Making Motherhood Safer
Half a million mothers die every year from complications of pregnancy and childbirth. Many of these women live in developed countries, but most live in the developing world. This figure is equivalent to one mother dying every minute in this world.
This astounding figure is made even more staggering when we realize that the ways to prevent most of these maternal deaths already exist today. So we have a disconnect between what we already know and what we are offering our pregnant mothers and their families.
And there is a ripple effect. In many cases where the mother dies during pregnancy and childbirth, the newborn infant follows her soon after, usually before their first birthday.
There are many reasons why mothers die in pregnancy. These include severe bleeding, infections, unsafe abortions, eclamptic fits, obstructed labour, poor nutrition and hygiene, poverty and limited access to healthcare resources, but one of the most important causes of maternal deaths is also one of the easiest to rectify: inadequate information.
In his two reviews on this subject, Dr Choolani argues the case for educating women and mothers on health and hygiene, and suggests that literacy alone can have a major impact in reducing maternal mortality.
Ambulatory care of pre-eclamptic patients
Pre-eclampsia is a very specific form of high blood pressure that only affects women during pregnancy. It is associated with the presence of protein in the urine, and swelling, sudden weight gain and possibly even fits (eclampsia). This condition poses a significant health risk to both the mother and her fetus, and is a major cause of death in both.
The condition usually presents in the second half of pregnancy and affects blood vessels, putting the mother at risk of a stroke and the fetus at risk of poor growth from placental insufficiency. The condition may warrant a premature delivery.
In the past, pre-eclamptic patients were hospitalized for long months at a time causing major disruptions to the family, and also putting the mother at risk of hospital acquired infections and deep vein thrombosis. To get around this, Dr Choolani investigated the role of ambulatory care of pre-eclamptic patients.
Extending these observations to monitor patients’ blood pressure at home, it was found that in some patients, home blood pressure measurements were generally lower than those obtained in the clinic. This condition is known as white coat hypertension, and can lead to unnecessary hospital admissions.
Introducing medical treatment of ectopic pregnancies in Singapore
Ectopic pregnancies pose a serious risk to pregnant women, and can even lead to maternal mortality. Ectopic pregnancies occur in early pregnancy, and is associated with pain and bleeding. Often, they occur in the fallopian tube; if they rupture, they can lead to significant intra abdominal bleeding.
Previously, open surgery through a laparotomy incision was the most common method of treatment for an ectopic pregnancy. More recently, laparoscopy, or key hole surgery, has become the method of choice for managing ectopic pregnancies.
These days, in properly selected patients, a non-surgical option can be used, using a medication known as methotrexate. Dr Choolani was one of the pioneers that performed the first study of the use of methotrexate for the treatment of ectopic pregnancies in Singapore. Together with a close friend and colleague, Dr Anandakumar, they were responsible for the introduction of the non-surgical management of ectopic pregnancies into Singapore medical care.
Early studies of medical termination of pregnancy in Singapore
In Singapore, terminating a pregnancy is legal, but only up to the 24th week of gestation. Dr Choolani doesn’t encourage terminations, but he does respect parents’ right to choose. If they are to be done, it is important that they be performed in the safest way possible, to reduce the surgical risk to the mother, and also limit the likelihood of any adverse impact on future pregnancies. Unsafe terminations, or abortions, can lead to severe blood loss, infertility and, sometimes, even maternal death.
Surgery had long been the standard method of terminating a pregnancy. Dr Choolani has been involved in research to make terminations safer. Hospitals in Singapore have now adopted medical options as the viable choice for terminations of pregnancy that occur after the first trimester.
Understanding heart diseases in pregnancy in Singaporean women
This research paper highlights how congenital heart disease, and no longer rheumatic heart disease, is the major cardiac condition presenting in pregnant women in Singapore these days.