Positive Parenting

Infections To The Unborn Baby
Pregnant Mum with Preschoolers
Chromosomal and genetic birth defects
Pregnancy & pre-existing medical conditions
I'm pregnant but why am I still menstruating?
Understanding pre-eclampsia
Diabetes in pregnancy

Infections To The Unborn Baby
Viruses, bacteria and parasites. These are organisms that
a mother should be wary of when expecting her baby.

By Assoc Prof Dr Tan Ay Eeng, Obstetrician and Gynaecologist

Pregnancy is a time of great anticipation. It is also a time for great care and precaution as infections abound and can infect the unborn child in a severe way. The most common infections are:

Chickenpox is caused by the varicella zoster virus. If caught in the first 13 to 20 weeks of pregnancy, it will result in a 1% to 2% risk of the baby developing eye problems, paralysis or deformity of limbs, or even brain damage. After 20 weeks, there is no risk. However, if chickenpox is caught within seven days before birth, the newborn baby may develop a severe form of chickenpox.

German measles (rubella) can cause miscarriage, stillbirth, or birth defects, such as deafness, brain damage, heart defects and cataracts. If the mother acquires the infection in the first 12 weeks of pregnancy, over 70% of babies will be affected to varying degrees.
Cytomegalovirus (CMV) is a “silent” disease, spread primarily through the saliva or urine of under six children through the sharing of food, drinks and eating utensils, or kissing them on the mouth or cheek. Symptoms of CMVinfected babies include liver, lung and spleen problems, jaundice, vision loss, a small head and mental retardation, lack of coordination, seizures and death.
Hepatitis simply means an inflammation of the liver. Hepatitis B (HBV) transmitted to the unborn child may develop chronic HBV infection, cirrhosis of the liver or liver cancer.
Herpes is a sexually transmitted disease (STD). Active genital herpes can be spread to the baby during delivery and can be potentially fatal. Caesarean delivery is usually recommended.
Toxoplasmosis is an infection caused by a parasite called Toxoplasma gondii found in cat faeces. Some infected babies show symptoms ranging from chorioretinitis (eye damage), enlargement of the liver and spleen, jaundice, seizures, a small or big fluid-filled head and/or brain damage.

Pregnant Mum with Preschoolers

While being pregnant is exciting and wonderful, having a preschooler at
home during this time increases your vulnerability to infections.

By Associate Professor Dr Tan Ay Eeng, Obstetrician and Gynaecologist

As a pregnant mum of a preschooler, you need to care for your pregnancy and meet the demands of your little preschooler. A reality that is often overlooked is your susceptibility to getting infections from your preschooler due to his exposure at school. Preventive measures are necessary during this time to prevent harmful effects of these infections on your unborn child.

Mild Infections

Upper Respiratory Tract Infections (URTI) are highly contagious as the infection-causing viruses are airborne. The cold and the flu are amongst the most common examples of URTI. While these infections do not cause much harm to the pregnant woman, some viruses have been found to cause miscarriages or birth defects in the unborn baby.

Skin diseases and parasites such as scabies and body lice can also spread easily from child to mother through physical contact. Scabies are caused by mites that burrow under the top layer of the skin, causing severe itching and tiny red marks on the skin. Lice are parasites that feed on human blood. They are commonly spread through head-tohead contact, or through the sharing of combs, brushes or hats.

Serious Infections

Chicken pox is an infection of the highly contagious Varicella virus, commonly spread by inhalation and touch. You are at risk of being infected if your preschooler catches it from another child at school. Pregnant women infected with chicken pox put their unborn babies at risk of birth defects. Therefore, you should be vaccinated against chicken pox before getting pregnant if you have not been infected in the past. This is especially necessary when your preschooler does not have any history of chicken pox infection.

Rubella commonly spreads through touch and close contact, especially in a closed environment such as a preschool. Symptoms of this infection include low fever, flu-like symptoms, swollen lymph nodes, and a rash. As the symptoms are mild, your preschooler may be infected without anyone realising it, thus risk passing it on to you. With rubella being a major cause of birth defects in the unborn child, you should be tested for immunity to rubella before pregnancy. If no immunity is found, then rubella vaccine should be administered.

Measles is highly infectious as it spreads through droplets and close contact. Symptoms include tiny spots in the mouth, a red spotty rash on the skin, fever, cough and red eyes. Pregnant women who contract measles risk passing the infection to the unborn child, may experience a miscarriage, early delivery or even deliver a stillborn baby. If you have not had measles in the past, you should be vaccinated against it before getting pregnant.

Prevent Infections

Keep yourself and your family healthy.
Consult your doctor on the appropriate vaccines before getting pregnant.
Wash your hands frequently with soap and water.
As viruses can spread through your child’s saliva and urine, avoid sharing utensils with your child even if there are no signs of him having an infection.
Avoid contact with people who have infections, even the common cold.

By Assoc Prof Dr Zaleha Abdullah Mahdy, Obstetrician & Gynaecologist

Birth defects are the leading cause of death among babies in their first year of life. Nevertheless, there are steps that you can take to prevent, if not prepare yourself to cope with, certain birth defects that stem from genetic factors.

The Risk Factors
Birth defects are abnormalities in baby’s physical structure, function or metabolism that are present at birth and which may result in physical or mental disability, and even death. The majority of birth defects have either no apparent cause or a combination of genetic (or hereditary), non-genetic and environmental causes. The risk factors include:

Maternal age at the time of conception (the risk of birth defects increases after the age of 35)
Defects or disorders in the parents’ genes
Maternal diseases (such as diabetes and heart disease)
Infections passed from mother to baby (such as rubella or toxoplasmosis, a parasitic infection from contact with cat faeces)
Certain medications taken by the mother
Drug and alcohol abuse by the mother
Cigarette smoking
Mother’s exposure to agents known to cause birth defects (eg methyl mercury, lead and radiation)

While it’s hard to be absolutely certain whether you are at risk of giving birth to a baby with birth defects, your doctor would want to help you identify the presence of any of the known risk factors. He will ‘interview’ you about your lifestyle, medical history, family history of chronic diseases and so on. It is crucial that you answer as accurately and completely as possible.

Birth Defects Due To Your Genes
There are two genetic causes of birth defects – (1) abnormalities in the number or structure of chromosomes that make up your genes and (2) defects in a single gene you carry. In addition, genetic disorders can sometimes result from spontaneous mutation that may happen to the egg or sperm – after fertilisation.

What Are Chromosomal Abnormalities?
Chromosomes, which carry genetic information, are rod-shaped structures located in the centre (nucleus) of every cell in the body. A normal human cell contains 46 chromosomes, arranged in pairs. Some common chromosomal abnormalities include:

Down syndrome (trisomy 21). This is a common chromosomal disorder. Children with Down syndrome have an extra number 21 chromosome instead of the normal two. Children with Down syndrome have a distinct facial appearance (with small head, flat face and upward-slanting eyes) and various degrees of physical problems and mental retardation.
Trisomy 18 and 13. Children with this disorder have three number 18 chromosomes (Edward Syndrome). A less common condition is having three number 13 chromosomes (a condition called Trisomy 13 or Patau Syndrome). Both disorders severely affect physical and mental development and affected infants rarely live more than two years. These are lethal chromosomal abnormalities and most babies die during pregnancy, some after birth.
Sex chromosome disorder. This occurs when baby is born with an extra or missing sex (X or Y) chromosome. Some of these conditions may cause varying degrees of disabilities in learning, behaviour and fertility.

What About Single Gene Disorders?
Genes are the DNA molecules that determine the characteristics baby will inherit from his parents. Genes are located at specific places (like beans in a pod) on a chromosome and always occur in pairs, one from the father and another from the mother. There are three types of single gene disorders:

Recessive gene disorders.
These occur when each parent contributes an altered gene, thus making both genes in the pair abnormal. Specific ethnic groups are at significantly greater risk of having certain recessive disorders. If you or your husband has a family history of a recessive genetic disorder, you both need to take a blood test to check whether you could be carriers of that disorder. If both you and your husband are carriers, the inheritance risk can be calculated and you may be advised to take special tests during your pregnancy such as amniocentesis or CVS (chorionic villus sampling) to ascertain whether your foetus is affected.

Thalassaemia is a common recessive disorder found among people from Southeast Asian and Mediterranean countries. It affects the blood, making the red blood cells unable to carry sufficient oxygen for the body’s needs. A child with thalassaemia major (one of the types) usually dies between ages 1 and 8, if untreated.Young couples with a family history of thalassaemia are encouraged to be screened for thalassaemia before deciding to have children. Both parents have to be thalassaemia carriers (or have thalassaemia traits) to have a 25% risk of having a baby with thalassaemia major in every pregnancy.

Dominant gene disorders occur when only one gene in the pair is altered. However, it overrides the other – normal – one. A baby can either inherit a dominant gene disorder from a parent (the chances stand at 50%) or develop a dominant gene disorder on his own (due to a mutation in his genes, his mother’s egg or father’s sperm).

Achondroplasia is a rare skeletal condition resulting in short arms and legs. It results from a dominant gene disorder arising from mutation of the father’s sperm due to advanced age. Huntington’s chorea (Huntington’s disease) is another example of a dominant gene disorder. This degenerative condition causes movement problems and increased senility beginning in adulthood.

X-linked gene disorders.
Normal males have one X and one Y chromosome, and normal females have two X chromosomes. X linked disorders involve an altered gene on the X chromosome and may be either recessive or dominant.

Haemophilia and Fragile X are examples of X-linked recessive gene disorders. These are generally passed from normal women carriers to their affected male babies. Female babies can be carriers but usually do not have any symptoms of the disorder. If you, the mother, are a carrier of an X-linked recessive gene disorder, each of your sons will have a one-in-two chance of being affected, and each of your daughters will have a one in two chance of being a carrier. X-linked dominant conditions are less common conditions in which an altered gene on one X chromosome is sufficient to cause symptoms (even though the other X chromosome is normal). In this type of inheritance, a woman can pass the condition to her sons or daughters, and a man can only pass it to his daughter.

Reduce The Risk Of Birth Defects
Parents need to be aware of the presence of chromosomal and/or genetic birth defects in their own parents, siblings and extended families. By informing your doctor before becoming pregnant or early in your pregnancy, tests can be performed to ascertain baby’s risk of inheriting those defects. Other than that, you can both take steps to minimise the non-genetic and environmental risk factors that may cause mutation of your egg, sperm or baby’s genes as well.

Lead a healthy lifestyle always, starting from before you become pregnant
Avoid recreational drugs, smoking and alcohol, especially during your pregnancy
Minimise or avoid exposure to any known pollutants (eg lead), radiation and harmful chemicals
Always check with your doctor before taking nutritional supplements
Do not take medications on your own that, under normal circumstances, require a doctor’s
prescription
Ask your doctor which over-the counter medications are to be avoided during pregnancy

Pregnancy & Pre-existing Medical Conditions

Assoc Prof Dr Tan Ay Eeng, Obstetrician & Gynaecologist

If you have a pre-existing chronic medical condition, you may be apprehensive about getting pregnant. Understand the risks and concerns connected with these medical conditions so you can prepare yourself for pregnancy.

Know your health status

When you plan to conceive, go for a full physical examination and blood test to see if you have any medical conditions. Or, if you know that you do have a particular condition, tell the doctor who is caring for you of your plans to get pregnant. Ask for a referral to an obstetrician/gynaecologist experienced in treating pregnant women with health issues.

The following are some of the more common chronic conditions experienced by Malaysians:

Asthma, a chronic respiratory disease that causes periodic chest tightness, coughing, wheezing and breathing difficulty. Asthma varies in severity from person to person.
Diabetes, a chronic disease in which the body is unable to properly process sugar. It can appear in childhood or adulthood and in varying levels of severity. Some women only acquire this disease in pregnancy (gestational diabetes) and most often will return to normal health after delivery. Women with gestational diabetes are more likely to develop chronic diabetes later in life.
Hypertension, or high blood pressure, a condition where the force of your blood flow is consistently measured at a level above the ‘normal’ level of 140/90. The two numbers indicate the systolic and diastolic blood pressure, respectively. Systolic pressure is your blood pressure during each pump, or contraction, of the heart muscle, and diastolic pressure is the pressure between pumps.
Cardiovascular disease describes any disease affecting the circulatory system. It includes heart diseases and disorders such as mitral valve prolapse, and diseases of the blood vessels such as arteriosclerosis.
Depression is the term used to describe a group of medical conditions that result in various emotional and physiologic symptoms. It is caused by a combination of different factors. Depression is not just the condition of ‘feeling sad’; some people with clinical depression are not sad at all but may have an unusual amount of anger, increased apathy towards things they would normally be enthusiastic about, or other symptoms that have nothing to do with sadness. Like many other medical conditions, depression is often treatable with medication and therapy.
Epilepsy, a range of seizure disorders resulting from abnormal electrical activity in the brain. Most people think of seizures as violent episodes of thrashing and unconsciousness, but there are many different types of seizures.

What are the risks?

Asthma.
During an asthma attack, the mother may experience low oxygen levels because of the interruption to the normal breathing pattern. This could be harmful to baby. The medications taken for asthma may also affect baby. However, under prudent medical guidance, it’s possible to minimise the risks to both mother and baby.
Diabetes.
Women with any type of diabetes do have a higher risk of having babies with birth defects than women without diabetes. Nevertheless, any pregnancy still has a more than 90% chance of resulting in a healthy baby. Diabetes sometimes causes weakness or abnormality in the blood vessels, resulting in poor blood flow to the placenta. Sometimes, the mother’s diabetes can cause the foetus to also have difficulty processing sugar because of insufficient insulin. One possible result of this is abnormally large babies, who are more prone to difficulties at birth. Another is that the baby experiences low blood sugar (hypoglycaemia) upon birth.

Hypertension.
Current obstetrical practices have reduced most of the risks to the babies of hypertensive women, but extra care does need to be taken. Some medications for hypertension may be dangerous to baby, so the doctor will probably change the prescription until after the birth. A condition called pre-eclampsia sometimes occurs later in pregnancy, causing high blood pressure which could endanger both mother and baby. Being hypertensive increases the risk of having pre-eclampsia, but taking the right precautions will help women with and without hypertension to prevent this condition.

Depression.
The direct effects of a mother’s depressed state on the foetus’ development have not been proven. However, depression can indirectly affect the body chemistry and functions such as breathing and pulse, which will in turn affect blood flow to the placenta. Medication taken for depression may also affect the foetus.

I’m Pregnant But Why Am I Still “Menstruating”?

Bleeding, especially in early pregnancy, is always
worrisome. While it may not always be harmful, it is best to
seek your doctor’s advice before assuming it is normal.

By Assoc Prof Dr Tan Ay Eeng, Obstetrician & Gynaecologist

“Light periods” or spotting during pregnancy can be due to a variety of reasons. Do any of the conditions listed below look familiar to you?

Early Pregnancy
Light pink or brown spotting in early days of pregnancy Termed as implantation bleeding, it happens when the fertilised egg implants. As the placenta sets in the uterine lining, it causes bleeding.

Implantation of embryo outside the womb
If the pregnancy takes place outside the womb, often in the Fallopian tube, it is called an ectopic pregnancy. When this happens, the tube may burst, resulting in abdominal pain and vaginal bleeding. You are at risk if you’ve had a previous ectopic pregnancy, surgery on a Fallopian tube, several induced abortions or infertility problems.

Bleeding with sensitive and tender cervix
After intercourse, some women may bleed because the cervix is tender and sensitive. Avoid intercourse until you have seen your doctor to ensure there’s no further irritation.

Can Bleeding Mean Miscarriage?

In some cases, yes. However, about half of the women who bleed during pregnancy do not have miscarriages.

Most miscarriages occur in the first trimester and affect 15% to 20% of pregnancies. If you’re bleeding, see a doctor quickly. If he finds that you’re experiencing a threatened abortion, you’ll need bed rest and may require medication to sustain the pregnancy.

If the doctor confirms that you’ve had an incomplete abortion or missed abortion, you’ll need to go to the hospital to have your womb cleaned and all foetal tissue removed.

Late Pregnancy

Bleeding with pain before or during labour
Bleeding may be caused by placental abruption – separation of placenta from the uterine wall before or during labour. You are at risk of this rare condition if you have high blood pressure, older than 40, have had five or more children (grand multipara), smoke, or if you have sustained trauma on the abdomen.

Bleeding without pain
Placenta previa occurs when the placenta lies low in the womb, partly or completely covering the cervix. Bleeding planceta previa is a serious condition that can harm both you and your baby and requires immediate medical care. Patients at risk are those with previous Caesarean births and other surgery on the womb.

Bleeding with abdominal pressure, backache and stomach cramps
The mucus plug covering the opening of the uterus may pass small amounts of blood. If you experience this a few weeks before your due date, you may be having a preterm labour. You will need immediate medical attention if this happens.

On Preterm Labour and “Bloody Show”

As the cervix opens up to prepare for labour, you may notice some light bloody mucous being discharged. Called a “bloody show”, this usually happens before the actual onset of labour.

If you discover this bloody mucous show before full term (38 weeks), you may be experiencing preterm labour. If preterm labour is diagnosed, your baby’s and your own well-being must be weighed against the benefits and risks of stopping the labour or allowing it to continue.

What Should I Do?

Bleeding any time in pregnancy should be taken seriously. See your doctor promptly.
Wear a pad or panty liner to monitor how much you are bleeding and what kind of bleeding you have. Describe what you have observed when you visit your doctor.
Do not wear a tampon or administer douche to the vaginal area.
Avoid sexual intercourse until you’ve been cleared by your doctor.

Understanding Pre-eclampsia

Watch out for signs of this potentially life-threatening condition
during the second half of your pregnancy.

By Assoc Prof Dr Tan Ay Eeng, Obstetrician & Gynaecologist

Some women sail through their pregnancy while others experience a bumpier journey. One relatively common condition you should be aware of is pre-eclampsia.

What is pre-eclampsia and how do I recognise it?
Pre-eclampsia is characterised by persistent high blood pressure (above 140/90); swollen face, feet and hands; and traces of protein in the urine. Because affected women often show no symptoms in the beginning, it is important to have your blood pressure checked at each antenatal visit. In severe cases, mother may experience headache, nausea, vomiting, blurring of vision and abdominal pain.

If left untreated, it can cause complications or death in both the mother and the baby. The mother may suffer liver or kidney damage; bleeding and seizures while the baby may not be getting sufficient nutrients or oxygen from the placenta, which may result in growth retardation.

Who are at risk?
Eighty-five percent of pre-eclampsia cases affect women in their first pregnancy. It is more common among women with diabetes, chronic high blood pressure, kidney problems and multiple pregnancy (carrying more than 1 foetus). It tends to run in the family and affects women older than 35 and teenage mothers.

How to manage pre-eclampsia?
Because nobody knows for sure what causes it, there is no known method to prevent it. Medical treatment aims to bring the blood pressure under control and to minimise its related complications. The only “cure” is through delivery of the baby. In fact, in some severe cases, labour may be induced to have the baby delivered prematurely.

Your doctor may prescribe medication to lower the blood pressure. If the condition is mild, you will need bed rest and have your blood pressure monitored regularly. If it is more severe, hospital admission and tests on both mother and baby may be necessary.

What happens after the delivery?
The blood pressure usually returns to normal within several days to several weeks after the birth. You may still need blood pressure medications and regular visits to your doctor for several weeks after being discharged from the hospital.

Diabetes in Pregnancy

According to Prof Dr Muhammad Abdul Jamil, Obstetrician and
Gynaecologist, the key to managing gestational
diabetes is controlling your blood sugar level.

Starting a family is perhaps the most exciting moment for a married couple. In the event of bringing a whole new life into the world, most women progress smoothly in their pregnancies, giving birth to healthy babies. In a few cases, however, some women may develop certain risk factors that can cause problems. One such medical condition that poses a risk to both mothers and babies is gestational diabetes mellitus (GDM).

What is GDM?
Diabetes is actually a condition in which the levels of blood sugar, better known as glucose are not properly regulated. This is related to a hormone, known as insulin, which controls glucose levels. During pregnancy, additional hormones particularly pregnancy hormones (such as estrogen, progesterone or human placental lactogen) create an anti-insulin effect. Under normal circumstances the insulin produced by the mother’s pancreas is sufficient to counter this effect but in some cases the production may not be sufficient. This results in high levels of glucose in the blood known as gestational diabetes. Thus, a higher amount of glucose passes through the placenta to fetus.

Gestational diabetes is the type of diabetes that is specific to pregnancy. It refers to when women develop diabetes when pregnant or when women with diabetes become pregnant. In an established diabetic who gets pregnant, it is very important that the blood glucose levels are well controlled before pregnancy. Any complication of established diabetes also needs to be corrected before pregnancy to decrease the risk to the mother, such as kidney, nerve or eye complications.

In general, gestational diabetes does not usually pose much threat to the mother. Those who have a risk of developing it must be tested because undetected gestational diabetes poses some risks to the baby. If gestational diabetes goes undetected, the baby has an increased risk of stillbirth, structural anomalies (including of the spine and heart). The baby is also prone to be overweight in utero and can have episodes of low blood sugar, increased incidence of jaundice and poor temperature control at birth.

How does GDM affect the mother and baby?
The major risk for babies born to women with gestational diabetes is macrosomia or excessive weight at birth. Many doctors define macrosomia as birth weight of 4.0 kg or more that causes difficulty in passing through the mother’s pelvis. These babies are therefore prone to injuries at birth as they are delivered with more difficulty.

Another problem that may develop as a result of GDM is hypoglycemia (low blood sugar level) shortly after birth. This occurs because the baby has been so accustomed to receiving high levels of blood sugar across the placenta and the supply is abruptly stopped when the umbilical cord is cut at birth.

Other complications of GDM include jaundice, hypocalcemia (low calcium level) and polycythemia. Newborn polycythemia occurs when a baby’s red blood cell count reaches a level so high that the blood is too thick to flow effectively through the body. As a result, this exacerbates jaundice when the cells break down. For the expectant mother, GDM is associated with an increased frequency of maternal hypertensive disorders and the need for caesarean delivery. Although GDM is not itself an indication for caesarean delivery or delivery before 38 weeks of gestation, prolongation of gestation past 38 weeks actually increases the risk of macrosomia. Thus, elective delivery at 38 weeks is normally recommended and if the diabetes has affected the pregnancy (eg baby has become too big or mother develops raised blood pressure) then a caesarean delivery is indicated. In most cases, gestational diabetes disappears after the birth of baby.

However, in some cases women who have had gestational diabetes face a higher risk of developing type 2 diabetes mellitus later in life. Babies born to mothers with GDM may face higher risk of impaired glucose tolerance or developing diabetes in late adolescence or young adulthood, and becoming obese.

Are YOU at risk?

Q: “I want to conceive but am I at risk of developing gestational diabetes?”

Women with clinical characteristics consistent with a high risk of GDM, namely over the age of 30, obesity, previous history of GDM, recurrent glycosuria (repeated presence of glucose in the urine) and a strong family history of diabetes (first degree relatives ie mother, father or siblings) should undergo a risk assessment for GDM. They will be given blood glucose testing in the early second trimester. At the initial testing, if there are no signs of GDM, they should be retested between 24 to 28 weeks of gestation.

What to do?

Q: “If I am already pregnant and discover that I have GDM, what should I do?”

A balanced diet is important during pregnancy. Ensure that you do not gain excessive weight during pregnancy. Do not consume too much sugar. In most cases, the key to managing gestational diabetes is to control your blood sugar level through a carefully planned diet, lots of exercise and regular testing of your blood glucose level.

Because of all the problems that might occur, you must get advice from your doctor on how you can keep your diabetes well controlled, in order to deliver a healthy baby.Your doctor will refer you to consult a dietitian for a diet plan that helps keep your blood glucose levels normal and achieve healthy weight gain during pregnancy.You must also test your blood glucose level several times a day (before eating in the morning and two hours after meals) at home to ensure that your levels are within normal limits.

As long as your blood glucose level is under control and baby is carefully monitored, baby will be able to grow normally. In most cases, gestational diabetes can be controlled through diet, regular physical activity and regular monitoring of glucose levels. If there is still difficulty in controlling your blood glucose levels in spite of the above measures, you will be prescribed insulin injections.

Q: “Does that mean that women who are at risk of developing gestational diabetes due to their age and family history of diabetes should not get pregnant for fear of giving birth to stillborn babies or bigger than usual babies?”

It is possible for women with the above risk factors eventually give birth to healthy babies. But, remember, you are personally responsible for not only your life, but also your baby’s! So, you just have to practise a healthy pre-pregnancy lifestyle. Also be completely motivated to maintain normal blood glucose levels so as to decrease the risk to you and your baby.