25 weeks, 6 days

The week started on a happy note. JD brought Summit up to the hospital. Amazingly, the hospital has a policy that allows well-behaved dogs to visit their owners. Describing Summit as well-behaved might be a stretch but she seemed to fool security personnel who actually requested that she stay with them instead of come visit me. The first thing she did was jump on my bed and curl up to snuggle. I was surprised she missed me given the love/hate relationship we've had over the past year. She is a wonderful dog but when she barks during nap time, we don't get along very well. The nurses loved changing those sheets saturated with dog hair that night.

On Monday, the medical resident checked the AFI and there was only a single pocket of fluid with less than 3 cm of volume. The first time she measured it, it was 2.99 and the second time it was 2.63. It was very hard to hear those results. My first question was whether they would decide to deliver the baby with levels that low but she explained that BD#2 is still better off staying inside for now. She reminded me that the problem isn't producing enough fluid, it is retaining it. She then reviewed the risks of low AFI and promised to return with reading materials before I could enter a search into Google.

She returned with a printed review from a trusted online medical resource called UpToDate and a yellow highlighter. I had been researching on that site earlier but the topic she provided was much more specific to our situation. I thought I would share some of the statistics with you in this blog post.

• I am considered a midtrimester preterm premature rupture of the fetal membrane (PPROM) which is the spontaneous rupture of membranes between 16 and 26 weeks of gestation.
• You might remember that the complication with KD was also due to PPROM only we were past that midtrimester window. Only 3% of pregnancies lead to PPROM. The chance of being a midtrimester PPROM is 0.4 to 0.7 % but the overall risk of being a PPROM again in a recurring pregnancy is higher, up to 30%. Because we were never able to identify the cause of the rupture with KD, my OB referred to it as a fluke and encouraged us to not worry about it happening again with a second pregnancy.
• The risk factors for PPROM are the same as those for any preterm birth and are listed in Table 1.

Table 1. Risk factors for preterm labor

Risk Factor Category	Examples
Stress	§ Single women § Low socioeconomic status § Life events
Occupational Fatigue	§ Use of industrial machines § Physical exertion § Mental or environmental stress
Cervical Factors	§ History of abortion § History of cervical surgery § Premature cervical dilation
Infection	§ Periodontal disease § Systemic infection § Bacteriuria
Placental Pathology	§ Placenta previa § Abruption § Bleeding
Excessive or Impaired Uterine Distension	§ Multiple gestation § Uterine anomaly (?) § Polyhydramnios (excessive fluid)
Fetal Factors	§ Congenital anomaly § Growth restriction
Miscellaneous	§ Substance abuse § Smoking § Maternal age (<18 and >40) § Previous preterm delivery

• I bolded the two that might apply to our situation. At the 13 week ultrasound for BD#2, the sonographer asked if I had ever been told that I have a heart-shaped uterus. My initial thought was how that must mean there is even more love in the uterus than usual. Unfortunately, that is not the case and having a septum like that prevents the uterus from being able to expand enough for a growing baby. It can be fixed surgically if identified before becoming pregnant. Unfortunately, we didn't learn about this until after pregnancy #2 and my OB still isn't confident in those ultrasound images to make a definitive diagnosis.
• The average amount of time from rupture to delivery is 17 days (we are on day 21) and by 28 days post-rupture, 73-88% of pregnancies have delivered.

There are two things that will haunt me for the rest of my life. The first is that my body is to blame for putting our two miracles in this situation. The second is having to hear survival and disability percentages presented to you multiple times a week as decisions are being made or results are being explained. I will not write or talk about what those percentages have been because I refuse to put validity to them and I refuse to believe anything but that BD#2 is a very strong and stubborn little boy. We recently bought a wall sticker to place by BD#2's crib that says "For One So Small, You Seem So Strong."

It seems for each low point of the day, there is a bright spot. Today the low point was being moved from a single room into a double room with a roommate (I am on the side without the window). She is a very nice person but having to share a room makes the situation that much more difficult. The best part of the day was the repeat AFI. After the low value on Monday, they started a continuous IV. I think I've received about 8000 mL or 8 Liters of lactated ringers solution. I am thrilled to tell you that the AFI today was 4.5. This news couldn't have come at a better time.

This is a very long post so I will sign off for now. I hope you are all having a very nice week.