a new spring

photo credit: Gazelle Valley Park, gvp.co.il

As an update to my previous post, at this past week's appointment I got to speak with the other MFM in more depth about the steroid shots. There are two MFMs who run the prevention of prematurity clinic, so I volley back in forth between them during my clinic visits. I think they are both really competent, and I appreciate having the two different perspectives.

In short, we've decided we will definitely do the shots at 28 weeks unless something changes in the mean time, in which case we would do them immediately. As Emily pointed out in her comment to my last post, Dr. W. said they work most effectively on more mature lung tissue, so from a lung maturation standpoint, they don't function optimally at 24-26 weeks. However, in this age group, they do decrease the likelihood of intraventricular hemorrhage (IVH), which in addition to the respiratory issues, is a major obstacle for micropreemies.

In the absence of any indication that I am going to deliver in the near future, she felt pretty strongly that it is best to optimize the lung maturation benefit we will get out of them and get good coverage during the 28-32 week window, which she sees as a more likely scenario than something catastrophic happening over the next few weeks. So I feel better having some resolution on that and I feel comfortable with our choice of waiting a few more weeks.

Baby girl is a bit of a chunker, which is great :) Last week her estimated weight was 1 lb. 9 oz., about a week ahead. Her other measurements put her in the 65% percentile for her gestational age. I am happy she is measuring a little big. I did my 1-hr GTT last week. I am a bit nervous about the results, because I didn't know I was doing the test and I had a couple of glasses of cranberry juice with breakfast before I drank the glucola.

I have a bad cold which is annoying, but it is nothing more than a nuisance. It felt really good passing V-day, but I will feel even better next week once we G-d willing pass 26 weeks and I am holding out for 28 weeks even more so. The outlook would still be quite bleak if our little girl was born this week, but still, reaching the point when there would at least be an attempt to intervene feels significant. I am hoping for this pregnancy to stay boring for quite a while longer!

I am also looking forward to March being over. February and March 2012 were two terrible months for us punctuated by complications, hospitalizations, and of course the loss of Aminadav and Naava. Since then, it has always felt to me like February and March were out to get us. Just one more week and we can kiss my dreaded season goodbye.

As the days get longer and warmer and we enter the spring holiday season, I remember the emptiness and hollowness of last spring. Most of all, I remember my empty empty arms after a winter spent gestating two vital little lives. This spring, I still carry that emptiness and hurt in my heart everywhere I go, but I feel thumps and spins and all sorts of acrobatics on the inside that I can't help but admit make feel hopeful and vital again. I guess you could say that finally I am expecting.

the steroid shot dilemma

At my last MFM appointment, my doctor let me know that this coming week (24 weeks), I am eligible to receive a course of steroid injections, which will help to mature the baby's lungs should she make an early arrival. Since respiratory issues are the most significant obstacle for many preemies, the ability to jump-start lung maturation is obviously a pretty big deal. There are 2 decisions we need to make 1) whether we want the steroid shots (or under what set of circumstances we would want them) and 2) when we want them.

I think it is the second issue - the timing of the injections, that I am having the greatest difficulty with. The potential side effects of the steroids to the baby are fairly minimal in my opinion - babies who have been subjected to repeated courses of steroid injections in utero tend to weigh less than their untreated counterparts. However, this is much less of an issue today.

Apparently, because there is a long-held belief that the steroids are no longer maximally effective after 7 days, it was common practice in the 1990s to give a course of steroid injections around viability to at-risk women and then to give repeat doses every 7-14 days if the woman hadn't delivered yet.

That is no longer done today - my understanding is that at most you might receive an initial course of steroid injections and then if you still haven't delivered, say 2 months later, but you are in imminent danger of delivering and the baby is still <34 weeks, then they might give a rescue course, so that is 2 courses of injections at the most.

The second minor concern is that in animal studies some rats exposed to steroids in utero at doses many, many times higher than the dose given to human patients showed minor neurodevelopmental deficits. Again, this doesn't really concern me very much, especially knowing that steroids have been used in the context of speeding up lung maturation in utero since the 1970s, so pretty good follow-up data exists for humans. In short, I see little downside to getting the injections.

The second issue is timing - a long-held belief is that the maximal effect begins to dwindle 7 days after the 2nd (final) injection. However, newer studies have called into question the original data that led to this conclusion and it seems possible that you actually get pretty good coverage past 7 days - maybe even up to a month after the 2nd injection.

That being said, there is no doubt that after a certain period of time, the effect diminishes, so if you don't deliver within x weeks of the 2nd injection, it is probably not super helpful. I found it really hard to get a good sense from the literature exactly how quickly and at what time point the effect of the shots becomes worthless...I think it is still a contested issue.

I could get the shots this week at 24 weeks, which could be really nice from an emotional perspective -  knowing that if G-d forbid something happens during what is a disastrous gestation for birth, our chances would be better. On the other hand, there is no hard data that leads me to believe I am in imminent danger of giving birth, just a whole lot of fear based on my past.

So far, my cervix has stayed stable. I have been contracting fairly regularly, but my doctors assure me this is much more annoying than worrisome since my cervix hasn't changed. My placenta scan looked great and I haven't had any bleeding. Aside from my awful past, there is nothing concrete to suggest imminent danger (in spite of this, of course I worry like crazy - I don't ever want to be the sucker who assumes everything is going to be just dandy only to be rudely awakened).

Based on this information, it seems wise to hold off on the injections for a few more weeks -- maybe wait until between 26-28 weeks, when then at least I will hopefully get some coverage from them until at least 30 weeks. But then there is the emotional part of me who doesn't want to say "I told you so!" if something horrible happens in the next few weeks.

So what do you guys think? What would you do? Clearly there is no single right answer here - if there was, I am pretty sure my doctor wouldn't be leaving the decision in our hands.