How to reduce back pain during and after pregnancy

Back pain after delivery affects up to 50% of women and is a very often overlooked problem. A woman's quality of life can be substantially affected especially during this very stressful period. Prevention is of course better than cure. Awareness that back pain will plague a great many women during and after pregnancy is the first and foremost important step. Why do pregnant women get back pain. Firstly, the hormonal changes in pregnancy affect the mobility of the joints of the spine. As a result the muscles that normally support the spine are in constant use and in overdrive what with the extra weight of the progressing pregnancy. During the labour, there is the added insult to the spinal muscles of the straining and awkward positioning that accompanies the delivery. And after delivery, the lack of sleep and extra work to the back muscles of having to carry the baby in and out of the cot.
Taking pain killers is not the answer and can be dangerous for the babies health when breastfeeding.

How then can one reduce back pain. The following are some suggestions:

1. As mentioned earlier, being aware and conscious of ones back throughout the pregnancy. Making sure that when standing, the centre of gravity is pushed slightly behind. So if one were to draw a straight line it would fall somewhere behind your heel. Of course, avoid using anything with heels! as this will add even more strain to your back. Always keep a straight posture and avoid slouching.
If you have a weak back you may benefit from a a pregnancy support belt.

2. Bend your knees first before lifting anything from the floor, and avoid bending forward to reach for objects at a distance.

3. When sleeping, bend your knees in a flexed position and rest the knees with a bolster behind. Your mattress should be moderately hard and definitely not sagging!. Adjust your pillows and position so that you are comfortable. You may take sometime to find the best position but it is well worthwhile so as to get the best sleep. Lack of sleep and anxiety will aggravate backache.

4. Do some light flexibility excercises as stiffness will always lead to back pain. Try to do some core muscle excercises as well, so that they are strengthened as the pregnancy progresses. The main ones would be the lower abdominals and back muscles. Remember to stretch before and after excercising!.

5. Do go for relaxing back and neck massages as often as you can during and after the pregnancy.

6. If you are to have to sit for long hours, it is best to get hold of a back support for your chair. It is also a good idea to get up and stretch, walk every 20 minutes or so.

7. Labour and delivery can cause a great deal of harm to the spine as the baby goes through your pelvis. It is a known fact that the baby's head may even cause a fracture of the tip of your spine (the coccyx) on it's way out!. Your pelvic bone joints which have been loosened in preparation for the labour will undergo a great deal of stretching and soreness. This will resolve after delivery and should not be too much of a concern. During the labour and delivery one should avoid harsh and sudden movements during labour pains. Having a good pain relief such as an epidural will go a long way to avoiding any such strain on the back. It is of course a fallacy that epidurals will cause back pain.

8. After the delivery, any back pain can be relieved by spinal manipulation. This is best done by an osteopath and  should be instituted as early as possible to avoid future chronic back pain.

Ways To Reduce Preterm Labour/ Delivery

Preterm delivery is the largest cause for perinatal mortality and morbidity amongst newborns, . It is also responsible for a multitude of problems in child development later. How can pregnant women reduce this risk factor then. There are several things that are within your control:

1. Check whether you yourself were premature. If you were,  then you would be at higher risk in your pregnancy. Your obsterician should be made aware of this.

2. Make sure that you are at an ideal weight before you are pregnant. Obesity and a high BMI carries an increased risk of preterm labour. Do not gain excessive weight during your pregnancy.

3. Make sure that if you have any medical condition such as diabetes, high blood pressure or thyroid problems that these are well controlled before pregnancy.

4. Ensure that there is a sufficiently long gap between pregnancies. A gap of at least 6 months would be ideal.

5. Ensure that you are not too stressed, have adequate rest and sleep throughout the pregnancy. Also eat well and nutritiously.

6. Have a checkup early in the pregnancy and have a cervical length measurement done at your first visit with an obstetrician. A short cervical length is associated with a higher chance of preterm labour.

7. If you are at risk of preterm labour your obstetrician should prescribe a hormone, progesterone as early as possible and continue this until the 36th week of your pregnancy.

8. You should have a swab taken at 32 weeks to rule out any vaginal infection which may cause you to have a premature rupture of the membranes.

9. Monitor for signs of impending preterm labour such as frequent painless contractions or bleeding early in the third trimestor. Inform your doctor as soon and early as possible. 

Ways to reduce exposure to toxic chemicals

1. Avoid all processed and canned foods. If possible eat only certified organic products. If not thoroughly wash all vegetables and fruits.

2. For beef and milk products only organic grass fed cows so as to avoid hormones, pesticides and fertilisers.

3. Fish should not be farm raised as they contain higher amounts of contaminants such as mercury and PCBs. Salmon should be Alaskan wild salmon

4. Avoid using chemical based toiletries and cleaning products. Instead choose organic, and earth friendly, animal friendly and non GMO products.

5. Do not use plastic bottles which can cause hormone disruption. Instead choose BPA free ones or glass.

6. Avoid using non stick pans for cooking and instead replace them with ceramic utensils.

5 ways to reduce the chance of miscarriage

1. Start your family as early as possible, the risks increase after 35 and are much higher after 40 years of age mainly due to abnormalities in the foetus.

2. Reduce your contact with all chemicals including hair dyes, lipstick, make-up etc. Reduce consumption of preserved and chemically treated foods.

3. Avoid flying as there is alot of radiation in the atmosphere.

4. Avoid taking any medication, even over the counter medicines such as panadol when trying to get pregnant.

5. Have a check-up with your gynaecologist and if it is suspected that you have an imbalance in your hormones, do a progesterone test as this is the hormone which sustains your pregnancy in your uterus. Ensure that you exclude any inheritable conditions diagnosable by a blood test.

Latest tests for Down's Syndrome and other genetic abnormalities

One of the greatest concerns for a pregnant woman is knowing whether her child will be normal. In this day and age when more women are getting pregnant at a later age especially in Singapore, this is of an even greater concern.
Fortunately, more advances have enabled us to do these tests at an earlier and earlier stage of the pregnancy. We are now able to allay a patient's fears even at 9 weeks of pregnancy!
The latest blood tests which now almost always replace amniocentesis (tapping of the baby's water bag) include the Harmony Test and the Panorama Test. These are non-invasive prenatal tests done as early as 9 weeks. During pregnancy some of the baby's DNA passes into the mother's blood stream. This DNA can be examined through a simple blood test. This is a great test since traditional tests such as amniocentesis or chorionic villus sampling all carry a slight risk of miscarriage. The Panorama test is about 99.5% accurate, however it is still a screening test and if the result comes back as positive the mother will still have to go through an amniocentesis.
The genetic conditions that are tested with the Panorama include Down's Syndrome (T21), Edwards Syndrome (T18), Patau's Syndrome (T13), Certain sex chromosome abnormalities such as Turner's Syndrome, Kleinefelters Syndrome, Triple X, Triploidy. The sex of the baby may also be known if requested.
The greatest drawback to these tests is the cost ranging from S$1500 to S$2000. I would normally advise these tests if the original Oscar test (traditional blood test for Down's Syndrome) comes back as positive or the patient is over 35 years. Of course it can be done for any patient upon request.

Hypothyroidism in Pregnancy

This condition is important to diagnose early in the pregnancy, and ideally before pregnancy begins. Even a mildly underactive thyroid may lead to conditions which affect the baby's brain development. It has been shown that low levels particularly those in the lower 5th percentile may lead to lower IQ's and autism.
Anyone with symptoms or a family history of Hashimoto's Disease ( an autoimmune disorder of the thyroid) should be treated before getting pregnant. I recently had a patient in her early pregnancy with this condition. She had been rightly treated by her GP with replacement therapy. However it is also important to have regular blood tests to monitor the thyroid levels as too high a thyroid hormone level may result in its own set of complications. The best tests would be the T4 and TSH, the latter of which should be kept to <2mIU/ml.
An underactive thyroid may be caused by a lack of iodine in the diet. Selenium taken before pregnancy may help in those who have mild hypothyoidism.

Types of Twin Pregnancies

I recently saw a young lady with no history of twins in the family thoroughly shocked but overjoyed (and maybe overwhelmed) when I told her she had twins. She was in her early pregnancy at 8 weeks. An ultrasound scan showed two distinct waterbags and two foetal echoes with heartbeats. This was a non-identical twin pregnancy which is more common than identical twins. It results from the fertilisation of two separate eggs that is released from the ovary. The incidence of twin pregnancies is 1% of which 2/3rds will be non identical and 1/3rd identical.
 Identical twins result from the splitting of the zygote after the egg and sperm have fused. There are two types of identical twins, one of which has two separate placentas and the other type has one single placenta. The types of identical twins is determined by the time at which cleavage of the zygote takes place. If before 4 days, the dichorionic diamniotic DC DA twin with two placentas is formed. This accounts for 25% identical twins. If between 4 and 8 days, the monochorionic diamniotic MC DA twin with a single placenta forms. This is the most common accounting for 75% identical twins. If cleavage takes place between 8 and 12 days, the monochorionic monamniotic MC MA twin with a single placenta occurs. This rare at less than 1%. Cleavge after 12 days may result in conjoined twins.
The importance of knowing which type of twin pregnancy lies in the complication rates. The MC MA twin unfortunately has an 85% chance of mortality mostly due to cord entanglement. The MC DA and DC DA have complications mainly resulting from twin-twin transfusion, and intra-uterine growth retardation resulting from the stronger twin drawing more nutrition and depriving the other. So as an obstetrician it is not always `joyful' to see a twin pregnancy and we have to be extra vigilant in the obstetric care of the patient.

Pregnancy and vitamin D deficiency

It is not widely known but vitamin D deficiency is associated with increased risk of pregnancy complications. Although there is no need to do vitamin D levels on every patient, it is prudent for all pregnant women to ensure that their diet is rich in vitamin D. Low levels are associated with gestational diabetes, pre-eclampsia, low birth weight babies, bacterial vaginosis. Vitamin D is obtained from sun exposure. However in Asia we tend not to like going out in the sun unlike westerners. Some sun exposure would be good for a pregnant woman. Other sources of vitamin D include foods such as oily fish rich in omega 3 wild salmon, a certain amount from meats such as chicken, beef and eggs. Vitamin D supplementation is usually not necessary unless there is a history of vitamin D deficiency. Excess vitamin D intake (more than 10,000 IU/day) in the form of supplements can lead to toxicity causing foetal abnormalities, kidney stones.

http://www.medpagetoday.com/OBGYN/Pregnancy/38113

Repeat caesarean section or vaginal birth

In a recent large study from the University of Adelaide, it was found that risks to both baby and mother were significantly lower if a mother has an elective caesarean section after a previous caesarean section compared with a vaginal birth. The risks for serious complications and death for baby was 2.4% for attempted vaginal birth and 0.9% after elective caesaean section. The risks for serious complications and death for mother was also also significant eg the risk of life threatening bleeding was 2.3% after vaginal birth and 0.8% after elective caesaean section.
This is one more study that shows that the idict, "once a caesarean section always a caeasean section" may be the wiser choice.
http://www.sciencedaily.com/releases/2012/03/120313185229.htm

Obesity in pregnancy

Most women know that smoking and drinking don't go with pregnancy and automatically will reduce or stop before getting pregnant. However few know that obesity and extreme underweight carry just as much risk if not more. Obesity may not be so common in the local context but I am increasingly seeing this as our foreign population in Singapore rises. Obesity is associated with hypertension, diabetes, beta streptococcal infection, large babies, premature labour, stilbirths, higher chance of caesarean section, greater risks than normal from caesarean section complications, postnatal depression. So counselling for those over and underweight should be part of the preconception consultation

Premature Labour

Although uncommon, there are certain factors that can bring about premature labour (defined as labour before 37 weeks gestation). The most common being a defect in hormonal production resulting in low or subnormal progesterone levels. A congenitally short cervix ( length 10-20mm) is also a factor and recent studies have shown that vaginal progesterone given throughout the pregnancy helps to delay the onset of labour. Other factors such as multiple pregnancy, multipara, inadequate nutrition, low lying placenta, medical conditions such as asthma, diabetes all predispose to premature labour. Those who have a threatened miscarriage in the early pregnancy are also at greater risk of premature labour and a case can be made for administering progesterone throughout the pregnancy in such cases

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.