Presented at First National Mind & Body Case Study Seminar, Hospital Kuala Lumpur. 27 September 2016.

1. “Saya nak cuci, doktor”
A depressed pregnant lady with
osteosarcoma
Dr Umi Adzlin Silim
Consultation-Liaison Psychiatrist@HKL
First #NationalMindBody
Case-Study Seminar 2016
Double Tree by Hilton,
The Intermark.
27 September 2016

2. 39 years old muslim
married housewife, G4P5,
with history of
osteosarcoma, diagnosed
2 years ago, currently
pregnant at 6 weeks
The Story of Puan Maimon*
(*not her real name)
She was referred for psychological
assessment in view of her request for
TOP
She was crying like a child!
Kept repeating “Saya nak cuci doctor,
tolong saya doctor”
She is a pious woman
A prayer mat and telekung at her
side..

3. Her osteosarcoma of left femur…
• She had a wide resection of tumour and chemotherapy,
currently ‘in remission’ and on surveillance
• She was walking with a walking aid, fully independent
on her ADL and functioning as a housewife
• Orthopaedic, oncology and O&G team stated “no
contraindication for pregnancy however she is to
deliver via LSCS because she can’t have a lithotomy
position”

4. Psychological assessment…
• She had depressive symptoms upon knowing that she was
pregnant a week prior to consultation: tearful, insomnia,
losing appetite, losing focus, feeling hopeless but not
suicidal.

5. Understanding her reasons for requesting
TOP…
•Difficulties with her mobility, how will she carry
her pregnancy?
•Difficulties to have regular antenatal follow up;
partly due to her mobility, financial constraint
and distance/inconvenient housing and clinic
set-up
•Difficulties to care for the newborn

6. Is there an
indication for TOP
from mental health
perspective

7. The Story of Zuria: A Muslim Girl, with Gang-
Raped Pregnancy
• 17 years old matriculation student being gang raped by foreigners
when walking alone
• Presented with abdominal pain in ED with UPT positive at 7 weeks
• PTSD symptoms, depressed, and deteriorating academic performance
• She and parents requested for TOP

8. The Story of Anisa: Should cancer kill twice?
• 27 years old with 3 children, diagnosed breast cancer during her
previous pregnancy, currently pregnant at 6 weeks, requested TOP
• Completed active intervention, mastectomy & chemotherapy
• Stage was uncertain, a lesion in the liver initially thought as a
metastases but no change post-chemo so most likely not
• Surgical team & oncologist – no contraindication to continue
pregnancy
• Psychological assessment
• – no depression/psychiatric morbidity

9. The Story of Lili:
My husband hit me in pregnancy
• 30 years old lady, G2P1, with last childbirth
4 moths ago, currently pregnant at 8 weeks
• Requested TOP due to poor spacing and lack
of support with intimate partner violence
started during her first pregnancy
• Had taken over the counter medication to
abort baby but failed
• Very depressed, feeling hopeless and
worthless, but her first baby was what kept
her going & protective to her in terms of
suicidality

10. Is there an
indication for TOP
from mental health
perspective

11. SURVEY OF
PROFESSIONAL DECISIONS

12. For each woman
who came forward
to request TOP in
public healthcare
setting, how many
did not come and
‘solve’ their
problems their own
way?

13. 2012
The Guideline on Termination of
Pregnancy in Government
Hospitals was developed to
create awareness among
government health care
professionals of the complexity
of the issues of induced
abortion and to be mindful of
existing provisions given by the
professional ethics, legislation,
religion and reproductive rights
during consultation with the
woman client.

14. Worldwide, the law
pertaining abortion
varies widely
influenced mainly by
culturally sensitive
perspective

15. Legal Perspective
• In Malaysia, induced abortion is ILLEGAL
under Act 574 of the Penal Code.
• However, an EXCEPTION clause has been
added to Section 312; a medical practitioner
registered under the Medical Act 1971 who
terminates the pregnancy of a woman if such
medical practitioner is of the opinion, formed
in good faith, that the continuance of the
pregnancy would involve risk to the life of the
pregnant woman, or injury to the mental or
physical health of the pregnant woman,
greater than if the pregnancy were
terminated.

16. Source: Facts on Abortion in Asia. 2015. The Guttmacher Institute. New York

18. Religious Perspective: Multi-faith views and considerations from Islam, Buddhism, Hinduism, Christianity.

19. Health Perspective
• ….` in circumstances where
abortion is not against the law,
health systems should train and
equip health service providers and
should take other measures to
ensure that such abortion is safe
and accessible. Additional
measures should be taken to
safeguard women’s health’

20. controversies
challenges
different perspectives
loopholes?
subjective
what is mental health injury?
Pro-life vs pro-choice
avoidance
stigma and taboo

21. Defining Mental Health Injury
Young (2008) considered mental health injury as a mental harm, suffering, damage,
impairment or dysfunction caused to a person as a direct result of some action or
failure to act by some individual. The mental health injury must reach a degree of
disturbance of the pre-existing psychological/psychiatric state such that it interferes
in some significant way with the individual’s ability to function.
Lord Llyod made the distinction of mental health injury clear in Page vs. Smith (1995)
by stating that it must occur in a recognizable psychiatric illness and not just shock,
grief, distress or some other emotions. Worth mentioning, in the context of
unplanned and unwanted pregnancy the emotions of shock, grief and distress may be
considered as ‘normal psychological reactions’ that are common and expected.

22. Applying Medical Model
Mental health indications for ‘therapeutic abortion’ should basically apply similar
medical principles in determining the indications for TOP based on other medical
reasons.
If the medical risks of continuing pregnancy to the mother outweigh the risks
of terminating pregnancy, TOP maybe indicated.
This must take into consideration on whether the condition is treatable or
untreatable, manageable or unmanageable, modifiable or non-modifiable
and whether all appropriate measures have been taken before decision for
therapeutic abortion is made, most of the time as the last resort.

23. Applying Medical Model: Examples
For example, TOP is not
indicated for mothers with heart
disease which is manageable
unless she is in a situation when
it involves life-threatening risks
for example Eisenmenger’s
Syndrome.
Similarly, TOP as in therapeutic
abortion context is not indicated
for mothers with depression as
treatment is available and
should be offered unless it
involves life-threatening risks
such as acute suicidality.

24. Possible Mental Health Indications for TOP
• Current severe chronic mental Illness with life threatening condition
or high risk of harming self or others - Chronic mental illness include
schizophrenia, bipolar disorder and severe mental retardation
• Acute suicidality – This risk is assessed by determining whether the
patient has immediate intent to harm self, and whether she has a
specific plan in mind.
• Anticipated long term severe mental Illness based on current clinical
condition (e.g. severe PTSD)

25. Resolving Issues of ‘Sole Psychosocial
Economic Reasons’
The practice of TOP solely due to
psychosocial and economic reasons is
against the law and not acceptable to
the major religions in this country.
Strengthening preventive measures and
psychosocial support is our priority.

26. Handling Religious Sensitivity
• The religious and cultural sensitivities of the patient and the medical practitioner
involved in the practice of the TOP should be taken into consideration before
embarking in TOP.
• The decision for TOP should be guided primarily by medical needs (i.e. mental
health injury) and the religious sensitivities of both the patient and the medical
practitioner involved as being practiced in some other medical procedures.
• This is in line with the ethical stand of Malaysian Medical Council when it comes
to medical technologies not approved by major religions for example in
reproductive technologies such as sperm bank or surrogate pregnancy (Malaysian
Medical Council 2006).

27. The story of Zuria: A Muslim Girl, with Gang-
Raped Pregnancy
• 17 years old matriculation student being gang raped by foreigners
when walking alone
• Presented with abdominal pain in ED with UPT positive at 7 weeks
• PTSD symptoms, depressed, and deteriorating academic performance
• She and parents requested TOP

28. Possible Mental Health Indications for TOP
• Current severe chronic mental Illness with life threatening condition
or high risk of harming self or others - Chronic mental illness include
schizophrenia, bipolar disorder and severe mental retardation
• Acute suicidality – This risk is assessed by determining whether the
patient has immediate intent to harm self, and whether she has a
specific plan in mind.
• Anticipated long term severe mental Illness based on current clinical
condition (e.g. severe PTSD)

29. The story of Anisa: Should cancer kill twice?
• 27 years old with 3 children, diagnosed breast cancer during her
previous pregnancy, currently pregnant at 6 weeks, requested TOP
• Completed active intervention, mastectomy & chemotherapy
• Stage was uncertain, a lesion in the liver initially thought as a
metastases but no change post-chemo so most likely not
• Surgical team & oncologist – no contraindication to continue
pregnancy
• Psychological assessment
• – no depression/psychiatric morbidity

30. Possible Mental Health Indications for TOP
• Current severe chronic mental Illness with life threatening condition
or high risk of harming self or others - Chronic mental illness include
schizophrenia, bipolar disorder and severe mental retardation
• Acute suicidality – This risk is assessed by determining whether the
patient has immediate intent to harm self, and whether she has a
specific plan in mind.
• Anticipated long term severe mental Illness based on current clinical
condition (e.g. severe PTSD)

31. What We Did
Medical & Dentistry
Advisory
Committee (MDAC)
as a ‘neutral’
committee assisted
in decision making
for TOP

32. The story of Lili:
My husband hit me in pregnancy
• 30 years old lady, G2P1, with last childbirth
4 moths ago, currently pregnant at 8 weeks
• Requested TOP due to poor spacing and lack
of support with intimate partner violence
started during her first pregnancy
• Had taken over the counter medications to
abort baby but failed
• Very depressed, feeling hopeless and
worthless, her first baby was what kept her
going & protective to her in terms of
suicidality

33. Possible Mental Health Indications for TOP
• Current severe chronic mental Illness with life threatening condition
or high risk of harming self or others - Chronic mental illness include
schizophrenia, bipolar disorder and severe mental retardation
• Acute suicidality – This risk is assessed by determining whether the
patient has immediate intent to harm self, and whether she has a
specific plan in mind.
• Anticipated long term severe mental Illness based on current clinical
condition (e.g. severe PTSD)

34. What We Did
• Regular psychiatric care
for depression – on
medication & intensive
psychological therapies
• Ongoing support for
intimate partner violence
– ensure her safety,
emotional support and
empowerment

35. 39 years old muslim
married housewife, G4P5,
with history of
osteosarcoma, diagnosed
2 years ago, currently
pregnant at 6 weeks
The Story of Puan Maimon*
(*not her real name)
She was referred for psychological
assessment in view of her request for
TOP
She was crying like a child!
Kept repeating “Saya nak cuci doctor,
tolong saya doctor”
She is a pious woman
A prayer mat and telekung at her side

36. Possible Mental Health Indications for TOP
• Current severe chronic mental Illness with life threatening condition
or high risk of harming self or others - Chronic mental illness include
schizophrenia, bipolar disorder and severe mental retardation
• Acute suicidality – This risk is assessed by determining whether the
patient has immediate intent to harm self, and whether she has a
specific plan in mind.
• Anticipated long term severe mental Illness based on current clinical
condition (e.g. severe PTSD)

39. What’s next? What We Did
• Motivational interviewing approach – goal-directed patient-centered
psychological intervention for behavioural modification
• Recommended a review by a physiotherapist to assist with mobility in
pregnancy
• Recommended a review by a social worker to assist on finance, and
options of childcare/adoption
• Recommended a multidisciplinary meeting following reviews of the
above to make a decision on TOP/supporting the pregnancy

40. Management

41. Management
(Beyond deciding for TOP or not!)
For any patient who is not
indicated for TOP, they must be
offered adequate psychological
and psychosocial support for
continuation of her pregnancy

43. Standardizing Assessment & Management
Primary Care to Obstetric Care

44. Strengthening of Counselling Components
• Pre-assessment counselling
• Pre-abortion counselling
• Post-abortion counselling
• Motivational interviewing – for
women requesting TOP but has no
indication

45. Coordinating Pathways to Support
Psychosocial & Practical Support, Home, Rehabilitation, Spiritual & Religious Engagement, Education, Skills Training, Adoption

46. TAKE HOME MESSAGE on Management
(Beyond deciding for TOP or not!)
For any patient who is not
indicated for TOP, they must be
offered adequate psychological
and psychosocial support for
continuation of her pregnancy

47. No woman will have to
suffer in silence like her
The Story of Puan Maimon*
(*not her real name)
“Saya tahu semua ini salah, doctor…
tapi…”
“… tapi saya nak cuci, doctor, tolong
saya doctor”
If only we can do more for her…
Thank you ©umiadzlin@gmail.com