Planning a 3rd pregnancy after 2 previous pPROMs?

[Lousli]

This is going to be really long, so a medal for you if you make it to the end!

I know that you can't actually give me medical advice, but I'm not yet even pregnant, so this is more of a WWYD kind of scenario. I'm thinking about becoming pregnant again, at 37, after having had 2 previous pPROM's resulting in a 36 week and a 33 week birth. My kids are now 8 and 5 and both totally fine.

The first was with no warning of any kind, water just broke and after an uncomplicated labor my daughter was born at 5 pounds 4 ounces and went home with me immediately. Some jaundice, sleepiness, and nursing trouble that all worked out okay. My second was more complicated because i was having contractions without dilation or effacement starting quite early on and was given terbutaline for them.

Then at 32 1/2 weeks I caught a stomach virus and things got complicated. I ended up going in to the hospital contracting 3 minutes apart and throwing up. In the end, there was a long series of complications, including 3 sleepless nights, lots of throwing up, contractions 8 minutes apart that couldn't be stopped, and pulmonary edema from the terb+IV hydration. I was given a diuretic for that, and on one of the many trips to the commode, my water broke. Up until that point I was not dilated and only about 50% effaced. I had a negative fetal fibronectin test. My daughter was born about 5 hours after my water broke and required a 3 week NICU stay.

I think the complications had a lot more to do with her premature birth than with my first one, and I'm inclined to believe that she would not have been so early if I hadn't been so sick. With that said, a recent trip to my OBGYN (who may not be the one I end up seeing if I become pregnant) confirms that they'd see me as high risk for preterm delivery and would probably send me to a perinatologist.

She talked about progesterone shots (which I am fine with), steroid shots (also fine with me), possible bedrest or leaving work earlier (which I will see how I feel about), and fetal fibronectin tests (which I am hesitant about having too frequently.) She did say that she thought it was very likely that I could have another late-term preemie but that she wouldn't consider me too high risk for a very premature baby.

So, now that you have all the background, here are my thoughts/questions. Do you think there is any benefit to having a very medicalized pregnancy in this scenario? Do you think that frequent fetal fibronectin tests would be useful (given that they don't predict PROM and that the one I had with my daughter was negative?) What do you think about the use of terbutaline or procardia in a patient with a history of lots of preterm contractions that were not productive but who ended up with a preemie anyway due to pPROM? Basically, I'm wondering how someone who is a little more natural minded would advise me now that I have the advice of an OB. I'm still going to seek out the advice of a perinatologist too.

[mothercat]

Your question is probably going to be moved to Birth and Beyond, but before it goes anywhere I'd like to ask a question or two.

Did anyone check for a change in vaginal flora such as seen with bacterial vaginosis?

Dr. Saling in Germany has been working toward a preterm birth solution for almost 35 years. Inflammation of the cervix is a major cause of the cervix not being able to stay closed for the entire pregnancy. A change in vaginal pH is the first indicator that the vaginal mileau is changing and inflammation may quickly follow.

Here's the link to his site (English version) and the program he runs. I have had e-mail contact with his institute and they are very willing to answer questions.

Most of what you need to know, and what to discuss with your doctor is found on his site.
http://www.saling-institut.de/eng/04...2programm.html

good luck

[Lousli]

I'm wondering about how much effect that has on PROM though? Both times, my cervix was closed right until my water broke and i went into labor. With my first, water broke at 9:30, I arrived at the hospital at about 11, not yet contracting much, and my first check I was just a fingertip dilated. My second, even though I was having many contractions, I wasn't having cervical change. And even when I did get ill and was contracting a lot, my cervix was still barely a 1 when my water broke.

I will ask about the bacterial vaginosis though, it definitely seems like one more thing to consider. I was GBS+ with my younger daughter.

[Peppamint]

I would also check into BV... and I wonder about herbs/supplements for creating a strong bag of waters. Vitamin C and Zinc are both good.

[mothercat]

The PPROM occurs because of an ascending infection from the vaginal area to the cervix and then the membranes and fluid. PTL and PPROM are two sides of the same coin. Saling recommends that women check their pH 2x/wk and if they notice a change in the pH, call their provider immediately for confirmation and/or treatment. Strongly recommends the use of probitiocs to maintain the normal pH and beneficial bacteria in the vagina. GBS and the bacteria that are associated with BV are opportunistic infections. They have a hard time getting a foothold if you have adequate levels of lactobacillus (beneficial bacteria) and normal vaginal pH. However, if those things are altered; GBS, BV and other vaginal infections like candida will be rampant.

My background: I spent about 5 years doing chart reviews for the statistical side of Roberto Romero's "Great Inflammations of Pregnancy" project at Wayne State University in Michigan. he was one of the physicians who established the link between cervical inflammation and PTL/PPROM. From his work came the steroid/ Ampicillin/ Erythromycin protocol that is now standard management with PPROM.

Read through Saling's stuff and there is a provider page that you can share with your doctor. Good luck!

[mothercat]

Forgot to add that one of the treatment options is the use of Gyneflor vaginal creme. It contains estrogen and lactobacillus. The estrogen helps the lactobacillus get established faster.

Gyneflor is a European/Canadian brand, but you can get a compounding pharmacist to make it up for you.

[Lousli]

Thank you, this is such great information! Would this be something you'd suggest getting going on while ttc or not until pregnant?

[mothercat]

Not sure of the answer to that. Probiotics started early won't hurt, but should have the BV/yeast/GBS thing checked out before TTC. That way you'll have a baseline and a healthy start. The important thing is to keep checking during the pregnancy so you know if things are changing toward altered vaginal flora.