By Terri, Mesa, AZ USAMy story is long, but I wanted to include as many details as possible to hopefully help others in my position. Please feel free to e-mail if you have questions.
PROM at 21 weeks + 2 days. Delivery at 32 weeks.
Story added: 2010-07-15
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After a completely uneventful first pregnancy (induced at 41 weeks, no complications during or after pregnancy), we were shocked when our next pregnancy ended in miscarriage at 12 weeks. Our doctor said it was OK to try again right away, and this pregnancy also ended in miscarriage (the baby stopped developing at about 8 weeks). With both of these losses, I had subchorionic hemorrhages (bleeding that may have been due to implantation).
We went through a panel of tests that revealed I had a gene mutation (MTHFR c677t) that some suggest may be responsible for miscarriages, but no clotting disorders or other obvious reasons. (My OB suggested miscarriages increase with age, and I was now 37.) A high risk perinatologist suggested I take extra folic acid (800mg / day) and a baby aspirin daily and gave us the go ahead to try again.
We became pregnant quickly, but at 5.5 weeks gestation, I began bleeding heavily (on a Saturday). The bleeding lasted several hours and included a few large clots, one the size of a silver dollar. I was convinced we had again miscarried and was shocked to see a beating heart and a baby measuring right on track when I went in for an ultrasound the following Monday. They determined that the bleeding had come from another large subchorionic hematoma. I was advised to stop the baby aspirin, maintain the extra folic, and when I asked about them, my OB prescribed progesterone suppositories through the first trimester.
I had weekly ultrasounds which showed the baby growing on track, but hematoma remained. (It continued to grow for the next 3 weeks or so, reaching 60 cm cubed. (My ultrasonographer calculated volume by multiplying the 3 dimensions together and dividing the result by approximately 2. I'm not sure why they use this measurement of volume, but it did allow us to compare size across u/s's, since the measurements would vary depending on the shape of the clot.) After week 9, the clot started to decrease in size, and by Week 16 they were unable to find it. I had my Level 2 U/S at 19 weeks and things looked like they were going well. (During this time I avoided lifting anything over 10 lbs, and generally took things easy.)
At 21.5 weeks, I felt a gush, and was certain I had another hemorrhage, however the fluid was clear. I called the OB on-call that evening and was told it was probably just normal discharge and to call my regular OB the following morning. I did so, and was advised to go to OB triage to make sure it was not amniotic fluid. A fern test, and a second test (Amnisure) were negative, and I was sent home. A few days later, at 22 weeks, I had another small gush. Another call to the (same) on-call OB had him assuring me that pPROM was very rare (1 / 1000 he told me) and that my earlier hemmorhage "barely" increased my risk. I was not confident in his advice, and ended up going in that evening to OB triage. This time, the fern test was negative, but the Amnisure test was "faint positive." A confirmatory U/S showed an amniotic fluid index of 5cm, which is very low. I was admitted immediately for pPROM and my care was transferred to a high-risk maternity group.
I spent 4 days in the hospital receiving IV antibiotics to ward off infection. No cervical examinations were done, as infection is a serious risk after pPROM. I was sent home on oral antibiotics for 6 days, ordered to maintain strict bedrest, and told to return at 24 weeks for admission for the duration of my pregnancy. Although concerned, I am grateful that the doctors remained optimistic and hopeful for a successful outcome, especially after reading many stories of discouraging doctors.
At 24 weeks, I was admitted and was given steroid shots to help the baby's lungs develop. I was told that they would be monitoring for infection, which was the biggest risk to the baby at this point. My temperature was taken every 4 hours around the clock and I was to report any abdominal pain. The baby's heartrate was also monitored daily. The doctors said if I went into labor, they wouldn't try to stop it because it usually means a subclinical infection and the baby would be safer out than in. They also said no more antibiotics would be given as it doesn't reduce the risk of infection any more than what I had already taken, and there are side effects of continued use. I received growth u/s's every 3 weeks. I asked about more frequent u/s's but they said that the results wouldn't change the treatment plan so it wasn't warranted. At each of these u/s's my AFI measured between 1 and 5 cm. I leaked fluid almost daily. Things remained uneventful until I began bleeding at about 26 weeks. I was tested for placental abruption and the test was negative. U/S also showed no obvious abruption. The doctors stated that sometimes small abruptions aren't detectable and as long as the baby was growing well, it was still safer to keep him in rather than delivering. For the next 6 weeks, I bled every few days, but everything progressed satisfactorily. The source of the bleeding was never found. I asked for, and was granted, continuous monitoring of the baby. The monitors were inconvenient, but I was very worried about cord prolapse, or something else happening and not knowing about it in time to do anything. The continuous monitoring really helped ease my mind, even if it made my stay physically less comfortable. I was vigilant about hygiene and limited visitors to reduce the chance of any infection. I also drank at least 1.5 l of water and an Emergen-C drink daily.
At 28 weeks I was given a "rescue dose" of steroid shots and told this would be the last dose, as research showed additional doses could be harmful to the baby. Doctors also said if I made it to 34 weeks they would induce, as the risk of infection at this point becomes greater than the risks of prematurity.
At 32 weeks I began having contractions that became more frequent and painful and began bleeding slightly more than usual. To this point, my monitor occasionally picked up a contraction or two that I had not felt. Ironically, even though I reported the painful contractions to the nurses, they stated that it wasn't showing on the monitors. I was told to empty my bladder, drink water, and was given a shot of terbutaline to stop contractions. (I initially objected to this, as I had been told no attempt would be made to stop labor. The nurses explained that at this point, they weren't sure if the bleeding was causing the contractions or the contractions were causing the bleeding and the terb would let us know. I consented, and the contractions lessened, but only slightly.) Within 6 hours, the contractions were very painful and I finally convinced the nurses to call the doctor. I was transferred from antepartum to labor and delivery at 615am and by the time they had me connected to monitors, the contractions were strong and only 3 minutes apart. A cervical check showed I was dilated to 3 cm. By the time of the next cervical check, the nurse could feel the baby's head. They called for the doctor, but I delivered my 3lb 15oz son to the hands of the L&D nurse at 657am before the doctor could arrive. Isaac was breathing and crying at birth with APGAR scores of 8 and 9. I held him for a moment and he was immediately brought to the NICU while I underwent a D&C for retained placenta.
Our son had a rough first 48 hours. He quickly developed pulmonary hypertension and was having difficulty breathing. He was put on a ventilator, given steroid shots and surfactant to help develop his lungs, and eventually placed on nitric oxide. I believe the NO saved him. By his 3rd day he was breathing room air only and continued to do very well. We had a few NICU scares of infection, but he did very well in general and came home on day 27 at 36 gestational weeks. He was sent home on an apnea monitor which went off a few times a day until he reached his due date, then he occasionally suffered from what doctors identified as reflux-related apnea spells (where he would reflux, hold his breath, and his heartrate would drop. These were always self-correcting and never seemed to pose a serious risk.
Isaac is now 5 months actual and doing well. We expect his doctor will cancel the apnea monitor at his next check-up in a few weeks. We will be both sad and happy to see it go. His last reflux-apnea was over a month ago and was only 3 or 4 seconds in duration. Presumably even term babies do this sometimes but it's not identified because most aren't on monitors.
It was a scary, intense roller-coaster ride, but I was happy with the research-based care I was receiving and as difficult as the 9w hospital stay was on me and my 2yo son, it was worth it in the end.