By Blair, Northbrook, IL USAAfter years of infertility treatment and what I previously thought had been a complicated pregnancy with my daughter, we became pregnant with twins in Feb. 2004 after another IVF cycle. I'll tell you my story in much detail, as it seems to be rarer even than the average PPROM, I had counsel from nearly every specialist imaginable, and I have a happy, happy ending.
PROM at 16 weeks + 2 days. Delivery at 36 weeks + 4 days.
Story added: 2005-02-21
At 9 wks, 4 days, I began to have some light bleeding. My OB had me come in for an ultrasound, which showed a very small subchorionic hemmorhage that he didn't feel was cause for alarm. The next day (a Friday), I had another u/s just to be sure -- same results. That evening, in my car on the way home from work, I felt a gush and tried to stay together on the rest of the drive home. When I got there, I saw I was bleeding heavily. I was crying and freaking out, and the doctor met my husband and me at the hospital. When we got there, he had a Maternal-Fetal specialist do the u/s just to be sure he was reading it right, and he too saw only a small bleed that didn't look like it threatened either baby or the pregnancy. Even so, they told me to stay off my feet as much as possible until the bleeding stopped.
By Tuesday, all was back to normal, and after the doctor examined me and told me I could get back to normal life. The next night, at 10 wks, 3 days, I was reading in bed, when I felt another gush and saw more bleeding. At the u/s the next a.m., the subchorionic hemmorhage was a bit bigger, tho still not large, but the OB put me on modified bedrest and I had to seem him every week for an u/s.
My bleeding lasted until 15 wks 1 day. When I saw my OB at 16 wks, 2 days, I hadn't had bleeding for over 1 week, so he told me I could cautiously resume daily activity -- no lifting, exercising, etc.
That VERY night, my husband and I went out to dinner with our daughter to celebrate my freedom. Again, as I sat there, I felt a big gush. I went to the bathroom, but this time there was nothing there but wetness with a teeny, tiny brown spot in the middle. I decided I wasn't going to over-react since I had made it through the worst (I thought!).
I called the OB the next morning, and he told me to come see him in his office immediately and that he didn't want me to see his partner who was at the suburban office that day. I knew that was a bad sign.
That day's u/s showed both babies still looked ok, but it looked to the OB like Twin B had less fluid than the previous day. Since he hadn't been measuring fluid exactly but monitoring the bleed, he couldn't say for sure but he said this was really the first time in my pregnancy that he was worried. He called the Maternal-Fetal specialist who had previously seen us, and said I could meet him at the hospital for an u/s that afternoon. The OB told me to call my husband to have him join me.
The MF specialist agreed that both babies had enough fluid, tho Twin B definitely had far less. Even so, at it's level that day (16 wks 3 days), it was fine, even if it was at the low end of normal. My OB put me on strict bedrest, told me to drink lots of fluids just in case....
I continued to feel the leaking, but no more gushes. Just over one week later, at 17 wks 4 days, we went in for a previously scheduled u/s test related to genetic screening (can't even remember what one!). One look at the screen, and my husband and I knew that Twin B didn't have enough fluid. The OB who was doing the Level II u/s turned white and when I asked if it was really bad, he said it was and asked us to meet him in his office. There, he told us that Twin B's amniotic fluid index was 0 -- no measurable fluid. He explained the implcations of PPROM on me and the baby, especially with a 2nd trimester rupture that continued to leak. He said with a 0, it's pretty impossible for the fluid to reaccumulate and that reducing to just Twin A might give that baby a better chance of survival and reduce the risk of infection to Twin A and me. After a long conversation with him and then my own OB the next morning after he spoke to MF specialist, we scheduled a reduction for the next week, at 18 wks, 3 days. I was sick, sick, sick with fear and depression until that day.
The day of the reduction, after the counseling but before the Dr (same guy who did Level II u/s) came into the room, the u/s tech asked us if we were doing the reduction to have a singelton pregnancy. We looked up at the screen and both of us knew right away there was a whole bunch of fluid. I was so scared to hope, but I couldn't help laughing. When the Dr came in, he was shell-shocked. He said in over 20 yrs of practice, he hadn't seen fluid come back from a 0 AFI. But it was measuring at 5. He said he needed 5 min to think, then came back into the room after 5 min, told me to get dressed and for us to come in his office.
We sat there while he called our OB (his partner) and then had another long talk. He felt that the risk of losing Twin A to infection or pre-term labor was still very large w/o a reduction of Twin B, especially since I continued to feel the leaking. BUT he said we were in unchartered territory, since Twin B ruptures are usually rare -- if it had been Twin A, we likely would have lost the pregnancy already, so we could take a leap of faith.... Now, I felt even more scared -- before the decision had really been made for us.
Without an appt, my mom took me to my OB's office first thing the next morning -- I was crazed with fear and hope. He called the MF specialist again and scheduled us for a formal consult and u/s with him in his office the Tuesday after Memorial Day -- I would be 19 wks 2 days by then, so decisions would have to be made very, very quickly after that.
After the U/S that day showed two pockets of fluid again (this group measure fluid differently w/multiples, but basically we were looking for AFI of 3 and 2 to 3 pockets)MF Dr told us that there was really nothing in medical literature about Twin B PPROM outcomes -- nearly everything was based on singletons and Twin A, and those outcomes generally were dismal.
However, he also said we were in unchartered territory and the only thing a Twin B reduction would do would be to give us CERTAINTY that Twin B wouldn't be born with lungs unable to support life. Nothing we could do could protect Twin A at this point. All evidence-based medicine supported that. Once there is a membrane rupture, even the reduction of Twin B doesn't eliminate an open membrane for bacteria to infect. And the PTL risk also wasn't cut by a reduction, except slightly as it relates to the higher risk of PTL in any twin pregnancy vs. a singleton one. With this pregnancy, if PTL began, there would be no stopping it. On top of it all, even tho this was so rare, this high risk group had another patient with EXACTLY the same Twin B issue right now with a rupture very close to mine in gestation, and she was now 8 wks further along and doing well (her story is also on this board!).
We talked to him for 2 hrs, and went home having to make an even harder decision now. We talked and cried the whole way home and before we even reached our house, we had reached the same conclusion -- keep both babies and take a leap of faith. We had fought so hard just to get pregnant, and now no doctor could say with all certainty that Twin B wouldn't maintain the fluid even at borderline levels thru the rest of the pregnancy. We weren't naive that we don't know what it feels like to lose a full-term child, but even with 50-50 odds on Twin B, we were going to take the chance, as those were awfully high odds everything would be ok. At 19 wks, 3 days, at my OB's urging, we officially moved our care to the high risk group for the duration of the pregnancy.
At first, they hoped we'd get to 24 wks when perhaps one of the boys could survive... then 26... then 28 (they liked those even numbers, tho we knew every day counted). The leaking stopped around 23 weeks. We went in every 2 weeks until 26 wks for growth u/s's, then every week, then twice a week for NST and biophysical profile at 30 weeks with a growth u/s thrown in every 2 wks.
When I hit 28 wks, I cried with joy -- at 32 I wanted to throw a party. At 30 weeks, they started monitoring for Intrauterine growth restriction, b/c Twin B's growth had slowed. Despite signs of IUGR, they felt it wasn't severe and the prospect for Twin A were best if we kept going. At 34 they actually told me I could stop bedrest and resume moderate activity -- no work or lifting or whatever, but I didn't need to be cooped up b/c at this point, anything further was gravy! We still watched the IUGR closely.
At 35 wks, 4 days I had another gush, and went to the hospital, but the tests came back negative for amniotic fluid and u/s was ok. They said I must have mistaken my bladder for the water breaking... ok, but it felt an awful lot like what happened at 16.2 weeks!
At 36 wks, 1 day, my NST and biophysical profile was fine and I was scheduled for a c-section exactly one week later, but a few days later I started to worry and at 36 wks, 4 days I couldn't stop crying with fear something was wrong. I was so scared that I actually thought about writing a note to my 2-year old daughter about the things I wanted for her in life. I felt pretty positive something wasn't right, and I wasn't sure if it was with me or with one of the babies. The MF dr told me to meet him at the hospital -- I think he thought I was having a nervous breakdown. I actually drove myself since my mom was sick and my husband was at work in the city!
Well, I wasn't crazy. When I got there, Twin B's heartrate was down to 90. They turned me on my left side and it stabilized at 140 after a few min, but after I got up to to the bathroom, it went back down to 90. Left side did the trick again. After an hour, I asked to move onto the Right side for just a few minutes of relief... HB back down to 90. Anyhoo, things moved very very fast at that point and my two sons were born by emergency c-section a minute apart within the hour. Twin A (Joseph Fletcher) came out first and I laughed when I heard him cry -- I was so happy but still so nervous. I didn't get to see him before they whisked him to the peds team but my OB (who scrubbed in with the MF specialist since he was at the hospital that day) sqealed with delight that he was peeing on him. Then, they said Twin B (Payton Colorado) was out and I heard him cry out -- I think the whole room (and there were A LOT of people in there) cheered. A nurse brought him around to me very quickly before running off to the peds team, and I realized they let me see him in case....
BOTH BOYS ARE PERFECT!!!!! Joe was 4 lbs 15 oz and Payton was 4 lbs 3 oz -- tiny but healthy. I went home after 5 days and THEY DID TOO!!! Payton (Twin B) only had normal premie issues with jaundice and heat retention -- but since it was c-section those few extra days I was there meant they could come home with me. We had to take them to the pediatrician the very next day and 3 days after that, but all was and is well.
I know this scenario won't play out for everyone on this site, and I used to read the many unhappy endings here as well as the happy ones just to manage my own expectations and be realistic. But, maybe there will be other women in a similar Twin B rupture situation, and I hope my story (as well as the other one here) allows you to hope if you decide to move forward.
--Blair