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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. 

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. 

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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13 Things You Don’t Want to Happen During Your Pregnancy

Pregnancy can be an exciting journey. However, beyond the themed baby showers, gender reveals, and carefully curated nursery designs it’s also important to look at the ugly side of getting pregnant. It’s important to be aware that as you cross milestones for the next nine months, there are also factors that can complicate this journey. Get to know 13 of them, below.

1. Preeclampsia

Hypertension, or high blood pressure, is fairly common in Singapore where it affects less than 1 in 4 between the ages 30-69. This is well within the age of conception in a lot of women in the country. If uncontrolled, this can result in a number of complications for you and your baby

Preeclampsia is one of the complications of hypertension, and it is described as a sudden increase in blood pressure after the 20th week of pregnancy. Initially, it will not show any symptoms, but early signs include high blood pressure and the presence of protein in your urine (proteinuria). If the condition progresses, the woman may experience fluid retention evidenced by swelling in the face, hands, ankle, and feet. The baby will also be smaller than expected (growth retarded) with low amniotic fluid levels.

Experts are not sure why preeclampsia occurs, but it was surmised that this may be linked to problems with the development of the placenta. The blood vessels that supply it are narrower than normal, which means blood flow is limited and it may also respond differently to hormones. 

If left untreated, preeclampsia can develop into eclampsia which bears serious consequences like seizures, severe bleeding, stroke, coma, placental separation from the uterus, or even death. There can also be abnormal kidney, liver and platelet function that affects the ability to clot. Although uncommon, complications from preeclampsia can be prevented if blood pressure levels are controlled and a mother commits to her scheduled prenatal appointments.

Preeclampsia can be cured if the baby is delivered, but in rare occasions where it starts early in pregnancy, delivery will not be a suitable solution. How the treatment proceeds will depend on the severity of your case. 

So if you’ve experienced this in the past, you must take your doctor visits seriously because it can reoccur in a succeeding pregnancy. In such cases, medications like antihypertensives, anticonvulsants, and steroids for fetal lung maturation will be recommended.

With good management, you can recover well from preeclampsia. Most women improve within a day or two after delivery, and blood pressure levels revert to its pre-pregnancy rate around 1-6 weeks postpartum. 

Check your symptoms!

  • Swelling of the face or hands 
  • A headache that will not go away 
  • Seeing spots or changes in eyesight 
  • Pain in the upper abdomen
  • Nausea and vomiting (in the second half of pregnancy) 
  • Sudden weight gain 
  • Difficulty breathing

Read: Preeclampsia: The Hidden Dangers of Pregnancy

2. Gestational Diabetes

Another condition you don’t want complicating your pregnancy is Gestational Diabetes Mellitus (GDM). It’s a category of diabetes that develops in the middle or towards the end of pregnancy and then resolves after giving birth. This is common in Singapore affecting about one in five women.

Those with persisting diabetes even after pregnancy probably had underlying diabetes, to begin with. Furthermore, even in women whose condition resolve after giving birth are at an increased risk of developing diabetes later in life. 

Since it’s so common and some women who develop GDM don’t show any symptoms, it became necessary that an Oral Glucose Tolerance Test (OGTT) is done between the 24th to 28th week of pregnancy. The blood tests are conducted at fasting, 1 hour and 2 hours after a pregnant woman has consumed a specific sugar load or a drink with high sugar content.

Proper diagnosis and treatment can help women with gestational diabetes have healthy pregnancies and babies. But when it is poorly managed, it can result in complications that can affect you and your baby.

GDM can be controlled with diet and exercise. If you are diagnosed with GDM, you will be taught how to monitor your blood sugar levels at home using a glucometer. However, if it’s unresponsive to lifestyle changes and an ultrasound scan revealed that the baby is larger than expected, you may be prescribed oral tablets or hormonal injections. 

Check your symptoms!

  • Being unusually thirsty all the time.
  • Frequent urination in large amounts.
  • Feeling tired or nauseous (which can be confused with early pregnancy symptoms).
  • Sugar detected in urine tests (conducted during a prenatal visit with the gynaecologist).
  • Blurred vision

Read: The Real Impact of Gestational Diabetes on Mom & Baby

3. Preterm Labor

A typical pregnancy is 40 weeks and its conclusion is marked by labour where the uterus regularly tightens and the cervix thin and open. But, when your body starts getting ready for birth too early in your pregnancy (usually around 37 weeks) it is considered preterm labour. However, preterm delivery doesn’t always follow. Regardless, this requires immediate medical attention to ensure that you and your baby are safe. 

While no one knows for certain what the main cause is behind preterm labour, there are known factors that raise a woman’s risk. These include:

  • Stress
  • Smoking
  • Infections
  • Being under 20 years or over 35 years old
  • Long-term illness such as heart or kidney disease
  • The use of illegal drugs such as cocaine
  • Abnormally shaped uterus
  • Cervix unable to stay closed
  • Having a preterm birth in the past
  • A placenta that separates from the uterus early
  • The placenta is in an abnormal position
  • A placenta that does not work as well as it should
  • Early breaking of the sac around the baby (premature rupture of membranes)
  • Birth defects in the baby
  • Problems with fetal growth
  • Having more than one baby in the womb

To check if you’re indeed going into premature labour, cervical exam or a transvaginal ultrasound scan will be done by your OB to check. Tests may also be ordered to check the amniotic fluid or fetal fibronectin or  phIGFBP-1 (proteins found between the amniotic membrane and uterine lining). 

The management of preterm labour will be based on your OB’s assessment of your case. If your baby will benefit from a delay in delivery, medications can be given to reduce the risk of complications, help the organs mature, prevent infection, and stall the delivery. A cervical cerclage, which is a procedure where the cervix is stitched closed, may also be done especially if it is weak and unable to stay closed. Bed rest may also be advised. However, if these treatments are unsuccessful at preventing preterm labour or the safety of your baby is compromised, delivery may ensue.

Check your symptoms!

  • Painful abdominal cramps, with or without diarrhoea
  • A change in the type of vaginal discharge (watery, bloody, or with mucus)
  • An increase in the amount of discharge
  • Regular or frequent contractions or uterine tightening
  • Your water breaks with a gush or a trickle of fluid (indicates ruptured membranes)

4. Premature Rupture of Membranes (PROM)

Sometimes, the membranes that surround the growing fetus breaks before a woman goes into labour, this is called premature rupture of membranes (PROM). But, if the sac ruptures earlier than 37 weeks of pregnancy, it is referred to as preterm premature rupture of membranes (PPROM), and it comes with a higher risk of complications for you and the baby. 

Rupture of membranes occurs naturally in the process of labour as the amniotic sac weakens with the force of the contractions. However, the cause is not known with PROM, but triggering factors include:

  • Infection of the vagina, cervix, or uterus
  • Cigarette smoking during pregnancy
  • Too much stretching of the amniotic sac due to having too much fluid or more than one baby putting pressure on the membranes
  • Having been pregnant before and had PROM or PPROM
  • Surgeries or biopsies of the cervix

PROM can be detrimental because it exposes placental tissues to infection, which puts you and your baby in danger. It is also linked to other complications such as compression of the umbilical cord, early detachment of the placenta from the uterus (placental abruption), a cesarean birth, and postpartum infection. PPROM, on the other hand, poses a significant risk because the baby can be born within a few days after membrane rupture. This is why you must alert your OB right away once you notice any symptom.

The treatment for PPROM will involve hospitalisation, monitoring and treatment of infection, medications to help the baby’s organs develop, and drugs to prevent premature labour. If the baby is more than 34 weeks, labour can be induced. Meanwhile, expectant management is done if the baby is below 34 weeks. 

Check your symptoms! 

  • Leaking of fluid from your vagina
  • A feeling of wetness in your vagina or underwear

5. Pregnancy Loss or Miscarriage

Also called a spontaneous abortion or miscarriage, this is a non-viable pregnancy up to 20 weeks gestation. It occurs in up to 1 in every 4-5 pregnancies, where most happen during the first trimester and is referred to as early pregnancy loss. This type of miscarriage happens so early on that some women may not even be aware that they are pregnant. However, it may also occur between 12-24 weeks which is called a late miscarriage. 

About half of early pregnancy losses are due to genetic or chromosomal defects. Smoking, alcohol, and caffeine have also been identified as possible causes. Maternal age is also a factor as the likelihood of a miscarriage increases in older women.

Pregnancy loss beyond the first trimester of pregnancy may be caused by factors like underlying health conditions in the mother or infections that can lead to the bag of water breaking prematurely before any pain or bleeding.  Miscarriages can also occur when the neck of the womb opens too soon.

Losing a baby at any time in pregnancy can be physically and emotionally hard for a mother, and even for other members of the family. Counselling and support can help the family cope through this difficult time. For those who are still planning to start a family, it’s important that you seek professional care especially if you think you are among those high-risk women. 

Check your symptoms!

  • Vaginal bleeding 
  • Cramping
  • Mild to severe back pain
  • Sudden decrease in the signs of pregnancy
  • White or pink mucus discharge from the vagina
  • Weight loss

Read: A Mother’s Guide to Miscarriage and Moving On

6. Stillbirth

Globally, stillbirth is among the most common adverse pregnancy outcomes. It is defined as fetal death or pregnancy loss that occurs after 20 weeks of pregnancy, either before or during delivery. In Singapore, it affects two in every one thousand births. While these numbers are among the lowest in the world, it’s not reason enough to keep your guard down from potential risk factors.

Identified factors that increase the likelihood of stillbirths include, birth defects, problems with the placenta, a mother’s medical condition (obesity, preexisting diabetes, chronic hypertension), or her lifestyle choices (e.g. smoking, alcohol). Adding to that, advanced maternal age, twin pregnancies, and pregnancy that used assisted reproductive technology also heightens the risk. 

Not all causes of stillbirth are currently known, but if you know aggravating factors, the signs to look out for, and when to seek help, you can reduce the chances of this happening.

Check the symptoms!

  • Spotting or heavy bleeding
  • Fever
  • Chills
  • Pain
  • Stopping of fetal movement and kicks
  • Absence of fetal heartbeat when you check through a stethoscope or doppler

7. Ectopic Pregnancy

In our efforts to get pregnant, we assume that the embryo that develops will soon burrow into the uterus. However, there are cases where the egg that is fertilised by the sperm in the Fallopian tube grows outside the uterus, especially if the tube is scarred, damaged, or distorted. In 1% of pregnancies, these fertilised eggs end their journey in the fallopian tube, This is called a tubal ectopic pregnancy, which is a non-viable, high-risk condition because fallopian tubes are not designed to hold a growing baby. 

There is no measure that can help save an ectopic pregnancy, and it can never turn into a normal one. If the fertilised egg continues to grow in the fallopian tube, it can damage or burst resulting in heavy bleeding. Hence, this requires urgent medical attention.

To diagnose an ectopic pregnancy, your OB will perform a pelvic exam, and a transvaginal ultrasound scan will confirm it. A blood test may also be done to check for pregnancy hormones.

After an ectopic pregnancy diagnosis is confirmed, treatment options may include medical, surgical, and expectant management. The surgical approach is advised for patients who are medically unstable or are experiencing life-threatening haemorrhage. It is also preferable if the bhcg levels are very high or the ectopic is large especially if there is positive fetal heart activity. For others, management can be based on the patient’s preference after the risks, benefits, and monitoring requirements of other treatment approaches have been discussed.

Medicine can be used if the pregnancy is found early and the tube has not been damaged. To spare the removal of the fallopian tube, a chemotherapeutic drug used to treat it can also end the pregnancy. It may let you steer clear from surgery, but it also comes with side effects. You may also have to undergo blood tests to make sure that the treatment worked. 

Check your symptoms!

  • Abnormal vaginal bleeding
  • Low back pain
  • Mild pain in the abdomen or pelvis
  • Mild cramping on one side of the pelvis

8. Placental Abruption

Placental abruption is a relatively rare complication of pregnancy due to the partial or complete separation of the placenta from the lining of the uterus before the baby is delivered. It may cause you to bleed and it also heightens the odds of stillbirth. 

This complication occurs when the blood vessels that run between the uterus and the maternal side of the placenta are torn and the placenta shears off. This can be dangerous because these structures deliver oxygen and nutrients to the baby. 

Factors like hypertension or substance abuse can stretch the uterus which is an elastic muscle. In the event that the uterine tissue suddenly stretches the placenta remains stable and the vascular structure that connects the two gets torn away. This damage causes bleeding, and when blood accumulates, it further separates the placenta from the uterine wall.

If you show symptoms of placental abruption, the doctor usually does a physical exam, an ultrasound and a CTG that monitors the fetal heart rate pattern. If the doctor finds that this is a severe case, treatment would be to deliver the baby, usually through an emergency C-section. Unfortunately, delivery doesn’t always guarantee that the baby can survive. For those that do, they often face complications associated with prematurity and oxygen deprivation. 

While it’s impossible to prevent placental abruption, the risks can be reduced. It mostly has something to do with lifestyle changes where you should avoid smoking, never use illegal drugs, and have your high blood pressure under control. 

Check your symptoms!

  • Vaginal bleeding (although there might not be any in some cases)
  • Sudden Abdominal pain
  • Reduced fetal movements 
  • Uterine tenderness or rigidity
  • Uterine contractions, often coming one right after another
  • Blood stained amniotic fluid (if membranes are ruptured)

9. Cervical Insufficiency

Also referred to as an incompetent cervix, this means that your cervix is unable to retain a pregnancy by opening up too early even in the absence of pain and uterine contractions. While the reason behind it is not well-understood, it is believed to involve a combination of structural abnormalities and biochemical factors (e.g. infection, inflammation) which are either acquired or genetic.

The tricky part about cervical insufficiency is that it can only be identified until a woman delivers a baby too early. This can be confirmed through a transvaginal ultrasound. 

To keep the cervix from opening, doctors place stitches around or through the cervix which is called a cervical cerclage. It is done during the 12-14 th week if the risk of cervical insufficiency is high eg previous history of incompetence, previous cervical surgery or early delivery less than 32 weeks and a shortened cervical length is detected on ultrasound. It can also be done during the second trimester if the cervix is shortening on ultrasound surveillance or as a ‘rescue’ attempt if the patient presents with a dilated cervix before 24 weeks. 

Check your symptoms!

  • Mild abdominal cramps
  • A sensation of pelvic pressure
  • A change in vaginal discharge (volume, color, consistency)
  • Light vaginal bleeding
  • Braxton-Hicks-like contractions

10. Placenta Previa

This is an obstetric complication where the placenta lies low in the uterus and partially or completely covers the cervix. The placenta may separate from the uterine wall as the cervix begins to open up during labor. This classically presents as painless vaginal bleeding in the third trimester. 

Like most of the complications in this list, the cause behind placenta previa is unknown. However, the risk is higher in women over the age of 35, in those who have a history of uterine surgery, women pregnant with multiples, or those who had more than four pregnancies.

Without proper intervention, placenta previa can lead to:

  • Major bleeding on the maternal end
  • Shock from blood loss
  • Fetal distress due to lack of oxygen
  • Blood loss for the baby
  • Health risks to the baby, if born prematurely
  • Premature labour or delivery
  • Emergency caesarean delivery
  • Hysterectomy, (removal of the womb) if the placenta fails to separate from the uterus (placenta accreta)
  • Death

A diagnosis of placenta previa can dampen the anticipation of a healthy delivery. You can expect bed rest and activity restrictions. Medication, intravenous fluids, and blood transfusions may also be needed depending on the severity of your condition. While this can make the journey challenging, there is hope in knowing that some women go on to deliver healthy babies. 

Check your symptoms!

  • Light to severe bleeding after the 20th week of pregnancy
  • Painless vaginal bleeding during the third trimester
  • Premature contractions

11. Molar Pregnancy

This type of pregnancy is also known as a hydatidiform mole. Receiving this diagnosis can be distressing and it crushes expectations when you learn that the growing baby is actually just a fluid-filled mass of cells. These cells are called trophoblasts which is why a molar pregnancy is also called trophoblastic disease

Developing a molar pregnancy is a chance event. But the possibility of mole formation is higher in older women and in those who had a previous molar pregnancy. While there are usually no signs of a molar pregnancy, it can be spotted during a routine ultrasound scan at 8-14 weeks, or through tests carried out after a miscarriage.

This type of pregnancy can be treated with a simple procedure to remove the growth of cells from the womb. In cases where some get left behind, further treatment will be needed to remove it. 

Check your symptoms!

  • Dark brown to bright red spotting or bleeding
  • Severe nausea and vomiting
  • Early preeclampsia
  • Pelvic pressure or pain
  • Rapid uterine growth
  • Vaginal passage of grape-like cysts

Read: The Empty Belly: Truth Behind Molar Pregnancies

12. Infections

Infections cover a wide scope, and you are more vulnerable to certain infections when you’re pregnant and it may even complicate your pregnancy if left untreated.

Intrauterine infections occur when the environment where the baby develops  (womb and amniotic fluid) become infected. The usual suspects are the natural bacteria that many women carry on the skin or vagina, which are normally harmless, but have migrated to other parts of the body where they shouldn’t be. The vagina and cervix have been tagged as common sites of infection, but it can also find its way to the placenta via the fallopian tubes or through an invasive procedure such as an amniocentesis

Infections can be treated without leaving complications at its wake, but in some cases, it can also lead to preterm labor, birth defects, or a miscarriage. It poses serious risks to a point where it can be life-threatening to you and your baby. Therefore, no matter how small, these must be taken seriously. 

Some infections pose problems mainly for moms, such as vaginitis, urinary tract infections, or postpartum infection. Meanwhile, some are troublesome for your little bun in the oven, such as toxoplasmosis, cytomegalovirus, and parvovirus. 

To ensure that you avoid the potential dangers of an infection, make sure to reach out to your doctor whenever you feel ill. As preventive measures, you may also get the necessary immunisations which will be advised to you during your prenatal check-ups. 

Read: 5 Common Maternal Infections During Pregnancy

13. SGA Babies

Small for gestational age (SGA) is used to describe babies who are smaller than the usual number  of weeks of pregnancy. Their weight lies below the 10th percentile, which means they are smaller than other babies for their age. 

Some babies are small simply because of genetics, or their parents are small. However, most SGA babies are the way they are due to fetal growth problems that occur during pregnancy. If ultrasound shows poor fetal growth while in the womb, the baby may also be described to have “IUGR” or intrauterine growth restriction. This condition means that the baby is small because it’s not growing at a normal rate inside the womb. It occurs when the fetus isn’t getting enough oxygen and the key nutrients for proper growth and development. 

Infants who are small for gestational age are at an increased risk for morbidity and mortality. It is a concern because not only does this involve their size, but their overall body and organ growth. It also follows that their tissues and organ cells may also be compromised.

Except for those factors that are uncontrollable, expectant moms can minimise the chance of having SGA babies by making lifestyle changes. For instance, you should avoid recreational drugs and smoking especially once you are aware that you are pregnant. It also helps that antenatal care is started early on in pregnancy. Improved management for those who fall under high-risk pregnancies can also prevent IUGR. 

We all want a healthy pregnancy, but we can’t brush potential dangers aside. By knowing what may complicate a pregnancy is a step in the right direction. So, when you plan to start a family, or if  you have a little one on the way, you must learn to take the good with the bad. Enjoy the exciting milestones for the next nine months, while keeping an eye out for red flags. 

You may have some questions brewing after reading this. If you wish to discuss them more in detail, you may schedule a consultation with Dr Pamela Tan today. Work on a healthy pregnancy with the right help. 

A Mother’s Guide to Miscarriage and Moving On

Miscarriages are relatively common in Singapore, with about 20% of pregnancies ending this way. This can be cold comfort when you are still coming to terms with a recent loss. But, one can gather strength from the knowledge of what just happened. Having that can help you grasp the situation, understand the underlying reasons with objectiveness, and move forward. 

We cannot tell you how to grieve over the loss, but we can help you make sense of it. We have gathered easily digestible information to understand the physical aspect behind pregnancy loss. Besides being of help to women who dealt with miscarriage, this information can also benefit those who are still planning to start a family.

What is a miscarriage? 

Miscarriage, also known as spontaneous abortion, refers to pregnancy loss before the 24th week of gestation. If a pregnancy ends after, it’s no longer called a miscarriage even though it’s a pregnancy loss but termed a stillbirth.

The American College of Obstetricians and Gynecologists (ACOG) estimates that about 15-20% of clinically recognised pregnancies end up in miscarriages. Some women may even miscarry even before they are aware that they’re pregnant, or before it was confirmed by their doctor. Compared to that in the first trimester, the risk decreases in the second trimester. That is why it’s a common practice for couples to make their baby announcement after the first three months. 

Types of Miscarriage - Infographic

Why do some women have a tendency to miscarry? 

There are indeed women who are more likely to miscarry than others. Sometimes, they may even blame themselves, but miscarriages usually happen for reasons that are beyond one’s control.

Causes like chromosomal abnormalities, abnormal placenta development, a weakened cervix, an abnormally shaped womb, and umbilical cord issues are causes that can be difficult to control, especially without professional help. A glitch in genetics accounts for more than 50% of miscarriages in the first trimester. Meanwhile, anatomical anomalies in the reproductive system also heighten the risk of recurrent miscarriages. Furthermore, complications involving the placental development or the umbilical cord can also compromise a pregnancy because it affects proper blood circulation between the mother and her baby. 

Fortunately, some of these potential causes are controllable, such as a poor diet  (e.g. high levels of caffeine and alcohol intake), medications, stress, and underlying health conditions (e.g. obesity, high blood pressure, severe uncontrolled diabetes, kidney disease, HIV, Malaria, Gonorrhea, Syphilis). Infections like german measles, listeriosis or chickenpox can also complicate and even terminate a pregnancy, especially if you contract it in the first trimester. 

All these causes strengthen the importance of getting preconception screening and regular prenatal check-ups

What are the factors that put me at risk of having a miscarriage?

Several risk factors can lead to miscarriage. If you’re planning to get pregnant or trying to make sense of a past miscarriage, you will benefit in knowing the contributing circumstances.

Here are the following risk factors that may lead to pregnancy loss:


Based on data by the World Health Organization (WHO), Singapore ranked second in overweight prevalence in the Association of Southeast Asian Nations (ASEAN) at 32.8 per cent in 2014. A study conducted by Singapore’s Health Promotion Board (HPB) also revealed that Singaporeans are 3 kilograms heavier than they were 15 years ago. 

Source: Food Industry Asia

Research also revealed that obesity is associated with increased risk of the first trimester and recurrent miscarriage. This lifestyle disease can also compound any risk factors that are associated with pregnancy loss. For instance, linked to high blood pressure, and it can also make diabetes difficult to manage.


On the other end of the scale, women who are underweight before they get pregnant have a higher chance to miscarry in the first trimester. 

Older maternal age

In terms of age, conceiving quite late may be successful for some, but it doesn’t mean that it comes without any risks. Women under 35 have a 20 per cent or less risk of miscarrying, while those over 40 have more than a 40 per cent chance. 

Previous history of miscarriage

A previous miscarriage can also increase your risk by up to 20 per cent. After two consecutive pregnancy losses, the risk increases by up to about 28 per cent, and 43 percent for three or more consecutive miscarriages.

Illicit drug use

Anything that is established to be harmful in regular individuals can have severe consequences to vulnerable populations like pregnant women and her unborn child. Illegal substances can cause miscarriage and preterm birth.

Alcohol intake

You don’t have to abuse alcohol to introduce risks to your pregnancy or the baby. One study showed that any amount increases the odds of a miscarriage by 19 per cent. In particular, binge drinking also comes with severe risks to the baby like fetal alcohol syndrome.


Cigarette smoke is also another habit that can put significant harm to your pregnancy. Research found that women who smoked heavily while pregnant (at least 20 sticks a day) have beyond twice as much risk as non-smokers to have a miscarriage. E-cigarettes are no safer option either because on top of nicotine it also contains a mix of other aerosolised chemicals.


Skipping coffee may not be an easy compromise, especially if your day jumpstarts with it. A 2016 study by the National Institutes of Health examined 344 pregnancies and found that the rate of miscarriage was higher if either one or both partners drank two or more caffeinated beverages a day in the weeks leading up to conception. The general advice is to keep to one cup of coffee a day in pregnancy. 

Exposure to workplace hazards 

Long work hours, psychosocial stress, physical efforts, and environmental exposure (e.g. chemicals or radiation) are just some of the dangers that a pregnant woman can potentially encounter in the workplace. Fortunately, these are preventable factors. Expectant moms should be mindful of what she is exposed to because while some are harmful at high doses, other factors can already do damage at low doses. 

What are the symptoms of a miscarriage? 

As mentioned earlier, some miscarriages go unnoticed, but for those that do, some women may experience the following symptoms:

What are the diagnostic tests used to check if you had a miscarriage?

Besides red flags that signal a miscarriage, some measures can confirm if there was indeed a miscarriage. Diagnosis is essential because any treatment done before a confirmed diagnosis can have harmful consequences such as interruption of a pregnancy, pregnancy complications, and birth defects

Diagnosing early pregnancy loss is relatively straightforward, requiring limited testing or imaging. For other cases, the doctor may use a combination of these diagnostic exams to confirm a suspected miscarriage, and these procedures include:

1. Transvaginal ultrasound

If you’ve had an ultrasound during the early stages of pregnancy, you may be familiar with a transvaginal ultrasound since it’s the usual device used to assess the baby before you reach 8 weeks of pregnancy. It’s a wand-like probe inserted into the vagina, to check a suspected miscarriage. It can also help reveal any abnormalities in the structure of your womb, which may have led to pregnancy loss. It may not be as comfortable as a trans-abdominal scan, but a transvaginal ultrasound provides an accurate image and details problematic areas. 

2. Blood Test

A blood test can also be ordered by your doctor to check the levels of pregnancy hormones in the blood and compare it previous measurements. Abnormal levels may indicate a problem, especially if a decrease in other pregnancy symptoms accompanies it. However, a conclusive diagnosis of pregnancy loss may require an ultrasound to check your baby’s heartbeat, followed by a confirmatory process involving scans conducted on multiple days.

3. Pelvic exam

A pelvic exam, on the other hand, can check if your cervix is thinning or opening, since this is a strong indication that you could be miscarrying. If you experienced spotting or light vaginal bleeding, but the cervix has not opened, this may suggest a threatened miscarriage, which is a relatively common condition. However, it means that the pregnancy is still viable. 

Furthermore, an ectopic pregnancy, a condition where the fertilised egg implants outside the uterus, may be suggested on a pelvic exam usually manifested in unilateral lower abdominal pain. Sadly, this pregnancy is nonviable, and it may turn into a medical emergency if left untreated. 

4. Fetal heart rate monitors

These fetal heart rate monitors, also called fetal dopplers, are handheld ultrasound devices which solely detect the sound of your baby’s heart through your belly. This device is routinely used during prenatal visits although occasionally some women purchase one for use at home. 

In the early stage of pregnancy, the lack of a heartbeat doesn’t mean that you had a miscarriage. A baby’s heartbeat doesn’t develop until 6th week in the womb, and it becomes audible using fetal heart rate monitors somewhere between the tenth and twelfth week of pregnancy. However, the exact time may vary based on the position of your uterus, the position of the placenta, and other factors. 

A lack of heartbeat after 12 weeks of pregnancy is a strong indication of pregnancy loss. Your doctor may conduct a full ultrasound scan to check for any heartbeat. 

What can I do to reduce my risk of a miscarriage?

Almost 80-90% of miscarriages happen in the first trimester (before week 14). After that, your chance of miscarrying drops. While most cases of pregnancy loss can’t be prevented, some precautions can help increase your chances of a healthy pregnancy. But, here’s how to lower your risk:

Watch what you eat

To avoid a recurrent miscarriage, it’s also essential that you watch what you eat. Ensure a well-balanced diet that is rich in folic and calcium. You can also supplement this with prenatal vitamins which you must take daily to ensure that your baby gets the key nutrients for development. On the other hand, there are also food options that pregnant women must avoid because they pose serious risks to a pregnancy, such as raw meat, unpasteurised dairy or fishes with elevated concentrations of mercury.

Run ALL your medications by your doctor

On top of choosing your meals carefully, you must also be mindful of the medications you take. We are aware that as much as clinical drugs are therapeutic, they also come with side effects or adverse reactions that may be harmful to pregnant women and unborn babies.

Check with your doctor first before taking any medications, including over-the-counter drugs. For instance, what may seem as a regular headache medication can already pose serious risks to a pregnancy which could lead to complications or pregnancy loss.

Maintain a healthy weight before pregnancy

Controlling your intake not only provides you with essential nutritional requirements, but it’s consequential to your weight. The ACOG currently recommends that doctors offer nutritional counselling to obese women who plan to start a family, so you can always approach your doctor for weight management. Professional guidance is helpful when you struggle to shed the extra pounds when trying for a baby, and it’s also beneficial during pregnancy to check whether you’re putting in too much or too little.

Source: Health Hub

Limit caffeine intake

With most of us dependent on coffee to start our day, pregnancy doesn’t have to push you to go cold turkey on caffeine. Current guidelines from the ACOG and other experts say that it’s safe for pregnant women to consume up to 200 milligrams of caffeine a day, or around one 12-ounce cup of coffee daily.

Ditch bad habits

Alcohol, recreational drugs, and cigarettes all bear adverse effects that can compromise a pregnancy. Remember that you pass much of what you eat, drink, and breathe into your baby. Besides the risk of pregnancy loss, the substances involved also pose certain risks to your baby’s development in the womb.

Attend all scheduled prenatal appointments

Prenatal care is an essential part of staying safe and healthy during pregnancy, and you must start it as early as possible. Doing so can help prevent problems for you and the baby. These visits are scheduled regularly for a reason, and you must come in for each one of them for the doctor to:

✔ track the progress of your pregnancy

✔ detect any problems along the way

✔ check your health and that of your baby’s

✔ clarify any concerns you might have about the pregnancy

✔ provide immunisation against infectious diseases

Beside prenatal appointments, pre-pregnancy care is just as important because it involves preconception health screening which can help detect any risk factor that may predispose you to have a miscarriage. 

Lighter regular exercise 

Physical activity doesn’t necessarily increase the risk of miscarriage, but it’s also an important point to discuss with your obstetrician during your prenatal appointments. If your doctor gives you the green light, you can consider which activities you can do safely. 

Benefits of Exercise During Pregnancy - Dr Pamela Tan

However, there are certain conditions or complications where this type of physical exertion may prove to be risky. These include the following: 

  • Certain types of heart and lung diseases  
  • Cervical insufficiency (the inability of the uterine cervix to retain a pregnancy in the second trimester) 
  • Being pregnant with twins or triplets (or more) with risk factors for preterm labour 
  • Placenta previa after 26 weeks of pregnancy (a problem where the placenta grows in the lowest part of the womb and covers all or a portion of the opening to the birth canal)
  • Preterm labour or ruptured membranes (your water has broken) 
  • Preeclampsia or pregnancy-induced high blood pressure 
  • Severe anaemia

Avoid environmental hazards

Besides what you introduce to your body, you must also be mindful of the hazards you are exposed to everyday, because a lot of these risks may just be right under your nose. For instance, cleaning products, cellphone radiation, and cosmetics may have compounding toxicity when used daily. Mom Junction provides easy tips on how to protect yourself, here.

What are the accepted management options for early miscarriage? 

Preferred treatment options for early pregnancy loss include expectant management, medical treatment, and surgical evacuation. The interventions may vary based on the unique presenting factors in a miscarriage. To know which among these is suitable for you means discussing it extensively with your OB.

Expectant Management

This approach involves watchful waiting for the miscarriage to happen by itself naturally without any treatment. With adequate time (up to 8 weeks), expectant management has been successful in achieving complete expulsion of pregnancy tissues in approximately 80% of women. Women with incomplete miscarriages ( already bleeding and passed out some pregnancy tissue) have a higher rate of complete expulsion then those with missed miscarriages or blighted ovums.

What to expect:

  • It may sometimes take a few weeks for the body to respond to a missed miscarriage. During a miscarriage, you may experience moderate to heavy bleeding and cramping. In general, the larger the gestation, the heavier or more painful symptoms are felt. Pain or bleeding should lessen or stop completely within 7-21 days.
  • You will be instructed on what to expect during this time and how to respond to it (e.g. tracking the severity of bleeding by counting soaked pads and reporting it to your OB).
  • You will learn when and who to call in case of excessive bleeding.
  • Prescription medications will be provided.
  • There may be a chance that miscarriage is incomplete, which means that there is a possibility that surgery might be needed.

Medical Management

This approach is suitable for women who have not encountered infection, haemorrhage, severe anaemia, or bleeding disorders and who want to shorten the time until complete expulsion but wish to avoid surgery. It increases the likelihood of complete expulsion compared to expectant management.  

What to expect: 

  • Medications will be prescribed to trigger expulsion of the pregnancy tissues. The most common side effects of the medicines are nausea, vomiting and diarrhea. 
  • You will be provided with pain medications.
  • Similar to expectant management, you may experience moderate to heavy bleeding and cramping during the miscarriage. Pain or bleeding should lessen or stop completely within 7-21 days.
  • Follow-up visits to document if there is a complete passage of tissue within 7-14 days using ultrasound.
  • If this approach fails, the treatment may shift to expectant management for a time agreed by you and your OB-GYN, repeated medication or consider surgery via a suction curettage.

Surgical Management

Surgical uterine evacuation has been the traditional approach for women who experience early pregnancy loss and retained tissue especially in women who need urgent care due to haemorrhage or signs of infection. It is also advised for those with medical conditions like cardiovascular disease, bleeding disorders, or severe anaemia. Many women opt for this type of treatment because it provides immediate completion of the process with fewer follow-up visits. Suction aspiration of the pregnancy tissue is performed under sedation as a day surgery procedure. 

Studies have demonstrated that either method used ,expectant, medical or surgical management of early pregnancy loss, all result in complete evacuation in most patients with rare serious complications. As a primary approach, surgical evacuation results in faster and more predictable complete evacuation. Intrauterine adhesions (scar tissue formation within the uterus) is a rare complication of surgical evacuation. Hemorrhage and infection can occur in all treatment approaches but rates are generally low. 

Support group in Singapore after pregnancy loss

So you had a miscarriage, and your reproductive system is in the clear. However, moving on after pregnancy loss can be a long and difficult process – but it’s not without help. There are support groups and helplines available in Singapore to help you cope. You can check out any of these: 

If you want to get help to minimize chances of a miscarriage, improve your chances of having a healthy pregnancy, or plan your next one, it helps to have professional help close by. You may talk to Dr Pamela Tan to help you through this process. 

Managing Menopause: A Quick Guide on What To Expect When You’re Expecting

How much do you know about menopause or its symptoms? This is a question women should concern themselves with because it’s a stage they’re bound to enter sooner or later. It’s a reality that must be lived, even though it’s not always wrapped in a bow.

As some women have shared, the road to menopause can be a struggle. But, you can choose not to turn it into a dreadful experience. The changes that your body is expected to go through is manageable, but to gain the upper hand, the key is to understand these transformations and how it can be dealt with.


The process that leads to menopause doesn’t happen overnight, rather it involves gradual changes. So, before you reach that stage, your body goes through a transitional phase called the perimenopausal period.

This prelude takes an average of three years and even stretches up to a decade in some women. It may kick in your late 30s and 40s as a result of declining ovarian function causing your estrogen levels to fluctuate. 

This hormonal see-saw can last for years and may result in a more symptomatic period for women. During this time you may start to notice irregularities in your menstrual cycle, but it can also cause other symptoms such as: 

A guide to Perimenopausal Symptoms - Dr Pamela Tan

Now you’re thinking, “Hey, this sounds like menopause!” 

This is usually where the misconception is. 

Most people think that these unpleasant symptoms are that of menopause, when in fact, these are hallmarks of perimenopause. However, these can also be referred to as symptoms of menopause because they indicate what is coming imminently. 

Perimenopause is the period where the “real action” happens. Unfortunately, there’s no way to predict in advance for how long the perimenopausal stage would last. This experience can vary for each woman, with some not even displaying any symptoms of being perimenopausal at all. However, one can get an idea as to when they might get into menopause based on their family history.

When exactly is Menopause?

Officially reaching menopause means that it has been a full year that you have not menstruated. To put it simply, it’s just that one day to mark the anniversary of your last period. 

In Western societies, the average age of menopause is 51, but in Singapore, it’s 49. However, menopause has a wide starting range, but it is usually expected within the ages of 42-58 – sometimes earlier.

If there’s no test to determine for how long perimenopause will run its course, for menopause, you can get a ballpark figure on when it may happen based on how old your mother and grandmother reached theirs. 

Reproductively, this is a major milestone because it marks the end of your fertility. Although for most women, the journey leading to it is riddled with discomfort, menopause is not a health problem, rather a natural phase in your life

Premature Menopause

When your menses have officially ceased for 12 consecutive months, but this happens before you reach 40, this is known as premature menopause or premature ovarian insufficiency

This can run in families, but there are external influences that affect your ovaries such as, medical treatments (e.g. chemotherapy, radiotherapy, ovarian surgery, hysterectomy) and lifestyle choices (e.g. smoking).

It can be hard for women to come to terms with a diagnosis of premature menopause, especially if they still desire to have a baby in the future. Besides infertility, this condition also increases a woman’s risk for osteoporosis, cardiovascular disease, and diabetes

So, if your period becomes infrequent, or has stopped before you reach 40, you must schedule a visit to your OB-GYN. You may be offered blood tests to measure hormone levels that will help diagnose premature menopause. 

Managing Menopause Symptoms

Fortunately, it’s not like you don’t have a choice over those uncomfortable symptoms. There are various treatments such as lifestyle changes, non-prescribed therapies, and prescribed interventions to help allay some effects.

1. Lifestyle changes

Lifestyle Changes - Dr Pamela Tan

You can minimise the blow of these symptoms with some lifestyle tweaks. For instance, eating a healthy diet should be established or improved to accommodate your metabolism which is now running at a snail’s pace. Together with regular exercise, this can help you maintain a healthy weight and improve sleep. You may also have to cut back on caffeine and alcohol to reduce night sweats and hot flashes. 

2. Non-Prescribed Therapies

Non Prescribe Therapy - Dr Pamela Tan

Herbal Medicines

Mother nature’s treatments can also help you manage your symptoms. Black cohosh and evening primrose oil have received quite a bit of scientific attention when research revealed that it can reduce the severity and frequency of hot flashes. You might have even heard of other popular names thrown out there such as Dong Quai, Red Clover, Ginseng, or Kava – and some women swear by them. However, you must take this with a grain of salt because herbal remedies have no established safety standards. It may also run the risk of interacting with any prescribed medications. Therefore, consult your doctor first before you consider this type of treatment. 

Alternative Therapy

Acupressure, acupuncture, and aromatherapy massage are some non-traditional treatments that can also be effective for some women. These have been tagged to improve symptoms like hot flashes, night sweats, and even anxiety. Again, this should be considered with advice from your doctor. 

Complementary Therapy 

Hypnosis, biofeedback and relaxation training are therapies that can be done alongside prescribed interventions to boost their results. 

Bioidentical Hormones

These are man-made hormones that are designed to be molecular copies of our natural hormones. However, concerns have been raised especially among custom-blended hormones for menopause because they tend to have unpredictable ingredient mixtures. This can pose reproductive risks which outweigh the relief of early menopause symptoms. 

3. Prescribed Interventions

Prescribed Interventions - Dr Pamela Tan

Hormonal Replacement Therapy (HRT)

HRT is a commonly prescribed treatment to relieve menopausal symptoms. It means being treated with the female hormones, estrogen and progestin since numbers decline as you approach menopause. 

HRTs offer the following benefits:

  • It can relieve hot flashes
  • Improve mood associated with menopause
  • It can improve sexual desire
  • Reduces vaginal dryness
  • Helps keep the bones strong, preventing osteoporosis

To know the different HRTs available for you, please check out the video below. 

However, this treatment is not for everyone, especially if you are pregnant, diagnosed with certain cancers, experiencing vaginal bleeding, have blood clots, have had a heart attack or stroke, or suffering from liver disease. 

Non-Hormonal Medications 

Medications can be prescribed to treat symptoms such as hot flashes. Some drugs can also be given to manage anxiety or depressive symptoms. 

Psychological Treatments

Cognitive Behavioral Therapy (CBT) is a form of psychotherapy that helps patients to modify dysfunctional thoughts, emotions, and behaviours. It can help with mood changes caused by hormonal fluctuations, and it may also help relieve associated symptoms like anxiety, depression, and even insomnia.


Stages of Menopause- Dr Pamela Tan

The post-menopause period starts the day after menopause – or pretty much the rest of your life. The transformation your reproductive system went through over the years can also have an effect during the post-menopausal period. For this, you must learn to adapt health-seeking behaviours that can help reduce the effects of menopause as you go into the next phase.

For the next couple of years, your body is exposed to the following changes and health risks: 

1. Bone changes

After the age of 35, it’s normal for men and women to experience a small amount of bone loss. But after menopause, you lose it at a rapid rate due to decreased estrogen levels. With excess bone loss, you increase your risk of osteoporosis which makes you vulnerable to fractures, particularly around the hips, spine, or wrist.

To keep bones strong in midlife, make sure that your fitness routine includes weight-bearing exercises. Do it regularly to slow down bone loss. Additionally, your diet must include foods high in calcium (dark leafy greens, dairy, and canned fish) and vitamin D (milk, orange juice, supplements, or 15 minutes of Singapore sunshine). You must also cut off any habit that compromises bone health, such as smoking. 

You may not notice your bones weakening just yet since it takes years before it shows any symptoms. A fracture is the first sign of the disease, which is why women above 65 are advised to get a bone mineral density test. 

2. Urinary incontinence

Almost half of post-menopausal women complain of urinary incontinence. Your low estrogen levels weaken the urethra, making you unable to control urine flow. You may have noticed this when you laugh, sneeze, cough, which is a common type called stress incontinence. To prevent this, you may empty your bladder as often as possible, control your weight, stay fit, or you can start doing regular Kegel’s exercise to strengthen your pelvic floor muscles. 

3. Sexual side effects

It is normal for changes to your sex life after menopause. Some say that they enjoy it more since they no longer have to worry about getting pregnant. However, others may no longer enjoy it as much. 

Decreased hormone levels can put a damper on your sex drive. It can even make sex less pleasurable as vaginal tissues become thinner and drier. A lot of women suffer in silence when they don’t need to because there are available treatments. If this is troubling you, don’t hesitate to seek professional advice from your gynaecologist. 

4. Heart attacks

The menopausal transition also breeds cardiovascular risk factors. This is even considered the biggest danger during the post-menopausal stage as rates of heart attacks spike roughly a decade in. 

Estrogen helps keep blood vessels flexible so they can easily contract and expand to accommodate blood flow. But, once it diminishes, this ability is lost giving way to problems like high blood pressure. This can thicken the walls of your artery which compromises blood flow making you vulnerable to heart attacks.

To protect yourself, you need to commit to a healthy lifestyle. There must be discipline in following diet modifications and regular exercise. If you have prescribed maintenance medications for high blood pressure, or any lifestyle disease, do take them regularly. 

5. Stroke

Premenopausal women are protected by the risk of cerebrovascular diseases such as stroke. As mentioned earlier, estrogen provides beneficial effects to blood vessels as it gives them more flexibility to expand to promote blood flow. However, for every decade after 55, the risk of stroke roughly doubles in women. The risk is further heightened in women with premature menopause. The low estrogen levels at this point triggers cholesterol build-up on artery walls including those that are in your brain. It results in this “brain attack” which is either caused by a blockage (ischaemic stroke) or rupture (Haemorrhagic stroke).

To prevent stroke, Singapore’s Health Promotion Board suggests the following: 

  • Eat healthily and in moderation
  • Keep blood pressure, cholesterol, and glucose under control
  • Exercise and maintain a healthy weight
  • Go for regular health screening and follow up
  • Avoid smoking

6. Gynaecological cancers

Cancers affecting your reproductive health are present even before menopause. However, you must still check for any warning signs such as bleeding after menopause. The risk increases as you age and in women who are undergoing hormone therapy to treat menopausal symptoms.

To maintain good gynaecological health during this reproductive milestone, you must seek regular cancer screening. You can read more about cancer screening in Singapore in our blog, here. If you have any bleeding after your menopause, you must seek attention immediately to rule out cancers of the womb and cervix. 

Some may look at menopause with a tinge of dread due to some horror stories shared by women who have gone through it or as played out in movies. While there’s truth to it, your journey doesn’t have to be that way. Now that you’re aware of what you could be going through in the coming years, you can prepare for it. With the right help, you can float your way through perimenopause with the least amount of issues, and even forge towards the post-menopausal period in good health.

We’re we able to tackle your concerns about menopause? For your questions and other concerns, you may book a consultation with Dr Pamela Tan today.