Showing posts with label pPROM. Show all posts
Showing posts with label pPROM. Show all posts
Monday, August 20, 2012
Premature Rupture of Membranes (PROM) and
Preterm Premature Rupture of Membranes (pPROM)
Premature rupture of membranes (PROM) refers
to a woman who is beyond 37 weeks' gestation and has presented with rupture of
membranes prior to the onset of labor. Rupture of membranes is more commonly
referred to as “water broke” or “broken sac”. Preterm premature rupture of membranes pPPROM) is a repture
of membranes prior to 37 weeks' gestation. pPROM
is associated with 30-40% of preterm deliveries and is the leading identifiable
cause of preterm delivery. pPROM
complicates 3% of all pregnancies and occurs in approximately 150,000
pregnancies yearly in the United States.[1][2]
Causes
pPROM is a bit more difficult to pinpoint causes, however it is likely due to the same mechanisms and premature activation of these pathways. However, pPROM appears to be linked to underlying pathologic processes as well, most likely due to inflammation and/or infection of the membranes. Clinical factors associated with pPROM include low socioeconomic status, low body mass index, tobacco use, preterm labor history, urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis. [3]
I was laying in bed while I was 25 weeks
pregnant with boy/girl twins, watching the evening news, when I felt wet “down
there”. I literally started
giggling as I thought to myself, “I’m only 25 weeks pregnant and I’m already
peeing my pants!” I got out of
bed, took my yoga pants off, and noticed it was a little more than the dribble
I felt. I walked to the bathroom
where I sat on the toilet, stood up, and a huge WOOSH of water came out. I knew right then and there that it
wasn’t urine, it was fluid, and that my water had broke. I called my OB and she told me to put a
pad on and get to the hospital. I
told them that at this point we were beyond a pad, hung up the phone, stuck a
towel between my legs, and headed to the hospital where they confirmed almost
immediately via an AmnioSense strip test that it was amniotic fluid. Looking back, I believe bleeding from a
subchorionic hemorrhage or hematoma present with
Baby A from weeks 9 until 17 deteriorated her sac and caused my pPROM.
Treatment and Risks
Unfortunately, there is no
treatment for PROM or pPROM. With
PROM doctors feel that, in the majority of cases, it is safer for both the
mother and baby to induce labor and deliver early. However, some doctors may choose to put a mother on hospital
bedrest and a non-stress test (NST) given daily to monitor the baby and ensure
there is no distress. Antibiotics
are likely to be administered to ward off infection. There remain different schools of thought, but PROM mothers
are likely to face immediate delivery.
The course of action for pPROM is significantly
different. Mothers are put on strict
hospital bed rest with constant monitoring unless there are other significant
risks to the mother and / or baby to consider including fetal distress. In those cases, immediate delivery is
suggested. The hope is to stop /
prevent labor and stave off infection for as long as possible with the goal to keep
the baby in for as long as possible until it is safer outside than inside. Since amniotic fluid is essentially
baby urine, a baby can last quite some time in a broken sac as long as
infection stays away. Magnesium sulfate is often given to stop labor and corticosteroid shots (ex. betamethasone) to help accelerate the development of the baby’s lungs. Magnesium sulfate is also linked to protecting the sensitive tissues of the brain in premature babies and can lessen the risk of cerebral palsy. An antibiotic regimen is also started to work against any potential infection and NSTs are conducted at least daily. Additional monitoring such as ultrasounds to identify size and monitor fluid levels may be prescribed as well.
An ultrasound was conducted that showed
Baby A, baby girl Keltie, had a broken sac and low amniotic fluid. Baby B, baby boy Colton, had a sac
still intact and both babies were not in distress. While in the admitting room, they also found I was
contracting every 3-4 minutes and I was immediately given a steroid shot (the
first in a series of two) and started on magnesium sulfate to stop the
labor. I was put on strict bed
rest where I couldn’t get up to use the bathroom or shower. But, I was willing to do anything to
keep the babies inside for as long as possible. I had three goals given to me: 1 – make it 24 hours for the second steroid shot, 2 – make
it another 24 hours past that to have the steroid series considered “complete”,
and 3 – make it to 26 weeks gestation where the survivability rate goes from
50% to 75% for the babies.
The vast majority of women proceed to go into
active labor and deliver soon after pPROM. With appropriate therapy and
conservative management, approximately 50% of all remaining pregnancies deliver
within one week after pPROM. Thus, very few women remain pregnant more than 3-4
weeks after pPROM. Spontaneous
sealing of the membranes does occur occasionally (< 10% of all cases),
mostly after pPROM that has occurred subsequent to amniocentesis; however, this
is the exception rather than the rule. [4] Women suffering pPROM should ensure
they are at a hospital with a Level III NICU capable of dealing with babies
less than 34 weeks gestation. If
not, a transfer request should be made to one able to handle complicated
premature babies.
I made it 4 days before Keltie stuck her
feet through my cervix and sent me into full blown labor. I was rushed in for an emergency
c-section and on January 24, 2012 at 3:19am at only 26 weeks and 1 day
gestation, I gave birth to two beautiful twins. Colton weighed 1lb, 13oz and Keltie weighed 1lb, 9oz and
both were 13 inches long. After
100 days in the NICU, Keltie joined us at home. Six weeks later and after 142 days in the NICU, her brother
Colton finally joined us – that was the happy ending we were waiting for. Today they are growing and thriving –
to learn more about our story, please visit: Project26WeekPreemies.
[1] http://emedicine.medscape.com/article/261137-overview#a1
[2] http://www.tommys.org/page.aspx?pid=972
[3] http://emedicine.medscape.com/article/261137-overview#a1
[4] http://emedicine.medscape.com/article/261137-overview#a1
Friday, July 20, 2012
After two years of infertility, multiple methods of advanced reproductive technology (ART), my fourth medicated cycle which was a converted one from IUI to IVF was successful. At my six week ultrasound, I found out I was carrying twins!
My pregnancy had some concerns. At seven weeks, they were concerned with Baby A’s yolk sac and its viability. However, a viability ultrasound at eight weeks showed this to be a non-issue. Then, at nine weeks, I started bleeding. I was diagnosed with a subplacental tear / subchorionic hematoma. I continued to bleed for eight weeks and it was a long, stressful time during my pregnancy. Finally, at week 17, it stopped and I breathed a sigh of relief. From that point on I was glowing! I felt like a million bucks, everything looked excellent with the babies on my ultrasounds, and I was so excited to be pregnant and enjoying my pregnancy to the fullest.
On Thursday, January 19, 2012, I was lying in bed watching the news and I thought I peed my pants. I literally got out of bed laughing because I couldn’t believe I was doing that kind of stuff at only 25 weeks. I took my pants off and noticed it was more than just a dribble – and then I went into the bathroom and I was gushing fluid. I knew right then and there that this wasn’t urine and that my water had broke.
I called down to my husband and told him we had to go to the hospital. He came running upstairs and couldn’t believe his eyes. I was hysterical but he grabbed me my phone so I could call the OB office and they told me to get to the hospital as soon as possible. My husband was literally frozen with fear – he was walking in circles and trying to secure the house and the dogs and I just lost it, grabbed my keys, and got into my car with him chasing behind me. I couldn’t wait one more second and just HAD to get to the hospital.
So, yes, I drove myself the 37 miles to our regional hospital all while on the phone with my mom, grandmother, and best friend (and fellow preemie mom) Julie. I made it in 30 minutes. My mom met me there and my husband soon followed. When I pulled into the hospital, I saw what I thought was the valet guy and literally hopped out of my car and handed him my keys. I didn’t care whether he was actually a valet or if I just gave my new car to some random guy in a red coat. I walked as fast as I could with a towel between my legs and made it to the birthing center where my mom was waiting. Note: it was a valet and I still have my car.
They started me on monitors for both babies heartbeats and contractions and they did a test that confirmed it was, in fact, amniotic fluid. I had suffered from preterm premature rupture of membrane (pPROM). The OB came in and did an ultrasound which did little more than confirm both babies were still breech and she did a physical exam and found that my cervix was still closed. I was apparently contracting, but didn’t feel them at all – I was 3-4 minutes apart when I came in! I was immediately given a steroid shot (the first in a two shot series) and they started me on magnesium sulfate to stop the labor. A neonatologist came in to talk with us and we were essentially told that at 25w4d gestation, the babies had a 50/50 chance of survival. We were heartbroken. But, the team of doctors (OBs, MFMs, etc…) were going to work as hard as possible to keep me pregnant for as long as they could.
I was then moved to a room in the birthing unit where I was monitored very closely. I was given an ultrasound Friday morning that confirmed it was Baby Girl’s sac that had broken and it was a full rupture. Her fluid level was considered “low”, but she wasn’t showing any signs of distress. In addition to the magnesium, I was given two antibiotics to ward off infection and because I tested positive for group B strep earlier in my pregnancy. That first night / morning is a blur to me – I wasn’t allow to sit up at all, had to urinate in a bed pan, and was literally left to lie in bed and do nothing. I was given three goals to try and make and they were:
- Goal #1: second steroid shot (Saturday at 1:30am)
- Goal #2: steroid series considered complete (Sunday at 1:30am)
- Goal #3: 26 weeks gestation (Monday)
I was moved to a new room in the birthing unit on Friday and I stayed there until Sunday morning. Again, I was closely monitored and completed the magnesium and steroid series successfully where I stopped contractions and it looked like labor was held at bay for the time being.
Sunday morning I was stable enough that they moved me to the maternity special care unit where I would stay until I delivered the babies. We didn’t know if that would be a few days or a few weeks, but we were hoping for the latter. I was allowed to finally get up, only to use the bathroom, and I could shower for five minutes a day. It was a lot of freedom compared to how I was monitored at the birthing unit. So many friends and family visited with me throughout the days I was in the hospital and on Monday night my mom came to watch the Bachelor with me…the last show I would watch before becoming a mom.
Before my mom left the hospital for the night, at around 10:00pm, the amniotic fluid that was leaking turned pink. The nurse came in and checked the babies and they sounded good and they hooked me up to the TOCO to check for contractions and there was nothing. The nurse spoke with my OB and they said that it can happen where the fluid changes colors and it was considered “normal”. At around 2:30am, I was having these lower abdominal pains – almost like I needed to have a bowel movement. I got up to try and go a few times but nothing happened. I finally called in the nurse and she checked the babies and both sounded good. She put me on the TOCO and it wasn’t registering anything. Then I was getting those lower abdominal pains more severely and I finally asked her to move the TOCO lower. Well, I was registering large, sustained contractions and so she called my OB once again. The OB came down to my room prior to her next c-section and did a “digital exam” to see if I was dilated and guess what? She looked up at me and said, “I can say I feel two little feet”. I about died. I was approximately 6cm dilated and Baby Girl had essentially kicked her feet through my cervix!
It was then like a scene from a movie – while they were rounding people into my room, I called my husband and we both knew he’d never make it. They made one attempt at an IV in my room and my OB finally said something along the lines of “we don’t have time for this – she’s got to go NOW”. I was then flying through the hallways – I was so scared that I was physically trembling. I went right into the OR and there wasn’t even time to give me a spinal so I was put under general anesthesia and that’s the last I remember before waking up in excruciating pain in recovery.
On Tuesday, January 24, 2012 at 3:19am I gave birth to two beautiful preemies:
- Colton Christopher weighed 1lb, 13 oz and was 13 inches long
- Keltie Grace weighed 1lb, 9oz and was 13 inches long
Both struggled mostly with breathing issues throughout their NICU stay. Other challenges presented themselves such as a pneumothorax (Keltie), nephrocalcinosis and hypertension (Keltie), bilateral hernia repairs (Keltie), severe reflux (Colton), aspiration of thin liquids (Colton), and retinopathy of prematurity or ROP (both babies). Keltie was discharged from the NICU at 100 days. Colton remained there an additional six weeks because of his spells which were related to his severe reflux – he was discharged at 142 days.
So – that is the birth story of our twins…or, as we refer to it, Keltie deciding to break her sac and then sticking her feet where they don’t belong. I can’t even begin to explain the amount of love I feel for these two peanuts. It actually overwhelms me at some points. They’re absolutely beautiful and fought long and hard to get to where they are today. I’ve learned to appreciate the small things – things that “normal” parents likely take for granted such as seeing their faces for the first time, touching them for the first time, their first poop, their first 1ml of breast milk feeding, overcoming breathing issues, etc… We are lucky to have them home with us – it’s wonderful to have our family together under one roof. More information about their NICU experience can be found at: http://project26weekpreemies.wordpress.com.
Monday, November 28, 2011
Our story actually
begins back in August of 2010, after 3 long years of battling IF my husband and
I decided we were ready to move forward with IVF. According to our RE it was
the "safest" way to hopefully have a viable pregnancy with the least
risk of mutiples. When the time came for our Egg Transfer, we were down to two
A quality embryos with two more that were B quality to be hopefully frozen for
later use. We made the choice to put those two A quality embryos back and two
weeks later we found out that our 1st IVF attempt worked! We were elated. We
also found out the other two embryos did not make it to freeze. It was another
4 weeks before our first ultrasound and I thought for sure I was going to have
to scoop my husband off the floor the first time, not one but TWO heartbeats
flickered on the screen and the doctor excitedly confirmed "IT'S
TWINS!"
I was sent home on
bedrest and told to follow up with my OB in a few days.
I ended up switching
OB's by week 14 because the OB we first went too was less the compassionate to
our situation and lacked bedside manners. It was around this time that we made
the decision for me to quit working as well. I remember always being to
exhausted (I must have slept 18 hours a day). Things stayed calm for a few
weeks until I got an alarming call from the OB just days before Christmas...my
AFI came back higher the normal (not uncommon in twins, but alarming
nonetheless). The day before Christmas Eve I was scheduled for an appointment
with a Peri, after finding out that all "appeared" well, they
revealed the gender of the twins... A BOY AND A GIRL... !!!! We were over joyed
and excited. I remember when we found out Twin A was a girl, hubby was holding
his breath until the tech revealed Twin B was a boy. He was covered in sweat
and pale. When he spoke he said, "I thought for sure we were having two
girls and I was going to spend a lifetime worry and cleaning my shot gun, at least
this way she'll have a brother to help me keep an eye on her." We all
breathed a sigh of relief.
And then the Braxton
Hicks contractions started, they were weird and unexplainable but nothing I
couldn't handle. The OB checked us and I had been to the Peri many times, all
was well, until Jan 12th. Something was off. I remember laying down for a nap
and feeling like I wet myself. For the most part I could have sworn there was a
baby on my bladder and I felt pressure and urgency. This caused my first visit
to L & D...after a 4 hour wait only giving a urine sample I was told
everything was fine and sent home, no sono, exam, nothing. This went on for 4
days and it was sporadic but uncontrollable. After another visit to L & D
and begging the on call to hear me out, they were convinced that I was
"leaking" amniotic fluid, but each baby's fluid level measured well
so I was sent home. the next day I saw the Peri again and Twin A's fluid was
very minimal. I remember the ultrasound tech leaving the room and the long long
wait for the Peri to come in.
Everything came to a
screeching halt.......words were flying around, "Micrognathia",
"ASD", "Possible VSD", "Not compatible with life if
born prematurely," "Risk for infection" and then
"Termination." The following words will forever echo in my mind, the
Peri (not our normal doc, but his covering doc) said, "I am sure this
pregnancy is very desired considering the route you took to become pregnant
however I am telling you that it would be safest to allow us to terminate Twin
A and give Twin B a fighting chance. And then we can test the other twin and
determine what caused all this." Thank God for my husband (who is often
quiet and reserved), he fought back when I was speechless and numb, I remembering
him saying, "Do you see that little girl on that screen? Do you see her
heart beating? That's OUR little girl, and not a chance in hell we'll
terminate. As long as her hearts beating we'll fight for her. She's not a
science fair project and she'd not a statistic for one of your textbooks. She's
a human being, and our child."
The Peri went on to call
us selfish and stated that "Clearly we didn't understand the risk, and I
could get an infection or worse. And we were risking loosing both babies."
At that point I found my voice and asked this Peri to leave. The ultrasound
tech was in tears with us, and paged my OB. Luckily for us he was in the same
location that day, and had me come in for an appointment. He explained all the
risks to us in a much more civil way and promised to support our choice. He
also helped us set up for a second opinion at another high risk center. I was
only 20 weeks along, babies born at 20 weeks don't survive. I was given a round
of antibiotics and sent home. Prepped for the worst...most pPROM (Preterm
Premature Rupture of Membranes) cases delivery within 24-48 hours.
Weekly appointments and
strict bedrest for the next 4 weeks...every day I prayed and cheered these
babies on. Pleading that they stay put. At 25 weeks I was admitted to L&D
for steroids, after they were complete I begged the docs to let me go home, the
thought of staying in the hospital was too overwhelming. The doctors understood
and sympathized but I would have to sign out AMA. In a bold move (that some
strong disagreed with), and with hubby's support I signed out. I came home on a
Friday. Saturday I felt ok, anxious but ok. Sunday I felt like I was coming
down with the flu. I couldn't get comfy and I felt like baby B was under my
chest and I was just plain miserable. By Monday morning (26 weeks) I knew
something was wrong. Before my husband went to work I attempted a shower, but
it didn't help. I was convinced this was it. Hubby called his boss and we
headed to the hospital. By the time they got the monitor hooked up right I was
contracting 3 minutes apart.
My OB walked in and did
an exam. Not dilated, but the look on his face told it all... Baby A
(Addison's) heartrate was dipping and the sky rocketing. My OB looked at me and
said, "Well Happy Valentine's Day! Your babies will be here by
lunch," he turned to the nurse, "Start prepping the OR." At 1:10
Addison made her debut and Blake arrived at 1:11. It took another 45 minutes to
stop my bleeding and stitch me up. The NICU team brought Addison by in her
"carriage", aka mobile isolette, and said "Hi Mommy," then
swoosh, gone. I don't even remember what she looked like. Blake was taken to a separate
OR with a separate NICU team, hubby was the only one who got to see him.
I "met" both
my babies for the first time around 6pm that night. It was then we were told
that Blake was stable, but Addison needed to be Baptized if we so desired (the
hospital only does them in life or death situations). It was all a blur I
nodded yes and the Pastor performed her bedside Baptism. I sobbed, the nurses cried
and then I was whisked off to my room in Mother/Baby to recover. I didn't make
it back to the NICU until much later when I was finally able to walk. By that
point the Neo had already paid us a visit and asked just how far we wanted him
to go with Addison... Without a doubt our answer was, "All that you can
do."
We later learned a lot
of things that we didn't know in the beginning. Addison left us for a period of
time once she arrived in the NICU, the doctors were sure she wasn't going to
make it. In the first 48 hours of life she had several chest tubes, was on the
Oscillator and we were warned that we might be faced with some tough choices in
the coming days. Blake was such a rockstart and did fairly well. He remained
stable most of his NICU stay. Once the dust settled, we learned that Addison
did not have Mircrognathia, she did have a PDA but no ASD or VSD. (How wrong
the Peri was). Genetically speaking all of her bloodwork was normal at this
point. Both of our babies continued to defy the odds every day.
They are both now 9
months old, we've had some rough times but we've all survive. Addison does have
a cleft palate that wasn't found until probably 35 weeks adjusted, and she had
surgery for a Nissin Fundo and G-Tube. Most of her nutrition comes from the
G-Tube, however we are working daily on increasing her oral feeds. Our goal is
to have her ready to transition away from the G-Tube after her cleft
palate repair in April/May 2012, so closer to her 2nd birthday. Blake came home
from the NICU on oxygen for feeds only and a monitor for about a month but is
otherwise doing well. He loves, loves, loves to eat solids and is undeniably a
Momma's boy.
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