By Mona Dash, Orpington UK
PROM at 14 weeks + 5 days. Delivery at 31 weeks + 5 days.
Story added: 2007-08-28

It had been a perfectly normal Thursday , I had worked from home, but suddenly started feverish in the evening. My husband was out on a work dinner so I ate early and decided to go to bed. I went to the kitchen to put my plate back when I suddenly felt a gush – I thought I was bleeding, but there on the kitchen floor was a pool of colourless liquid. My first thought was I wet myself, but looking at the liquid, I knew it had to be amniotic fluid. I was only 14 weeks 5 days, this couldn’t be happening!!

It had been a long journey for us already. In 2000 I lost my first baby, a boy to a rare inherited genetic disorder called Severe Combined Immune Deficiency (www.scid.net). He was 8 months of age and after his death we were told that I had a 50%:50% risk of having another affected child if it was a boy. A girl however would be healthy or at most a carrier like me.Scid is not treated in India.

We moved to the UK from India in 2001, but it wasnt till May 2004, that we decided have another baby. In Jan 2005 I was diagnosed with endometriosis which had created large cysts in both ovaries . A laparoscopic surgery followed; 2 cycles of clomid, but 18 months later I still wasn’t pregnant. The only resort was IVF and we decided to do one privately with a consultant Mr S (who had performed my laparoscopy)in August 2007. Then I found I was pregnant in July! We were delighted that finally it had happened and that too naturally.

At 6 and 7 weeks I had some minor bleeding, but scans in the Early pregnancy diagnostic unit (EPDU)unit showed us a nice little sac and a heartbeat. I was prescribed Clexane injections throughout the pregnancy by Mr S as I had high protein C. This stopped the bleeding. Mr S was also a NHS doctor and he asked me to come to his maternity clinic in Farnborough hospital. I consider myself lucky to be under the care of excellent staff- a positive and good doctor as Mr S , a caring GP and midwife,a sincere EPDU nurse, other staff such who were all sympathetic about my background.

With the first trimester ending I assumed things would go normally; my nuchal scan in Kings college, London had also gone well so my only worry was the sex of the baby for a boy would carry a risk of having Scid. I was to have a scan at 15 weeks in Kings to check for the sex of the baby. Depending on what we saw, we would decide if we would do an amnio to check for Scid.

But at 14 weeks 2 days, I once again had some bleeding and made frantic visits to the EPDU and Mr S- both scans showed baby swimming in fluid. Mr S did ask me (it was only the evening before) if I had fever as he thought the bleeding might be from an infection- but I had been fine.

When my husband returned that Thursday night he found me burning with fever. After that gush, I continued to leak even though I was lying flat.I had to wear a sanitary pad as liners weren’t working and my pants got soaked. Strangely neither of us thought of going to the hospital- I meant to call the midwife in the morning and take her advice.B

She couldn’t believe that it was a fluid loss so early on, and suggested I try to meet Mr S through the GP. I got an emergency appt at the surgery and met my GP- She listened to the baby’s heartbeat and to my relief it was loud and clear! After checking my urine sample she prescribed me antibiotics as she thought it might be an UTI . She also fixed an appt with Mr S in a private hospital and he came to see me even though he didn’t have clinic that evening.

A scan showed minimal fluid and we could hardly see baby now- no more little flips and hand waves. Mr S did a swab and got some bloods taken to check for infection, I was prescribed oral Metronidazole, for a suspected vaginal infection .

The urine culture was negative, and the swab showed a bacterial infection. We went for a scan with Mr S 5 days after the rupture and had naively thought the fluid would have increased since there had been hardly any leakage following that incident. But the scan was again fuzzy. Reality hit me as I listened to Mr S telling us that this was quite a serious condition with a risk of prematurity etc etc - I fainted in shock as it sank in that this pregnancy would probably never get back to being a normal one. He prescribed erythromycin as a general antibiotic to be continued.

We went to Kings for the sex check scan, but the appointment was now focussed on the premature rupture and fluid levels.The reaction we got there was worrying to say the least. I was scanned thrice by different levels of doctors- and each of them pronounced the worst. The main risk was pulmonary hypoplasia , and there were many other smaller issues to contend with. On top of that, it looked like it was a boy even though the scan wasn’t clear due to the lack of fluid – so we had the additional risk of Scid. King’s advice was we would need to terminate the pregnancy , but on other hand since my AFI was 1.2 and I was infection free they agreed that we needn’t take a decision that very day. I was given an appointment in 2 weeks though the senior consultant said, 'I don’t think you will be back’.

As it happened we were back. Baby had grown and the detailed scan to check his heart, kidneys etc was all good. He was in a breech position and my placenta was also low, though they expected it would move up as the pregnancy progressed.

Thus it continued throughout the pregnancy- 2 weekly scans in Kings, 2 weekly checks by Mr S , weekly blood tests to check infection levels.Though the doctors didn’t think bed rest was of any help, I wanted to do the best I could to keep baby and it just seemed a safer option to not move around. My parents came over from India to help us and this was a godsend. I drank litres and litres of water, cranberry juice, probiotic yogurt to keep myself infection free. I was also a member of the prprm group and hung on to the stories of hope. It was only due to some of the positive stories I read that I decided to disbelieve the King's doctors and hold on to baby.Everytime we went for a scan, I would look at the fuzzy shape and silently tell him 'Baby, you hold and I will hold'

Inspite of the doom and gloom predicted by Kings (one consultant guaranteed us that this pregnancy wouldn’t work!!) my AFI increased slowly, it was just short of 5 by about 24 weeks, plus there were pockets of fluid near the cord and face which wasn’t being included in actual index calculation. Mr S remained positive and assured me he would do his best to give baby the best chance possible.

Things remained steady till I reached 24 weeks 3 days. At 2 am on Dec 19th I had a little bleeding -enough to send us to the hospital. Once again a heartbeat monitoring showed baby was fine and happy, but I had to stay in for observations for a minimum of 24 hours.

Two days passed without incident, but just when I was about to be discharged .I suddenly felt another huge gush and found my pad soaked with bright red blood. Placental abruption was my first thought! The nurses told me to stay calm and just rest; I had an appt with Mr S in outpatients, so my husband sent him a message about my bleeding. He came to see me and assured me it was a case of my low lying placenta moving , and not an abruption, I was put on complete bed rest .

But the next day, the doctor on ward duty got me checked with a speculum and thought I was 1.5 cm dilated. He made arrangements to transfer me to a hospital with level 3 NICU. Inspite of my insistence of getting Mr S opinion before being sent off to a hospital across town, the doctor didn’t pay any heed and in a few hours we were in an ambulance headed to Queen Charlotte hospital.

My arrival was an anticlimax as the staff there were waiting to deliver a 24 weeker, but found me fine with no contractions! They did another speculum check and thought it was normal, in fact the doctor said that no one ‘see’a dilation without doing an internal examination.The general opinion was that I was sent off as they didn’t want to take a risk of my complex case during the holidays season. I had to stay as Queen Charlotte didn’t intend to send me back till 28 or 32 weeks, if I made it to then .

Weeks went by. The fetal medicine consultant , Dr S assured me the risk of pulmonary hypoplasia was small as my AFI had never really been below 1, he couldn’t however rule out any underlying lung issues. Queen Charlotte was a much nicer hospital with excellent staff, my only problem was that they didn’t prescribe erythromycin . Mr S had continued me with it as erythromycin prolongs a pprom pregnancy and secondly he didn’t want the baby to be born with an infection in case it was a Scid baby. I have to confess I continued my antibiotics on the sly as I trusted M S’s judgment.

I stayed in Queen Charlotte till 28 weeks without any major incident.My placenta moved to a normal 5 cm from the cervix; the fluid levels were now on the low end of normal and baby’s growth was perfect. There was a scare that I might have gestational diabetes , but the fasting test came out negative. They decided to transfer me back to my local hospital Farnborough. This time I insisted I had to be under the care of Mr S and team ; I was discharged after four days of observations as things were normal.

My follow up protocol included blood tests twice a week , monitoring in the day care unit, appointments with Mr S. I was back on erythromycin and my clexane was to continue till the delivery. Apart from the protein C clexane also had an inflammatory effect which might have helped in keeping my womb infection free.

We went for one more scan in Kings at 30 weeks, my fluid levels were on the low end of normal around 10. They told us we needn’t be monitored by them anymore and could be scanned at the local, strangely they did not seem pleased to see me carry the pregnancy so far!!I don’t think I really sealed for I had a few drops of something every now and then- I hoped it was urine! My CRP remained consistently below 5 or 10 , though the WBC remained inflated throughout. A date for a C section had been fixed at 37 weeks, since baby was still breech a c section was inevitable.

After 31 weeks though, I felt increased leakage and it seemed cloudy as if there were epithelial cells in it. I was also increasingly uncomfortable as I was very constipated perhaps from a lack of movement and high dosage of iron tablets due to low Hb during the pregnancy. I was 31 weeks 3 days when I got a low backache and didn’t feel enough movement from baby. I thought of going to the hospital to be monitored but knew they would keep me back and another prolonged hospital stay wasn’t appealing . But in the middle of the night I went to the toilet to find a very small clot of red blood- again it wasn’t much but I felt the familiar panic rising me. My husband agreed we needed to go to hospital specially as I still was in pain.

I was immediately strapped on to the heart monitor, and once again, baby’s heartbeat was fine, though the graph also showed up uterus tightenings. They did a speculum but didn’t find dilation. The doctor on duty Dr R, a lady from Mr S team worried. She wanted to keep me in, but the hospital was full, so I would have to stay in the labour room. My backache seemed to have gone, and I mentioned we had a scan with Mr S that evening privately so somewhat appeased, she let me go with the promise that I come back immediately if I felt in the slightest bit uncomfortable. We lived about 10 minutes away from the hospital.

The evening’s scan showed adequate fluid around baby- but I was leaking so much that as I got on to the scan table, I felt my trousers were wet and there was a wet patch on the chair. My backache had come back , but not as bad.Mr S was pleased to see I made it so far and said he would do the C section himself.

Later in the night though the pain increased.Assuming it was constipation I kept going to the toilet in the hope it will make me feel better I tried to sleep but the pain was coming and going, I was feeling very uncomfortable and constipated. I couldn’t take it anymore and we left for the hospital around 2.30 am.

Before they put me on the monitor I tried once more to go to the toilet- as I was straining, there was a pop and a lot of fluid came out again. A second rupture?! This time when I was hooked on the monitor they registered clear contractions. At that moment my husband I looked at each other and thought.. this is the night then.. A doctor came in to do a speculum and through all the leaking fluid he thought I was well dilated, they would need to do an internal. It was normally avoided in case of Pprom, but considering I was to deliver the risk of infection didn’t matter now.

Dr R came in, she was on duty that night as well and I was relieved to see her, she did an internal and then quickly started giving instructions to the team. M husband asked ‘is she 3 cm dilated or so?’ And the answer was ‘Its much much more, we hardly have time’ I could have delivered vaginally if baby hadn’t been breech! And I had gone through all that pain not even knowing I was in labour, so strong was my denial to have baby at 32 weeks.

The rest of the night was as if a dream.I was rushed to theatre and given a spinal. Outside it was snowing very hard, in fact we had reached the hospital in time for the snow was creating roadblocks . After some 15 minutes the anesthetist told us baby is out.
‘He’s out but hes hes not crying?’I heard myself ask my husband.. hardly had I finished the sentence there was a loud cry and within minutes they wheeled him out in a special incubator. I just got a glimpse of a little round perfect face.

My lovely baby Krish Varun Misra was born at 5.05 am on 8th Feb 2007 on a beautiful snowy morning.He was due on the 8th April, so he was almost 2 months premature.

The pediatricians came round to me in the recovery room. Krish was fine, weighed 1.8 kilos which was good considering his age , he was on CPAP and apart from some dry skin he didn’t have any of the problems cited by Kings. He needed the CPAP for only a few hours the first day, he did get jaundice but recovered from it in a couple of days. Within the first 8 weeks of life, he needed two inguinal hernia operations but that was an effect of prematurity rather than pprom. He certainly has a good set of lungs as he can scream very loudly!

It is another matter that as per previous discussions between Guy’s Hospital and Gosh, his cord blood was sent for testing and we knew on the evening of his birth that Krish had SCID as well. At 5 days he was sent to Gosh, London for a bone marrow transplant.

He had a stem cell transplant from his dad as door at 6 weeks, and since then we have been in relative isolation at home. His cell counts are now almost normal and he has functioning T cells- we go to Gosh for monthly checkups and pray for the time he also regains his B cells which would mean he wouldn’t need any Immunoglobulins.

This is a very long story but I wanted to write down all the details as concisely as possible and hope it will help others to retain faith that pprom is not always negative. Everyday was a big question mark and the stress was excruciating but it was all worth it.Pprom is an ugly condition and theres no treatment for it and most doctors are horrendously negative- I felt that the bed rest, fluids, erythromycin and lots of prayers contributed to things working out for me. Barring a few, I met some great medical professionals who treated my case with a lot of attention.

Indeed it is a real miracle that today I have a very smiling lovely little baby in my arms.

Feel free to email me if you have questions and I will help if I can!