frequently asked questions
A miscarriage is a pregnancy loss within the first 24 weeks of pregnancy. Most miscarriages occur in the first 12 weeks.
It is estimated that one in six to seven pregnancies end in a miscarriage. The risk of a miscarriage decreases as the pregnancy advances. Certain medical conditions increase the risk of miscarriage.
ln most instances, the exact cause of miscarriage is unknown, but att conception, the baby receives half the genes from the sperm and half from the egg, and for unknown reasons, genetic information is lost. This results in an unhealthy baby that cannot survive and ends in a miscarriage. Certain maternal medical condition predispose to miscarriage, such as uncontrolled severe diabetes, thyroid disease or auto-immune disease.
What is certain is that a miscarriage does NOT result from eating specific food, carrying heavy things, exercise or sexual intercourse. A miscarriage does not occur as a direct result of something you or your spouse has done during the pregnancy.
The common symptoms would be bleeding from the vagina and abdominal pain. If such symptoms occur, please consult your obstetrician, who will do an internal examination. An ultrasound is usually performed to determine if the pregnancy is a viable one.
This will depend on the condition of the pregnancy. lf the bleeding is light and painless, and scanning confirms a live foetus, rest (with medical certificate coverage) at home with medication to help support pregnancy is prescribed.
If the pregnancy is not viable, an “evacuation of the uterus” is performed, where the neck of the womb is opened up and the womb is emptied. This is to reduce infection risk and bleeding from the vagina, which can be alarming.
Normally, it is suggested to wait for the first period before trying for another pregnancy. The exact timing is dependent on when the couple is ready to start trying, as some need time to get over their loss.
One miscarriage does not mean that subsequent pregnancies will also end in miscarriage, as there is a very good chance of having a healthy baby. Leading a healthy lifestyle helps to improve the chances of conceiving; by stopping smoking, reducing or stopping alcohol, exercising regularly, ensuring a healthy diet, and leading a less stressful lifestyle. Taking folic acid during the period of conception reduces the risk of brain and spinal cord defects.
lf you have had three or more miscarriages then your doctor may need to do further investigations. Please consult your doctor if you have other concerns.
PAP Smears and Cervical Cancer Information
- lrregular vaginal bleeding
- Frequent, foul-smelling, bloody vaginal discharge
- Bleeding after sexual intercourse
Unfortunately, by the time these symptoms are present, the cancer may advanced already. Therefore, it is important to have a regular PAP smear, even if you are feeling well.
It is a simple and painless test, where a speculum instrument is gently inserted into the vagina, and a brush is used to obtain the cells. The cells are then examined under a microscope for cell changes.
The PAP Smear is a good test but it is not perfect, as occasionally, the results can be normal even though abnormalities are present. Fortunately, most cervical cell changes progress very slowly, so a regular PAP will find almost all abnormalities.
Women who are sexually active require PAP Smears from the age of 25 years onwards, and earlier if required. This should be repeated every 1-3 years until the age of 65, provided there are no abnormalities. Your specialist may recommend that you have a Pap Smear more frequently.
An abnormal pap smear does not mean that you have cancer. It means that there are abnormal cells requiring further assessment. This is done by having a Colposcopy examination.
More often, the cell changes are due to infection, or to menopause-related thinning of the cervical skin. This can be easily treated with a topical antibiotic or hormonal cream.
A colposcope is a specialised microscope that obtains a detailed view of the cervix. It is a painless procedure that takes no more than 15 minutes. A speculum is inserted into the vagina, and the doctor then examines the cervix after applying a mild vinegar-like solution (acetic acid). A tissue biopsy may be taken for microscopic evaluation. Depending on the results of the biopsy, you will be advised on the best treatment. Colposcopy cannot be done when you are having a period, so please postpone the appointment until after the period is over.
There are several treatment methods for pre-cancerous changes of the cervix. These include:
- Laser vaporisation
- LEEP (Loop electrosurgical excision procedure)
- Cone biopsy with laser, diathermy or knife
These procedures can be performed under local, regional anaesthesia in Day Surgery. However, some women may require a general anaesthesia and this may involve staying in hospital for a day or two.
Antenatal care is designed to ensure both mother’s and baby’s health, by actively looking for, preventing or treating problems that arise in the pregnancy. At each visit your obstetrician will perform routine urine testing, check blood pressure, appropriate weight gain, and an abdominal examination will be performed to ascertain the position and size of the baby. A bedside ultrasound scan is frequently done, to check fetal growth and wellbeing. ln the latter part of pregnancy, the baby’s heartbeat can be detected using a Doptone or CTG machine, assessing for in-utero health. There will be ample opportunities to discuss any questions or concerns during the course of the antenatal visits.
The assessment also involves the following blood tests:
- Full Blood Count (FBC) to exclude Anaemia and Thalassaemia (a common genetic blood disorder in South East Asia).
- Blood Group and Antibody Screening in the event a blood transfusion is required.
- Hepatitis B and Syphilis Screening.
- HIV Screening to exclude infection as this has important implications for mother and baby.
- Rubella Antibody Screening (which is optional) to establish a history of exposure.
The following tests are offered at the appropriate time:
- At 11 – 14 weeks, First Trimester Screening (FTS), calculates the risk of chromosomal abnormalities, and is very good at predicting “low-risk status”, with a 90% accuracy. This is done by measuring the neck skin thickness (nuchal translucency) and a blood test, measuring two substances in the mother’s blood.
- At 16 – 20 weeks, a Maternal Serum Screen (MSS) can screen for chromosomal abnormalities and for open neural tube defects (NTD). This is based on a blood test from the mother. In simple terms, the MSS has a 60% accuracy in assessing “low-risk status” for chromosomal problems.
If the risk is high for either screening tests, a diagnostic procedure is offered, and this is either a Chorionic Villus Sampling (CVS) or an Amniocentesis. This ought to be discussed in-depth with your obstetrician, if such a need arises.
- A detailed screening scan done at 19 – 22 weeks, looking for major physical or structural problems in the developing baby. If there are abnormalities detected, there is a need for discussion of amniocentesis or further specialist input with respect to fetal wellbeing.
It is a common myth that one needs to eat for two. Women do not need extra calories in the first six months, and require an extra 200 calories per day during the last three months of pregnancy. However, it is important to eat regularly to even out fluctuating blood sugar levels, thus healthy snacks in between meals is advised. On average, women can gain between 7 – 13 kg during pregnancy, although this will vary with individuals. Stringent dieting is strongly discouraged, as it could deprive the baby of vital nutrients. A healthy diet should contain key nutrients, including foods containing iron (eg. green leafy vegetables, red meat, beans and pulses); calcium (eg. dairy products, fish like sardines or ikan bilis, and bread) and folic acid (eg. green beans, oranges, spinach, kale or broccoli).
Try to eat something from the following food groups daily:
- Fresh fruits and vegetables: 2 – 3 servings/day
- Bread, rice, breakfast cereals, potatoes: at least 1 serving at each meal and 3 – 4 servings /day
- Lean meat, poultry, fish, eggs, pulses and nuts: 2-3 serving/day
- Dairy products: 2-3 servings/day
Try to avoid the following:
- Raw eggs which may contain salmonella bacteria
- Home-made mayonnaise and ice-cream
- Blue cheese, soft cheeses and unpasteurized milk
- Liver or pates, raw or undercooked meat or shellfish
Folic acid (folate) is a type of vitamin B crucial in the development of the baby’s nervous system. lt reduces the risk of Neural Tube Defect (NTD – a structural abnormality of the nervous system) in the baby by at least 60%. Folate is easily destroyed during cooking, and large servings are necessary for adequate intake. Hence, the simplest way is to take a folate supplement (5 mg tablet daily) for the first twelve weeks of pregnancy. Folate is particularly important if you suffer from Diabetes Mellitus (DM), Epilepsy, Thalassaemia or have a family history of relatives with NTD.
Smoking should be stopped completely or reduced, as it is associated with an increased risk of miscarriages and ectopic pregnancies, placental bleeding as well as low birth-weight babies and premature births. There is also an association with decreased intellectual development in babies and an increased risk of Sudden lnfant Death (SID).
Alcohol consumption in excess of 15 units (1 unit = 1 small glass of wine) per week has been associated with a reduction in birth weight, whilst consumption of 20 units or more per week has been associated with intellectual impairment in children and developmental abnormalities. There is no conclusive evidence of adverse effects on growth or IQ levels below 15 units per week. It is still recommended that women should avoid consumption of alcohol in pregnancy.
There should be active discussion between patient and their GP or obstetrician before taking any medication, especially during the first few months of pregnancy when the baby’s organs are developing, as certain drugs can affect the structural development. If one is on long-term medications, the ideal time to review them is when planning for a baby.
It is important to be fit and healthy during the pregnancy and for the upcoming labour. Hence, it is ideal to inform your gym instructor of your pregnancy (to modify and tweak your work-out regime) if you are already part of a gym, exercise class or have a fitness membership. For sedentary women, there should be strong consideration to start low impact, regular exercise. Exercising not only improves the metabolism, it helps with back/ligamentous pain, and has emotional benefits. Twenty minutes of activity such as swimming, walking, yoga or pilates, three times a week are excellent forms of exercise. Foot and lower limb exercises are helpful in improving circulation and reducing swollen ankles, whilst pelvic rocking strengthens muscles and eases backache. Pelvic floor exercises also reduce the risk and severity of stress incontinence (urine leakage). Remember to warm up before exercise and to to cool down after with stretching. The usage of saunas and spas should be avoided during pregnancy, due to risk of overheating and heat stress.
Many pregnant women have fulfilling sex lives in pregnancy. The pregnancy hormone changes may improve responsiveness; but as the pregnancy progresses, the enlarging womb may cause discomfort during sexual activity. Certain positions during intercourse may be more comfortable, so it is useful to experiment. However, if there has been any early pregnancy bleeding, premature labour or the presence of a low-lying placenta (Placenta Praevia), then it is best to consult an obstetrician before continuing such activities.
Whilst most women can safely continue to work in pregnancy; certain jobs are hazardous and include those dealing with substances like pesticides, insecticides, radiation exposure, and exposure to hydrocarbon solvents like dry-cleaning fluids, lead or mercury.
Breastfeeding has many benefits, for both baby’s health and in developing the bond between mother and new born. Breast milk contains all the necessary nutrients required for growth; but more importantly, it contains antibodies that protect the baby from harmful illnesses. Breastfeeding also reduces the chance of allergies, such as Eczema and Asthma developing in a child. Most hospitals have an experienced team of lactation nurses/consultants who are capable of teaching and advising on breast care and baby care issues.
Commercial air travel poses no special risks to an uncomplicated pregnancy. Domestic travel is permitted until 36 weeks gestation, whereas international travel is usually curtailed after the 34th week of pregnancy. An air-travel document, stating your expected date of delivery can be provided by your obstetrician. As there is an increased risk of developing deep vein thrombosis (DVT – blood clots in the legs) in pregnancy, air travel should be kept to a minimum. It is advisable to walk every hour during the flight, or to flex and extend the ankles to exercise the calf muscles. Fluids should also be consumed liberally as dehydration occurs in aircraft cabins. Certain conditions like severe anaemia or a low-lying placenta are relative contraindications to flying; and unexpected events may also occur while in mid-air, like vaginal bleeding or labour. It is important to seek medical review and clarification before air travel.
Most of these problems are caused by hormonal and physical changes the body is undergoing. They are usually temporary discomforts and can be treated simply.
BLOATING – This is due to fluid retention and is aggravated by prolonged standing. It is important to remember that limiting fluid intake does not prevent oedema. It is important to drink 2 Iitres of fluid a day, and limit intake of tea, coffee and other caffeinated beverages as it will affect the absorption of dietary vitamins, particularly vitamin C. Some women feel better after restricting their salt and monosodium glutamate (MSG) intake.
CONSTIPATION – please ensure a diet with adequate fibre and plenty of water, with possible use of stool softeners prescribed by your doctor.
FAINTNESS – This arises from transient low blood pressure, so avoid prolonged standing, getting up overly quick and getting overheated, especially in a warm bath or shower.
HEARTBURN/INDIGESTION – the burning sensation in the chest or acid regurgitation in the throat and is especially common in the early months of pregnancy can be reduced by eating small frequent meals and avoiding spicy, fatty foods or alcohol, coffee, chocolate and very cold liquids. Sit upright where possible and prop yourself up with pillows at night during rest.
MORNING SICKNESS – unfortunately, it can occur at any time of the day and usually abates by 14 weeks gestation. Foods with added ginger can be consumed to ease the nausea. One of the main causes is low blood sugar (hypoglycaemia); hence, adequate carbohydrate intake is important, in small and frequent amounts – a piece of dry toast, a cracker or a biscuit often helps to ease the discomfort.
PILES/HAEMORRHOIDS – These are dilated veins in the anus and can cause pain, itch and discomfort, usually occurring from the third month onwards. A high-fibre diet and plenty of water reduces the risk. Alternatively, prescription suppositories and creams like Anusol or Proctosedyl can give relief.
SLEEPLESSNESS – This could be due to anxiety, heartburn, pressure on the bladder causing nocturia or the pregnancy itself. A warm milky drink and shower may aid in relaxation and sleep.
STRETCH MARKS/STRIAE – These are raised red lines on the breasts, abdomen, thighs or bottom and are usually permanent once they occur. Intensive moisturising helps to prevent or reduce occurrence.
SORE BREASTS – Wearing a good support bra helps as the body prepares for feeding a new born baby.
THRUSH – This yeast infection affects as many as 75% of women, and can treated with an anti-fungal cream and pessaries.
STRESS URINARY INCONTINENCE – This is due to pressure effects on the bladder and pelvic floor and can occur during laughter, sneezing or physical activity. Regular pelvic floor exercises during and after pregnancy can aid in control.
VAGINAL SECRETIONS – Tend to increase in pregnancy, and is normally creamy-white and not malodorous.
VARICOSE VEINS – These distended veins around your calves, back, legs or thighs may be reduced by avoiding prolonged periods of standing and exercising regularly. There are graduated compression stockings for ladies who already suffer from varicose veins.
This is the commonest antenatal complication affecting 1 in 10 pregnancies and one in five first pregnancies. In certain cases, the illness can severely affect both the mother and the fetus. The main symptoms include headaches; feeling dizzy; nausea and vomiting; blurred vision; general feeling of unwellness and pain in the upper abdomen. Unfortunately, PE can also develop without any obvious signs; therefore, it is important to have regular antenatal follow-up.
Babies born premature are at risk of several complications, especially breathing problems. Women in preterm labour may benefit from steroid injections, as this promotes lung maturation in the baby should childbirth be inevitable. Special medications to reduce or stop uterine contractions and to treat the cause of the pre-term labour (eg. Infections) may also be used. At term (after 37 weeks of pregnancy), labour begins with regular painful uterine contractions, bloody show (blood-stained mucus) or rupture of the amniotic membranes (leaking liquor). Preterm labour occurs when these signs are present before 37 weeks.
The commonest reason for bleeding is due to implantation, when the embryo attaches to the womb at 4 – 5 weeks of pregnancy. However, light spotting or bleeding in early pregnancy may indicate a possible miscarriage or ectopic pregnancy (pregnancy implanted outside of the womb, usually in the fallopian tubes).
Light bleeding mixed with mucus at term could be a ‘show’ – a sign that you may go into labour within the next few days or week. Bright red could also be from a low-lying placenta or from placental separation.
REDUCED FETAL MOVEMENTS
Babies are most active when the mother is at rest, as one is more aware of their movements, typically in the evening or at bedtime. There should be at least 10 movements in a I2-hour period, suggesting a healthy baby and excessive movements should not be a cause for worry. If there is persistent reduced foetal movements, then one should be concerned and seek immediate help. Some stillbirths (babies who pass away in the womb) are preceded by decreased foetal movements.
PRE-LABOR RUPTURE OF MEMBRANES
Normally the water-bag ruptures (either spontaneously or by your obstetrician) when labour begins. Rupture of your water-bag before the onset of labour is associated with complications such as infection or umbilical cord prolapse through the cervix. If you feel a sudden gush or continuous flow of clear fluid from the vagina, please contact your obstetrician.
During office hours in the work week, it is an expedient matter to contact your obstetrician if you have any queries or worries, and a review can be easily performed. It is also possible to:
- Gleneagles Hospital A&E – This is for all patients who have problems in pregnancy, and even after. This can be utilised after office-hours, when private clinics are closed, but their specialist can review them.
- Go to your GP – Your GP can be utilised for the common minor medical problems like influenza, tummy upsets and diarrhoea, or minor skin rashes in pregnancy.
- KK Women’s & Children’s Hospital – This is for pregnant patients who encounter problems, after office-hours, when their own specialist is unable to attend to them.