High risk of preterm birth - what monitoring / treatment?

[Bumbers]

Hello

I was hoping others might be able to share what monitoring/treatment they received if at high risk from preterm labour (and if it was successful)?

I lost my twins at 23 weeks a bit over two years ago when I went into extreme pre-term labour. However, as it was Christmas, I was out of area with my family and so saw the consultant where I gave birth rather than my "home" hospital. His recommendation for future pregnancies was progesterone and monitoring of cervical length every two weeks, with a cervical stitch if it shows signs of shortening.

I have had a brief call with my local hospital and am due to see the pre term unit this week. However, on the phone they have already said they do not use progesterone, so at odds with the advice of my previous consultant. I am worried (especially with COVID) they will also not do the monitoring recommended. It looks like a complex area, but the NICE guidance seems to recommend progesterone.

I wondered if anyone else had any experience?

Wait and see what the actual consultant says and discuss it with them. I wouldn't be worrying about what a receptionist or whoever told you on that one call. Take a copy of the NICE guidelines with you and ask questions at the appointment.

@Couchpotato3 - I spoke to a nurse / midwife I believe who was able to arrange a prescription for progesterone for me as I was already on progesterone due to an IVF pregnancy and, given my previous advice, they agreed to continue this until at least my meeting with the preterm unit. So I am confident that is not their usual approach (and the evidence is rather contradictory).

I think I am more concerned than usual as it is a COVID hospital and they are pushing to cancel so many treatments that I don't want to risk having less scans than normal due to this. As such, I was hoping to understand what others had experienced. They can also be quite tricky to get hold of, so I would rather go to the first meeting armed with full knowledge so I can fully understand and discuss the position / options.

Fair enough, and I'm sure you know a lot more about it than me. Good luck

Thank you @Couchpotato3 - I want to feel well prepared as obviously DH can't join the meeting and I always come out of these discussions (with my IVF, the consultant re previous loss etc) thinking of other questions I SHOULD have asked. So trying to be extra prepared (esp with slight pregnancy brain)!

Oh God, the porridge brain..... I remember it so well!!

Hi OP, waters broke at 25 weeks so like you can go into labour at any moment! I’m 30 weeks now but in terms of monitoring and treatment it’s as follows:

• steroid injections as soon as possible - these are in your bum cheek, twice, over a 24 hour period! These frigging hurt 😂 These are to develop your babies lungs should you go into early labour
• if your go into labour or they think you’re immediately going to, you’re given magnesium sulphate. This develops the brain, or helps to!
• CTG monitoring (belts over your belly to measure your baby’s heartbeat) at the hospital twice a week, every week from 26 weeks! It’s a Doppler before that
• urine tests twice a week at the hospital and bloods every week at the hospital
• if you waters have broken but you aren’t In labour yet you have a prophylactic 10 day course of antibiotics
• additional growth scans - mine are every 3/4 weeks
• if you make it that far, induction of labour at 34 weeks (37 if you’re doing ok). You can discuss c section like I did but induction is better for a preterm baby

Do not worry about Covod! Literally CANNOT emphasise this enough! You’re a high risk pregnant and that won’t be put aside because of the pandemic! Also my hospital has a covid ward below our delivery/assessment unit that I’m in each week and the hygiene/protective measures taking place cannot be faulted!!

Hope this helps x

Also so sorry to hear about your twins! That’s utterly heartbreaking and I can’t even begin to imagine the pain.. x

Also also, sorry OP I may have miss read your post. I don’t have any experience of early pregnancy/getting pregnant with a high risk or early labour! Only what happens later on x

Thank you @MrsRose2018 that is really helpful. Gives me some hope that, should my waters break early (but hopefully a bit later) again there is something they can do and it isnt instantly all over. Because the twins were so little they didn't think it was right to do anything (and I support/understand that decision) but just means I am so terrified of it happening again. I am not sure I could cope with it again.

Wishing you all the best with your pregnancy. Hoping your little one stays put until ready!! Thank you so much.

I'm 20 weeks with my first, I have a condition that makes me a higher risk for pre term labour and due to my cervix shortening at around 17 weeks I was put on progesterone and told to stay on until 28 weeks at least, I narrowly missed having a cerclage. Their plan for me was to scan fortnightly from 16-24 weeks and this wasn't compromised by the current covid situation at all. They've stopped scanning me now as they feel it's causing more anxiety and my cervix will hold. I was told that as its my first pregnancy progesterone and cerclage have equal benefit for me, but if I'd had the cerclage they would have kept me on the progesterone too. I don't think either are foolproof sadly.
I hope everything goes well for you, and for your loss.

Oh I was also told to drink lots and avoid UTIs like the plague, and they also swabbed me for vaginal infections as both can trigger early labour. I think there's a test they can do to see if you're likely to go into labour within the next couple of weeks but I can't remember what it's called!

@islandislandisland thank you so much for sharing your experiences. It is really helps. None of my friends have had anything similar, so it feels quite a lonely place. I agree, I don't think there is any foolproof approach to this and a lot of the studies I have seen inconclusive as to what the best approach might be.

Crossing my fingers that your pregnancy continues safely.

Hi, I had an emergency cerclage and then progesterone pessaries at 18.5 weeks. Am now nearly 37 weeks and due to have it out this week. It all worked well for me thankfully and I would definitely have both again next time although earlier as a precautionary measure. I rate both in case you need them. Best of luck!

Thank you! I think it depends if there was any particular reason that happened to you, but I would definitely push for the cervical length scans straight off, if that's the issue they might put a cerclage in early which is more effective apparently. I know if I had had a previous loss then I would have been told to have the cerclage with my cervix measurements as they were, rather than given a choice. It seems like they're keener to take preventative action when you've had a loss already so hopefully they'll keep a good eye on you.

Thank you @Chester6 - Did you know you were at risk / were you being monitored, or did you go in because something was wrong?

So happy that you have made it to 37 weeks!!

I made it to 30 weeks.
The steroids bloody hurt, but they are so worth it.

Progesterone and extra scans
The steroids are a bit stingy but they are so so essential and try not to tense or it hurts more

Thanks Bumbers. Yes I had pre-cancerous cells removed years ago and happened to mention it at an early midwife appointment so was being monitored with scans fortnightly and at the second scan they noticed quite a big decline in cervix length (to be honest I had started to feel a little pressure low down so wasn't that surprised) so they booked me in for an emergency cerclage the next day thankfully. They were quite relaxed about whether I take progesterone pessaries as well but I had heard positive stories about them so insisted I use those also. They also booked me off work until 28 weeks on bed/sofa rest with a view to reassessing if they would extend it to 34 weeks but luckily my company signed me off for the rest of the pregnancy anyway. I have a friend who just used the pessaries though (no cerclage and continued working) after a previous late miscarriage so I guess each case is different. I really hope it works out for you. Best of luck. x

@Chester6 @NotaFreeloader @OnlyJudyCanJudgeMe Thank you so much for sharing your stories. It is making me feel calmer and like there can be a plan (even if it doesnt work for me). And feeling like I am not the only one. Sounds like monitoring/ cerclage / progesterone and steroids if needed should be there as the options and then hopefully can work out what would be best.

@Chester6 interesting they were relaxed re progesterone but could be persuaded. I think I might try and keep taking these (already taking due to IVF), even if more of a comfort blanket than anything else!

No problem Bumbers. I know it's so tough and such a worry, I was the same. Funnily enough mine is an IVF pregnancy too so I was also used to taking the pessaries and that made it even more important to me to do everything I could. I think that's why my doctor agreed to the pessaries also - as he knew how much I had been through to get there and how wanted the pregnancy was (although I know all pregnancies are 😊) I took them until 34 weeks just FYI. Now I just need to have the stitch out shortly which makes me nervous but it has helped me so much so I am thankful. Wishing you lots of luck x

Sorry to hear about your twins.

I’ve had a previous preterm delivery at 34 weeks. I realise that’s a completely different kettle of fish from what you’ve been through, but my early labour was completely unexpected and unexplained.

I had cervical length scans at 16, 20 and 24 weeks and as these were all fine with no signs of shortening they didn’t do any further cervical length scans. I was under consultant care though and also had scans at 28, 30, 32 and 36 weeks for growth and to assess placental blood flow. I didn’t have steroids as I think they thought I was unlikely to go into premature labour 2nd time round and they were correct as I made it to term.

One thing I was also going to ask is whether you’re currently pregnant? I think your post suggests you are. If so, is it a singleton this time? I just wondered as the risks are much higher with a twin/multiple pregnancy.

Sorry to hear about your twins. You sound very well informed already. Just wanted to add a couple of things in the hope it will help you feel positive about this pregnancy :)
Standard care would usually be fortnightly cervical length scans 16-24 weeks.
Progesterone is not well evidenced in your situation - it is not proven to make any difference if there is a history of one previous preterm birth. (Your consultant should be able to discuss all the evidence with you if need be). It is shown to be helpful if your cervix shortens to under 25mm. There is no harm to it though.
Cerclage is an option also if the cervix shortens to under 25mm. There is no benefit to doing it with your history, unless the cervix is also short, and the discussion varies depending on exactly what’s happening.
I assume you don’t smoke - but if you do, stop.
To reassure - with one previous preterm delivery, the chances of another preterm delivery (meaning anything up to 37 weeks) is only 15%. Given that your pregnancy last time was twins, which increases preterm birth risk massively, you may actually not be at much increased risk at all. I’m not suggesting you skip all the monitoring - just trying to reassure - chances are extremely extremely high you’ll be meeting your baby this time at full term.
I hope your consults go well and you come away with a plan you’re happy with. Congratulations on your pregnancy x

@Bumbers
It’s not very clear in my post above, but when I mentioned having cervical length scans etc this was in my second (to full term) pregnancy not the one in which I had a premature delivery.

@fyinglemur I am 12w 4 days pregnant and definitely a singleton!! The main advice from the consultant was dont have twins again, which as my previous pregnancy was natural didnt feel that helpful! But meant that we knew we would only ever have one embryo transferred with IVF.

@ThenThousandSpoons0 Thank you so, so much for this detailed information. It helps so much.

I think the main thing I want is the regular monitoring so that if my cervix shortens we can look at an intervention and I also wont constantly be obsessing about if I am going into labour (I had Braxton hicks a week or so before, then contractions started as irregular back pain etc).

I can see the evidence is v mixed with progesterone - so clearly not a massive impact. Did feel like keeping taking it (as I have been taking it with the IVF) felt comforting / what harm could it do (which I alightly despise myself for as I like to think of myself as wonderfully rational / scientific, but this process seems to bring out that side of me).

I can see the odds arent awful. The consultant said it upped my chance to around 15% (although maybe less with a singletonas you say), and then IVF and PGD even more seems to up this slightly. So not a 100% certain, but so much more than I would like.

Thank you so much for your message - it has really helped organise my thoughts.