Many of us might be aware that there is an increased risk associated with pregnancy after the age of 35.
Actually, pregnancy at any age comes with risks.
“Pregnant women think they only need to see a medical specialist for a detailed scan after a certain month.
“They should see us before conception or very early in the pregnancy so we can modify their care, especially women who are in the high-risk group,” says consultant obstetrician and gynaecologist Dr Muniswaran Ganeshan, who subspecialises in maternal fetal medicine (MFM), a branch of medicine that focuses on the health concerns of both the mother and fetus.
His expertise lies in managing high-risk pregnancies such as in women who have undergone kidney or liver transplants, are undergoing chemotherapy, have experienced complications from Covid-19, as well as those with heart ailments.
“A lot of times these women are told not to get pregnant or to terminate the pregnancy as continuing it may be more harmful.
“If they don’t want to stop and are not being optimally monitored, they can develop complications, which can lead to maternal death.
“The leading cause of why women die during pregnancy is due to medical disorders such as heart disease, cancer or suicide.
“Other complications include miscarriages, Caesarean births and prematurity,” says Dr Muniswaran who completed his MFM training in 2016 and established the high-risk pregnancy clinic in Hospital Kuala Lumpur before moving into private practice.
Lack of holistic care
According to the Statistics Department, the country’s 2023 maternal mortality (death) risk was 25.7 per 100,000 live births, a slight decrease from 26 per 100,000 live births in 2022.
The figures have fluctuated in recent years, with a peak of 68.2 in 2021, which was attributed to the Covid-19 pandemic.
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Dr Muniswaran says: “We have progressed to a level where we can minimise and prevent complications to a degree that pregnancy can be managed without causing significant morbidity and mortality.”
High-risk pregnancies include:
- Women who have a pre-existing medical condition such as heart disease or diabetes
- Women who are healthy, but develop a complication during pregnancy, e.g. a liver disorder where they start to itch
- Women who have a history of stillbirths, miscarriages or premature delivery
- Women who are of advanced or very young maternal age
- Fetuses with birth defects, heart problems and blood disorders, among others.
As is typical of most Malaysians, many patients only seek advice when a complication has occurred.
“Sometimes, with heart disease, they may see a cardiologist, who may not be comfortable managing pregnant women.
“The woman then doesn’t get the right care.
“In our modern world, a pregnant woman is not getting holistic care, e.g. if she gets diabetes, she sees an endocrinologist; if she develops depression, it’s a psychiatrist, etc.
“Ideally, there should be one doctor who ‘owns’ the patient and knows her goals and direction.
“Similar to a geriatrician who looks after the elderly, we need a one-stop care for pregnant women,” opines Dr Muniswaran.
Complications during pregnancy may have implications later in life, e.g. if the mother has pre-eclampsia during pregnancy (high blood pressure, high levels of protein or other signs of organ damage), she has a 50% increased chance of having a stroke and heart failure later in life.
Motherhood at any age
It’s a woman’s right to become a mother at any age and society shouldn’t stigmatise or judge them.
Dr Muniswaran says: “Please support women in achieving their desires – it’s all about making pregnancy safe.
“My oldest patient was 58 and had already menopaused, but all you need is a uterus to get pregnant.
“It was her one and only child conceived through in vitro fertilisation (IVF).”
The oldest woman to give birth to date is Erramatti Mangamma from India, who conceived via IVF and gave birth to twin girls at the age of 73 in 2019 via a Caesarean section.
“Often, we think only the age and health of the mother is important, but this is not true as if the father is aged, a smoker or obese, it can also affect the baby.
“Both the couple must be healthy.
“And it’s not true that you need a Caesarean section if you belong to the high-risk group.
“It’s what happens throughout the nine months, not what happens in the nine hours of childbirth,” he points out.
Additionally, people think exercising is healthy during pregnancy, but what you do in that nine months does not really matter, it’s what you did before, that is more important.
So, if you’re new to exercise, Dr Muniswaran cautions against embarking on a fitness regime during pregnancy.
Giving another example of a high-risk pregnancy, he cites the case of a patient who succeeded in getting pregnant via IVF, but started experiencing headaches and shortness of breath, and found a lump on her breast, soon after.
Upon investigation, she was diagnosed with breast cancer and was advised by her obstetrician to terminate her pregnancy.
Dr Muniswaran says: “She was referred to me and we found her cancer was not localised, but it was in the early stages.
“We had to balance the benefits against the risks of pregnancy.
“Her desire was to have the child and we had to respect her wishes, especially end-of-life wishes.
“So we commenced chemotherapy – it’s safe during pregnancy – and managed to optimally treat the cancer.
”We now know that interventions like CT and MRI scans, as well as angiograms and angioplasties, are also safe for pregnant woman.”
The patient delivered at term, but unfortunately, passed away six months later.
The next time someone tells you you’re at high risk for pregnancy, see the right expert to get the right care, and get a second opinion if necessary.
Fluid in the fetus’ lungs
When Ong Hui Er, 36, was four months pregnant with her second child, her obstetrician found a dark shadow on the fetus during one of her ultrasound scans.
As he was unable to detect what it was, he referred her to Dr Muniswaran in Kuala Lumpur.
Ong, from Melaka, says: “My husband and I were told my baby had fluid in the lungs.
“Dr Muniswaran gave me antibiotics and asked me to rest and return in a week.
“By the third day, I started bleeding, but I couldn’t rush to KL, so I went back to my regular doctor, crying.
“He said it was nothing serious and to rest more.
“Back in KL, Dr Muniswaran noticed there was no change in the fluid, so he recommended pleural tapping to remove the excess fluid.”
Naturally, she was extremely worried about losing her child, but kept positive, thinking of her firstborn.
“He only managed to remove 50% of the fluid, but thankfully, the water slowly decreased before I delivered my son on April 4 last year.
“The baby stayed in hospital for a while because he was on antibiotics.
“Now, we’re taking him for follow-ups at Institut Jantung Negara as his heart is bigger than normal, but otherwise, he is fine,” says a relieved Ong.
Having the two boys is enough as she is afraid of going through another pregnancy.
“My oldest is four, but he doesn’t love his younger brother – he’s jealous!
“The small one is also naughty, but they are my world,” she shares.
Altering medications for the mother
In 2018, Sally (not her real name) was diagnosed with lupus nephritis.
This is an autoimmune disease in which the body’s immune system mistakenly attacks the kidney’s healthy tissues.
She had been undergoing treatment at a public hospital, and once her disease was finally in remission, her physician switched her medicines to “pregnant-friendly” ones in 2023, as she was eager to have a child.
After one miscarriage, the 35-year-old was thrilled to discover she was pregnant last year.
She recalls: “Within three weeks of finding out I was pregnant, my nephritis readings went haywire.
“I was advised to terminate my pregnancy.
“The doctor said it was too risky as my lupus could worsen.
“My husband and I were both sad and disappointed, but thankfully, we were introduced to a MFM specialist and consulted him for a second opinion.”
Sally was given a few options to control her flares and increase her chances of carrying the baby to full term.
Under the close monitoring of the MFM specialist, along with her obstetrician and nephrologist, Sally’s medications were modified and her disease was suppressed.
Except for some small hiccups during her pregnancy, she delivered a healthy baby boy who is now four months old.
“However, I can’t breastfeed as I’m back on my old medicines to control my lupus.
“My baby hasn’t been diagnosed with lupus, although I’m aware that it can be inherited, so we’re watching him closely.
“My kidney disease is now at stage four, and if it deteriorates, I will have to be on dialysis.
“I hope my condition stabilises because I want to have another baby – a girl this time,” she says.
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