Preterm Premature Rupture of the Membranes

Or PPROM for short.

On my last post here, I mentioned the unexplained bleeding I was having at around 15 weeks. It ended up continuing for another 14 days and then completely went away. Then late last week, we went along to the 20 week morphology scan.

Every single scan I’ve had during this pregnancy has begun with such a strong feeling of something wrong and this one felt no different. I walked in with my usual sweaty palms and fidgeting hands, just hoping that everything was going to be alright. I’ve been feeling movements and tiny little kicks now for weeks so my nervousness makes no sense. The screen flicked on and showed a strong heartbeat as always. As the sonographer checked over all the organs and confirmed the correct bone measurements, I started to relax. But I couldn’t help but notice how grainy and difficult it was to make out details in the images. Towards the end, I was finally asked if I has noticed any amniotic fluid leaking or if I’d had any bleeds. I mentioned my previous unexplained bleeding and that I hadn’t experienced any losses of amniotic fluid, at least nothing that I had noticed anyway. She measured the 4 quadrants of amniotic fluid and found they were well below the normal range for this age of gestation. The total average of all 4 pockets of fluid was 2.91cm. We found out the average for 20 weeks is meant to be 14cm, with anything below 6cm considered dangerously low. It indicated a huge problem.

The next few days were hard while we waited over the weekend for our appointment with our OB to find out what this all meant. Our OB is usually so positive so it was painfully clear to us when we walked in that something was wrong. She went on to explain that low levels of amniotic fluid at this point meant one of 3 things;

  • Either there was a problem with the baby –  such as an inability to swallow, kidney function or problems in the bladder. She explained that at around 20 weeks, it’s the baby that is responsible for replenishing and maintaining 90% of the amniotic fluid through swallowing and urinating so this could explain why levels were so low.
  • A production issue with the placenta
  • Or lastly, a tear or rupture in the amniotic membranes. This would usually be obvious, like a huge gush as if my waters had broken. I knew that hadn’t happened so we initially thought it must have been one of the other 2 options.

She booked me in for another scan, this time with an Associate Professor who she explained was an obstetrician who specialised in performing ultrasounds on pregnant women. He no longer delivered babies or worked in obstetrics – ultrasound diagnostics was his niche. We were still freaking out but this gave us peace of mind that we would soon know for sure, what the problem was.

The scan was early in the morning and quickly ruled out any problems with the baby’s kidneys and bladder. The bladder was full, in turn meaning the kidneys must be functioning and the baby was also seen to be swallowing throughout the scan. There was also no problem discovered with the placenta flow. This left only the third option – a rupture in the membranes. It was towards the end of the scan that he discovered a small separation on part of the uterus wall. He asked about the bleeding and quickly pieced together that this separation was the space that held the subchorionic hematoma that must have caused the unexplained bleeding. Subchorionic hematomas are pockets of blood that build up between the folds of the outer membrane and are usually fine and clear up without issue but it appears that mine was large enough that when it ruptured it actually made a small tear in the membrane and I’ve been very slowly leaking out amniotic fluid over the last 5 weeks.

The bad news is that there is nothing to be done. The tear can’t be repaired and as hard as the baby tries, she can’t refill it quickly enough to stay on top of the leaking. He told us that at this point of being only 20 weeks, some parents choose to terminate as the chance of a live baby if I go into labour now are zero. But he also said that sometimes the baby continues to grow and stays safe inside, just long enough to survive a premature birth. He pointed out that our baby is completely healthy, she’s measuring perfectly for her gestation but noted that it’s clear that the lack of fluid is starting to affect her. Her chest is slightly smaller due to the compression forming around her. He explained to us that her biggest hurdle if she initially survives once out of the womb, would be her underdeveloped lungs. Even if by a miracle, she stayed inside until 30 weeks, her lungs would only be developed to that stage of a 24 week old because without the fluid around her, she is running out of space to suck anything in to stretch and strengthen her lungs and practice breathing.

We left that appointment and went to see our OB straight after to discuss what options we had. We now knew that termination of the pregnancy was an option, though she didn’t mention it. She said all we can do for the next couple of weeks is take it one day at a time. There’s literally nothing else we can do at this point. She explained that the earliest a baby can be revived at birth is 22 weeks and 5 days but the survival rate is next to nothing. The next milestone would be 23 weeks and 4 days where survival rate is still less than 30%. After I reach 24 weeks, there are a few things that can be done such as giving me injections of steroids to help mature the lungs and magnesium sulfate by IV to delay labor when it starts. So that’s our goal for now. In 3 weeks and 3 days, I’ll be 24 weeks pregnant and at least then I will feel like we have some sort of control or plan in place. If I make it 24 weeks, our OB also wants to set us up with an appointment at the Neonatal Unit at the Mater Hospital. She said it’s important that we are aware of the harsh reality of having a micro premmie is actually like. The side effects of being born so early often result in life long disabilities and injuries such as cerebral palsy, brain damage etc which is why I suppose some people choose to terminate rather than go down that scary road. But there are also stories of babies fighting long and hard and ending up completely healthy children. I don’t want our baby to suffer but I don’t want to give up on her while she’s healthy either. This is the most terrified and unsure I’ve ever felt in my life.

I’m off work, resting and drinking lots of water. I’m trying to stay positive but I’m painfully aware of how bad things are. I’m hyper-aware of every little pain or ache I feel, worried it might be the beginning of labor. Every little wriggle or kick I feel, breaks my heart. It feels so cruel. Not knowing if we will still be feeling her kicks in a few weeks or whether we will be planning her funeral. This feeling of helplessness is so dark and so scary. We just have to keep reminding ourselves to take it day by day. If I don’t do that, I think I’ll sink. I’ve never been more thankful for Oscar, he is the only thing in this world that can take my mind off it and actually make me laugh and smile. That child is pure sunshine and we are so lucky to have him with us through this.

I’m not sure when I’ll update again, maybe in a few weeks.