Failed contraceptive and pregnancy

I had a patient who recently conceived after taking oral contraceptives. The failure rate is very low in the order of 0.01% but it does happen. One has to be careful and counsel that sometimes this can happen when one just starts taking the oral contraceptive pill and that certain antibiotics taken together with OCs can lower it's effectiveness. The dilemma is whether the pill will have any effect on the pregnancy. OCs are a category C drug ie it has shown to have effects on animals and on humans. It has been shown to have virilising effects on a female foetus. However one should not jump straight to having an abortion, as the findings are sporadic and there are many women who have taken progestogens in pregnancy without any effect on the foetus. One has to consider the effects of an abortion and weigh the risks viz. damage to the cervix, damage to the lining of the womb, infection and blockage of the tubes, against the risks of a virilising effect on the foetus.The patient has decided to continue with the pregnancy and in my opinion this was the wiser decision.

Is preeclampsia in pregnancy preventable?

A few days ago I had to do a caesarean section for a young lady in her first pregnancy. She was only 28 weeks into her pregnancy. Unfortunately she had developed severe preeclampsia, a condition of the placenta characterised by high blood pressure, swelling and protien in the urine. She had underlying essential hypertension which was probably inherited and subsequently developed this condition. As her blood pressure became uncontrollable despite all medications, I made the decision to deliver her as it would otherwise have endangered her life and that of her baby.

There have been many proposals put forward over the years to prevent this condition but none proven. These include, a high protein diet but the World Health Authority concluded that in the abscence of a deficiency it would not be of benefit. Fish oil supplementation once proposed but subsequent trials have shown no benefit. There are more ongoing studies in New Zealand and Scandinavia. Calcium supplementation was shown initially to have some benefit in small trials but a large trial published by the New England Journal showed that there was no benefit in 1997. Low dose aspirin has been shown to have some benefit in those who have had previously had a pregnancy with preeclampsia and at risk in subsequent pregnancies so this may be of benefit but only on hindsight. The most recent study by the British Medical Journal showed that high doses of L-arginine together with anti-oxidants are of benefit but further studies need to be done.

www.eurekalert.org/pub_releases/2011-05/bmj-nss051811.php

How many caesarean sections is safe

It is a common belief that if you have had one caesarean section, you can only have only one more child if it is also by caesarean section. I believe that this misconception arose from the time of "two is enough" family planning policy in Singapore, and those who had a caesarean section were encouraged to have their tubes tied after their second caesarean section. In actual fact one can have as many children as one wishes by caesarean section and I have personally done six caesarean sections on one woman. The risks however increase with each caesarean section although a great deal depends on who performed the operation and the healing process that takes place afterwards.

The main risk is that the placenta implants on the caesarean section scar and this results in a placenta that is low down in the womb and one that becomes difficult to remove during the operation and the possibility of heavy blood loss. The other main risk is that with each operation there may be sticking of the bladder to the womb and injury may occur during the operation. During the second caesarean section, your obstetrician will most likely be able to advise you as to whether you would be able to have more children.

Ectopic pregnancy

The incidence is low 1:700 and unless there is a history of pelvic infection causing some damage to the lining of the fallopian tubes, an ectopic pregnancy is not common. Ectopic pregnancy is a pregnancy that is outside the womb. It can be on any portion of the fallopian tube or even grow on the ovary. This abnormal location of the pregnancy means that it is not possible for the pregnancy to grow to full term and needs to be removed. The risks with an ectopic pregnancy are that as it grows in the tube, it will erode through the tube and rupture a blood vessel resulting in bleeding into the abdomen.

Thus the importance of an early check-up with the obstetrician as he will be able to diagnose an ectopic pregnancy before any serious mishap. Unfortunately an ectopic may be difficult to view on ultrasound scan but will be suspected if there is no pregnancy sac in the womb, and blood pregnancy hormone levels show a slow rise. Sometimes the sac can be seen in the tube and it will give the typical vivid appearance of surrounding blood vessels called the 'ring of fire'.

Diagnosis is by laparoscopy ( inserting a telescope through the belly button) and viewing the fallopian tubes. Treatment is either removing the pregnancy alone by cutting open the afected tube, or removing th entire tube if it is too badly damaged. The alternative is to use a cancer drug to try and dissolve the pregnancy.

Syphillis and pregnancy

Syphillis is a sexually transmitted disorder. With the rising incidence of sexually transmitted disorders especially in China, routine screening during pregnancy is important. Syphillis may have no symptoms especially in the early stages but the infection can cause sudden death of the foetus after 28 weeks. If it is not screened for and therefore missed would be a travesty as if detected, a single dose of penicillin antibiotic would avoid a stilbirth due to this sexually transmitted disorder.

Why you should sleep on your left side

A recent article  showed that sleeping on the back and right side predisposes to a higher incidence of sudden death of the foetus. Although further studies need to be done, it would be prudent to follow this rule especially if you are in your third trimestor. The incidence of stilbirth is not high and is less than 1: 10000. Very often it is attributed to a cord accident but in a large proportion no obvious cause is found. It may be that sleeping on the back and right could well be a cause. Pregnant women have always been told to sleep on the side and the reason is that there is a major vessel running parallel to the spine on the right and behind the womb. As the womb expands there will be increased pressure on this vessel. This blood vessel also supplies the foetus with oxygen and nutrition. The womb is naturally tilted to the right, thus it would make sense that sleeping on the right and back would increase the pressure on this vessel possibly reducing the oxygen to the foetus.
So always remember to sleep on the LEFT side!

http://www.medscape.com/viewarticle/744648?sssdmh=dm1.695983

Down's Syndrome and other chromosome abnormality testing

With more women having children after the age of 35 years, testing for Down's Syndrome ( Mongolism ) and other chromosome abnormalities has become even more important. The test with the highest accuracy of course would be the amniocentesis, however this is an invasive procedure and it would not be practicle to perform this on every pregnant woman above 35 years. Testing has evolved from the triple test (measuring 3 markers in the blood at 15 weeks onwards ) to tests which are done in the first trimestor ie 11 -14 weeks.

In my practise, I will start with looking for the nasal bone between 11and 14 weeks. An absent nasal bone is strongly suggestive of a chromosome problem.  I will do two tests. The first is the measurement of the nuchal translucency ( this is the fluid at the back of the foetal neck which is present in all foetus's but is greatly increased in one with a chromosome disorder ). This should be <2.5mm. There are false positives and I increase the accuracy by combining this test with measurement of 2 markers in the blood, one a hormone beta-HCG and a protein PAPP-A. The combination of these tests is called the Oscar test. This gives a predictive accuracy of 95% for a chromosome abnormality.

If the tests are positive then an amniocentesis or CVS is offered. The alternative is to retest with a triple test and nasal bone measurement at 16 weeks, and if positive an amniocentesis should be done as the likelihood of a chromosome abnormality is high.

Normal delivery or caesarean section?

Obstetricians have always been taught that normal delivery was best, unless there was an indication for a caesarean section. It was assumed that every pregnant woman would want to have a normal delivery. But is normal delivery really better? The caesarean section rates have always been on the rise and now account for about 1 in 3-4 deliveries. I would say that after 25+ years of practising obstetrics, it would appear to me that a caesarean section delivery has a lot more going for it than a normal delivery. I will probably be shot down by many fellow obstetricians for this statement. However I have seen way more complications arising from a normal delivery than caesarean sections. Many pregnant women are unaware that a normal delivery has a higher risk to the baby ( this is only logical since a baby would be more prone to foetal distress having to traverse the female pelvis in its passage to this world, and a long labour may leave both mother and baby exhausted and more prone to potential hazards ). One would argue that recovery is faster with a normal delivery. This may not necessarily be true for a long labour or one with multiple vaginal tears.

Pregnant women now want to be more involved in decision making with regard to mode of delivery and this is a good thing so that a proper informed decision can be made. The obstetricians role is now more of a facilitator and educator in the antenatal care and delivery of the baby. Having weighed the pros and cons joint decisions are made, sometimes even with the input of of various family members.

Premature labour

One of the many concerns I often get asked is will my baby come early? The question should actually be will my baby be premature or preterm. Labour anytime before 37 weeks would be considered as premature. It is common for the baby to come between 37 and 40 weeks but this is not a problem. The incidence of preterm labour is about 12% of all pregnancies. The most common causes are infections eg strept B, trauma to cervix eg after an abortion or cone biopsy, multiple pregnancies, poor nutrition, inadequate rest, chronic medical illnesses eg asthma. In a large number, the cause is unknown. The preterm labour tends to recur with each pregnancy.

Your obstetrician may want to perform a vaginal scan in the early or late second trimestor to determine the length of your cervix if there is a history of preterm labour or other risk factors. A short cervix ( between 10-21mm ) indicates a high risk of preterm labour.

Rest and good nutrition are very important. It is my practise to start the pregnancy with utrogestan as very often early threatened miscarriage and later preterm labour are associated with a lack of the pregnancy hormone, progesterone. Utrogestan is micronised progesterone and is very safe for use in pregnancy. I will continue this until 36 weeks. I have many patients with recurring miscarriages and preterm labour, when put on utrogestan achieve a full term and healthy baby. Tocolytics such as ventolin can be added if there are signs of excessive uterine contractions or impending labour.It also appears that consuming moderate amounts of  fish prevents preterm labour and tends to prolong the pregnancy in a recent study.

Bleeding in early pregnancy

The most common problem in the first 12 weeks of pregnancy is bleeding. This can be very alarming and distressing but the good thing is that although common, the majority resolve without adverse effect on the foetus. The miscarriage rate is about 1:5 overall.

Bleeding is most often due to insufficient pregnancy hormone, progesterone. The pregnancy then threatens to dislodge from the uterine wall resulting in bleeding. If the bleeding is slight, it will appear as a brown stain but if more serious there will be passage of clots associated with abdominal cramps.

It is prudent to visit your gynaecologist early in the pregnancy ( best time is 5-6 weeks) especially if there has been a previous pregnancy with bleeding ( since bleeding in pregnancy tends to repeat itself with each pregnancy ). Treatment can then be instituted before too much damage has been done. It is especially not wise to come after repeated episodes of bleeding as each subsequent bleed may jeopardise the foetus. A scan can be done to determine if the foetal heartbeat is seen. This is usually detectable at 6 weeks pregnancy. Hormone therapy can then be instituted. If there is heavy bleeding, or a history of more than one miscarriage, it is my practice to administer a course of HCG injections + utrogestan. If only slight bleeding,  bed rest and utrogestan is administered. With hormonal treatment, the bleeding should stop within a few days and if it persists more than a week, should be reviewed to exclude other causes for the bleeding.

Nausea & Vomiting in pregnancy

Most pregnant women will experience some degree of nausea and vomiting (NVP). It usually starts at about 6-8 weeks when the hormone levels are at its highest. Some 20%, the lucky few will not have this experience. You can tell if you will or will not experience NVP by whether you are prone to car or sea sickness!. Nevetheless if you get it it is a good sign in that the pregnancy is likely to be on going and the risk of miscarriage lower. The converse however does not hold true. If severe NVP is present this may sometimes be due to twin pregnancies!

If severe it can be quite debilitating and creates depression and worry whether the baby is getting sufficient nutrition. Overall the foetus is quite hardy and unless really severe to the point of dehydration, is unlikely to affect the foetus. You should initially try eating small meals several times a day, avoiding situations which might trigger off the NVP such as strong smells, noisy surroundings, certain foods. NVP is also called morning sickness but it rarely occurs in the morning and usually before or after midday. If you are able to after eating lying down often helps, or chewing on ice chips. Sea bands round the wrist from the pharmacy may help.

If more severe, your gyne may want to give you two medications that are the gold standard for treatment of NVP without side effects or effects on the foetus. Pyridoxine (vitamin B6) up to 40mg/day or a combination of pyridoxine and an antihistamine such as phenergan often will make alot of difference. It is the occasional patient who will require admission and an intravenous drip. Most NVP resolve by 12 weeks unless there are associated gastric and intestinal problems such as gastritis, gastric or duodenal ulcer.

Flying, radiation and pregnancy

With all the news about radiation and the nuclear catastrophe in Japan, I thought it appropriate to visit this topic. Firstly pregnant women should not get unduly alarmed. Although air travel has been on the increase, there does not appear to be an increase in the number of children with abnormalities or developing leukaemia. air travel exposes the foetus to cosmic radiation. The amount of radiation is low, less than that of a normal chest xray. however, the longer the exposure the greater the potential risk. Long haul flights (>4 hours) would increase the risks. Foetal cells are at greater risk of damage than adult cells. In the first trimestor and up to 18 weeks, the risks would be that of miscarriage, damage to the chromosomes resulting in foetal abnormalities especially the brain. after 28 weeks, the foetus is fully formed. The risks then is that of cancer eg leukaemia in the future.

To avoid the potential risks to your baby, it would therefore be prudent not to travel up to 18 weeks, and if you have to travel, confine it to short haul flights. Minimise the number of flights overseas throughout your pregnancy. http://www.safety.duke.edu/radsafety/fdose/fdrisk.asp

Diet and pregnancy

Its always been the case that your obstetrician will tell you that its not good to put on too much weight. Well, from the mothers point of view this makes sense since excessive weight gain leads to diabetes, bigger babies and more difficult births. However, there appears to be new evidence from a study that showed that low carbohydrate diets and dieting in general during pregnancy is not good for your baby as it can lead to obesity in your child later in lofe. the study showed that pregnant women who were on a low carbohydrate diet increased the methylation of the gene which is responsible for obesity in childhood. http://diabeted.diabetesjournal.org/content/early/20-0979.abstract  So little weight gain and dieting in pregnancy can lead to fat kids later on. This is logical since starvation causes 'survival mode' to kick in allowing for increased fat stores in foetus. the answer would probably lie somewhere in between, eat a sensible diet high in protein and a moderate amount of complex carbohydrates. Oily fish such as wild salmon would be a good choice in addition tolean meats and vegetables. Aim to gain about 1-2kg per month. Weight gain will not be even but an overall weight gain of 12-15 kg would be about right.