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Author Topic: Sludge/Contraction/Short Cervix/Preventative Cerclage - 16 weeks  (Read 307 times)

Lauren

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Here's a doozy:

We recently lost our first child due to IC at 24 weeks and became pregnant again after our first cycle.

This has been an incredibly anxious pregnancy as a result.  I had a preventative cerclage at 13+5 and take daily progesterone suppositories (200mg).

I just came back from an elective ultrasound at 16 weeks. During this ultrasound, they found that my cervix had shortened to 2.4cm. I had a cerclage placed at 14 weeks, and it is sitting at 2cm on the cervix - it looks like a strong stitch with good placement.

They discovered during the vaginal ultrasound that I was having a contraction, and this may have influenced the cervix measurement (I'm hoping that because the contraction was low, it was the cause of a shortened cervix, but I have no medical info to back that up).  The tech told me that painless contractions are usual for many women during pregnancy and not to worry.  She was hoping that the contraction would resolve before the end of the exam, but it didn't. 

In addition to this, the US tech thought she saw funnelling through the contraction, leaving only .4cm between the stitch and the end of my cervix. The doctor said she didn't see any funnelling. Again, not sure what to think. How can two experienced professionals see two completely different things?

All of this has left me me anxiously wondering why I would have such a long contraction and whether or not it was in fact impacting my cervical length and whether I am funnelling and if I should take additional precautions.

Finally, and scariest of all, is that they found "sludge" in the intrauterine sac. This puts me at a higher risk of infection. Infection in the intrauterine sac means immediate delivery. They tried to reassure me that "sludge" is common with women with IC, and that it doesn't guarantee infection, it just increases the risk.

My mad Google online research has resulted in 2 findings:

1.  Women with short cervix and presence of sludge have a 50% chance of delivery prior to 24 weeks (2007 study).

2.  Age of gestation for women with cerclage is not impacted by the presence of sludge  (2010 study).

Has anybody else had a preventative cerclage and found out later that there is sludge in the amniotic fluid?  What were your outcomes?
« Last Edit: March 13, 2018 at 10:43 PM by Lauren »

EnglishRose23

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Re: Sludge/Contraction/Short Cervix/Preventative Cerclage
« Reply #1 on: March 12, 2018 at 07:53 PM »
Hi Lauren,

I can't be much help to since my complications are quite different, but my heart goes out to you, that is so soon after a devastating loss to be dealing with a high-risk pregnancy. Given your ultrasound results I would try and seen by your dr for another ultrasound again as soon as possible, they will probably be able to get a much clearer idea of what's going on with your cervix if they do a scan when you aren't having contractions (I'm guessing braxton-hicks since you weren't feeling them?). The sludge does sound terrifying, are you already seeing a high-risk ob (mfm)? On bedrest? So many doctors don't prescribe bedrest anymore, but don't be afraid to make that decision for yourself if it will give you any peace of mind.

Lauren

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Re: Sludge/Contraction/Short Cervix/Preventative Cerclage - 16 weeks
« Reply #2 on: March 14, 2018 at 12:45 PM »
Ended up in ER last night after a gush of clear fluid after inserting progesterone suppositories.
Was concerned that it was amniotic fluid, as this was something the doctor told me to look for.
Luckily, everything came back negative, and baby is still doing just fine.

Will be following up with an MFM ultrasound this afternoon. Fingers crossed for good news - stable cervix and no funnelling would be awesome!

OBmom

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Re: Sludge/Contraction/Short Cervix/Preventative Cerclage - 16 weeks
« Reply #3 on: March 14, 2018 at 04:35 PM »
Hey Lauren,

How are you feeling today?
In general, any fluid that drips to the floor if you are standing and have no underwear on is a good reason to go to the ER. That being said, good news that everything checked out. I'd say your discharge can be just a reaction the progesterone. Keep it up anyway, there's a recent and major article saying it reduces preterm birth.

Regarding your scan, funneling is a dynamic event and can be an on-and-off phenomenon depending on whether your uterus is contracting. So no wonder the doc and tech may have seen different things. What I don't agree with is the "normal" contractions part. There are no "normal" contractions this early in second trimester, painful or no.
And don't give up hope just yet, sludge is kind of tricky to diagnose and doesn't always mean infection. Especially if there is no PPROM. It's a sign of a fragile cervix, but you knew that already so..

Please let us know about your ultrasoud today. Hope everything goes well.

Lauren

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Re: Sludge/Contraction/Short Cervix/Preventative Cerclage - 16 weeks
« Reply #4 on: March 14, 2018 at 06:42 PM »
Back from the ultrasound.

Baby looks good.

Amniotic levels are perfect, so they really don't think that the membranes ruptured last night.

Cervix has shortened again. I think she said 1.7 or 1.9, but I can't remember.  It was definitely lower than 2cm.  I'm feeling disheartened by the change in length.  However, the doctor said that she's not worried about the length at all because that's not the best predictor of a loss, especially with the cerclage. What is a good predictor is whether or not it's closed. Currently the cervix is closed. So that's good.

The sludge is still there. It still puts me at higher risk. There's still nothing they can do about it.

There was another "contraction" today in the exact same place as it was on Thursday.  Again, there was no concern.  It seems to me when looking at the ultrasound that the contraction is "pinching" off the part of the cervix that has the sludge.  Hopefully it doesn't pinch too hard and rupture the membranes!

US doctor thinks that it's a good idea that I still continue to take it easy and not to return to work at this point.  I have a follow up with my OB tomorrow and another ultrasound booked for Monday.

@OBmom - thank you for your words of wisdom and support.  I really appreciate it, especially regarding the sludge.  Worried about your take on the contractions and will be asking my OB tomorrow if there is anything that we can do to relax the muscles.

Lauren

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Re: Sludge/Contraction/Short Cervix/Preventative Cerclage - 16 weeks
« Reply #5 on: March 15, 2018 at 07:34 PM »
OB follow up:

The doctor said that he is not concerned about the cervix length - it is open to the stitch, but the cerclage is doing its job and he cervix is closed. There was no funneling seen, which would have been more concerning.
2 doctors and 1 tech have now said no funnelling, so that's good.

He also said further ultrasounds are not needed until the one on the 29th because our course of action will not change.

He said that sludge is rare and there isn't a lot of research. He thinks that it could potentially be from bleeding at 8 weeks when I spotted for a couple of days. So, he hasn't ruled out infection, but just said that the spotting earlier on could be the cause of the sludge - apparently it takes a long time for the blood to dissolve if it's being carried in the sac.

That being said, my OB gave me a RX for antibiotics to help with the sludge, just in case (although there doesn't seem to be that much research out there to support the benefits of antibiotics, I'm glad that we're doing what we can).

He is not worried about the contraction at all and says that it's absolutely normal and expected.  He did not want to prescribe any sort of medication to help restrict contractions because they are not related to labour and do not pose a risk to this pregnancy. He is the 4th doctor/tech to say that, so I'm going to try to drop that from my worries.

Finally, I asked him if we need to prepare for another loss. He said at this time, no. He reiterated that it's a possibility, but he thinks we are more likely to be successful than not, but as I knew before I got pregnant after our first loss, pregnancy doesn't guarantee a baby, and I am at high risk.  So... yeah.

He hesitantly admitted that if we lose this child/decide to try again, that he would do the transabdominal cerclage, which is highly frustrating because that's what I wanted with this one. I was told that they don't perform TAC in Canada until you have experience a loss with a TVC.  It breaks my heart to think that if we lose another healthy child, it's because we didn't have that surgery.

Anyways, I'm off work until the end of pregnancy.  Only 23 weeks left to go...


Lauren

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Re: Sludge/Contraction/Short Cervix/Preventative Cerclage - 16 weeks
« Reply #6 on: March 23, 2018 at 11:34 AM »
Down to 1.3cm, funnelled to the stitch.
Having a pessary placed this morning at 10am as a last ditch effort.  Best case scenario is that things will stabilize.
Doctors seems less reassuring about a positive outcome with these developments so early  :'(

OBmom

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Re: Sludge/Contraction/Short Cervix/Preventative Cerclage - 16 weeks
« Reply #7 on: March 23, 2018 at 12:45 PM »
Hi Lauren.

So sorry to hear about your development with the cervix shortening. Still, if your stitch is holding up, that's pretty good news.
Also good that you're placing the pessary (I have one too, it's been in for 6 weeks now. Also had one for my first pregnancy, and I am totally convinced it was what held my cervix  - only had 0.8cm then). Any help you can get is good.

I've told other moms on the forum before: where I work, we only admit for in-patient surveillance moms with a cerclage and CL less than 5mm. Everyone else is allowed to stay at home on modified bed rest.

I know it feels like it's a long and hard road ahead, but try and divide up your goals. In 2 weeks time you should be able to check your baby head to bottom in the anatomy scan, and knowing he/she is healthy will go a long way towards lifting your spirits. The fact you caught things early on in this pregnancy gives you the advantage in dealing with the insufficiency - you have options.

How are the contractions by the way?? Do you feel any at all?
And one last thing: are you on magnesium supplements? It's completely unproven but still, most OB doctors here in Portugal recommend them for uterine irritability.

#GoTeamPessary! :)

Lauren

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Re: Sludge/Contraction/Short Cervix/Preventative Cerclage - 16 weeks
« Reply #8 on: March 23, 2018 at 03:58 PM »
@OBmom - do you also have a cerclage with the pessary?

I don't feel any of the contractions, so that's a good sign.  Nobody seems to think that I'm in preterm labour. 
I'm on 500mg of magnesium every day.  It gives me looser stools, but I figure that's not a bad thing - no straining for me! lol

The sludge is way at the bottom of the cervix, basically sitting against the stitch. It's like my body is trying to get it as far from the baby as possible.

My favourite OB placed by pessary today.  He reminded me that the stitch is doing its job - cervix is still closed, and there is still some length (my new mantra).

I feel so much better with this bit of reassurance and the added support of the pessary.

Hoping I can breathe a little easier until our next appointment - the anatomy scan at 20 weeks.

I may have found a new calling in life: medical researcher for women with cervical insufficiency. 
How can there be so little data on something that impacts so many women???


OBmom

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Re: Sludge/Contraction/Short Cervix/Preventative Cerclage - 16 weeks
« Reply #9 on: March 24, 2018 at 06:51 AM »
I don't have a cerclage. At the beginning of this pregnancy I didn't meet the criteria for preventative cerclage placement (meaning I had only 1 previous PTB, without the characteristic history of cervical insufficiency). If I went for a third pregancy it would be a different story, because I would then have 2 previous threatened PTB at 28 and then 23 weeks - I would probably get a cerclage then around 15-16 weeks, just for prevention. Right now I'm just hoping really hard for a happy healthy baby, 'cause I don't think I want to sign up for all this stress again.

In my case, this time we were already checking for short cervix every 2-3 weeks. I was diagnosed at 23w with an 18mm cervix, and we thought it was risky doing a cerclage because of the higher risk of PPROM after the intervention. So we placed a pessary - it worked wonders the first time around. 

The fact that you don't feel any contractions but the cervix is still shortening is highly suggestive of cervical insufficiency. I totally agree with your OB, the cerclage is still doing it's job and keeping the cervix closed. What the pessary does is slightly different - it gives structural support and changes the angle of the cervical canal, so as to take pressure from the internal opening. So cerclage + pessary + progesterone is definitely a winning combo for you, though it may be a bit too much for everyone else's case.

One more thing -  don't freak out if the pessary increases your discharge. It's called "foreign body reaction" and you may feel tiny drops all day long, and it can be clear fluid, and it can be pretty darn scary. Keep in mind that PPROM at this stage tends to be one big gush of fluid (like "waking up soaked").

Sorry for the long post. I am totally supportive of your new career choice :) Because of my career choice I do have some literature on this, let me know if you need any more info.