Good Midday

Gail's had Jakob all morning, which is amazing. They went to play gym, then swimming, and then came to see me!

I've been feeling really hot, so my nurse brought me a fan! It is amazing. I hope that I am not getting a fever :S That would not be good at all. Fever = infection = indication for delivery.

I'm waiting on a visit from the mfm on call today. I already met with the med student, who was awesome, but she wasn't sure on some things, like indications for delivery (other than for infection, and fetal distresst), etc...

I am seriously concerned about infection, as I've mentioned before. Even more than I was before, because I found out that little Gideon, who's mama pPROM'd at 21w6d, and delivered at 25w6d, lost his battle due to infection at 17 days old :(

I also found out that one of my friends on the ward had to have her twins a couple days ago, and the little one didn't make it. And, another mama on the ward just had a stillbirth. These losses sure don't do much to reassure me that everything is going to be okay.

From the literature I've read, once you reach 32 weeks, if fetal lung maturity can be confirmed (they do this by testing a pool of amniotic fluid in the vagina) delivery can happen. I'd almost rather go that route, we're 32 weeks tomorrow. I am so, completely consumed by fear that she might get an infection if we try to wait until 34 weeks. There's no benefit to her staying in, if her lungs are mature, and we've had the two rounds of steroids. Because I am gbs positive, despite the antibiotics, our risk of chorioamnionitis increases... the chance of us getting it increases every day we go without inducing or my going into labor on my own. I don't really like the idea of waiting two more weeks. I don't know that what I think will have any impact on what they decide. But we'll see what the doctor says.

Here's one research document I found about management of pPROM at this point in pregnancy:

pPROM Near Term (at 32–36 Weeks' Gestation)

When pPROM occurs at 32–33 weeks, fetal pulmonary maturity assessment from a vaginal pool specimen should be obtained if feasible (see later). Amniocentesis by a skilled clinician should be considered if there is inadequate vaginal fluid for pulmonary maturity testing. The infant with documented lung maturity at 32–36 weeks' gestation is at low risk for major morbidities related to preterm birth.⁴⁷ Alternatively, conservative management of pPROM near term will increase latency only briefly (36 vs. 14 hours, p < 0.001), increases the risk of amnionitis (27.7 vs. 10.9%, p = 0.06), and places the fetus at risk for occult cord compression with prolonged oligohydramnios. Because there is little neonatal benefit to be gained by brief pregnancy prolongation when fetal pulmonary maturity is evident with pPROM after 32 weeks, and the risk of amnionitis increases with conservative management, expeditious delivery is recommended.

When fetal pulmonary maturity assessment is unavailable or if fetal pulmonary immaturity is suspected through testing after pPROM at 32 or 33 weeks' gestation, there may be a significant risk of complications related to pulmonary immaturity and other gestational age-dependent morbidity. Unfortunately, there are no studies involving only this specific population on which to base management. Cox and coinvestigators evaluated 129 women undergoing immediate delivery or conservative management after pPROM at 30–33 weeks and 6 days' gestation,⁴⁸ and found only a brief increase in latency (59 vs. 100% delivered at 48 hours, p < 0.001), a significant increase in amnionitis (15 vs. 2%, p = 0.009), and no reduction in infant morbidity with conservative management. This population had a significant risk of RDS (35%), one stillbirth caused by suspected cord compression with conservative management and three neonatal deaths (2 sepsis, 1 pulmonary hypoplasia) with immediate delivery. However, antenatal steroids were not administered to reduce the risk of RDS, and this study was performed before antibiotics for pregnancy prolongation and group B streptococcus prophylaxis were routinely administered. While this study suggested that immediate delivery might reduce fetal exposure to intrauterine infection and avoid loss caused by cord compression, it confirms the risk for neonatal morbidity in the infant delivered at 30–33 weeks. If amniotic fluid is unavailable for testing or immature at 32 or 33 weeks, conservative treatment with close fetal monitoring, adjunctive antibiotic therapy, and induction of fetal pulmonary maturation should be considered. Alternatively, if these measures to reduce gestational age-dependent and infectious morbidity are not attempted, such patients may be better served by expeditious delivery.

It is important to reiterate that all three prospective studies evaluating pPROM near term have found significant increases in perinatal infection and only brief pregnancy prolongation with conservative management. As such, expeditious delivery should be considered unless the fetus is considered to be at significant risk for gestational age-dependent morbidity and efforts to suppress infection and enhance fetal maturity are undertaken.