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.