Common Obstetrics & Gynaecological Conditions

Gestational Diabetes is high blood glucose that develops during pregnancy and usually disappears after giving birth. Most women with gestational diabetes have otherwise normal pregnancies with healthy babies. However, it can cause problems such as your baby growing larger than usual, leading to difficulties during the delivery and increases the likelihood of requiring a caesarean section. More importantly, women who have gestational diabetes are also at risk of developing Type 2 diabetes in later life. Recent local studies have shown that close to 25% of Singaporean women will develop Gestational Diabetes. As such, all pregnant women are advised to undergo screening for Gestational Diabetes between 24 and 28 weeks of pregnancy. Should you be diagnosed with Gestational Diabetes, you will be taken care of by a dedicated team of experts (obstetrician, diabetic nurse educator, dietician, endocrinologist) who will manage your pregnancy to ensure the best outcome for both mother and baby.

For a long time, the adage of “once a Caesarean section, always a Caesarean section” had been the impression patients have as to the mode of delivery after having had a Caesarean section. However with better surgical techniques, knowledge of healing and fetal monitoring in labour, there is a place for a Trial of Labour after a Caesarean, (TOLAC for short).

A vaginal delivery is the natural way to deliver the child and it has definitely more advantages compared to having a Caesarean section. The pain after the delivery is definitely much less than after any abdominal operation. With less pain, the mother is more mobile and will be able to bond, breastfeed and look after the baby within an hour after the delivery. There is less need for pain medications - baby is able to room in with mother and one can expect to go home 24 hours after delivery.

A Caesarean section is performed when it is not possible to deliver the baby vaginally. Reasons could be maternal e.g. a low lying placenta, severe high blood pressure or it could be fetal e.g. breech presentation, fetal distress, failure to progress in labour, etc. In Singapore, almost all our Caesarean section involve making an incision over the uterus (just behind the bladder) from right to left. After the baby and placenta have delivered, the uterus is usually closed in 2 layers with a strong absorbable suture to enable better healing. The cut is much longer than that sustained during a vaginal delivery, resulting in pain which can impair one’s mobility postnatally. This may increase the risks of developing Deep Vein Thrombosis (blood clots in the leg veins) and Pulmonary Embolism (clot migration to the lungs).

The main worry about allowing a TOLAC is the risk of scar rupture during labour – the risk has been estimated to be slightly less than a 1%. To mitigate this risk, we would look for factors that could have affected the wound healing e.g. any complications during her operation, wound infection, poorly controlled diabetes, close interval between pregnancies. During labour, the mother and baby are monitored very closely. In the presence of any suspicious symptoms or signs, the patient would be strongly advised to have a repeat Caesarean section.

About 60% of our patients who attempt TOLAC will have a successful vaginal birth after Caesarean Section (VBAC).

Endometrial cancer or sometimes also known as uterine cancer is the most common gynaecological cancer in Singapore women with rising incidence. Endometrial cancer (uterine cancer) is a type of cancer that begins in the uterus. The uterus is the hollow, pear-shaped pelvic organ in women where fetal development occurs. Endometrial cancer (uterine cancer) begins in the layer of cells that form the lining (endometrium) of the uterus.

Endometrial (uterine) and ovarian cancers are common in women who work and live in an urban environment where they are likely to have fewer pregnancies, breastfeed less and are more likely to have conditions such as obesity and diabetes. These factors alone do not explain why women get endometrial cancer, but they are factors that are more commonly found in women who have endometrial cancer.

The endometrium is the lining of the womb or uterus. It is into this lining that the very early foetus or embryo implants and continues to grow, making the uterus its home for the nine months of pregnancy till birth. This important tissue layer changes over entirely every single month, growing in anticipation of a pregnancy then shedding when no pregnancy occurs.

Cancerous changes in the lining of the womb typically take place in a woman’s late 40s and cancer of the endometrium is most commonly diagnosed in women in their 50s and 60s. Unlike ovarian cancer, most women with endometrial cancer (uterine cancer) are found to have their disease before it has a chance to spread outside of the uterus. This is because even early or pre-cancerous changes in the endometrial lining will result bleeding that most women will know to be “abnormal”. Because there are troublesome signs that appear early, most women will see a doctor, make the diagnosis and get timely treatment. This is why endometrial cancer (uterine cancer) is unlikely to be deadly although it is a very common gynaecological cancer.

The ovaries are part of a woman’s reproductive system. They are located in the pelvis. Each ovary is the size of an almond. The ovaries make the female hormones – estrogen and progesterone. They also release eggs. An egg travels from an ovary through a fallopian tube to the womb (uterus). When a woman goes through her menopause, her ovaries stop releasing eggs, resulting in far lower levels of hormones being produced. The ovaries contain primitive cells, which are cells that go on to become eggs, and epithelial cells. Primitive cells that become cancerous are called germ cell tumours. Epithelial cell cancers of the ovary are more common than germ cell cancers.

Ovarian cancer is the 5th most common cancer in Singaporean women. Its incidence is increasing in Singapore. Ovarian cancer is known as the deadliest gynaecological cancer because it is usually detected in its later stages of development and spread. The main reason for this is that the ovaries are located deep in the body cavity and hidden away in this manner, pre-cancerous and early cancerous changes are not only difficult to medically detect but also are not obvious or apparent to the women with these early changes.

The CA125 blood test and other related tumor marker blood tests are NOT effective screening tests for ovarian cancer. Regular ultrasounds of the ovaries in normal healthy women with no obvious family history of ovarian, breast or colon cancers are also NOT effective in screening for ovarian cancer. These tests are often offered as part of routine health screening packages and may help to pick up other non-cancerous conditions, but are NOT effective in detecting ovarian cancer in the general population. If you are in good general health and your mother, her sisters or your sisters have never had ovarian, breast or colon cancer, inform your healthcare provider that you would like to decline the CA125 blood test.

The most effective early detection tool against ovarian cancer is YOU, armed with the knowledge of early symptoms, being aware of your own body and having regular pelvic examinations by your gynaecologist.

Fertility issues affecting men account for 40 - 50% of couples who seek help for assisted conception. Semen analysis will be performed to determine if one or a combination of low sperm concentration or poor sperm motility contribute to lower chances of conception. Male sexual dysfunction can also result in conception problems. Occasionally, some men require further tests to evaluate their fertility problems and may even require surgical retrieval of sperm. Our team of specialists (fertility specialist, andrologist, urologist, laboratory expertise) are equipped to assess and manage these conditions to assist our couple to fulfill their goals of achieving a pregnancy.

Women face higher risks of subfertility, pregnancy losses, fetal anomalies and obstetric-related complications as they get older. This is due to the gradual loss in the number and quality of eggs as women age. The sharp decline in women's fertility occurs after 37 years of age.

Additionally, the success of IVF is also very dependent on the age of the woman. For example, IVF pregnancy rates start declining from 40% at less than 30 years old to 10% at 40 years old and 1-2% after the age of 45 . This is again largely due to the lower number and poorer quality of eggs available for IVF as the patient ages.

Low ovarian reserve is also associated with surgery, especially cystectomies performed for ovarian endometriotic cysts. Smoking is also detrimental and should be discouraged.

As such, fertility treatments should be prioritised, customised and applied in a timely fashion in order to optimise pregnancy rates.

Endometriosis is a condition where the endometrium, the tissue lining the inside of the uterus, is found outside the uterus. Like normal endometrium, these tissues also respond to hormones secreted by the ovary and is built up and shed off the same way. However, unlike the normally sited endometrium, this “internal menses” doesn’t flush out of the body. Over time, this process can lead to the formation of ‘chocolate’ cysts (brownish fluid-filled sacs) in the ovaries, nodules/ deposits around the uterus, swollen fallopian tubes and scarring. . Endometrial deposits can also be found in or on the bowel and bladder, or at sites remote from the pelvis.

Endometriosis is a condition affecting about 20% of women in the reproductive age group. The common symptoms being painful periods, painful sex and infertility. It is diagnosed via clinical examination, ultrasound scan or other imaging modalities like MRI scans. The treatment involves medical (hormone modulation/suppression) and surgical management in the multi-disciplinary setting.

Our department is a regional referral centre for endometriosis management.

The endometriosis clinic is run by doctors with special training in the management of endometriosis. There is a specialist nurse who helps provide additional support to patients suffering from this chronic debilitating condition. Laparoscopic surgeries for endometriosis are performed by the specially trained surgeons, in conjunction with the colo-rectal and urologist colleagues to ensure complete resection and reduce the need for repeated surgeries.

Uterine fibroids are non-cancerous growths arising from the uterus which are found in up to 20% of all women. Fibroids develop within the uterine wall and subsequently can grow either towards the outer surface or the inner lining of the uterus. Depending on their size and location, fibroids may result in symptoms such as heavy periods, abnormal menstrual bleeding, pressure symptoms or infertility and some women with fibroids may have no symptoms at all. The cause of uterine fibroids is unknown but linked to hormonal influences or a genetic predisposition.

Uterine fibroids are diagnosed using pelvic examination in conjunction with various imaging platforms like ultrasound scanning. Women with asymptomatic fibroids may not need any treatment and only need to be monitored. Less than 1% of fibroids may become malignant and these generally demonstrate rapid increase in the size.

Some fibroids can be managed medically or using hormonal implants whereas others need to be resected surgically. With advanced surgical skills, most fibroids can be operated using minimally invasive methods. Hysteroscopic resection performed vaginally can be used for fibroids developing towards the uterine lining. Laparoscopic (key-hole) methods can be used for ones developing within the uterine muscle wall or towards the surface. In our department we are able to perform minimally invasive surgery for more than 90% of the fibroids.

The two main types of UI are overactive bladder (OAB) and stress urinary incontinence (SUI). OAB patients are troubled by the need to pass urine frequently in the day and night, usually associated with urgency and uncontrollable leakage of urine before reaching the toilet. Patients with SUI leak urine when they cough, sneeze or exert themselves physically. We would investigate their causes and treat them holistically with a combination of counselling, conservative, medical and surgical treatments. The surgeries for SUI include the minimally invasive mid-urethral tapes/slings and laparoscopic colposuspension.

Pelvic Organ Prolapse (POP) includes the sagging, descent or prolapse of the bladder (cystocoele), uterus or vaginal vault (uterine or vault prolapse) after a previous hysterectomy (womb removal) and rectum at the top, apex and bottom of the vagina respectively. These cause the patient to have a lump at or outside the vagina, causing discomfort, difficulty in daily activities, passing of urine and faeces and sexual intercourse. POP patients would be investigated and treated with vaginal pessaries or surgery: including vaginal hysterectomy, native tissue repair, vaginal meshes and lapascoscopic sacrocolpopexy. Some patients have both stress urinary incontinence (SUI) and POP and both of these conditions would be treated concurrently.