QuestionQUESTION: Hello, I hope you can help me. I am pregnant with baby #3. Some background: My first pregnancy was full-term and I delivered a healthy baby boy after my water broke first, then I began to have contractions and went into labor, my 2nd pregnancy was compromised due to a subchorionic hematoma that bled at 5 weeks on and off up until 11 weeks, when I bled quite heavily and passed many clots. After 2 months of bedrest, it seemed the clot had resolved, baby was doing fine and I was allowed off bedrest. Then at 28 weeks 1 day, my water broke in the middle of the night. Went into the hospital, was placed on bedrest and did not have any contractions until 3 weeks later, when I began to have contractions they allowed me to go ahead and I had the baby naturally at 31 weeks. He was VERY sick, had severe RDS, developed BPD, was in the NICU for 3 months and was on oxygen at home until he was one year old. He's great now, 4 years old and very healthy, considering his difficult beginning. This 3rd pregnancy has been fine, but of course we've been very nervous about another premature birth. My OB said we were fortunate to have some kind of explanation for the previous premature delivery, that the hematoma may have led to the pPROM, thru irritation or making the placenta not very healthy, or something along those lines, and since I wasn't having any problems with this pregnacy so far that the odds were good I would not go into premature labor again. She offered to do two cervical length ultrasounds to measure & compare and see what showed up. My 1st vaginal u/s showed a closed cervix with a length of 2.75 cm with no change while bearing down at 25 weeks. My 2nd u/s at 28 weeks this past Wednesday showed a cervical length of 1.7 cm with a change to 1.2 cm while bearing down and v-shaped funneling (I'm sorry, I don't remember the measurement of the funneling, but it was a very large & distinct shape on the u/s). Previous to the u/s my doctor did a fFN and after the u/s she sent me to the hospital to go on the monitors and to wait for the test results. The monitors showed no contractions, and the test came back negative and they sent me home. My care plan is to receive a fFN every 2 weeks, but no bedrest, just reduce activity, no sex, no heavy lifting, etc. My questions: Is this treatment aggresive enough considering the implications of another premature baby? Will my cervix continue to shorten? What happens if it does? Will my cervix begin to open/dilate? I've felt no contractions or pain, so how will I know if my cervix continues to open? Will this shortening/funneling cause my water to break again? Will I be able to carry this pregnancy for another 12 weeks, considering my cervix changed so much in the last 3 weeks? Should I be asking for more monitoring or more aggressive treatment to keep this baby in longer? I'm sorry for such a long story, but I was trying to think of all information that might help you!
ANSWER: Dear Amy,
I'll try to take your questions one at a time so I don't miss one...
1. The treatment of pelvic rest and a fFN every two weeks seems appropriate. Obviously staying off your feet as much as possible would be a great thing, but full bedrest would not necessarily be indicated at this point. The pelvic rest should prevent any undue stimulation of the area which might result in a hastening of any cervical dilation and the fFN can be a great predictor of impending labor.
2. Your cervix may or may not continue to shorten. It depends. The pelvic rest and additional rest could definitely slow down that process. Also remember not to strain in any way - even with stools. If you are in any way constipated, that will need to be addressed with the doctor so that you are not even tempted to strain.
3. If it does continue to shorten, your doctor will likely put you on complete bedrest as a first step. At home to begin with and, if there is no halt to the shortening, then probably in hospital.
4. At a certain time, once the cervix shortens to a thin enough point, dilation or opening of the cervix will begin. You need to think of the cervix like a slinky toy - or at least the way a slinky works. If the slinky is stretched out to about 4 cm, that is normal. When the slinky begins to squeeze in shorter and shorter that is the same way a cervix thins out or effaces. At 4 cm is considered 0% effaced; once it is paper thin, it is 100% effaced and ready for delivery. The frequent monitoring your doctor orders should help to determine whether there are ANY cervical changes, including any dilation beyond the funneling. Some doctors will order weekly ultrasounds if changes warrant it.
5. Cervical weakness or incompetence is one of the few identifiable causes of PROM. 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. This is something that will need to be monitored and I'm sure is why your doctor will want frequent fairly ultrasound checks.
6. Again, with the prescribed treatment, the shortening may slow, so there's no way to know how long you will be able to carry the pregnancy. However, any pregnancy that goes to 37 weeks is considered full term, so you actually only have a 9 week goal. :-)
I hope this has helped you and answered your questions. I wish you well.
Brenda
---------- FOLLOW-UP ----------
QUESTION: Hi Brenda! Thanks for getting back to me and for being so helpful. I have a couple of follow up questions, now that you have addressed my previous ones.
1) My doctor has already said that they would not do any more TVU to measure my cervix, that the fFN would give them better information as to if I were to go into labor or not prematurely. But, as I understand it now, the fFN is not predictive of continued cervical shortening & funneling which can lead to the physical effect of the bag of waters protruding into the opening cervical os and rubbing against it and possibly bringing about pPROM. In my previous pregnancy, this is what I experienced, I believe. My water broke at 28 weeks without any contractions or other indications, and it wasn't until 3 weeks later (after hospital bedrest for my pPROM) that I went in premature labor with contractions. I'm not just concerned about PTL contractions, I'm concerned about preventing pPROM.
2) My doctor explained to me that the cervix is dynamic, that it can change throughout the course of pregnancy but obviously, mine shouldn't be so short this early! But, is it possible that it could lengthen with the pelvic rest and reduced activity or even bedrest? Or is it more likely that it would stay the same, approximately?
3) I feel better when I am looking at a situation as realistically and with the best information I can receive. I understand that you cannot answer with any certainty what is going to happen in my individual situation, but would you guess in an educated way that it is probable that this pregnancy will end prematurely? I have done a lot of research and reading on this subject, but my doctor refuses to give me any indication one way or another on this question. I think she doesn't want to scare us or worry us, but I would rather have a better idea of what to possibly expect, I am much more comfortable with a realistic viewpoint.
4) Do you think that if I ask for additional care, as far as either more frequent office visits or more TVU's for cervical assessment, that a doctor would accommodate this request from a patient? I am concerned that unless I am actually contracting or leaking water they won't look at me twice. I am concerned that they are only considering the negative value of my fFN on April 23rd, and not what I am experiencing. I want to prevent pPROM & PTL as aggressively as I can, if I can, by voluntary bedrest if need be and more monitoring by my doctor's office. What if they say it's not necessary?
Again, thank you for all your help!
AnswerDear Amy,
I think the only new thing here that I didn't already address is the voluntary bedrest. If you want to put yourself on bedrest - or near bedrest - that is something you can do on your own. They may tell you it is not necessary due to the fFN results, but I truly believe that if you explain that you want to try to avoid a repeat of a 28 week delivery and two years of a sick child as aggressively as possible, they will understand and be empathetic to all of your concerns. I can't imagine that they wouldn't if they know your previous experience.
Be well! Good Luck!
Brenda
