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Dr Pamela Tan is an obstetrics and gynaecology specialist practising at Thomson Medical Center in Singapore. Prior to leaving for private practice, Dr Tan was a female Consultant in the Department of Obstetrics and Gynecology, KK Women’s & Children’s Hospital.

She obtained her undergraduate medical degree at the National University of Singapore and her post-graduate MRCOG in London at the Royal College of O&G. She is a specialist accredited with the Specialist Accreditation Board (Ministry of Health) and is a Fellow of the Academy of Medicine, Singapore (FAMS). She is an accredited member of the Society for Colposcopy and Cervical Pathology of Singapore (SCCPS) with a subspecialty interest in colposcopy (for pre-cancer of the cervix and vagina) and vulval disease.

In further pursuing this interest, she was a fellow for pre-invasive disease at the colposcopy and vulval unit at the Whittington Hospital in the United Kingdom. She is a visiting consultant at KK Hospital for colposcopy and is still involved in research on computer imaging analytics for screening cervical cancer in low resource settings in a joint collaboration with the National University of Singapore.

While in the United Kingdom, she was also a fellow at the Assisted Conception Unit in Guys Hospital to learn the latest in reproductive techniques and approaches to infertility. She is accredited to perform advanced Level 3 minimally invasive keyhole surgery such as laparoscopic hysterectomy, myomectomy and cystectomy (womb, fibroids and cysts removal).

Her philosophy to doctoring is one that is focused on building relationships with her patients. She strives to deliver patient care that is warm, caring, professional and well advised. She is a believer of pro natural birthing and providing an optimal birthing experience as desired by her patients.

Dr Pamela Tan is an obstetrics and gynaecology specialist practising at Thomson Medical Center in Singapore. Prior to leaving for private practice, Dr Tan was a female Consultant in the Department of Obstetrics and Gynecology, KK Women’s & Children’s Hospital.

She obtained her undergraduate medical degree at the National University of Singapore and her post-graduate MRCOG in London at the Royal College of O&G. She is a specialist accredited with the Specialist Accreditation Board (Ministry of Health) and is a Fellow of the Academy of Medicine, Singapore (FAMS). She is an accredited member of the Society for Colposcopy and Cervical Pathology of Singapore (SCCPS) with a subspecialty interest in colposcopy (for pre-cancer of the cervix and vagina) and vulval disease.

In further pursuing this interest, she was a fellow for pre-invasive disease at the colposcopy and vulval unit at the Whittington Hospital in the United Kingdom. She is a visiting consultant at KK Hospital for colposcopy and is still involved in research on computer imaging analytics for screening cervical cancer in low resource settings in a joint collaboration with the National University of Singapore.

While in the United Kingdom, she was also a fellow at the Assisted Conception Unit in Guys Hospital to learn the latest in reproductive techniques and approaches to infertility. She is accredited to perform advanced Level 3 minimally invasive keyhole surgery such as laparoscopic hysterectomy, myomectomy and cystectomy (womb, fibroids and cysts removal).

Her philosophy to doctoring is one that is focused on building relationships with her patients. She strives to deliver patient care that is warm, caring, professional and well advised. She is a believer of pro natural birthing and providing an optimal birthing experience as desired by her patients.

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Major Thyroid Disorders During Pregnancy

Your Thyroid Gland at a Glance

The thyroid gland is a butterfly-shaped organ located in the base of the neck. It’s about 2 inches long and it is wrapped around your windpipe (trachea). It’s part of the endocrine system, and it plays a vital role in the growth, development, and metabolism of the human body. 

Thyroid Anatomy - Dr Pamela Tan

The thyroid makes and stores hormones (T3 and T4) that are essential to how every cell in the body functions. Among many other things, these hormones help regulate body processes such as your heart rate, blood pressure, body temperature, metabolism and even fertility. 

Thyroid Function in Pregnancy

Thyroid hormone is important during pregnancy for normal fetal development. During the first 10-12 weeks, your baby completely relies on you for thyroid hormones for brain development. This explains why your thyroid hormone requirements increase during pregnancy. 

By the end of the first trimester, your baby can already produce thyroid hormones on its own. However, it will continue to depend on you to get adequate iodine intake to make thyroid hormones. 

To avoid pregnancy issues related to thyroid hormone levels, striking a balance is vital. Studies show that deficiencies can result in several complications and even irreversible damage. Meanwhile, overproduction isn’t any better since it also poses health risks for both mother and child. 

Thyroid Disorders in Pregnancy

Thyroid disorders are relatively common, but many are unaware that they have it. 

Besides being a pre-existing disease, thyroid problems can also develop during and after pregnancy. It can even alter thyroid function in women who have no abnormalities to begin with. Pregnancy-related hormones, estrogen and human chorionic gonadotropin (hCG) may cause your thyroid levels to rise making it challenging to diagnose thyroid diseases during pregnancy. This is why it’s important to get thyroid hormone levels screened before planning for pregnancy or soon after you discover that you’re pregnant. 

Moreover, women can still develop thyroid problems up to a year after giving birth. This is why post-partum doctor visits will help keep everything in check. 

Here’s a closer look at two major thyroid issues during pregnancy. 


Symptoms of Hypothyroidism - Dr Pamela Tan

Hypothyroidism is a condition where the thyroid gland is unable to make enough thyroid hormones to keep the body running normally. It can stem from several causes, the most common of which is the initial presence of an autoimmune disorder called Hashimoto’s thyroiditis. It can also occur in women with inadequate treatment for hypthyroidism, or in hyperthyroid women who got over-treated with anti-thyroid medications. 

Having an underactive thyroid means crucial body processes slow down. Mild hypothyroidism may show no symptoms and even if there was, it may be attributed to pregnancy. However, in severe cases, complications are more likely to occur. Maternally, it can increase the risk of miscarriage, pre-eclampsia, congestive heart failure, placental abnormalities, and postpartum bleeding. If left untreated or if poorly managed, these complications can be life-threatening to you and your baby.

Inadvertently, hypothyroidism can also impair a baby’s brain development. Babies who are born with hypothyroiditis will suffer from cognitive, neurological, and developmental abnormalities. They are also likely to be born prematurely with low birth weight. 

Planning ahead and discussing thyroid status with your primary care physician and OB helps prevent complications, especially among high-risk women. This involves proper screening tests, optimised treatment prior to becoming pregnant, and close monitoring throughout your pregnancy. For hypothyroidism, the goal is to provide adequate thyroid hormone replacement.

New mothers must ensure that they get follow-up medical attention even after delivery because thyroid conditions don’t usually resolve by itself. Some may even develop postpartum thyroiditis, which is the occurrence of a thyroid problem in the first year after pregnancy. Hence, therapy may have to be continued as necessary. 


Symptoms of Hyperthyroidism - Dr Pamela Tan

Normally, pregnancy hormones can cause the thyroid gland to slightly enlarge during pregnancy. However, in hyperthyroidism, there is an excess production of thyroid hormones which results in a goiter. This complication in pregnancy is often linked to an autoimmune disorder called Grave’s disease

This condition mostly affects young to middle-aged women in their child-bearing years, and it also tends to run in families. It may first appear during pregnancy or it may already be a pre-existing condition. Nevertheless, Grave’s disease poses a risk for both mother and baby if left unmanaged. 

Pregnant women with uncontrolled hyperthyroidism may experience a dangerous rise in blood pressure called pre-eclampsia. They are also at risk for miscarriages, pre-term delivery, and congestive heart failure. For some women, they may experience a sudden worsening of symptoms which is a medical emergency referred to as a thyroid storm

Furthermore, hyperthyroidism also carries a high risk for the baby with complications such as  intrauterine growth retardation, birth defects, and increased incidence of stillbirths. 

For the proper treatment of hyperthyroidism, your doctor will first review your symptoms and do appropriate screening tests to measure thyroid hormone levels. This condition entails frequent monitoring throughout your pregnancy. Medications will also be prescribed to control thyroid hormone production. Radioactive iodine is also a common treatment for hyperthyroidism, but it is not advised in pregnant and breastfeeding women. In some cases, surgery is needed to remove part of your thyroid, especially if there is an overactive nodule. 

Diagnosing the Problem

Since the symptoms of thyroid problems are closely similar to that of pregnancy, a correct diagnosis can be easily missed. 

The challenge with pinpointing thyroid problems in pregnancy is distinguishing the symptoms of the disease from that which are typical in pregnancy. Depending on the severity of the condition, a correct diagnosis can be easily missed. So, if you notice that something doesn’t feel right, alert your doctor as soon as possible. 

Diagnosis can be made through blood tests and imaging tests. Your blood can be extracted to tst for TSH (Thyroid Stimulating Hormone), T3, and T4 levels. Checking for thyroid antibodies may also be done to check for any autoimmune disorders – a condition where your immune system attacks the thyroid gland by mistake. 

Imaging tests may also be done to arrive at a diagnosis. An ultrasound of the thyroid is used to detect the presence of nodules, it is also a necessary tool for disease management. A thyroid scan and uptake can also be done to check the size, shape and position of the thyroid. However, this is advised against pregnant and breastfeeding women because it uses radioactive materials. If there is a lump or nodule found during these diagnostic tests, a needle aspiration biopsy will be done where a small sample of that growth is removed to check if it is cancerous or not.

Women with thyroid problems can increase their chances of a healthy pregnancy if they get early prenatal care and closely work with healthcare providers in disease management.  Get in touch with Dr. Pamela Tan today for a thorough evaluation and customised medical advice.

5 Types of Mental Health Crises During and After Pregnancy

It’s not easy to admit that you’re not okay at a time when people would expect you to feel otherwise. In social media, pregnancy, childbirth, and delivery are often depicted through rose-tinted glasses through beautiful maternity photoshoots with friends and family sharing in your excitement. But this is not the case for you – and you don’t understand what’s going on. 

It’s important to know that just as you would carefully attend to you and your baby’s physiological needs, your mental health during and after pregnancy is also a real concern. Learn about the different psychological issues you can possibly encounter and what can be done about it.

1. Perinatal Depression

Perinatal is an umbrella term encompassing the time during your pregnancy up to a year after giving birth.

Perinatal depression may affect a woman during (antenatal or prenatal depression) or after (post-natal depression) pregnancy. We are familiar with the latter but less is commonly known about antenatal depression. Whether you are pregnant or not, everyone can benefit from understanding these conditions more. 

Antenatal Depression

For some women, instead of reeling in excitement during their pregnancy, they find themselves dealing with antenatal depression. Locally, it affects one in five women. Even though it’s common, it’s not easily observed because people often mistake it for the mood swings expected during pregnancy. 

Due to the relatively high levels of progesterone during the first trimester, women usually feel poorly around this time. However, hormonal changes alone don’t conclusively account for antenatal depression, it is an interplay of the following factors:

  • An unplanned pregnancy
  • A history of depression
  • Previous miscarriages
  • Domestic violence
  • A difficult birth experience
  • Poor support 
  • Stressful living conditions or major live events
  • Struggling with the pressure to meet the usual expectations of an expectant mom
  • Poor self-esteem and difficult childhood experience
  • Fetal abnormalities

Since this type of mental crisis is less understood, it’s difficult for expectant moms to fully grasp what they’re going through, and for the people around them to understand. Some celebrities were brave enough to open up saying that antenatal depression can be isolating because friends and families would expect you to ‘snap out of it.’ Unfortunately, it’s not something you can nurse over a good night’s rest – or if sleep would even be restful at all. 

Though it’s common, it’s not easily observed because people often mistake it for the mood swings expected during pregnancy. 

To know if your mood changes need to be flagged out to your doctor, observe if you have the following signs and symptoms:

  • Withdrawing from friends and family
  • Sleeping too much or not very well at all
  • Irritability 
  • Loss of interest
  • Poor appetite 
  • Loss of concentration
  • No interest in intimacy
  • Sense of hopelessness about the future
  • Engaging in risk-taking behaviour 
  • Panic attacks 
  • Having thoughts of death or self-harm

In the first trimester, treatment may come in the form of therapy, counselling and familial support. Antidepressants are not advised at this point, unless depression is severe, because it may harm the baby’s developing organs. However, these medications may be given in serious cases during the second trimester while gradually weaning as you inch closer to your delivery. 

We have the tendency to attribute our feelings of stress to our hormones. But if what you’re going through is already beyond the normal worry and stress of pregnancy, and you find yourself being consumed by doubt and fear all the time, talk to your OB-GYN about it.

Post-Natal Depression

Post-natal/Postpartum depression should not be confused with baby blues. This deep emotional pain that comes 3 weeks after childbirth is marked by intense feelings of sadness, despair, and anxiety that prevent a new mom from doing her daily tasks. Meanwhile, baby blues involve mood swings and crying spells that typically lasts 2 weeks after giving birth. 

Baby blues typically worsen by the fourth or fifth day, but the symptoms subside on their own after two weeks. Unfortunately, a few develop postpartum psychosis, which is a rare but life-threatening disorder that requires immediate treatment. Postpartum depression lies between these two states and it can last up to a year. 

Considered as a major form of depression, symptoms include:

  • A depressed mood or sadness
  • Frequent mood changes
  • Sleeping problems
  • Change in appetite
  • Inability to concentrate
  • Thoughts are consumed by guilt or worthlessness
  • Reduced energy levels/constant fatigue
  • Loss of interest in usual activities
  • Crying spells
  • Less interest in food, sex, or self-care
  • Thoughts of suicide

Hormones play a primary role in postpartum depression as the levels of estrogen and progesterone plummet 48 hours after delivery. This hormonal crash can result in emotional instability, especially in women who are biologically vulnerable. In addition, stress hormones also go out of whack which adds to a woman’s distress. Furthermore, a history of depression also increases the risk of postpartum depression. Stressful experiences such as lack of sleep and support also worsen the situation. 

New dads are not spared too. Around 1 in 10 men experience paternal postpartum depression (PPD) within the first year after the birth of a child. Conventional wisdom would tell us that a mother’s postpartum depression is triggered by hormonal fluctuations, but studies also show that a man’s hormones go into a spin along with the mother’s during and after pregnancy. Testosterone levels drop, while estrogen, prolactin and cortisol go up. Researchers speculate that the change might be about psychologically preparing to be a father.

Around 1 in 10 men experience paternal postpartum depression (PPD within the first year after the birth of a child).

After the baby arrives, the stress of adjustment can also take a toll on a new dad which can lead them to develop paternal depression. They express this through irritability, anxiety, anger, and aggressiveness. 

2. Perinatal Anxiety

Perinatal Anxiety - Dr Pamela Tan

Perinatal anxiety is a distinct and definable syndrome that is tied to a state of anxiety linked to common pregnancy-related stressors. These concerns may revolve around your health, your baby’s health, your impending birthing experience, and parenting role. 

It’s normal for mothers to feel anxious even during a normal pregnancy. Since anxiety is so common and expected response to any life transition, one of the challenges that women and care providers face is distinguishing normal or appropriate anxiety in a given situation from one that requires further attention and treatment. Not much is known about it that those affected remain undetected and untreated.

In one Singapore study, researchers found that 1 in 6 participants persistently experienced symptoms of perinatal anxiety. These symptoms may include excessive worry, panic attacks, loss of appetite, restless sleep, chest tightening, or repeated thoughts about something bad happening to the baby. This explains why perinatal anxiety often presents with elements of obsessive-compulsive disorder or panic disorder, but it falls short of meeting the criteria to make a diagnosis. Furthermore, it also overlaps with certain depressive symptoms

There are available screening tools to help diagnose anxiety disorders during the perinatal period. To improve clinical outcomes, the American College of Obstetricians and Gynecologists (ACOG) suggests that screening should be coupled with the appropriate referral, follow-up, and treatment.

Treatments for perinatal anxiety include talk therapy or Cognitive Behavioural Therapy (CBT), self-help resources, and medications. You may choose one of these options or you may be offered a combination of talk therapy and medications. Physical activity, a shift in your focus, and breathing exercises can also help whenever anxiety attacks occur. Forging relationships through support groups can also help you with this struggle. 

3. Perinatal OCD

This is a type of anxiety disorder that comes with three components, these include: 

  • Thought or images that repeatedly come to mind, which are called obsessions
  • Anxiety that arises from obsessional thoughts.
  • Thoughts or actions which you feel you have to do repeatedly to reduce anxiety, which is called compulsions.

Obsessive thoughts can be distressing as you wrestle with unwanted thoughts, doubts, images, or urges. These concerns often tread along perfectionism, where you find yourself making a strong effort to get everything exactly right.

Anxiety comes when you feel the need to carry out your impulsive thoughts. The desire to see it through is validated when you feel better after you’ve done it. However, any relief you feel will be short-lived.

Compulsions may include rituals, checking (e.g. repeatedly checking your baby if he/she is still breathing), seeking assurance, correcting obsessional thoughts (e.g. counting, praying or saying a special word), and avoiding situations or activities that trigger their obsessions and compulsions (e.g. mothers avoid spending alone time with their baby).

There is a specific form of CBT called exposure and response prevention (ERP). This involves talking therapy that will help you understand how your OCD works and how you can overcome it. For this, you need to confront your obsessions and resist the urge to act on your compulsions. Medications may be given to manage your anxiety.

4. PostPartum PTSD (Post Traumatic Stress Disorder)

Postpartum Depression - Dr Pamela Tan

This is another type of anxiety disorder that is caused by certain reproductive trauma. This refers to any experience related to reproductive health events that are perceived as a threat to your physical, psychological, emotional or spiritual integrity.

Common reproductive traumas include:

  • Infertility 
  • Unplanned pregnancies
  • Pregnancy complications
  • A prolonged and difficult labour 
  • Short, intense labour
  • Medical complications in your baby/ NICU stay
  • Miscarriage
  • Abortion
  • Stillbirth
  • Maternal complications during or after delivery
  • Sexual assault

Postpartum PTSD involves extreme alertness or feeling on edge, avoidance of feelings and memories, and re-living aspects of the trauma. Those who suffer from it may experience intense distress, vivid flashbacks, intrusive thoughts, panic, aggressive behaviour, lack of concentration, and feeling detached/’emotional numbing.’

Treatment for PTSD involves Trauma-focused cognitive behavioural therapy (CBT) designed for PTSD patients and Eye movement desensitisation and reprocessing (EMDR) which involves rhythmic eye movements that are designed to help speed up readjustment and recovery.

5. Postpartum Psychosis

Postpartum psychosis (PP) is a serious but rare illness compared to the rates of postpartum depression or anxiety. It has a sudden onset which often occurs within the first 2 weeks postpartum. Anyone suffering from it will experience a mix of depression, mania, and psychosis

Women who are predisposed to PP are those with a family history of the illness, a clinically diagnosed bipolar disorder, a previous psychotic episode, and a traumatic birth or pregnancy. However, you can also develop PP even if you have no history of mental health problems at all. It’s also common in first pregnancies than subsequent ones. 

Common signs and symptoms of postpartum psychosis include:

  • Delusions or strange beliefs
  • Rapid mood swings
  • Confusion or disorientation
  • Severely depressed
  • Hallucinations
  • Feeling very irritated
  • Paranoia and suspiciousness
  • Difficulty communicating
  • Decreased need for or inability to sleep

With professional help, postpartum psychosis is temporary and treatable. However, it is considered an emergency and it is essential that you receive immediate help. To manage your mood and psychotic symptoms, you may be offered an antipsychotic drug or an antidepressant. But if you don’t respond to other treatments, electroconvulsive therapy (ECT) is also an option.

With professional help, postpartum psychosis is temporary and treatable.

If you or someone you know may be suffering from postpartum psychosis, call your doctor or an emergency crisis hotline right away to get the help you need. 

Mental problems in pregnancy and the postpartum period can be distressing for women. But the good thing is that these problems can be remedied. It takes the right help to overcome these challenges, but more importantly, it takes courage to admit that you need it.

Besides getting professional help for the physiological milestones of pregnancy, don’t hesitate to seek help for your mental health when you sense that something is off. Find caring treatment with Dr. Pamela Tan. Discuss your concerns today through a personal consultation. 

Pregnancy and Cardiac Disorders

Pregnancy is a time when you focus on a heart-healthy lifestyle. The changes your body goes through for the next nine months will stress your heart and circulatory system. In fact, cardiac disease is the most common cause of mortality in pregnancy. However, a woman’s body is designed to withstand this surge of cardiac load, and it’s still possible for women with heart conditions to have a successful delivery and healthy babies with proper care. 

Concerns about cardiac health highlight the importance of being aware of the risks and how to prevent complications. 

Your Heart During Pregnancy

Pregnancy increases your blood volume by a whopping 50 percent as your body accommodates your growing baby. These changes put extra stress on a woman’s body with profound effects on your cardiovascular system. With increased cardiac output, your heart rate at rest also increases by up to 30-50 percent.  

Labor and delivery also add to your heart’s workload. The demand for your heart increases during contractions and as labor advances. Furthermore, bearing down during delivery can cause a sudden change in blood flow and pressure, and it will take a few weeks before your heart reverts back to its pre-pregnancy state. Blood loss during delivery can also place an intolerable strain on an abnormal heart. 

Pregnancy increases your blood volume by a whopping 50 percent as your body adjusts to support your growing baby.

Pregnant women with congenital heart disease (CHD) have a higher risk of developing complications during pregnancy and delivery, especially if they have other pre-existent diseases. Depending on the type and severity of the disease, some of these heart conditions may pose life-threatening risks to the mother or the baby. Therefore, some women are required to undergo major treatments before they conceive, or they are advised to avoid pregnancy if they’re dealing with a rare congenital condition. 

Preparing Your Heart for Motherhood

Women of reproductive age with congenital or acquired heart disease must have access to specialised multidisciplinary preconception counselling to empower them to make choices about pregnancy. 

If you’re among those who are at risk, it’s important that you consult your OB and cardiologist before trying to conceive. The management of high-risk pregnancies and deliveries are done on an individual basis.  It is aimed to optimise your condition during pregnancy, monitor for deterioration, and minimise any additional load on your cardiovascular system during delivery and the postpartum period. 

You will undergo a pre-pregnancy evaluation which involves a risk assessment for you and your baby. Your doctor will also review the management of your heart condition and consider the necessary changes before you conceive and to accommodate your future pregnancy. For instance, certain cardiac medications are not advised for pregnant women, but due to circumstances, your doctor might adjust the dosage or prescribe a substitute. 

If you were born with a cardiac abnormality and have undergone an operation to correct it, it doesn’t mean that you are off the hook. Surgery may leave some scarring to your heart which makes you more prone to infections and an irregular heartbeat.

If you were born with a cardiac abnormality and has undergone an operation to correct it, it doesn’t mean that you are off the hook.

To ensure you and your baby’s safety, you will have multidisciplinary care where you can expect frequent prenatal visits.  This involves:

  • Close monitoring of your weight, cholesterol, blood sugar and blood pressure
  • Measurement of body mass index in early pregnancy
  • Diet management
  • Development of a treatment plan that could run along the spectrum of usual labor and delivery procedures, even up to the postpartum period
  • Blood tests
  • Urine tests
  • Medications
  • Echocardiogram
  • Electrocardiogram

A Mom’s Healthy Heart Means Healthier Children

A woman’s cardiovascular health during pregnancy also affects the baby’s environment in the womb. Maternal heart disease may deprive the baby of optimum oxygen levels and nutrients as the heart is unable to pump blood efficiently. This can slow down fetal growth rates, and it is also associated with preterm delivery and low birth weight

Adopting heart-healthy habits and precautions while pregnant sets your baby’s heart health on the right foot. Researchers found that a heart-healthy lifestyle has a strong link to a child’s cardiovascular health in the long term.

Labour and Delivery

A discussion on labour and delivery in consideration of your heart condition is also necessary especially if you’re making a birth plan.

You need to give birth in a hospital with the appropriate facilities for monitoring. It is still best to wait for spontaneous labour, unless the baby has to be delivered early to avert maternal or fetal compromise.

Women with congenital heart disease won’t be automatically offered a caesarean section. However, it may be recommended so you can have pain-free labour. This will entail the use of an epidural to mitigate large fluctuations in your heart rate and blood pressure associated with the pain brought by uterine contractions. Your doctor may also use vacuum and forceps to assist you in delivery and avoid excessive straining to push the baby out. 

Take This to Heart, Mommy

Heart conditions and diseases may lead to a high-risk pregnancy, but adequate preparation on your end coupled with the right medical management are vital steps towards a positive outcome. The decisions you make now regarding your heart health and pregnancy can have effects on you and your baby later in life.

As you plan to grow your family, start your preparations with professional help. In Singapore, you can approach Dr. Pamela Tan for caring and individualised management. 

Obstetric Cholestasis (What’s the Itch All About?)

If there is any milestone in a woman’s life that brings a string of changes, it is pregnancy.  However, the entire experience is not all rosy for women. Morning sickness, bloating, and weight gain are just some of the side effects that open your eyes to the unglamorous side of pregnancy. However, aside from the usual complaints, conditions like Intrahepatic Cholestasis of Pregnancy is one that must be taken seriously. Besides the disruptive itch, it also poses serious risks, so read more to protect you and your baby. 

What is Intrahepatic Cholestasis of Pregnancy (ICP)?

Intrahepatic cholestasis of pregnancy, which is also known as Obstetric Cholestasis, is a liver condition where the normal flow of bile slows down or is blocked. Instead of leaving the liver, it builds up in the organ resulting in bile salts leaking into the bloodstream and causing severe itching.

…bile salts leaking into the bloodstream…cause severe itching

For expectant moms, severe itching unaccompanied by spots or rashes is the main red flag.  You can either experience the itch localized to your palms and the soles of your feet, while others get generalized body itching. Itching usually worsens at night where it can impair your sleeping pattern.

Other less common signs and symptoms of obstetric cholestasis include:

  • Yellowing of the skin and the whites of the eyes (jaundice)
  • Nausea
  • Dark urine
  • Light-colored stool
  • Fatigue
  • Pain in the upper right side of your belly
  • Decreased appetite

The symptoms may appear earlier for some women, and worsen during the third trimester or as your due date approaches. The reason is that pregnancy hormones are at their peak during this stage.

What causes cholestasis of pregnancy?

This condition is thought to be caused by a combination of hormonal, genetic, and environmental influences.

Bile produced by the liver is supposedly stored in the gallbladder. However, additional estrogen hormones during pregnancy can change the way these two organs function. Hormonal changes slow down the normal flow of bile, which triggers a cascade of events that lead to itching.

Evidence shows that this condition tends to run in families. It is also common in certain ethnic groups in the South Asian, South American, Nordic, and Scandinavian regions. It can also be expected to reappear during subsequent pregnancies, with a 45-90% recurrence rate.

How is intrahepatic cholestasis of pregnancy diagnosed?

An accurate diagnosis relies on a high index of suspicion supported by abnormal liver function tests and raised bile acid levels. The doctor makes this conclusion after organic causes of liver disease has been ruled out.

Other lab tests include prothrombin time to check how well your blood clots. An ultrasound exam may even be done to assess the tubes that carry bile (bile ducts) for liver abnormalities and gallstones.

Is intrahepatic cholestasis of pregnancy dangerous?

Obstetric cholestasis runs a serious risk of complications to your developing baby. These include:

  • Preterm birth/Stillbirth. An early delivery improves a baby’s chance to thrive when they are exposed to the risks associated with intrahepatic cholestasis while in the womb.
  • Fetal distress. This results when your developing baby is not thriving well.
  • Meconium in the amniotic fluid. While in the womb, your baby’s gut normally collects a sticky, green substance in their intestines called meconium which may be expelled into the amniotic fluid if a mother develops cholestasis.
  • Respiratory problems. Meconium in the amniotic fluid can potentially be aspirated by the baby which can cause respiratory problems in a newborn or stillbirth. Steroids may be given at 34 weeks to help the baby’s lungs mature, especially with preterm births.

On the maternal end, obstetric cholestasis reduces your ability to absorb fat-soluble vitamins (A, D, and K). This effect puts you at risk for vitamin K deficiency, which can result in postpartum hemorrhage. It explains why you need to have your clotting time checked so that you get proper treatment before giving birth. Otherwise, you’ll run the risk of excessive bleeding during delivery.

What extra care do I need if diagnosed with ICP?

After a diagnosis, you’ll be advised to have additional antenatal checks. This will include liver function tests which is done as often as once or twice a week until you deliver. Additionally, your baby will also be closely monitored. This involves fetal heart monitoring and ultrasound scans to measure growth and the fluid around your baby.

While these efforts may not guarantee the prevention of stillbirth, they can still help you and your doctor be on top of your baby’s well-being inside the belly.

Does cholestasis go away after pregnancy?

You may continue to itch for some time after delivery, especially in prolonged cases, or if you have several pregnancies over a short period of time. It is fortunate that this condition typically goes away after your baby is born.

…this condition typically goes away after your baby is born.

How is intrahepatic cholestasis of pregnancy treated?

The goal of treatment is to relieve itching and prevent complications. Aside from the seemingly unbearable itching, it is the fear of not knowing how the condition is affecting your baby that increases your anxiety. To ensure your baby’s safety, treatment may include:

  • Home remedies. Cold or ice baths slows down blood circulation, which can help relieve itching, and wearing loose-fitting cotton garments help minimise it.
  • Skin creams and ointments. These products help relieve the itching temporarily and are considered safe interventions for pregnant women.
  • Proper assessment. Your doctor will carefully examine your skin to check if the itch is related to other skin conditions. 
  • Fetal monitoring. Management may vary with each OB, but it may often include recommendations increased antenatal monitoring for women with ICP. This will include fetal heart monitoring and contraction recordings.
  • Medicine. Drug treatment may include corticosteroids and ursodeoxycholic acid (drug that can decrease the concentration of bile acids). Antihistamines will be given but not so much for the itch, but only to help you sleep. While histamines cause the common itch, ICP is directly or indirectly caused by bile salts in your bloodstream.
  • Early delivery. The benefits of delivering the baby at 37-38 weeks outweigh the risks associated with early delivery. This is a necessary step to protect the baby from the complications attached to cholestasis.

What follow-up should I have during the postpartum period?

It is advised that you get a follow-up appointment with your doctor 6-8 weeks after giving birth. This visit is necessary to assess your symptoms and liver function thoroughly. Persistent symptoms and abnormal liver function test results suggest a different problem which calls for a referral to a specialist. It is generally not advisable to be on the oral contraceptive pill after such a condition.

This may not be a common condition, but it’s essential that you are aware of how obstetric cholestasis poses a real threat to your baby. Having this knowledge will help you adopt proper health-seeking behaviors if ever you experience this condition.

Therefore, if you are experiencing a rashless itch or other unusual symptoms, bring your concerns to a certified obstetrician. In Singapore, you can schedule your appointment with Dr. Pamela Tan.

Preeclampsia: The Hidden Dangers of Pregnancy

Hypertension can complicate a pregnancy. Preeclampsia and other hypertensive disorders of pregnancy can have serious effects to you and your baby, made worse by delayed diagnosis or management. By making yourself aware of the signs and symptoms, just might spell the difference between life and death.

What is preeclampsia?

Understanding preeclampsia can save you and your baby from potential medical emergencies during pregnancy and childbirth. This highlights the importance of understanding this condition because even though it is serious, it is manageable especially with early diagnosis and prompt treatment.

Originally known as “toxaemia,” preeclampsia is a complication that occurs during pregnancy or rarely after the baby is born.  While the cause remains unknown, it is associated with problems in the placenta, which is the temporary organ that serves as a lifeline between your own blood supply and that of your baby’s. 

Pregnancy Disorders

In preeclampsia, changes in blood vessels deprive the placenta of proper blood supply resulting in harmful effects to you and your baby. The first identifying factor is the time in which it occurs – that is during the second half of pregnancy, or anytime after the 20th week. On rare occasions, it can also happen earlier, during labour, or six weeks postpartum.

Preeclampsia is diagnosed by persistent high blood pressure with increased amounts of protein in the urine. It must not be confused with elevated blood pressure occurring after the 20th week unaccompanied by any traces of protein in the urine, which is gestational hypertension. 

Swelling that is localised to the face and hands is also a classic sign of preeclampsia. This significant increase in body fluids also explains the sudden weight gain. This may be accompanied by mild symptoms, or fall seriously ill with problems extending to the lungs, liver, brain, and even your blood clotting system. 

What puts me at risk of developing preeclampsia?

Preeclampsia can strike at any pregnancy, however there are also predisposing factors. Your risk of developing preeclampsia increases if:

  • This is your first pregnancy.
  • You are aged 40 and above
  • You have an existing high blood pressure (140/90 mm/Hg and above)
  • You are carrying more than one baby
  • You have a history of obesity or a Body Mass Index (BMI) of 35 or more
  • You have certain medical conditions such as diabetes, thrombophilia, lupus, or migraine
  • You have developed preeclampsia in a previous pregnancy
  • You have chronic hypertension and kidney disease
  • It has been a decade or more since your last baby
  • If you have any close relatives who have had preeclampsia
  • You have had an in vitro fertilization

If you fall under any of these criteria, seek medical help to ensure that you get a thorough assessment and close monitoring. 

What are the complications associated with preeclampsia? 

If left untreated preeclampsia can develop into a full-blown eclampsia, where high blood pressure results in seizures. It also involves loss of consciousness and agitation.

Your health can be further compromised when eclampsia results in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). This is characterised by damaged red blood cells, impaired clotting, and internal bleeding of the liver resulting in chest or abdominal pain. This is a medical emergency that can have lifelong effects or fatal consequences. 

Aside from maternal risks, preeclampsia also has profound effects on your little one. The lack of oxygen and nutrients caused by poor placental circulation can impair your baby’s growth. It can also result in preterm birth which can cause serious complications (e.g. congestive heart failure, high blood pressure, diabetes) later in life that would require ongoing medical care. Babies who are born early may sometimes fail to thrive especially with immature systems.

What signs and symptoms should I look out for?

Learning to recognise the warning signs of preeclampsia is critical to you and your baby’s safety. Remember that you will be your own first responder to any unusualities. Along with elevated blood pressure, important symptoms that may suggest preeclampsia include:

  • Headaches, similar to migraine, that don’t go away and is sometimes accompanied by nausea and vomiting.
  • Shortness of breath
  • Severe pain just below the ribs, on your right side. 
  • Confusion
  • Heightened state of anxiety
  • Visual disturbances (e.g. oversensitivity to light, blurred vision, seeing flashing spots or auras)
  • Severe swelling on the hands
  • Sudden weight gain

Since you know your body, the key here is to trust your instincts if you notice anything that is off. While these symptoms are not always serious, it is important that you immediately seek medical attention once you experience them. 

How is preeclampsia diagnosed?

With this risk present in each expectant mom, a routine screening will be done which includes blood pressure monitoring and urine protein tests. Along with thorough assessment, the doctor will determine if what you have is mild or severe preeclampsia from which they will base their management on. 

How is preeclampsia managed?

Mild preeclampsia can be managed in a hospital or an outpatient basis. This means you can stay at home while your doctor or midwife closely monitors your condition. By yourself, you can do a daily kick count to keep track of your baby’s movements alongside blood pressure monitoring. 

Report your observations during your antenatal doctor visits which is done once or twice weekly. At 37 weeks, you may be recommended to deliver your baby, but if test results continually stay in the red, you may be advised to have the baby earlier.

Preeclampsia with severe features require hospital admission. It is often recommended that you have your baby at 34 weeks once your condition has stabilised. But, if you are less than 34 weeks pregnant and under stable conditions, you may be advised to wait to deliver your baby. Medications will also be given to control your blood pressure and a seizure precaution. Magnesium sulfate will be given intravenously to prevent eclampsia. Corticosteroids will also be administered to help the baby’s lungs mature.

Preeclampsia Management

How is postpartum preeclampsia managed?

Preeclampsia eventually goes away after the delivery of the placenta. This may take hours or up to six months after giving birth. However, in some cases, this condition makes its entrance for the first time up to 4 weeks after birth.  

Blood pressure monitoring must be continued soon after birth because there are cases where a woman’s condition could deteriorate after delivery. This necessitates a longer hospital stay until it is established that your blood pressure has stabilised for 24-48 hours. Medications to control blood pressure and prevent seizures may be given as well. 

Most women with preeclampsia are able to deliver healthy babies and fully recover, while others proceed to experience life-threatening complications. Since the condition has a tendency to escalate quickly, it’s important for pregnant women to be proactive in observing symptoms and in monitoring their blood pressure at home. 
With this knowledge, we hope that expectant moms or those planning to have a baby, seek medical guidance as soon as possible. Preeclampsia is manageable when caught early, so, get your blood pressure levels closely monitored. Talk to your OB-GYN now, or book an appointment with Dr. Pamela Tan today.

Beyond Sanitary Pads and Tampons, What Are My Other Options?

Have you resigned to the fact that stained panties and soaked tampons are part of your reality until menopause makes its entrance? What if I tell you that there are other options that just might save you from these messy situations? Read on to know more!

Menstrual Cups

If this is your first time to hear about menstrual cups, you might think that these are new-age inventions. But did you know that it was first introduced way back in the 1930’s? Initially, it didn’t get a warm reception for religious and cultural reasons, but as we’ve seen today, its 80-year trajectory panned out differently. 

Today, menstrual cups are making the rounds with more women swearing by it as an alternative to their usual menstrual support. If you haven’t tried it yet, here’s what you need to know. 

Menstruation in a cup?

Menstrual cups are bell-shaped devices made from flexible material (silicone, latex or rubber) to be used inside the vagina to collect menstrual blood. It can be left in place for 4-12 hours before it is emptied, rinsed, and re-inserted. You’ve read that right; menstrual cups are reusable!


You can use a cup all throughout your period, but you must empty and clean it more often on heavy flow days to avoid leakage. This sounds familiar, right? But, compared to sanitary pads and tampons, which absorbs the blood, menstrual cups are set in place to collect it. The way it works may seem foreign to most women in Singapore, but those who have tried it vouch for its reliability. 

However, some would say that there is a learning curve to using the cup. Not all women are comfortable during the first few tries of inserting it. But once you get the right size and fit, it can give you the comfort and confidence to move even on your red days. One study even concluded that a menstrual cup is a satisfactory alternative to tampons. 

But, are menstrual cups safe?

The fact that cups are left inside the vagina for several hours raises concerns. Fortunately, with proper use and care, menstrual cups are safe to use. A 2017 study done on Kenyan schoolgirls indicated that there is no evidence that menstrual cups are hazardous.

However, menstrual cups are not advised for women who have an intrauterine device (IUD). The movement caused by the placement and removal of the cup may dislodge it. While there are studies which found no evidence of this risk, it is still important to discuss this with your OB-GYN so you can be properly advised. 

Getting by with a little help?

More women today embraced the use of menstrual cups, with some even praising it for changing their lives. While it’s true that it can do the job, we’ve discussed that it’s not a perfect option. This is reflected in the contradicting feedback surrounding this device. 

Some complain that, just like pads, it also has a chance for leakage probably due to an improper fit, particularly among those with a tilted cervix, or heavy flow. For days like these, sanitary pads may be needed for additional support.

But, did you know that women today are lucky that even concerns over having clean panties during these “leaky” situations are also covered? Enter Period Panties – probably what one would call a menstrual sidekick that prevents heavy flow from victimizing your favorite underwear!

Period Panties


Besides the promise of clean panties throughout your period with their layers of protection, period panties have the capacity to replace tampons, liners, and cups. It’s just like your usual underwear except that it can protect you from light, medium, to heavy flow – sometimes even absorbing up to 2 tampon’s worth of fluid. 

These panties are designed with moisture-wicking, breathable cotton that draws wetness and dries fast. This means that you don’t get the discomfort you often feel with soaked pads. On top of that, they are also leak-resistant, so you brush off any worries over accidental stains. This should give you the license to wear white pants even in the middle of your period! 

Furthermore, these period panties also come with odor-controlling technology that neutralizes smell, giving you 24-hour freshness. 

For pragmatic women, period panties can be a budget-friendly addition to your feminine hygiene repertoire because these are washable, reusable, and easy to maintain (just remember to skip the bleach and fabric softener). Having to wash these panties is a preferable downgrade than sacrificing your sheets, towels, and other items of clothing like bloody casualties of war every time your period floats by. 

Finally, put a period to embarrassing stains!

Let’s face it ladies, we are familiar with the struggle of pads slipping out of place, winged ones bunching up to the side, tampons filling up too fast, or your menstrual cup leaking over. Period panties gives you peace of mind because they are leak-proof to protect you from menstrual flows of different intensities.

As they become increasingly popular in Asia, women are now offered more options as different brands put their own spin on them. Some even went as far as creating a compartment where you can place a warm compress to help relieve period pains! Some also dial up the aesthetics so that these special garments still look chic and fashionable. 

Why you might want to make that switch

Menstrual cups and period panties for menstrual management became popular subjects of discussion today because it fits well into our social awareness narrative. With the clamor for environmental consciousness, many are now seeking sustainable solutions. 

Your feminine needs don’t have to harm the environment.  

As reusable forms of menstrual support, menstrual cups and period panties allow you to minimise the waste you contribute to landfills every year, compared to using tampons or sanitary pads. These are also cost efficient because some of these cups can be safely used for years before replacements are needed. This means that you also save yourself from your monthly trips to the pharmacy.

So, would you like to make that switch today? For any concerns, always talk to your doctor first for proper medical advice.  

Get down and dirty with some real talk to understand how you can maintain feminine hygiene and ensure safety with these options. For your questions, talk to Dr. Pamela Tan today at +65 6254 2878 (Thomson).