By Melanie, Philadelphia, PA USAI spontaneously ruptured at 16 weeks, though we didn’t discovered the rupture until our regular ultrasound at 19 weeks. I had occasional leaking, which we and our doctors assumed was simply incontinence. We had almost no amniotic fluid which could be due to genetic defects, kidney problems, or a rupture. We scheduled an amnioinfusion to confirm ruptured membranes.
PROM at 16 weeksDelivery at 32 weeks + 3 days.
Story added: 2009-07-06
Fortunately, our specialist (Dr. Frank Craparo at Abington Memorial Hospital in Abington, PA) is one of few who perform the amnioinfusion. He injected dyed fluid into the uterus using a long needle inserted through the abdomen (opposite of an amniocentesis). If the dyed fluid leaks out, it confirms the PPROM diagnosis. Doing an ultrasound with the fluid in place also provided a much better picture – we could tell that our baby looked fine anatomically (including kidneys and a full bladder), that we didn’t appear to have any early visible complications from the oligohydramnios/anhydramnios (low fluid/lack of fluid, both of which described our diagnoses at various times). We were also able to tell our child was a boy.
In cases of spontaneous rupture as early as ours, the options were very limited and the prognosis is dire. The likelihood of labor onset and risk of infection make even reaching viability unlikely. If we did get there, the regular risks of prematurity were increased by the likelihood of developing pulmonary hypoplasia (lack of lung development). In the meantime, we’d be risking my health and even my life with the possibility of infection. Spontaneous “resealing” is always a possibility, but is uncommon. We basically were going to have three choices: pursue treatment, wait and see, or terminate. Termination is a very common course of action in cases such as these, and historically termination was the standard of care. We weren’t automatically opposed to termination, but preferred to explore the other two options before making a final decision.
One of the treatment options was serial amnioinfusion. Fluid is added every 3-7 days to maintain fluid levels. Among other requirements, the rupture has to be small enough to retain sufficient fluid during that interim period. I was not a candidate for Dr.Craparo's serial amnioinfusion protocol as my membrane was so ruptured that almost all the fluid leaked out by the conclusion of our discussion. Dr. Craparo also described the amniopatch you’ll read about online in addition to an amnioplug procedure performed by Dr.Sciscione at Christiana Hospital in Wilmington, DE. This procedure involves sealing the cervix and allowing the amniotic fluid to build up in the womb. We met with Dr. Sciscione but opted against this as the risk of “sealing in” a subclinical infection is not well understood and the effectiveness of the procedure is greatest when performed immediately after rupture (within several days). In other words, there was a significant but unknowable risk for almost no upside in our situation. We went to Johns Hopkins for a second diagnosis and consultation, which confirmed what we’d learned earlier. Most treatment options are for PPROM cases resulting from amniocentesis. We also talked to several doctors who practice “expectant management” for patients opting not to terminate. Under expectant management, both mother and baby are frequently monitored with particular vigilance on the mother’s health, especially in watching for signs of infection. At the first sign of infection (fever, discharge, tenderness), the baby is delivered no matter the gestational age. Normally, expectant management takes place in the hospital – the mother is admitted for the duration of the pregnancy.
As we explored treatment options, we were approaching Pennsylvania’s legal deadline for termination (without an exemption for health of the mother). It was an excruciating decision for us. We were terrified of forcing him into a life of pain and suffering (whether short or long) and of risking my health and life for such a slim chance of a good outcome, but alternately of having to look back and live with what might have happened otherwise. There was also always the possibility of a spontaneous healing or a spontaneous miscarriage taking the decision out of our hands. Our heads told us that the safe and smart thing to do was terminate. Our hearts told us that we wanted to know we’d given our son every chance to survive, and that we should (to an extent) let nature run her course. We ultimately went with our hearts and opted for expectant management. This was just before 24 weeks.
I had been on home bedrest since the diagnosis, and we continued our program of weekly doctor visits and proactive anti-infection measures (gallon of water a day, temps every few hours, super hygiene, no sex, light activity to preserve strength). We also rented a Doppler heart rate monitor (like those used in the doctor's office) to track fetal heart rate a few times a day. We did two courses of steroids, one at 24 and one at 27 weeks. We never did a course of antibiotics. Our doctors saw no benefit, since we’d discovered the rupture after several weeks had passed and they’re only proven to be effective when given immediately after rupture.
At 27 weeks I entered the hospital We had reached a point where our son was not only officially viable but where an early intervention detected through constant monitoring could potentially improve our outcome. In the hospital, I was on continuous fetal heart rate monitoring and we did an ultrasound every day. My amniotic fluid levels were normally around 1 or 2 cm. His heartrate never dipped or accelerated outside acceptable levels (90-180 bpm) even while in labor. I never bled and didn't have contractions until the day I delivered. We had a number of conversations about method and timing of delivery. In the end, we collectively decided to induce and attempt to deliver vaginally at 34 weeks. If he went into distress, or presented with standard indications calling for a C-Section, we’d go that route instead. Delivering at 34 weeks in these cases was the standard of care in our team, as his is the point where prematurity risks recede and become are outweighed by the risk of infection. Getting through hospital bedrest with continuous monitoring, was the most difficult thing I’ve ever had to do. I was able to get up to use the bathroom and shower once (or twice) a day, and got to leave the room only to visit the ultrasound center. It’s impossible to get long periods of sleep - when he moved, the nurses had to come in and adjust the monitor, unavoidably waking me up. It was the worst part of the entire ordeal.
We didn’t have to wait until 34 weeks – our son Marcus came on his own at 32 weeks and 3 days. I had back labor slow building through the day, peaking at night. When we got to labor and delivery, he came quickly and with no complications. The best part of the entire experience was when Marcus came out and started crying. We were ecstatic. Marcus was passed to the neonatology group immediately for treatment. We got to give him a kiss before they wheeled him away to the NICU. It is imperative to be at a hospital with a good level 3 NICU. Visit beforehand and make sure you are comfortable with their philosophy and confident in their medical capabilities.
In the end, he needed respiratory assistance (ventilator for 1 day, CPAP for a few more days, and at six weeks of age still has oxygen cannulas at a very low flow and blend). His prognosis is good, though. We think he’ll just need a little more time for his lungs to develop and catch up, and that he’ll be off of oxygen shortly after coming home, if not before. His feet were cramped in the womb due to the lack of fluid, and they are curled inward, though the orthopedic staff believes they are fixable with range of motion exercises. We're still in the NICU, but he’ll probably be coming around roughly around his due date.
This is one of the most difficult situations a person can face. Be confident that whatever decisions and choices you make, you are doing the best you can for your family. If anyone would like more information, feel free to contact me at melanie.anderson25@gmail.com