Singapore obstetrician on being a friend to mothers-to-be

PHOTO: Singapore obstetrician on being a friend to mothers-to-be

SINGAPORE - Obstetricians are the ones who are privileged to look after two individuals simultaneously - a life within a life.

Unlike most other patients, our patients come bearing happy news.

We become the witnesses of their journeys, helping them along the way.

However, this journey is not always smooth. Sometimes, they do not reach their desired destinations.

One needs to be vigilant, taking hints from the family and medical history, looking out for likely complications and improvising the management as the need arises.

Among those who encountered unexpected hurdles was Mrs M, 37.

She had been pregnant thrice before, but was still without a child.

Her first pregnancy ended very early with a miscarriage.

The second time, she carried the pregnancy till 20 weeks of gestation.

She could feel the movements of her foetus.

However, one fateful day, her water bag broke and she lost her would-be child.

The third time round, the pregnancy continued unhampered till 23 weeks before, once again, her dreams were shattered. She went into labour and gave birth to a baby weighing barely 500g.

The baby was not ready for independent existence and eventually died.

When Mrs M first came to our high-risk pregnancy clinic during her fourth pregnancy, she was understandably quite anxious. I could sense that she would not be able to handle yet another disappointment.

PROCEDURE TO KEEP BABY

After going through the records of her previous pregnancies, I realised that the most likely cause for her previous pregnancy losses was cervical incompetence.

This means her cervix, that is, the neck of the womb, starts opening up prematurely.

This may be because of some inherent defect in the cervical tissue or may be a result of any past surgical procedures on the cervix. The prevalence of cervical incompetence in all pregnancies is quite low, at 1 to 2 per cent, but in patients with second trimester miscarriage, the condition may be responsible for almost 20 to 25 per cent of cases.

This was confirmed when an ultrasound scan of her cervix showed it to be very short. A short cervix at early gestation is diagnostic of cervical incompetence.

I explained the diagnosis to her and offered her a small operation called cervical cerclage.

This involved putting a piece of tape around the cervix to try and keep it closed until the foetus was mature enough to be born. The surgery itself carried a small risk of miscarriage.

While the decision was not very easy for the couple, in the end, they agreed that she would undergo the surgery. It was carried out. Mrs M was also started on drugs to prevent premature uterine contractions. During her third pregnancy, she had started having premature uterine contractions and had miscarried.

Even though the surgery did not have any complications, she was still very apprehensive and required a lot of emotional support. She became more hopeful once she passed the threshold of 24 weeks.

Subsequently, the tape was removed when she eventually gave birth to a healthy baby boy after 36weeks of pregnancy.

EMOTIONAL ROLLER COASTER

Another case was that of Mrs S, 31, who was diagnosed with breast cancer when she was pregnant.

She was advised to terminate the pregnancy to allow the treatment of breast cancer to proceed unhindered.

Deeply traumatised, she could not bring herself to agree to this. Eventually, the pregnancy ended in a miscarriage.

After recovering from the breast cancer, she conceived again.

However, this time, the pregnancy was ectopic - the fertilised egg had implanted itself in the fallopian tube.

She underwent surgery to remove the affected fallopian tube. But her troubles were not over yet - she was later diagnosed with a pre-cancerous condition of the cervix.

To treat this, she underwent an operation that involved taking away a big chunk from the cervix.

Thankfully, she became pregnant soon after recovering from surgery and came to see me in the clinic.

I explained to her that her risk of miscarriage or very premature birth was high as the surgery on the cervix had made it very short, and so it was very likely to open up prematurely.

I discussed the option of cervical cerclage with her.

Her surgery, though very challenging due to the length of the cervix, was carried out successfully.

Fortunately, her pregnancy continued without complication and she gave birth to a healthy baby girl.

Patients such as Mrs M and Mrs S make me realise that being an obstetrician is so much more than simply looking after the physical well-being of mothers-to-be.

We need to be their friends and take care of their emotional health.

We cannot forget the fathers-to-be too. An undesirable outcome is equally disturbing for them and it is equally important to look after them.

My colleagues and I who run the clinic have the privilege of developing close bonds with our patients.

When a patient eventually visits us with a baby in her arms, it is a very happy day for me.

womens_clinic@nuhs.edu.sg

Dr Anita Kale is a consultant at the division of maternal fetal medicine at the National University Hospital Women's Centre.


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