We reached out to doctors at the KK Women’s and Children’s Hospital (KKH) to better understand complications and health concerns about stillbirth, miscarriages, GDM, and preeclampsia.
Here’s an excerpt from our email interview.
Stillbirth, Miscarriages, Gestational Diabetes Mellitus (GDM), And Preeclampsia Complications: All You Need To Know
1. Does one stillbirth increase the risk of future stillbirths?
The vast majority of couples experience healthy pregnancies after stillbirth, although parents with genetic defects or maternal diseases (e.g. diabetes or hypertension) may be at increased risk for subsequent stillbirths.
While the overall risk for having a stillborn is low for most couples, the risk is a bit higher for couples who have already had one such experience. If the previous stillbirth was due to genetic defects, couples who have had a stillbirth should consider undergoing genetic counselling before trying to conceive another child.
A genetic counsellor can advise couples about the risks of recurrent stillbirth and complications associated with a second conception and pregnancy. There may be some steps that can be taken to reduce a woman’s risk during subsequent pregnancies. If the stillbirth was due to a maternal illness such as diabetes or high blood pressure, for instance, steps can be taken to make sure the condition is well under control before the woman tries to conceive again.
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2. What special precautions should I take to reduce stillbirth risk in the future?
With increased knowledge and better treatment of maternal conditions, the number of stillbirths has decreased. To help decrease risk of experiencing a stillbirth even further, the measures for pregnant women are as follows:
- Go for antenatal care early (in the first trimester)
- Attend all antenatal appointments; It is important to attend regular antenatal appointments throughout your pregnancy. During these appointments, your doctor will check to make sure your baby is developing properly and that your placenta is healthy and of normal size. Regular prenatal appointments can also help to identify any additional health problems early on
- Monitor baby’s movements: After the 26th week of pregnancy, it is recommended that all pregnant women monitor their baby’s movements. Count the number of kicks that your baby makes every day. If your baby is kicking less than 10 times a day, or seems to be abnormally quiet, consult your doctor
- Avoid infection: Many infections responsible for stillbirth are preventable during pregnancy. Avoid handling cat litter during pregnancy, and do not eat raw or improperly cooked foods. Get tested for syphilis, early in pregnancy
- Report pain or bleeding: Monitor for any abnormal bleeding or pains during pregnancy. Report any of these symptoms, no matter how minor, to your doctor
- Avoid smoking and drugs
- Patients with medical conditions should follow doctor’s advice, for example, to have good control of hypertension and diabetes which will reduce risk of stillbirths
- Have a child at an earlier maternal age
3. In the event of an early miscarriage, should I flush it or take it to the hospital?
A miscarriage is the loss of a baby before 20 weeks of pregnancy, and majority of miscarriages occur before 12 weeks of pregnancy. In the event of an early miscarriage (before 12 weeks of pregnancy), please keep the pregnancy tissue or fetus in a container and bring it to the hospital. You will require further checks such as a pelvic examination or an ultrasound. If the womb is completely empty, no surgery will be required.
However if there is some residual fetal or placental tissue in the womb, you may be given antibiotics and a surgical procedure may be performed to evacuate the remaining fetus or tissue from the womb. At the same time, investigations can occur, in an attempt to determine the cause of the miscarriage (although the cause is largely unknown).
4. Is there any possible way to stop miscarriage once cramping starts?
The most common signs and symptoms of a miscarriage include spotting or vaginal bleeding, fluid or tissue passing from the vagina, abdomen pain or cramping, and dull pain in the lower back.
However it is important to note that these signs and symptoms on their own does not necessarily mean that a miscarriage is taking place. Hence it is important to seek medical attention soonest possible for further investigations and assessments to take place.
Preeclampsia: All Your Questions Answered
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5. What is Preeclampsia? What are the risks associated with it?
Preeclampsia or high blood pressure in pregnancy, is a common medical problem in pregnancy. Severe preeclampsia can cause damage to many organs in the pregnant woman and lead to poor baby growth and stillbirth. If not properly managed, it can lead to eclampsia – a condition where the brain of the mother is severely affected and seizures (fits) occur. It causes serious health complications to the mother, threatening the mother’s life.
Reduced blood flow to the placenta in preeclampsia leads to reduced supply of oxygen and nutrients to the fetus and therefore problems such as low birth weight and poor growth may arise. There may also be a need to deliver the baby early to protect the mother’s health, and the baby may suffer from the effects of prematurity. There is also the condition of placental abruption where the placenta prematurely separates from the uterus, and this can also deprive the baby of oxygen and cause heavy bleeding in the mother.
Eclampsia (or seizures) may be preceded by symptoms such as severe or persistent headaches, vision changes, upper abdominal pain or mental confusion. When these happen, anti-seizure medications such as magnesium sulphate will be prescribed. It is only by delivering the baby that the mother can eventually recover from preeclampsia.
In KK Women’s and Children’s Hospital (KKH), the preeclampsia rate is about four per cent. Worldwide, preeclampsia rates ranged three to eight per cent of pregnancies. However, with better management over the years, the rates for complications from preeclampsia, such as eclampsia (convulsions from severe preeclampsia), have dropped significantly. However, there are still cases of stillbirths and various complications from preeclampsia, resulting from patients not seeking antenatal care early or defaulting follow up.
6. How to prevent Preeclampsia?
From our studies in KKH, the risk factors for preeclampsia are women over the age of 35 first or multiple pregnancies, obesity and diabetes. If a pregnant woman has pre-existing high blood pressure or high blood pressure in a previous pregnancy, she will have a higher risk of developing preeclampsia during pregnancy.
Currently there is no way to prevent preeclampsia, as not all risk factors to high blood pressure are controllable or manageable. However, to optimise good health, it is recommended for women to conceive at an early age, adopt a healthy lifestyle, avoid smoking or drinking alcohol, reduce caffeine and sodium intake, control their weight gain, and consume adequate supplementation.
7. How to manage Preeclampsia if it occurs?
In mild cases, anti-hypertensive medication may be prescribed to reduce the blood pressure while follow up on the pregnancy and the baby continues. In severe cases, admission to a hospital is necessary, and medication will be administered intravenously to prevent the mother from developing a seizure or fit.
Pregnant women with this severe condition may have symptoms such as severe headaches, severe nausea and vomiting, right-sided upper abdominal pain or visual disturbances. The definitive treatment of preeclampsia requires the delivery of the baby to prevent the preeclampsia process from worsening and causing serious complications for the mother and baby.
Fortunately, close monitoring and advancements in maternal and neonatal care over the years have helped to manage pregnancies optimally. There are also more accurate biomarkers that can help predict preeclampsia. KKH was involved in the landmark MAGPIE (Magnesium Sulphate for Prophylaxis of Eclampsia) Trial Study in 1998 to 2001, on the use of magnesium sulphate as a treatment for eclampsia, a serious complication of preeclampsia where the mother has life-threatening convulsions.
This international collaborative study radically changed the management of preeclampsia worldwide. As a result of this study, it has become a routine practice globally to institute prophylactic magnesium sulphate for severe preeclampsia to prevent eclampsia.
The Perinatal Team in KKH made innovative efforts to develop perinatal translational research applications to improve perinatal care outcomes, resulting in KKH having among the lowest mortality and eclampsia rates in the world.
We studied and streamlined our process to perinatal and obstetric responses, including consistently having the shortest recorded time between decision to delivery for obstetric emergency caesarean sections, for cases related to severe preeclampsia.
The Integrated Perinatal Care Project at KKH (Singapore, led by PRIMO Team was awarded the World Health Organization – United Arab Emirates (UAE) Health Foundation Prize in 2009 for making an outstanding contribution to health development, while decreasing maternal mortality and eclampsia rates.
Having among the lowest rates in the world, we became a global leader and provided a model for perinatal care to the rest of the world.
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8. What causes Preeclampsia during pregnancy?
Risk factors of preeclampsia include advanced maternal age, obesity, first pregnancies, history of chronic high blood pressure, diabetes, kidney disease, previous history of preeclampsia, or multiple pregnancies.
It has also been shown in KKH studies that possible genetic or dietary factors may predispose Malay women to preeclampsia as well.
9. What are some of the early signs of preeclampsia and how is it diagnosed?
Preeclampsia typically starts after the 20th week of pregnancy. The early signs and symptoms of preeclampsia are high blood pressure and protein in the mother’s urine (proteinuria). In more severe cases, there may be a persistent headache, vision changes, intense pain or tenderness in the upper abdomen, nausea and vomiting.
At times, swelling, especially in the legs and feet, known as oedema may accompany preeclampsia. Oedema on its own is very common even in uncomplicated pregnancies. However, the oedema may be even more significant in cases of preeclampsia. This occurs when changes in your blood vessels cause your capillaries to “leak” fluid into your tissues.
Sometimes, preeclampsia may develop without any symptoms; or can occur slowly; or very quickly. Hence, monitoring the blood pressure regularly is key in early detection because the most common sign of preeclampsia is high blood pressure exceeding 140/90. Some other possible symptoms of preeclampsia may include severe headaches, nausea or vomiting, right sided upper abdominal pain or visual disturbances.
Preeclampsia is diagnosed when a woman’s blood pressure is above 140/90 and protein is found in her urine. The patient can also has low platelet count, impaired liver function, signs of kidney problems, fluid in lungs and new onset of headaches or visual disturbances.
Gestational Diabetes: All Your Questions Answered
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10. What is gestational diabetes? What are the tips for managing it?
Gestational diabetes mellitus (GDM) is diabetes during pregnancy. Poorly controlled or untreated GDM can put the mother and her baby at risk and at increased complications
Women should understand the importance of prenatal health and nutrition, and should adopt a healthy lifestyle and habits even before pregnancy. Women who are diagnosed with GDM should be educated on the need for regular antenatal follow-up. This is to control the blood sugar levels well and to avoid the complications of high blood sugar in pregnancy which includes an abnormal large baby at delivery. If GDM is detected early and managed timely and appropriately, the mother and child will usually have a good outcome.
Although GDM resolves in most women after their pregnancy, these women still have up to 70 per cent risk of developing Type 2 diabetes in their lifetime following delivery. Type 2 diabetes, if not detected early or not well-controlled, can be associated with permanent complications to the kidneys, eyes and blood vessels.
There is evidence that certain lifestyle changes to diet and exercise can help delay or even prevent the development of Type 2 diabetes after GDM. Follow-up after delivery is therefore important for detecting persisting or the onset of Type 2 diabetes, in order to achieve prompt and optimal control and treatment of the condition.
Women who are diagnosed with GDM should be educated on the need for regular follow-up with their family doctor through which better health outcomes can be made possible.
This would include regular screening and managing their risk factors for diabetes with medical advice from their family doctors. This would apply to all women with GDM, even if the first test post delivery is initially normal, and regardless of the woman’s age.
11. What causes gestational diabetes mellitus during pregnancy?
Diabetes can happen in pregnancy when the body does not produce adequate amounts of the hormone insulin to deal with sugar control during pregnancy. As a result, the sugar levels in the pregnant woman may rise. In most cases, GDM disappears after delivery.
In others, the condition may persist and long term follow-up and treatment of the diabetes is required. A repeat oral glucose test (OGTT) for diabetes will be performed six weeks after delivery.
The reason why some pregnant women develop GDM and others do not is not very clear.
A woman’s risk for developing GDM increases if she:
- Is over the age of 35 when she became pregnant
- Is overweight before she became pregnant
- Has pre-diabetes before she became pregnant
- Has a family history of diabetes
- Has high blood pressure
- Had a previous pregnancy which led to an unexplained miscarriage or stillbirth; or the birth of a baby who weighed over four kilos
12. What are the signs of gestational diabetes?
Typically, pregnant women with GDM display no symptoms. Their raised blood sugar levels are likely to be discovered during a routine antenatal check-up. However, some pregnant women may experience increased thirst, urination, appetite, and fatigue. That is why it is important for women to undergo routine GDM screening.
13. What are the risks of gestational diabetes for me and the baby?
Risks of gestational diabetes for the baby:
- Excessive weight at birth > four kilos (macrosomia)
- Fetal abnormalities
- Sudden fetal death
- Fetal respiratory distress syndrome
- Low blood sugar or hypoglycaemia after birth
- Jaundice after birth
- Type 2 diabetes later in life
Risks of gestational diabetes for the mother:
- High blood pressure/preeclampsia and eclampsia during pregnancy
- Urinary tract infection
- Premature delivery
- Caesarean delivery
- Gestational diabetes in future pregnancy
- Type 2 diabetes in future
14. Which exercises should I do if I have gestational diabetes?
As mentioned above, the key to managing GDM is through diet and exercise. Hence, leading a physically-active lifestyle prior, during and after pregnancy have many benefits for the mother and baby, and can regulate the pregnant woman’s blood sugar levels.
Singapore’s first set of guidelines on physical activity and exercise in pregnancy, led by KKH, was launched in January 2020. The set of guidelines aims at standardising advice on exercise and physical activity for pregnant women to improve their health outcomes and that of their child.
For more details on the guidelines for pregnant women, please refer to the media release here.
15. Will I develop gestational diabetes if I’m overweight?
A woman’s risk for developing GDM increases if she:
- Is over the age of 35 when she became pregnant
- Is overweight before she became pregnant
- Has pre-diabetes before she became pregnant
- Has a family history of diabetes
- Has high blood pressure
- Had a previous pregnancy which led to an unexplained miscarriage or stillbirth; or the birth of a baby who weighed over four kilos
However it is important to note that even a pregnant woman without risk factors can still have GDM. Hence from January 2016, KKH and Singapore General Hospital have started offering GDM screening to all pregnant women at 24 to 28 weeks of gestation using a more sensitive and internationally recognised (International Association of Diabetes and Pregnancy Study Groups) criteria.
This screening has since been adopted by all hospitals offering maternity services in Singapore, to achieve better health outcomes for all pregnant women through early detection and intervention.
16. Which foods should I eat or avoid if I have gestational diabetes?
Pregnant women diagnosed with gestational diabetes (GDM) should adopt a healthy, balanced diet that applies to all expectant mothers. A healthy and balanced diet helps to improve blood glucose control, ensure adequate nutrition for mother and baby, as well as achieve an appropriate weight gain during pregnancy.
When a carbohydrate-containing food is consumed, it gets digested into glucose in the body and gets absorbed into the bloodstream. Whilst carbohydrate-containing foods increase blood glucose levels, it is not recommended to be avoiding all of them.
Important points to consider include the types of carbohydrate-containing foods, the quantities and the timings in which these foods are consumed. It is important to note that diet for pregnant women with gestational diabetes is individualised based on several other considerations, such as pre-pregnancy weight status and rate of weight gain during pregnancy, blood glucose level control as well as individual’s lifestyle and medical management.
The key principles of a healthy diet are as follow:
1. Types of carbohydrate-containing foods
- Choose whole grains, pulses, fresh fruits and non-starchy vegetables as these foods are higher in fibre, which helps to delay the absorption of glucose into the bloodstream, thereby helping to control blood glucose levels.
- Choose skimmed or low fat plain milk and yoghurt, hi-calcium unsweetened or reduced sugar soy milk for adequate calcium intake.
- Avoid sugars, sweet foods and beverages, as these are usually low in nutrients and high in energy value, which can increase your weight gain too quickly. Artificial sweeteners may be consumed in moderation.
- Avoid fried and oily foods as these are digested slowly, thus keeping blood glucose levels high for a prolonged duration. High fat foods can also contribute to excessive weight gain.
2. Quantities and timings of carbohydrate-containing foods
- Regular distribution of carbohydrate-containing foods throughout the day helps to optimise blood glucose levels. Instead of three large meals a day, it is recommended to try having small, frequent meals throughout the day, i.e. three meals and three snacks.
- Having regular meal timings every day is also important. In addition, eating the same amount of carbohydrate-containing foods daily at each meal and snack helps to regulate blood glucose levels.
Besides carbohydrates, protein-containing foods are also essential to ensure optimal growth and development for the baby. Sources of protein `include lean meats, poultry without skin, fish, seafood, eggs, reduced-fat cheese and soy products. Although most protein foods do not directly increase blood glucose level, excessive intake can increase weight gain too quickly.
It is important for a pregnant woman with GDM to perform an oral glucose tolerance test six weeks after delivery to confirm that her blood glucose level has returned to normal. If diabetes persists after delivery, she will need to continue with the diet and seek further dietary advice, as necessary.
However, women who had GDM but resolved after delivery, will continue to be at a greater risk of developing type 2 diabetes at some point in their lifetime. Therefore, it is recommended to continue adopting a healthy, balanced diet even if the results of the oral glucose tolerance test after delivery is normal.
The following practices can help to minimise risk of developing diabetes later in life:
- Breastfeeding
- Achieving and maintaining weight within a healthy range (BMI 18.5-22.9kg/m2)
- Exercising regularly
- Seeing a doctor annually to review blood glucose level
Professor Tan Kok Hian is Head and Senior Consultant, Perinatal Audit and Epidemiology Unit, Division of Obstetrics and Gynaecology, KKH. Prof Tan initiated and led in the implementation of universal GDM screening and also introduced the new IADPSG criteria in KKH and SGH since January 2016. He is the key champion of GDM universal screening, which has now been adopted in all hospitals in Singapore with obstetric service. As Chairperson of College of Obstetricians & Gynaecologists. Singapore GDM Committee 2017-2018 and Chairperson, Expert Group GDM Appropriate Care Guide of The Agency for Care Effectiveness (ACE), Ministry of Health 2017-2018, he was instrumental in leading GDM management. He facilitated the Asia Oceania Consensus in Gestational Diabetes in January 2018. He initiated the Perinatal Society of Singapore Advocacy Group for Engagement in Optimal Perinatal Nutrition in August 2018.
Prof Tan is the Lead Principal Investigator for RIE2020 NMRC Collaborative Centre Grant – Integrated Platform for Research in Advancing Metabolic Health Outcomes of Women and Children (IPRAMHO) which builds core research capability and capacity in metabolic health for women and children of Singapore and Asia. Prof Tan received many awards for his academic and clinical contributions. These included World Health Organisation – UAE Health Foundation Prize 2009 as Integrated Perinatal Care Project Team Leader.
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Ms Kellie Kong is a Dietitian with the Department of Nutrition and Dietetics in KK Women’s and Children’s Hospital (KKH), and is an Accredited Practising Dietitian with the Dietitians Association of Australia.
At KKH, she cares for pregnant women with gestational diabetes mellitus, including assessing their nutritional intake and requirements, planning and designing suitable diets, and providing personalised dietary counselling. Ms Kong also has a special interest in neonatal nutrition and paediatric oncology
Question 1-15 is answered by Professor Tan Kok Hian Head And Senior Consultant, Perinatal Audit And Epidemiology Unit, Division Of Obstetrics And Gynaecology.
Question 16-17 is answered by Ms Kellie Kong, Dietitian Nutrition And Dietetics Department.
