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Pregnant After PROM (PAP) Guidelines Whether you are preparing to be pregnant after PROM (PAP), or you're already PAP (and if you're already PAP, congratulations!), you probably have many questions about how you and your health care team can best manage a PAP pregnancy. The members of the PROM list have created these PAP guidelines using our own experiences and research to help you and your health care team minimize the possibility of repeat PROM, and maximize the opportunities for carrying your baby or babies to term. Many health care practitioners believe that PROM is a "fluke" -- especially if there were no signs of cervical weakness or infection at the time the rupture occurred. Your practitioner may believe that the odds of experiencing repeat PROM are very, very low, and might not recommend any changes to your management, monitoring, testing, or activity in your PAP pregnancy. It is true that the odds are good that you will not PROM again, even without making any changes in how you manage your PAP pregnancy. Many members of the PROM list have had successful PAP pregnancies by following only some of the PAP guidelines listed in this article -- or none at all -- according to what was appropriate or realistic to their circumstances. However, you should also know that many women do experience repeat PROM. Because the possibility of repeat PROM does exist, we thought it would be useful to put together a comprehensive list of PAP precautions. Much of the information in this article reflects what the PROM list members have learned from their PAP pregnancies, and what they found helpful for identifying potential problems. This article presents a very conservative approach to managing a PAP pregnancy, and will be especially useful for women who would like to feel that they are doing everything in their power to avoid a repeat PROM. Keep in mind however, that these guidelines are not "one size fits all." Because a PROM-free pregnancy is not guaranteed even if you follow every one of these guidelines exactly, some women will opt for additional precautions on top of what is in this article. Other women may find that the PAP guidelines require a level of caution that is not appropriate or realistic to their situation and may choose to follow only some or none of these guidelines. Since you know your body better than even your doctor, it is only appropriate that where your pregnancy is concerned, you do what works best for you. The key is to find what works for your own peace of mind. Print out this article, discuss the PAP guidelines with your health care practitioner and your family, and adapt them to your needs and constraints, especially if you have small children who require your help and supervision. If at any time during your PAP pregnancy you have the sense that something is wrong, including signs of preterm labor, contact your health care practitioner immediately. For a description of the symptoms of preterm labor see the March of Dimes website: [http://www.marchofdimes.com/pnhec/188_1080.asp]. This article provides primarily practical information and doesn't address the
anxiety and other emotional challenges that often accompany a high-risk pregnancy.
We invite you to join the PROM list so that we can provide emotional support
through your PAP pregnancy, and share our experiences with you. We've also included
some online and book resources at the end of this article that can help you
and your family cope during your PAP pregnancy. Finding the right health care practitioner Some health care practitioners are much more proactive with PAP pregnancies than others. Because you have experienced PROM, you should find a practitioner who is knowledgeable about high-risk pregnancies (including PAP pregnancies) and is willing to work closely with you to follow the appropriate standards of care. The practitioner you select should also be sensitive to the fact that you may be quite anxious in your PAP pregnancy and should be willing to be available to answer questions and to allay any fears that he or she can. Depending on where you live, the practitioner you select may be an obstetrician, a perinatologist, a nurse-midwife, or other type of practitioner. When choosing your health care practitioner, ask:
Testing and monitoring The scope and frequency of testing and monitoring during your PAP pregnancy will depend on your health care practitioner's expertise and philosophy, as well as whether your health care team was able to pinpoint the cause of your PROM. The amount of testing and monitoring you receive also may depend on practical factors like how far away you live from your practitioner or hospital, and your transportation situation. The following are tests and monitoring you may want to request or discuss with your practitioner. Don't be shy about requesting more testing based on your own comfort level. Consider printing out information from the websites listed to show your practitioner in case he or she is unfamiliar with the tests or their benefits. Trans-vaginal ultrasound Cervical weakness is one of the few identifiable causes of PROM. Health care practitioners routinely monitor for weakness in the lower half of the cervix to prevent preterm birth. However, most practitioners do not routinely screen for changes in the upper half of the cervix which can also dilate and shorten, giving it a funnel-like appearance. This cervical "funneling" occurs when the internal portion of the cervix closest to the baby begins to open. A funneling cervix can allow the bag of waters to slip down into the cervix and rub against it, which could cause PROM. Members of the PROM list have reported cervical funneling as early as 12-13 weeks into the pregnancy. Cervical funneling cannot be detected during a speculum or vaginal exam, which only evaluates the lower half of the cervix. Trans-vaginal ultrasound is the best way to detect cervical funneling because it evaluates the entire cervix, including the upper half. In addition to identifying cervical funneling, trans-vaginal ultrasound and monitoring will allow your practitioner to detect other cervical change such as:
If your practitioner detects any cervical change, including funneling, he or she may recommend strict bedrest and/or placing a cerclage to help keep the cervix closed. (See the cerclage section of this article for more information.) Monitoring for cervical changes is important even if your practitioner believes that you do not have an incompetent cervix (IC) because you had a previous full-term pregnancy or a normal-length cervix after you PROM'd. The cervix is a dynamic organ and it may look very different after PROM than before the rupture occurred. Members of the PROM list have found that cervical change is often detected between 15 and 24 weeks of pregnancy, perhaps from the growing weight of the baby and amniotic fluid. During this period, more frequent (weekly, instead of bi-weekly) monitoring is ideal. For a more in-depth discussion about the advantages of trans-vaginal ultrasound, see this article: www.obgyn.net/us/us.asp?page=/us/cotm/0002/Monteagudo Bacterial infection cultures Along with cervical weakness, bacterial infection is one of the only identifiable explanations for PROM. Bacterial infection can weaken the membranes to the point of a premature rupture. Whether or not a bacterial infection caused your PROM, it is important to do routine tests to make sure that bacterial infection does not complicate your PAP pregnancy. Ask your health care practitioner to do wet preps or cultures, not just a dipstick test. A culture is more accurate because the sample is given time to grow or show traces of the infection, compared to a pH or dipstick test which can sometimes give misleading or inaccurate results. Also, a culture can more accurately pinpoint what medication will be effective to treat the infection. Be aware that the health care community is divided about which bacterial infections require treatment during pregnancy and at what point during the pregnancy, and whether long-term antibiotic use is advisable. If you think you should be treated even though your practitioner does not feel treatment is necessary, do more research and present the information to your practitioner. Infections to test for and treat as soon as possible include:
Monitoring for early first-trimester bleeding Early first trimester bleeding can cause a premature rupture if a blood clot becomes lodged in your uterus and weakens the membranes. Many women experience some bleeding in the first trimester and do not experience PROM, so don't be alarmed if you experience first trimester bleeding. However, you should alert your health care practitioner to bleeding at any point in your pregnancy and ask for a high-level ultrasound if you need reassurance. fFN (fetal fibronectin) test Fetal fibronectin (fFN) is a protein produced in pregnancy that functions as a "glue" attaching the amniotic sac to the uterine lining. The fFN test measures the amount of fetal fibronectin in vaginal secretions (performed like a pap smear). A determination that the fFN "glue" is disintegrating may be a sign that a woman is at risk for preterm delivery, even if she is otherwise asymptomatic. The fFN test is most useful in ruling out preterm delivery. In other words, a negative fFN test is a reliable predictor that delivery will not occur in the next 2 weeks, but a positive fFN test does not necessarily indicate that preterm delivery is imminent. Most health care practitioners will not order an fFN test before 22 weeks since it is normal for there to be some fFN in the vaginal fluids up until then. If you are asymptomatic, your practitioner may not order repeat testing. Also, your health insurance may not cover initial or repeat testing if you are not showing any other signs of preterm delivery. For more information about the fFN test, see www.ffntest.com. Preventative measures In addition to monitoring and testing, you may also be (or become) a candidate for one or more of the following preventative measures or interventions. Discuss with your health care practitioner as early as possible whether any of these measures -- or some combination of all -- would be appropriate for you. Cerclage If your previous PROM pregnancy was linked to cervical weakness or irritability (also known as "incompetent cervix" or IC), your health care practitioner may recommend preventative cerclage to stitch your cervix closed. A preventative cerclage can be put in place as early as 12 weeks, before any cervical change occurs. Some women opt for preventative cerclage even if it is unclear whether their PROM was related to cervical weakness. Because of the risks associated with cerclage (see below), your practitioner will likely not recommend preventative cerclage if there is no evidence indicating that you have cervical weakness or that funneling is taking place. If you or your practitioner feel strongly that preventative cerclage is appropriate for you, make sure you both understand the reasons and the risks. As an alterative to preventative cerclage, you can take a wait-and-see approach and opt for cerclage only if your practitioner identifies some cervical change. The cervix is a very dynamic organ and can change very quickly so if you decide to take this approach, it is extremely important that you are monitored weekly to ensure that the emergency cerclage can be put in place in time to be effective. The types of cervical change your practitioner will look for include:
Regular monitoring is critical as your cervix can appear long and closed one week, only to show the changes described above at your next appointment. A cerclage can be done on an emergency or as-needed basis, except under certain circumstances such as if you are more than 4cm dilated or once PROM has already occurred. Members of the PROM list have found that cervical change is often detected between 15 and 24 weeks of pregnancy, perhaps from the growing weight of the baby and amniotic fluid. During this period, weekly (rather than bi-weekly) monitoring is ideal. The general belief is that the earlier a cerclage is put in place, the more effective it is in correcting cervical weakness. There are two types of cerclage: cervical (four variations) or transabdominal. The type of cerclage you receive generally depends on your practitioner's expertise and the length of your cervix. Transabdominal cerclage is typically used if a woman has a very short or almost nonexistent cervix. A transabdominal cerclage is permanent and requires birth by caesarean section. A cervical cerclage is usually removed at the 37th week to allow for a normal delivery, unless there is a reason to remove it earlier. There are some risks of cerclage, including infection, preterm labor, and even PROM. In addition, your cervix could be damaged either from the stitch or if you go into labor before the stitch is removed. There may also be some other risks depending on what type of anesthesia you choose for the procedure. Discuss types of cerclage available, risks, and long-term implications with your practitioner. It is important not to dismiss cerclage as a viable form of treatment simply because you had a prior full-term pregnancy or because your cervix looked long and closed after PROM. As discussed in the monitoring section, the cervix is a dynamic organ and can change very quickly in a short period of time. Pressure from the growing baby and increased amniotic fluid can cause a weak or incompetent cervix to funnel, dilate, efface, or ripen (or some combination) leading to PROM. After the amniotic fluid is lost, the pressure on the cervix lessens and the cervix may return to its "normal" shape by the time of post-PROM examination, leading doctors to mistakenly rule out cervical weakness as the cause. If you are unsure whether a cerclage is necessary, talk with your practitioner about frequent monitoring. For more information about cerclage, see this website: http://pregnancy.about.com/cs/incompetentcervix/a/aaincomp.htm P17/17P shots Weekly injections of 17 alpha-hydroxyprogesterone caproate (known as 17P or P17) have been shown to reduce the risk of preterm delivery. Members of the PROM list have had success with preventing preterm labor and controlling "irritable uterus" syndrome by using P17 shots in their PAP pregnancies. Discuss with your health care practitioner whether weekly P17 shots are right for you, and at what point in your pregnancy you should begin the shots. Also, check with your insurance to see whether this therapy is covered. For more information about P17 shots, see this website: www.hydroxyprogesterone.com. Progesterone supplements Progesterone supplements (usually administered as vaginal suppositories) are sometimes given in the first trimester to support implantation of the embryo and the developing pregnancy. Progesterone supplements after week 12 may also reduce the risk of preterm delivery, similar to P17 shots. Discuss with your health care practitioner whether supplemental progesterone is right for you at any point in your pregnancy. Tocolytic therapy If you start showing signs of preterm labor, your health care practitioner may prescribe tocolytic drugs to slow down or halt your contractions. Common tocolytic agents include magnesium sulfate, terbutaline (administered orally or subcutaneously via a pump), nifedine (Procardia), and indocin. Members of the PROM list have reported receiving magnesium sulfate and/or terbutaline as early as 17 weeks. Talk with your practitioner about whether or when tocolytic therapy would be appropriate for you. Day-to-day guidelines This is a list of day-to-day guidelines compiled from PROM list members' suggestions. Taken as a whole, these guidelines represent the most conservative approach to managing a PAP pregnancy, and are especially useful for women who are looking for a comprehensive list of PAP precautions others have found helpful so that they can feel that they are doing everything in their power to prevent recurrence. Keep in mind, however, that following these guidelines exactly may require a level of caution that is not appropriate or realistic to your situation. Many members of the PROM list have had successful PAP pregnancies by following only those guidelines below that made sense in their circumstances -- or even ignoring them all (including the precautions about sex and orgasm). The key is to find what works for you to give you peace of mind. Adapt these guidelines to your needs and constraints, especially if you have small children who require your help and supervision. You may want to print out this list and have your health care practitioner check off all the boxes that apply to you. General guidelines - apply to entire pregnancy from positive home pregnancy test through delivery Everyday Activity
Additional PAP guidelines for after the first trimester In addition to the above, add the following: Monitoring and Preventative Measures
Support and resources A PAP pregnancy is considered high risk and will likely be very different from your PROM pregnancy or any previous full-term pregnancies. Like any high-risk pregnancy, a PAP pregnancy is a team effort for you, your partner, your family, your friends, and your health care team to tackle together. Here are some of the many online and book resources available for high-risk pregnancies that can help you and your loved ones weather the emotional, physical, and interpersonal challenges ahead. Online support
Article by Kay Squires & Holly Norman, january 2005 © 1998-2024 Inkan, The PROM Page
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