Please visit CoMANEH website for more information
We will conduct MAMANEH 15th AGM 2015 with details as below;
“The Way Forward After MDG Towards Improving Maternal & Neonatal Health
Date : 18th October 2015 Venue : Academy of Medicine of Malaysia, Kuala Lumpur. Time : 8.00 am -12.00 pm
By Dr Ariza Mohamed
Consultant Obstetrician & Gynaecologist , Ampang Puteri Specialist Hospital
Ramadhan is just round the corner.!! Even if one doesn’t follow the Islamic calendar, one would still know that Ramadhan is just round the corner because some shopping centres are already blasting out Raya songs! It’s probably only in Malaysia that people ‘miss’ out the Ramadhan month and instead celebrate Idul Fitri a month earlier.
For the pious, Ramadhan is revered and very much anticipated. The ‘waiting’ for Ramadhan usually starts from the Rejab (Islamic calendar) which corresponds to the last week of June. The Prophet has taught Muslims to recite the prayers which goes something like this…’ Dear Allah, bless us in our Rejab and bless us in our Sya’aban and may we arrive in Ramadhan’.This is due to the feeling of fear of not being able to celebrate Ramadhan as well as hoping very much that one’s life is prolonged to be able to achieve the blessings and forgiveness from Allah during the coming Ramadhan.
The purpose of this article is to give a wider horizon for the practising Muslim doctors on how to handle their pregnant and nursing mothers and also to give some insights to our Non-Muslim doctors on why Muslims fast and also to give them some information probably needed as they handle their pregnant and nursing Muslim patients.
The Muslims are ordained to fast during the whole of Ramadhan when surah Al-Baqarah Verse 183 was revealed to Prophet Muhammad.
‘Oh you who believe! Observing As Shaum ( the fasting) is prescribed for you as it was prescribed for those before you, that you may become Al-Muttaqun (the pious) ‘ (Al- Baqarah : 183)
Fasting is compulsory for all Muslims who has reached puberty. Muslims all over the world fast the whole of Ramadhan in submission to Allah. Although fasting has been shown to have many health benefits, this is not the reason why Muslims fast. Fasting is one of the five pillars in Islam and is compulsory.
However, some group of people are given exemption from fasting as the following verse showed:
“Fasting for a fixed number of days, but if any of you is ill or on a journey, the same number ( should be made up) from other days. And as for those who can fast with difficulty,(eg old man), they have a (choice either to fast or) to feed a poor person for (every day). But whoever does good of his own accord, it is better for him.And that you fast is better for you if only you know”
(Al Baqarah : 184)
The few groups given exemption are those who are ill, or is on a journey. For these group of people, the verse clearly says they are exempted from fasting but should replace the number of days missed in other months.
Let’s look at one seerah- Rasulullah was at one time making a journey during Ramadhan with the sahabah. Some sahabah chose to continue fasting and some sahabah chose not to fast. The Prophet Muhammad has also been noted to break fast while on a journey.
Some people argue that travelling now is already so convenient and comfortable that Muslims who chose not to fast were sometimes frowned upon. However, this (breaking fast) should be taken as following the sunnah/ways of Rasulullah and should be commended. Just like how prayers can be shortened and combined during travelling, irrespective of whether the journey undertaken now is so much more pleasant compared to before.
Of course those who do not fast will need to ‘pay back’ when Ramadhan is over ,ie to fast the same number of days that he had missed.
Menstruating women and women in confinement are not allowed to fast. Seeing from the medical point of view this is good for the menstruating women and those in their postpartum period as she would be losing some blood and it will be for her benefit to eat and have her iron supply replaced. Although personally we know of some women who took pills to stop her menses during Ramadhan so as she could fast the whole month! How Islam looked at this need to be further discussed.
We know that the sick are not required to fast. What about pregnant and nursing mothers? Are they considered sick?
Pregnant and nursing mothers are not ‘sick’, they are in fact healthy women undergoing a normal process in life. And so they don’t fall under the sick category .
However, in the same verse, it also says…’ and for those who can fast with difficulty, they have a choice either to fast or to feed a poor man every day ( that they missed).’
Let’s look at a nursing mum. When a mother is fasting, would it affect the quantity and the quality of her milk? The quantity might be affected. What about the quality? Some party claimed that the quantity as well as the quality of breast milk is not affected even in women in war-torn countries whom are deprived of good nutrition.
If the baby is still fully breast feeding and has not been weaned yet, the baby will depend wholly on the breastmilk produced by his mother. A fasting mum who finds that her baby is feeding well even when she is fasting could continue to fast. However if a mum finds that she is producing less and the baby is showing signs that he is not getting enough from breastfeeding could opt not to fast. On the other hand, if the mother insist on fasting, she might want to stop breastfeeding or will want to mix feeding with bottlefeed /infant formula and this is not encouraged. The WHO has stated that babies should be exclusively breastfed for the first 6 months to achieve the full benefit of breastfeeding. A mum who continue fasting would be doing so at the expense of her baby being introduced to cow’s milk /infant formula which is less healthy for the baby. A baby who is denied full breastfeeding will be at a higher risk for infection compared to one who is fully breastfed. On top of that, breastfeeding mum who fasted reported feeling lethargic and exessive hunger and this is probably due to dehydration.
So, should a breasfeeding mum fast?
According to the ulamas, the term….‘those who can fast with difficulty..’ here includes nursing mum. Although she can fast, it will be with a lot of difficulty since the baby will require to breastfeed every few hours and this in turn will make the new mum dehydrated and lethargic.
In my opinion, a nursing mother whose baby is below 6 months and is not weaned yet, need not fast if she feels worried that her baby might not be getting enough milk or she feels exessively lethargic. However, mothers whose babies are already on other form of food and not fully dependant on breastmilk should continue to fast . Mums who find that their babies are well fed and they are not excessively lethargic also should continue fasting.
What about a pregnant mother then?
A pregnant mother, as we all know, will experience symptoms of pregnancy especially in the first three months.
During these period, some women face a lot of difficulties with vomiting and coping with tiredness. Usually doctors would encourage them take small frequent meals as to try and reduce vomiting. There’s no known “cure’ for hyperemesis gravidarum, with anti emetics like maxolon most of the time not really effective. Therefore , encouraging the patient to have frequent sips of water is important to avoid dehydration and need for parenteral iv infusion.
These category of mother clearly falls under the ‘ fasting with difficulty’ category and according to Islam , don’t need to fast.
Mothers who are in their second and third trimester are usually happy, healthy and buoyant (well…most are..). therefore , they have a choice to fast or not to fast. If they feel easily tired, bearing in mind that mothers now are mostly career women, then they have a choice not to fast.
The ulamas are in agreement that nursing and pregnant mothers are given this very special exemption.They are also in agreement that if the mother worries about the health of her baby, or if there’s any reason at all for the doctor attending her to suspect possible harm on the baby, then the woman should not fast. Therefore, any woman with Diabetes on treatment or hypertension or IUGR etc need not fast and need not have their medication adjusted. I think this is the challenge that we usually face in pregnant mothers with medication who wishes to fast during Ramadhan.
But does fasting have any effects at all on the fetus?
A few groups of doctors in Turkey had looked at women fasting in Ramadhan and measured the fetal parameters (BPD,FL,EFW) and fetal well being (BPP,AFI,Doppler). They found no maternal ketonemia or ketonuria and no significant adverse effect on intrauterine fetal development or fetal health.( J Obstet Gynaecol Res.2008 Aug:34(4): 494-8.) Others who did similar studies also found no significant effect on fetal health. My own personal observation on my patients found that none had problem of IUGR or slower growth due to fasting.
Even though mothers are given flexibility in fasting during pregnancy, most usually insist on fasting. Why? Well, I feel that apart from the genuine yearning for ‘pahala’ that one gets with fasting, mothers are also worried that they have to ‘pay back’ so many days of Ramadhan missed.
The ulamas are in consensus that fasting and breastfeeding women can break their fast. However there are different opinions on how to replace the missed days. They are a few views on this .
Some say they need to replace their fasting in other months the same number missed during Ramadhan. For example, if she missed 10 days, then she had to fast 10 days outside Ramadhan. (according to Imam Hanafi)
Some ulama says, just feeding a poor man the same number of missed days, ie missed 10days, so feed a poor man 10 days or give food to 10 men/women.
Some says, both need to be done.
Some says, none need to be done.
The common practise by Malaysians is to replace the missed fastingdays ( for mum who worries about herself) and on top of that to feed the poor if mum is worried about her baby. ( Imam Shafie and Imam Ahmad)
However, according to Ibnu Abbas and Ibnu Umar, which were renowned Islamic scholars, the second option ie feeding a poor man without needing to replace the days with fasting on other month is more appropriate. (reference:translation of FIQH Sunnah-by Sayyid Sabiq, volume 3)
Generally in Malaysia, Muslims follow rulings by Imam Shafie ie replacing back lost days by fasting on other days in other months. The decision to follow one Imam is to ensure uniformity and to reduce confusion amongst the less knowledgeable.
However, it is good for Muslims to know that they are other ‘school of thoughts’ regarding how to replace lost days during Ramadhan. All these ‘school of thoughts ‘are acceptable as all are ‘evidence-based’ ie they are all based on Al Quran and sunnah with different interpretation.
As for me, this is a new information which I had gathered while writing this article. Women in Malaysia had generation after generation ‘paid back’ their missed fasting days with fasting in other months. And from my experience,it is not easy to repay back 30 days of fasting if you missed the whole month! Fasting one month in Ramadhan cannot be compared to fasting in other months, since fasting in Ramadhan is lots lots easier ( and of course fasting in Ramadhan gives you a lot of ‘pahala’ or returns)
If I had a choice, I certainly would rather feed a poor man…..furthermore, the baby will be breastfeeding sometimes up to a year and the mother will still have difficulty to ‘pay back’ her fasting, and before you know it, the next Ramadhan comes or the mother gets pregnant again!!
Anyway, as Allah says in the subsequent verse, he intends for us ease,and does not want to make things difficult for us.
‘ The month of Ramadhan in which was revealed the Quran, a guidance and the criterion between right and wrong. So whoever of you sights the crescent on the first night of Ramadhan, he must observe shaum (fasting) that month, and whoever is ill or on a journey, the same number of days must be made up from other days. Allah intends for you ease, and He does not want to make things difficult for you…………’
Al baqarah 185
Islam is a religion which is easy to practice and we should not make it difficult. With that, to all Muslims, a happy and Blessed Ramadhan.
by Dr Zarina A Latiff, Hospital UKM
What is jaundice?
Jaundice is the yellow discolouration of the sclerae (whites of the eyes) and skin. It occurs in ˜60% of mature babies and 80% of premature babies during the first week of life. Jaundice is often apparent on the face first and as it increases in severity will progress downward i.e. from the abdomen towards the legs. Jaundice may be demonstrated by pressing lightly on the skin with a finger; the yellow colour is seen more easily in the ‘fingerprint’ area than in the surrounding skin. This examination should be done under either natural/fluorescent light as other light source/bulbs may emit a yellowish tinge, which will only cause confusion. There are 2 types of jaundice: unconjugated and conjugated of which the unconjugated type is more common in the newborn.
Why is my baby jaundiced?
Jaundice is due to the deposition, in the tissues, of a yellow pigment called bilirubin. When the bilirubin exceeds a certain level, jaundice becomes obvious to the observer. Bilirubin is the end product of breakdown of red blood cells. This unconjugated form of bilirubin is then processed by the liver to become the conjugated form. Conjugated bilirubin is further processed in the gut and finally excreted from the body via the stool. In healthy newborns, elevation of unconjugated bilirubin occurs commonly and is known as physiological jaundice. This occurs because:
- There is increased red blood cell (RBC) volume in newborns
- The life span of red blood cells (RBCs) is shorter in newborns as compared to adults
- The liver function is still immature
Physiological jaundice may occur from the 2nd day onwards and peaks by day 3 or 4 of life. Physiological jaundice, however, does not occur on the 1st day nor does it exceed beyond the 2nd week of life in mature babies (or 3rd week in premature babies). If the jaundice persists beyond this period or if the level of jaundice is severe, then your baby should be investigated for other underlying causes. These will include conditions in which there is increased rate of RBC breakdown; amongst the more common conditions include:
- G6PD deficiency (common amongst our population)
- Blood group incompatibility between mother and baby — Rhesus; ABO
- Abnormal red blood cell (RBC) shape — spherocytosis (rounded RBC); elliptocytosis (oval shaped RBC)
- Too much red blood cells
- Extravasated blood (bruises or blood clot) — e.g. cephalhaematoma (collection of blood below the membrane/layer which covers the skull bone) or subaponeurotic haemorrhage (collection of blood below the layer of muscle insertion). The blood within the swelling gets reabsorbed and broken into bilirubin, which subsequently causes jaundice. Both of these conditions are more likely to occur in babies delivered via forceps/vacuum extraction.
If all of the above conditions have been excluded and if it is unlikely that your baby has any other less common conditions (e.g. hypothyroidism — decrease in/absence of thyroid function; infection), there is a possibility that your baby has breast milk jaundice. In breast milk jaundice, the jaundice usually appears at the end of/after the first week of life and may persist up to several weeks or even months. Breast milk jaundice occurs as a result of ‘abnormal’ milk content, which inhibits the bilirubin conjugation activity. Interruption of breastfeeding for 1-2 days with substitution of formula for breast milk (in moderately severe jaundice) will usually result in a rapid decline in bilirubin level after which breastfeeding may be resumed. Provided there are no additional risk factors, babies who have either physiological or breast milk jaundice will remain well and recover completely. All of the problems mentioned so far cause unconjugated jaundice. On the other hand, there are also many causes of conjugated jaundice, the most important being biliary atresia. In biliary atresia, the jaundice is due to obstruction of the bile duct draining the liver. Such obstruction will make the stools look pale (like chalk) and the urine dark. This condition requires urgent investigation and should not be ignored.
Are there any serious effects of jaundice?
Yes, but this will depend on the type and severity of jaundice. Unconjugated bilirubin may penetrate into the brain cells. This occurs when the level of unconjugated bilirubin is very high. Hearing problems is one of the earlier effects detected but if the jaundice is allowed to progress without medical intervention, this will lead to progressive brain damage and at the extreme end, the baby may even be mentally retarded and die.
How is jaundice treated?
Upon admission, the doctor will first evaluate your baby. Appropriate blood tests will then be carried out. Depending on the bilirubin level, phototherapy is usually commenced. Additional intravenous fluid therapy may be required if your baby appears dehydrated and oral feeding is insufficient. Regular monitoring of bilirubin level will be done from time to time and the frequency depends on the severity of jaundice. These levels will be compared to standard charts (which takes birth weight, age and level of bilirubin into consideration) to decide whether phototherapy should be continued, discontinued or whether exchange transfusion is required. Monitoring of bilirubin level is also usually done 24 hours upon termination of phototherapy to ensure that there is no rebound or unexpected rise in bilirubin level again.
What is phototherapy and are there any side effects?
Bilirubin in the skin absorbs light energy maximally in the blue light range. Toxic unconjugated bilirubin is subsequently converted into an alternative non-toxic water soluble form which is readily excreted/removed from the body. Phototherapy should be applied continuously. The baby should be nurse naked to ensure maximal skin exposure and the infant should be turned regularly. The baby’s eyes should be covered to protect the eyes from the light source. Body temperature and hydrational status are also closely monitored. Complications of phototherapy though rare include loose stools, skin rashes, overheating and dehydration. Although retinal damage secondary to phototherapy has only been reported in animal studies, the eye shields are worn to prevent this possibility. Otherwise all these side effects are transient and there are no long-term side effects of phototherapy.
What about exchange transfusion?
Exchange transfusion is used when the bilirubin level is severely elevated or if it remains beyond 340mmol/L (in a term baby) despite effective and adequate phototherapy. Exchange transfusion helps to remove and reduce bilirubin from the baby to a lower acceptable level; it is important that consent to exchange transfusion be obtained quickly when needed as further delay will only increase the likelihood of possible brain damage. Exchange transfusion is usually done via a small catheter (tube) placed in the umbilical cord blood vessel (the vein) where small aliquots/volume of blood is removed slowly and gradually from the baby and is replaced immediately by fresh whole blood obtained from the hospital’s blood bank. The duration of exchange transfusion is usually ˜11/2 to 2 hours depending on the baby’s weight and overall condition. Throughout the process, the baby will be closely monitored. The bilirubin level will also need to be carefully monitored following exchange transfusion to ensure that it does not rise rapidly again. Occasionally, a repeat exchange transfusion may be needed should the levels rise beyond the accepted range once again. Exchange transfusion is an accepted mode of treatment. It has been used worldwide. The main drawback to exchange transfusion is the risk of transmitting major blood borne related infections (e.g. hepatitis B, HIV). However, with continuously improved screening techniques of donor’s blood, this risk is minimised. As with all other form of treatment, the need and benefits for the treatment should be weighed carefully against the possible side effects. In the case of severe jaundice, the risk of brain damage is real and exchange transfusion needs to be strongly considered.
How can I help?
Most babies admitted with jaundice require phototherapy. It is important to ensure that your baby has adequate feeds, more so since phototherapy is used (as fluid loss in increased with the use of phototherapy).It is also advisable that traditional medications be avoided for the time being as its true contents may be unclear and there may be existing substance that could worsen your baby’s jaundice. Another important point to note is that basking your baby underneath the morning sun is not an effective mode of treatment and should therefore be discouraged.
What happens after my baby is discharged?
The need for subsequent follow-up will have been made by your baby’s attending doctor(s). Uncomplicated cases of neonatal jaundice do not require special follow-up; only those with severely elevated bilirubin level (usually unconjugated bilirubin level of >300mmol/L) and especially those who required exchange transfusion will be given NICU clinic appointments. During this follow-up(s), your baby will be assessed in terms of growth and developmental status. In addition to this, a hearing assessment appointment will also be given to ensure that there is no hearing appointment.
If there are any points, which are confusing or unclear to you, or your question is not covered by the information in this article, please ask the doctor looking after your baby.
Prof. Dr Rohaizak Muhammad, Breast & Endocrine Consultant, UKMMC
Introduction: Breast cancer is one the most common cancer among female worldwide. It is also the most common cancer among female in Malaysia with reported incidence to National Cancer Registry of new cases in 2006 to be 3525, giving an Age-standardized Incidence ratio of 39.3 per 100,000 populations. According to the ethnicity, the Chinese has the highest incidence, followed by Indian and Malay but this might not reflect the true racial distribution as many new cases are not reported. In many developed country, the disease is most prevalent among the older women but unfortunately, in Malaysia, the peak age specific incidence was at 50-59 years for Malays and Chinese and 60-69 years in Indian.
Figure 1 Figure 2
Figure 1. Ten most frequent cancer in Peninsular Malaysia 2006
Figure 2. Ten most frequent cancer in female in Peninsular Malaysia 2006
Definition : When we talk about breast cancer, we are referring to the common types of breast cancer which are infiltrating ductal carcinoma and infiltrating lobular carcinoma. There are also cancer of the breast, not arising from lactiferous duct or lobules such as Cystosarcoma phylloides (Phylloides tumour), angiosarcoma of the breast or malignant metastasis to the breast.
Investigation : The most important is “Tripple Assessment” which includes Clinical Examination, Cytology/Histology and Radiology (Mammogram and/or Ultrasound). Mammogram is performed mainly for symptomatic patients who are more than 35 years of age as the younger patient tend to have dense breasts. For these group of patients, ultrasound will be more sensitive in picking up lesion in the breast. For asymptomatic patients, the recommendation is to start screening at the age of 40, to be done 1-2 yearly.
Treatment : Primary treatment for early breast cancer is surgery either in form of breast conserving surgery(BCS), or mastectomy with axillary clearance or sentinel lymph node biopsy. For those who underwent BCS, this has to be followed by external beam radiotherapy to the chest. Premenopausal patients with high grade, large tumour or lymph nodes involvement will be recommended for adjuvant chemotherapy. In some patients with locally advanced tumour, a neoadjuvant chemotherapy is recommended to downsize the tumour, making them more amenable for surgery. Hormonal therapy in form of Tamoxifen is recommended for Estrogen receptor positive patient regardless of the menopausal status. Aromatase inhibitors such as Anastrazole, Letrozole or Exemestane can only be used in ER positive, menopause patient or pre-menopause patient with ovarian ablation (medical or radiotherapy) or oophorectomy. Patients with over-expression of c-erbB2 / Her2/neu have a poorer prognosis but will benefit from immunotherapy using Tratsuzumab or Lapatinib. Threatment for metastatic breast cancer is mainly palliative. This may include systemic chemotherapy, cranial irradiation, hormonal therapy, radiotherapy to the ulcerated lesion or bone metastasis, or the the use biphosphonate
In many communities the stool of infants is considered harmless. However, infants are frequently infected with enteric pathogens and their stool are actually an important source of infection for others. This is true both of infants with diarrhea and for infants with other fecal-associated infection.
Fecal Flora of Infants
For normally health infants, the microbial population of feces is high. The numbers of aerobic and anaerobic bacteria reach as high as 10 /g weight. The composition of fecal flora in healthy infants consists of approximately 20 genera and 100 species to include:
- Bifidobacterium breve
- Closstridium paraputrificum
- C. perfringens
- Bacillus subtilis
- Lactobacillus acidophilus
- Escherichia coli
- Streptococcus bovis
- Pseudomonas aeruginosa, etc.
The presence of bacterial overgrowth and a quantitative and qualitative alteration of intestinal / fecal microflora is an important factor for the severity and persistence of the diarrhea and other fecal-associated infections.
Diarrhea is very common and can be life-threatening because of the dehydration and malnutrition it causes when untreated. Diarrhea is the second most frequent cause of death in children after pneumonia. It claims the lives of more than 2,000,000 children each year worldwide.
|Methods of Intervention||
About 10% of diarhea episodes in children less than 5 years of age have visible blood in the stool, and these account for about 15% of diarrhea-associated deaths in this age group worldwide. Compared with watery diarrhea, bloody diarrhea usually lasts longer, is associated with more complications, is more likely to adversely affect a child’s growth, and has a higher case fatality rate.
Rotavirus infections are the most common cause of severe gastroenteritis among infants and young children worldwide. Other common diarrheal diseases and illness include:
- Cholera caused by Vibrio cholerae
- Giardiasis caused by Giardid lamblia
- Cryptosporidiosis caused by Cryptosporidium parvum
Enteroaggreative Escherica coli (EAEC), an increasingly recognized cause of diarrhea in developing countries, has been particularly associated with persistent diarrhea (more than 14 days), a major cause of illness and death.
A number of interventions have been proposed for preventing diarrhea in young children and infants. Most of which involve measures related to infant feeding practises, personal hygiene, cleanliness of food, provision of safe water, safe disposal of feces, and immunization. For example, studies in Bangladesh have shown that safe disposal of young children, handwashing with soap and water before handling food, and handpump-water use for drinking and washing significantly reduced the diarrhea incidence in children in aged 6-23 months, compared to children living n households where none or only one of these practises was observed. As another example, Baltazar and Solon studied the relationship of disposal of feces of children under two years old and diarrheal incidence from a clinical-based case-control study in the Philippines. The results of this study showed that unsanitary disposal of young children’s stools was associated with an increase in clinically diagnose diarrhea and also in increase in pathogen-positive diarrhea relative to those who were following sanitary practises.
Hepatitis A is an infection of the liver caused by the hepatitis A virus (HAV). Young children and infants often have no symptoms or very mild symptoms of disease.
Adults and older children are more likely to have typical symptoms, which include fever, loss of appetite nausea, diarrhea, and generally ill feeling (malaise). The skin and whites of the eyes take on a yellow color (jaundice). Importantly, a person who has no symptoms can still be infectious to others.
|Methods of Intervention||
HAV is spread by the fecal-oral route. This means the disease is spread by putting something in the mouth that has been contaminated with the stool of an infected person. It can also be spread when a person eats food or drinks beverages which have been handled by a person infected with HAV and not subsequently cooked.
Outbreaks of hepatitis A among children and infants attending child care centers and persons employed at these centers have been, recognized since the 1970s. Because infection among children is usually mild or asymptomatic and people are infectious before they develop symptoms, outbreaks are often only recognized when adult contacts (usually the parents), become ill.
Poor hygienic practices among staff who change diapers and also prepare food contribute to the spread of hepatitis A. Children in diapers are likely to spread the diseases because of contact with contaminated feces. Good hand washing and hygiene practices are recommended to prevent the infection from spreading to other children and families.
Non-polio enteroviruses are common and distributed worldwide. Infection with them often has no consequences for the affected patient. However, these viruses are also associated with occasional outbreaks in which a larger-than-usual number of patients develop clinically-identifiable diseases, some of them with fatal consequences.
|Causes / Transmission||
|Methods of Intervention||
Replication of the enterovirus begins in the gastrointestinal or respiratory tract and once the virus is present in the blood stream, the disease may affect various tissue and organs, causing a variety of distinctive diseases. Transmission of the virus occur easily and the majority of infections are symptomless or mild in nature, the most common effect being a non-specific illness, with fever. Other manifestations include exanthems (rashes), herpangina (vesicular eruption and inflammation of the throat), acute respiratory disease, conjunctivitis, aseptic meningitis, encephalitis (inflammation of the brain), myopericarditis (inflammation of the heart tissue), and, occasionally, paralytic diseases.
Many enteroviruses are associated with specific syndromes, for example, the group B coxsackieviruses more commonly cause meningitis or myopericarditis and enterovirus 71 causes hand-loot-mouth disease (vesicular eruption and inflammation of the throat and mouth with rash) with or without encephalitis.
Many adults may have been infected with enterovirus 71 as children and, therefore, may be immune to reinfection. Infants, children, and adolescents ale less likely to have previously been infected with enterovirus 71 and are more likely to be susceptible to infection.
Measures that can be token to avoid getting infected with enterovirus 71 include frequent handwashing, especially after diaper changes; disinfection of contaminated surfaces by household disinfectants such as bleach (20 ml/litre of water) or rubbing alcohol (70% isopropyl); and washing soiled articles of clothing.
All enteroviruses infecting humans are found worldwide and humans are the only known natural hosts. Young children and infants are most susceptible to infection. In less developed areas, children may become infected during early infancy while in more socio economically advanced areas, first infection may not occur until adolescence. Transmission 6 is usually by the fecal-oral or by the respiratory route where there is an associated respiratory illness. Improved sanitation and general hygiene are important preventive measures.
From the Writer to the Reader
First of all, allow me to thank Madam Editor, Dr Nor Azlin, for “sms-ing” me her shortest message to have some write-up of my life experience. She must have a very good reason for asking or I must say that I have quite a story to tell. Being a life-time neighbour-turn-sister to Dr Nor Azlin, I saw my fingers blankly type OK before I even had time registering it let alone thinking about it. The next sms I received from her was a gentle reminder of the deadline which is like 7 days apart (inclusive my weekend retreat at Langkawi). Again, my replied was OK despite the fact that I was over occupied with my latest research in Langkawi. You see, I was in Langkawi on an invitation to check up a place located at an area believed to be a crater caused by a meteor from outer space that came crashing on the land some million years ago during dinasour age. Well…at least for now, you can pull my intriguing side-story away unless you are able to take some days off for a holiday trip there.
A Life Journal in the Making…
No, no I’m not into astronomy neither a fossil digger nor holding Mahsuri bloodline. I was just trying to be catchy that’s all. But in case you’re going there, make sure you tour the place called Mahsuri Ring, you’re sure to hear more about the legend. Before you move on, let me tell you what you are about to read is my own story being left unwritten. All I managed to do was either keeping some notes in the pages of my diary or as you might have intelligently guessed, are just left hanging in my thoughts. So, here is from me to you – a written report of my thoughts and life – Living Through Cancer During Pregnancy.
It was 8 years ago. I was 33 years old and had such a good life with family and friends. Leading a prosperous life, I always had been active and so full of fun and enjoyed every minute watching my children grow. The first is my daughter, Nur Ilham Kamilah and the second is my son, Ikmal Hakim. I had a great family, great job and was building assets. Somehow I wonder, if this wonderful feeling will last forever…
Having had two beautiful children, I thought it was just the right time to add more to my family. My prayers answered – I conceived my third child during the first few months in 2001. My two children grew, my pregnancy grew and …the tumour in my right breast grew. Little that I knew, there was a gradual change in my right breast. I started to recognise the change when the areola surrounding the nipple looked more wrinkle than the other. Then, the whole nipple was contracted inside. Surrounding flesh felt lumpy – one side hardened while rest remained soft. I tried dabbing it with soft towel soaked in warm water, hoping that the nipple will soften and back to normal but after a few trials, it looked as if it had its own mind and stubbornly stayed contracted. The whole right breast felt tight. Both my husband and I decided to find out what was happening and decided to confide in my gynaecologist who at the same time monitored my pregnancy. She called in a surgeon who immediately did a biopsy and asked me to wait for the result in 3 days. I had a mixed feeling – I knew that there is vigorous hormonal change during pregnancy and it may cause some changes or irregularities in the breast. Another voice from within sort of advised me to be ready for the worse result that could appear out of the biopsy test. Instinct told me to be strong and prepared and a lot of what-if came about. I even wondered why there seemed to be many talk shows on TV talking about breast cancer besides continuous reports on Sept 11 tragedy in New York (my biopsy done in the same week as the Sept 11 tragedy). Finally, I was in the doctor’s room ready to hear the result of the test. My instinct took hold and I knew right there and then, even before the doctor had to say anything.
I remembered my first question to the doctor was what I should do next. The next thing I knew, both my husband and I had to learn new vocabulary very, very hard and fast – surgery, abortion, chemotherapy, radiotherapy, adriamycin, taxol whatsoever – all this came into pictures and became our daily talks. Information was critical as I was held responsible (by myself) to make ‘wise’ decisions prior to any treatments. Both of us became glued to the internet whenever we had time to find out more and more of what’s-this-and-that. I had to deal with many specialist doctors coming from various departments i.e. surgery, oncology and gynaecology in the hospital (HUKM then, now PPUKM). My search for information did not end at one hospital, but a few others just to satisfy my gut feeling.
Cancer Treatment – do I have a choice?
It was quite an easy decision for me to follow the doctor’s strong advice for mastectomy. I knew I could not wait…and why wait when I knew the result of waiting will require my life! I was quick to understand that when there is a bad agent in the body, the best treatment is taking it out from the body. What a learned patient I was, I could almost hear sigh of relief coming from the doctors’ room; at least they could save their precious consultation hours for other critical reasons. Then, there was the pathology report of the surgery – the tumour was bigger than enough to request me for another big decision as to go for chemotherapy which had to be done within 60 days from surgery date; that means chemo had to be done while I was still in pregnancy. Well…this is it. My information seeking continued only more vigorously. I found it’s quite common and most of the time treatable in the U.S. I couldn’t find anybody with the same case here that I could turn to for peer support.
I went to my list of gynaecologists to just find out whether he/she has any resolutions for my foetus in case there is chemo complication and even asked them how is abortion like and the pain and the like. To my relief, all of them gave such good encouragement that both of us (mother and foetus) will be all right. However, all the doctors agreed that chemo could not put its toll too much on the foetus, thus I need to deliver the baby at the 8th month when the foetus size and being is good. I had the longest scan of the tummy to ensure this. To describe how I feel as the day of chemo getting nearer may require me to write a book!
Chemo had its two cycles while I was pregnant and it had been doing its job well without hassling me and my foetus. I had very minor nausea and my taste buds and energy level was quite normal – I had no complains. I was in high spirit all the way. Then I took a break from the chemo cycle just enough to allow me to deliver my baby. It was midnight and my husband was beside me all the way. The baby was small weighing 2.27kg which the doctor believed incubator may not be necessary. Early the next morning I found that my baby had to be pushed into NICU for breathing assistance. Fondly remembering his assuring twists and turns in my tummy, I could feel his level of energy and motherhood instinct assured me that the breathing assistance would only be temporary while he was adjusting to the real world – anyway, he was forced to come out remember?
The chemo continued one after another. Then, there were 20 times of radiotherapy. My husband told me that if there were hundred people looked like me, he would have no problems identifying me. Why? Because the radiotherapy mapping drew the biggest square-shaped tattoo on my chest skin! Anyway, it has gone out now.
How I Feel Having To Go Through All That
My pregnancy was five months old when I had mastectomy. Bearing my child while dealing with cancer gave me the inner strength I never knew I had. It gave me such unimaginable will power to push myself through the sickness. Suddenly losing a breast seemed small compared to my agony to live a healthy life not only for myself but for the baby I was conceiving. Apart from dealing with physical trauma, an equally tough challenge for me was dealing with negative thoughts and emotion. I learned not to feed my sadness, fear or any negative feeling as I felt these emotions were not only unpleasant but a complete waste of time and energy. You could feel sorry or extremely fearful but it would not cure you. Normally it just makes you feel more distorted. I come to realize that a sick mind cannot help a sick body. Of all the things I have done in my life, the ability to think in a healthy way is the most powerful which have helped me go through the challenges and gave such great courage.
I feel that having to go through two major challenges in life at the same time, is truly my calling. Looking back, I have no regrets having cancer and accept it willingly (if I’m allowed to choose) despite being a life-threatening disease. The experience of delivering a life when my own life was at risk had really awakened me with the essence of livelihood and the greatness of our Creator. Perhaps the journey of living through cancer has prescribed me with the need to do more soul-searching. What a wonderful reason to be alive! I hope that the writing of my life journal will inspire and brave the hearts of those affected by cancer in one way or another. Talking from my experience, information and knowledge is the mother of all cures. Knowledge would guide you to understand the sickness and the treatment positively. In endeavouring that, I would recommend joining a support group organized by any cancer-care societies like KanWork (Persatuan Kanser Network) and help out with organizing the activities. Not only it helps to enrich your knowledge but the social interaction and companionship with others is unbelievably stimulating and spiritually uplifting. Last but not least, I would love to take this opportunity to thank all my doctors who have poured such great devotion and have gone beyond requirement of their profession to touch my life. God Bless…
By: Nor Aida Kamaruddin