radiation from the sun and outer space as well as from our own inventions such as televisions and computers. It is usually of low energy. According to the World Health Organization, the Food and Drug Administration and the Federal Communications Commission of USA, exposure to this radiation has not been shown to have any negative effects on human health. There is also no conclusive evidence that low levels of radiation from everyday devices is harmful to the unborn child. The Federal Trade Commission (FTC) in the US has advised consumers to avoid products that claim to “shield” users from this type of radiation. It is interesting to note that a recent report (2018) conducted by a Chinese Academy of Sciences recommended laboratory found that the anti-radiation clothing, which has been popular with pregnant women in China actually increased radiation exposures by trapping them in the body like a greenhouse. The researcher found that though the garments proved effective in blocking 90 per cent of electromagnetic waves coming from the front, they let in radiation from other parts of the body not covered by the clothing. The study concluded that this type of clothing actually intensifies the radiation as the electromagnetic waves have no outlet to be dispersed once they get inside the garment from other directions. I would not advise you to use the so called anti-radiation suit. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/

She had to pee a few times every night. “Doc,” she said” I have difficulty going back to sleep again. I feel very sleepy at work the next day. My appetite is affected and I become very anxious. Will the insomnia affect the health of my baby?” Felicia, 29, a first-time mum is at 11 weeks of her pregnancy. She is not alone with problems in sleeping. Four out of five women have inadequate, disturbed or poor-quality sleep during pregnancy. There are many reasons, the most common being the discomfort, abdominal pain and back aches as the womb expands with the growing foetus. Frequent urination at night, hormonal changes and anxiety about the arrival of the baby are other reasons. Whatever the reason, studies have shown that insomnia will not have any negative impact on foetal health. To cope with the sleep problems during pregnancy, the following measures may help. 1. Create an environment conducive for sleeping: · Keep the room comfortably cool, quiet and dark. · Aromatherapy may help · Firm mattress to support the spine so as to reduce the backache · Soft pillows to support the abdomen. · Have soft and soothing music in the background 2. Self-discipline; · Have a fix sleep schedule and adhere to it · Afternoon naps should not be too long. Otherwise, insomnia may occur. · Exercise regularly, but only until the early evening as exercising too near your bedtime may result in difficulty sleeping. 3. Reduce discomfort · Have a light snack before sleep to avoid hunger pangs and to reduce heart burn · Massage and relaxation techniques: Yoga, Pilates, meditation · Have a warm bath before sleeping · Wear loose clothing 4. Cut off stimulant · Avoid Coffee and chocolate at bedtime. Have a cup of chamomile tea instead. · Stay away from sugar at night · Switch off hand phone, laptop or other electronic device early. The blue light emitted from the screen can suppress levels of melatonin, the hormone that regulates the sleep cycle 5. Anxiety management: · Don’t look at the clock: getting too anxious as the minutes creep by can only make sleeping problems worse · Reduce stress Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/.

Myth: HPV infection is not common Fact: HPV infection is very common. Four out of  five people (80%) will have the virus at some point in their lives. A healthy lifestyle can help you reduce your risk of infection. Eat well, exercise regularly and stop smoking. These can help boost your immune system which is responsible for fighting off the infection. Myth: Only women get HPV. Fact: Men can get HPV too. According to the Centers for Disease Control and Prevention, USA, most sexually active men will have at least one HPV infection at some point in their lives. Any person who is sexually active can contract HPV, even if you have had only one sexual partner. Myth: You will know if you have HPV infection Fact: HPV infection normally has no signs or symptoms. A person who has been infected with the virus may never know that he or she has the infection. Only about 1% of all sexually active people would have visible signs of genital warts. HPV infection is usually detected by abnormal pap smear and  biopsy of the cervix(neck of the womb). Myth: If you use a condom you won’t get HPV Fact: Wearing condoms can reduce your risk of getting HPV but not completely as  the virus can live on the skin in and around the genital area which may not  be covered by the condom. It can therefore be transmitted through sexual contact including genital to genital contact, oral, vaginal and anal sex. Fact: HPV vaccination can reduce the risk of infection by the HPV types targeted by the vaccine. Three vaccines have been approved: Gardasil®, Gardasil® 9, and Cervarix®. While all the vaccines are available for women, only Gardasil is available for men. These vaccines provide strong protection against new HPV infections, but they are not effective at treating established HPV infections or disease caused by HPV (15, 16). Regular pap smear  is just as important even if you have been vaccinated as it may detect abnormalities caused by other types of HPV.

I am a first-time mum. I am advised to have my baby’s cord blood stored. What are the benefits of storing the cord blood? A. Umbilical cord blood, once discarded as waste material, is now discovered to be a rich source of stem cells which are useful in the treatment of many diseases. It contains two types of stem cells, the hemopoietic stem cells and the mesenchymal stem cells. Stem cells are unspecialised cells with 3 basic characteristics. First, they renews themselves by producing identical daughter cells. Thus, they are able to  maintain their own population throughout life. Second, they are capable of changing into other types of cells in the body, e.g. they can differentiate into cartilage or bone cells. Third, they may renew and regenerate tissues they populate. For example, blood-forming stem cells will constantly produce and replace all types of blood cells in an orderly manner. Scientists have explored the vast potentials of stem cells of cord blood therapeutically by means of transplant. About 80 life-threatening diseases in the past decades have since been treated with cord blood transplants and many clinical trials for other diseases are ongoing. At present, cord blood has been used successfully in the treatment of certain blood disorders and cancers such as leukemia (cancer of white blood cells). Some metabolic storage disorders and genetic diseases of the immune system may also benefit from stem cell transplants. The advantages of storing the baby’s cord blood are as follows: • Cord blood transplants may be needed for the baby or his/her family members later in life. •  There is only one chance to collect and bank the baby's cord blood at birth. •  The collection process is simple, painless, and harmless to the baby and mother. •  Patients who need bone marrow transplants may have problem finding a match.  By using the baby’s cord stem cells, the odds of having a proper match for the baby or another family member improve. • Future medical advances might allow stem cells to treat even more diseases and be used in more transplant cases than current medical practices.

Magnesium is an important mineral crucial for many functions in our body. It is ​essential for muscle contractions and for transmission of messages by the nerves. It keeps​ the heart beating steadily, ​the immune system strong and helps in regulating ​the body temperature. Female fertility With regards to female fertility, studies have suggested that lack of magnesium may result in undue contractions of the fallopian tube making the fertilised egg difficult to implant in the womb. These spasms ​are usually not noticeable  but may contribute to issues of fertility. Magnesium helps ensure proper blood supply to the womb and is important for the production of progesterone, the hormone that is important for maintaining the pregnancy. Magnesium is also a natural stress reliever. Deficiency in magnesium causes the levels of stress hormone, cortisol, to rise. When this happens, our body’s hormonal system goes into disarray. Ovulation is affected ​ and the chances of conception become reduced. Male fertility For male fertility, several recent studies have suggested  that improving magnesium levels in our body increases the levels of total testosterone, the hormone responsible for sperm production. Pregnancy Magnesium is important in maintaining a healthy pregnancy. Low levels of magnesium in the blood have been linked to an increased risk of miscarriages, foetal growth retardation, gestational hypertension, pre​-​eclampsia and premature​ birth. Magnesium in our food The recommended daily intake of magnesium for women in childbearing years is 300mg a day, increasing to 450mg ​a day during pregnancy. Foods that are rich in magnesium include green leafy vegetables, seaweed, wheat bran, almonds, dried figs, whole grains, black beans, edamame and avocado. ​ While a healthy level of magnesium is important for fertility, a combination of ​ other factors such as regular exercise , eating a balanced diet and​ seeking ​ professional help are keys to starting a family.

Most men would shudder at the thought of a scalpel getting close to their penis. They would usually not go for circumcision in which the foreskin is surgically removed unless it is for ritualistic and cultural reasons. In a recent seminar, I was asked whether there is a link between fertility and circumcision. Medically, there are 2 conditions when circumcision may help improve fertility. They are phimosis and balanitis. In phimosis, the foreskin is too tight and becomes difficult to retract during an erection. This makes sexual intimacy painful. In balanitis, there is infection of the head of the penis (Glans penis) which becomes inflamed, itchy and red. If the head of the penis is always covered with the foreskin, the infection would not subside and sexual intercourse would be difficult. It is common for phimosis and balanitis to coexist together and they are more commonly found in patients with diabetes. Other than the above conditions, circumcision probably does not affect fertility. It is also not certain whether the procedure improves or reduces sexual pleasure. However, circumcision does have other health benefits. These include: · Easier hygiene. Circumcision makes it easy to wash the penis. · Reduce risk of urinary tract infection: The risk of urinary tract infection in babies under one year is low, but it may become more common in uncircumcised baby boys. Severe infections early in life can lead to kidney problems later in life. · Lower the risk of penile cancer: Although cancer of the penis is rare, it is even less common in circumcised men. The foreskin is believed to act as a reservoir for the human papillomavirus(HPV) which can cause penile cancer. · Help prevent the spread of HIV and HPV: Circumcision effectively eliminates the extra foreskin which traps the viral loaded secretions. This reduces the likelihood of spreading the disease. Research studies have found that HIV infection rates decreased by about 60 percent in circumcised men compared to those that were not. But circumcision also has drawbacks. They include: · Pain · Excessive bleeding and infection: these complications are uncommon. · The foreskin may be cut too short or too long · The foreskin fails to heal properly. If the remaining foreskin reattaches to the end of the penis, minor surgery may be needed to correct it.

Recently, my friend delivered her baby early, at 32 weeks gestation by caesarean section. Fortunately, the delivery was uneventful and both mum and child are well. I would like to know the causes of premature birth and the immediate health issues of the baby. A normal pregnancy usually lasts 40 weeks. Premature birth is one that occurs before 37 weeks of gestation and happens in about 10 %of all pregnancies. Depending on how early the birth occurs, it is further subdivided into: • extremely premature (earlier than28 weeks) • very premature (28 to 32 weeks) • moderate to late premature (32 to 37 weeks). Very often, no specific cause of premature birth can be found. However, there are factors that may be associated with premature birth. These include: · Intrauterine infection of the membranes and/or amniotic fluid that surround the baby. It is estimated that the infection is associated with about 40% of premature births · Excessive amniotic fluid as found in gestational diabetes and multiple pregnancies e.g. twins and triplets. · Hypertension during pregnancy, in which Caesarean section or induction of birth has to be done early for medical reasons · Chronic medical conditions in the mother e.g. kidney failure, heart disease and diabetes mellitus. · Teenage pregnancies · Laxity of the neck of the womb (cervix) resulting from repeated abortions or surgery to the cervix · Structural abnormalities of the womb (uterus) e.g. uterine septum, double womb · History of a previous premature birth · Smoking · Poor nutrition Understandably, premature birth gives the baby less time to develop in the womb. Premature babies, especially those born very early, will have organs that tend to be less developed, which make them more prone to complicated medical problems. They can also become ill fast, when a mild condition can suddenly deteriorate and prove fatal. Not all premature babies experience complications. Generally, the earlier a baby is born, the higher the risk of complications. Life-threatening complications include: · Respiratory distress syndrome: Immaturity of the lungs will present this breathing problem from lack of surfactant. Naturally occurring, surfactants are substances that keep the lungs inflated and help prevent the air sacs in the lungs from collapsing. Some preemies may experience prolonged pauses in their breathing, known as apnoea. · Heart problems: The most common problems are patent ductus arteriosus (PDA) and low blood pressure (hypotension). PDA is a persistent opening between two major blood vessels leading from the heart. This heart defect often closes on its own. Left untreated, it can cause heart failure and other complications. · Temperature control: Preemies can lose body heat rapidly; they don't have enough stored body fat of a full-term infant to keep warm. Smaller preemies require additional heat from a warmer or an incubator until they are larger and able to maintain body temperature without help. · Brain haemorrhage: The less developed blood vessels in the baby’s brain are delicate and more likely to break and bleed. The baby may show slow reflexes, weak suction of the mouth, fits and apnoea. Most bleeding episodes are mild and resolve with little short-term impact. But some babies may have larger bleeding resulting in permanent brain injury. · Intestinal inflammation: Preemies are more likely to have immature gastrointestinal systems, leaving them more prone to intestinal inflammation. Occasionally, serious complications such as necrotizing enterocolitis (NEC) in which the cells lining the intestine wall are injured, can occur. · Blood infection: Due to an underdeveloped immune system, preemies are more likely to get infection which can quickly spread to the bloodstream causing sepsis, a life-threatening complication.

I am 28 weeks pregnant. I am travelling to Hong Kong where there is a recent epidemic of flu. Is there any way to prevent the flu? Should I get the flu vaccination before I go?  Is it safe for the baby?  Any side effects? A 'flu' is a contagious illness caused by influenza viruses that infect the nose, throat, and the lungs. It is spread through the air from coughs or sneezes and can cause severe lung infection(pneumonia) which can be life threatening. The best way to prevent the flu is by getting yourself vaccinated. The Centres for Disease Control and Prevention (USA) and the American College of Obstetrics and Gynaecology recommend that all pregnant women should get a flu shot during the flu season, regardless of their trimester. Besides preventing lung infection in the mother, flu vaccination also reduces the risks of miscarriage, premature birth and intrauterine growth restriction(IUGR).  It also helps protects your baby from the flu after birth. The vaccine is made from an inactivated virus. It is safe for both mother and the foetus. It usually takes about 2 weeks to work. The side effects are generally mild. Common side effects include: Soreness, redness, and/or swelling at the injection site Muscle aches Nausea Fatigue Headache Fever These side effects usually begin soon after the shot is given and generally last for 1-2 days. Rarely, it can cause serious problems, like severe allergic reactions.