Ultrasounds after week 24?

[littlemissamanda]

Hi all,

I was hoping I could get some advice or at least, some other perspectives on this.

Story so far: threatened miscarriage at week 13, went to ER with bleeding, diagnosed with IC and funneling. Emergency cerclage and modified bed rest ever since. Bi-weekly ultrasounds have shown varied cervical lengths, but all above 3cm.

We had our Level II ultrasound two weeks ago and everything was great. The specialist there was concerned that my regular OBGYN has not been doing ultrasounds vaginally since stomach ones are less reliable. But I also know my regular OBGYN has been trying to limit anything "down there". They did a transvaginal U/S and cervical length was between 3.5cm and 3.8cm. All great.

I went back to our regular OBGYN office this week (we rotate through docs) and saw someone new. The doctor who did my cerclage has always insisted on the modified bedrest, but this other doc said she would like me to get up and move around more. Drive short distances, do simple chores, go for short walks, rest sporadically etc. I am a little nervous about this, since I think my good cervical lengths have been down to me resting for most of the day. Thankfully, my husband agreed that I should probably not take this advice too literally; I will move enough to avoid blood clots but still rest as much as I can.

My greatest concern is that after my next appointment in two weeks (week 23), this doctor said I will not be getting any more cervical checks/no more ultrasounds. She said that after 24 weeks, the cervical length checks are not as useful. I asked about other measures - progesterone, FFN checks etc and she said because my length has been good and because I have had no preterm labor symptoms, those things are not needed.

I know I SHOULD feel like this is good news - that I am maybe getting the chance to have a somewhat "normal" pregnancy, but I cannot help feel that all of my safety nets are suddenly being taken away. I know I still have the cerclage, but I still feel so far from any real milestone for a healthy baby. Should I be THAT woman and be more pushy when I go back to the doctor's in two weeks? (I'll be seeing someone new again) I am terrified that the moment the doctors stop checking, my cervix is going to fail again.

Thanks in advance.

[OBmom]

Hi Amanda.

First of all, great news the fact that you've been stable for these past weeks. That alone is reason enough to celebrate.
I'm all in favor of moving more, but moving with caution. All the studies available at this point say strict bedrest is harmful for the moms with no benefit for the baby. They also say when you're in preterm labor, staying still is not going to help. But of course, as most moms here can tell you, we tend to feel better and have less contractions when we rest.
All in all, I would say IF you feel well, start moving around the house - preparing breakfast (NOT a meal for 10 members of the family), 5 minute showers (NOT scrubbing the toilets), short walks (this one is personal but I don't think you should be driving - if you have a painful contraction you can step on the brakes or swerve, and someone else can end up in danger).

As for cervical checks, here's the deal: yes, transvaginal ultrasound is more reliable than abdominal measurements. BUT, when you have great lengths such as yourself (anything over 25mm really), it doesn't really matter how you measure it. (As opposed to really short cervix like 8-10 mm, in those cases you can't see that well with abdominal, and should ask for vaginal probe). I agree with your OBGYN in "not poking around in there", as a matter of fact, that's what I chose for my own evaluations. As a general approach, we do bi-weekly checks until 34 weeks or 6 weeks stable. I can understand them wanting t stop the checks (even tough it gives you some reassurance, fact is you've been stable and each check means getting out of the house, driving, waiting rooms, etc..)

I would ask if they're planning on a growth scan around 28 weeks - that would be a great time to take another look at cervical length.

If things change for any reason or you have ANY symptoms of preterm labor, make sure you head to L&D - no living soul will refuse to do a cervical length check if you're feeling pressure or contractions.

There! Sorry for the long post!

[EnglishRose23]

Hi Amanda,

Just wanted to let you know that this is standard practice where I am too. With this pregnancy and my previous one my different MFM groups (Vermont with my son, NY with this pregnancy) have both said they don't do any routine cervical length checks after 24 weeks because it lacks predictive value after that point. My checks have all been vaginal, but they usually do a quick belly measurement too and I haven't noticed a big difference between the measurements.

Like OBmom said they will still check you if you go in with ANY symptoms at all. As you reach viability it is very important to go in at the first warning sign so that the steroids have enough time to help baby's lungs.

Congrats on the great cervical lengths and staying stable!

[littlemissamanda]

Thank you both! It is reassuring to know that this is standard practice; the specialist doctor who was critical of the abdominal U/S being used made me doubt my OBGYN which is unfair, because she has been awesome! I probably would have lost this little stinker in the ER if it hadn't been for her quick action.

I think my concern is that being a first-timer, I'm not always sure if something is a preterm labor symptom or a regular ache/pain. For example, I have had some back pain today. I don't want to run to L&D because of it, but I also don't want to dismiss it as normal just in case. It's so hard to decide what is best. I have become incredibly anxious again.

OBmom - it is so reassuring to have a professional on here! I read on your post that things are going well for you and you're getting closer and closer to the big day! That's so exciting! But please don't leave us just yet!

EnglishRose23 - I think of you often, since there is only a day or two between us. Can you believe we are almost at week 22 already?! It seemed so far away when this all began.

Thanks again, ladies. Have a great weekend!

[jmomma]

I've been anxious about this exact thing littlemissamanda! I'm also 22 weeks, and have my last cervical length check on Friday (when I'm 23 weeks). I've been wondering and worrying what to do after, although I believe after that mark, until you actually experience symptoms, the best thing that has been shown to prevent PTL is progesterone. At least in my case, where I've already had one PTL. I'm not exactly sure what the research says about first time moms, although I think you've got the odds in your favor with a cerclage and the great measurements you've been having.

My cervical lengths have not warranted any sort of restrictions at this point, even when they were around 26mm. At my last appointment I was measuring 31mm (so I seem to be lengthening!), and have really not been taking it very easy at all, other than avoiding major heavy lifting and any kind of exercise or prolonged walking. So at least in my case, at this point, my CL doesn't seem to be affected by more activity. I truly believe it's the progesterone that's helping the most, as the research shows!

So all this to say, unless I hear differently, I'm not sure the research shows anything beyond 24 weeks as necessarily beneficial (other than continuing progesterone). You've been doing all that needs to be done (cerclage, bi-weekly scans) and since those have come up good, I think you already fall into the percentage that has a good chance of not going into PTL. I will still be asking my doctor Friday though, because I agree, it seems like all the safety nets are just gone.

[littlemissamanda]

Hi all,

Sorry I haven't replied in so long. My husband decided we needed to upgrade our cars so I have been immersed in research and shopping for the past week or so. It was a welcome distraction.

We are 23w 4d today and had our final cervical length check this week. Cervix looks stable - still in the 3cm range. I was SUPER disappointed with the care I received on Monday and even now, three days later, it's still weighing on my mind. Thought I would share with you all and see if you have any thoughts.

We were told at our last check-up that we would receive no more u/s and although I was super worried at first, time and your feedback made me see that this would be ok. We have only ever received abdominal ultrasounds for fear of upsetting my cervix, but this week, for a reason not shared with me, they decided to do a transvaginal. The woman who performed it was VERY rough and for the rest of the day and into the evening, I experienced some pain and cramping. I was so upset but after resting, it went away. She also didn't even look at baby, nor measure the heartbeat. The doctor measured my belly and said I was the right size for week 23. When I asked about a growth scan, I was told I would receive that at week 36. WEEK 36?? I asked about progesterone and FFN tests again and was told empathically, "No", since I haven't had any signs of PTL. I was close to tears and just came away feeling really scared. My OBGYN practice rotate us through the doctors and they keep saying I cannot go back to my original one (the one who performed my cerclage) until I have met the others. My husband wondered if we should change doctors but it's this one, or the army hospital, or ones that are a very long drive away. And I really liked the first lady. I just don't know what to do now.

I get that ten weeks have passed since my operation and all of my cervical length checks have been 3cm+, no bleeding and no actual (just imagined) scares. Should I just accept that I am doing ok and therefore, start relaxing? Or do I need to go back and be a badass until I get more care? Any thoughts? I know you're not doctors but wondered if you had any advice.

Thank you! Hoping everyone's journeys are still going well. 

[EnglishRose23]

Hi

Sorry to hear about your rough ultrasound experience. I found vaginal ultrasounds quite painful when I was pregnant with my son (vaginal varicose veins and a extremely low pubic bone to blame) this time round I knew to insist on inserting the wand myself to avoid damage and that has helped a lot.

I feel like it would be reasonable to expect another ultrasound before 36 weeks, especially since you are still anxious about things. I would call them back and see if they can schedule a growth scan around 28 weeks.

I don't care much for the ob group i'm with either. Will definitely be switching if I make it far enough along to not need the MFM care and level IV NICU. At the end of the day you need to be comfortable with the people who will be delivering your baby!

Other things you can consider to help with your anxiety, daily kick counts and maybe one of the at-home devices for listening to baby's heart..I haven't tried one myself but they are very affordable now. It sounds like things are looking good for you though, so try to start preparing for having a healthy full-term baby

[littlemissamanda]

Thank you! My husband is pretty laid back (whereas I am the worrier), but he came away feeling pretty disheartened too. I think I am going to insist on a growth check before week 36 and hopefully when I am done seeing each of the doctors, I can go back to the first one.

We actually have a doppler - one of the nurse's at the doctor's office suggested it since I have been so anxious. I try to limit my use of it to just a few times a week and for a minute or so at a time. It has helped my stepchildren get excited about the baby too. I cannot wait to be able to take kick counts; right now, I have days where I feel baby really clearly and other days where I barely feel him/her at all.

Thanks for listening! I know I have to get out of my negative funk and start looking forward to being a mommy!

[jmomma]

I'm sorry you were not happy with your care, it seems it's always hit or miss when there are many doctors in a practice.

Since this is my second go around of the cervical issues, I do know that sometimes they are extremely quick, just to check the length, and most of the time the baby isn't even looked at, as long as your anatomy scan and everything else checked out fine. And yes, vaginal u/s can be painful and cause cramping afterwards.

Is this your first? From everything I've experienced and read, it's not standard practice to start progesterone for a first pregnancy unless you have signs of PTL or a really short cervix, but since yours seems stable, I don't think it would warrant progesterone at this point. I know it's tough, but I think there just isn't a way to know if it's helpful at this point with a first pregnancy. All the signs DO point to you being able to carry to term even with you not on it right now.

Also, unless there are concerns about the baby's growth, at least in my experience, I don't receive growth scans at all. With my 1st, I just had an u/s at 6 weeks because I had some bleeding, then the anatomy scan at 20 weeks and that was it. With my second I had the cervical scans until 24 weeks and none after. With this baby I am scheduled for a growth scan around 28 weeks, I think because the baby is measuring somewhat small, but I know it's because I ovulated later than they are calculating, so I'm not too concerned.

I totally get the anxiety. I'm very much the type of person that needs constant reassurance, and every little thing makes me paranoid. However, based on the research and based on the assurances of one of the doctors I saw who I immediately knew knows his stuff, I'm convinced the care I'm getting (and from what it sounds like, you're getting as well) is right in line with everything proven to help at this point. Anything more is just there to "make us feel better" because as the doctor put it, often doing something feels better than doing nothing even if it truly doesn't help.

And I know how hard it is to just wait it out. I've been there once and am there again (I'm 24 weeks today!) I wish there was more I could do to ensure I won't deliver early, but at this point medically, everything IS being done that can be, and the chances are good, but even with all that there's still the chance of going into PTL. Just be sure to watch for any real signs of labor, listen to your body, and enjoy the milestone you have reached and focus on meeting the next one!

[OBmom]

Hi littlemissamanda.

So sorry to hear about your rough experience, sometimes it's difficult for healthcare professionals to relate to how we feel -  not only the anxiety, but the exposure and the discomfort.. Glad to hear your cramping passed with rest and there has been no bleeding.

I was going to answer your post but then I read @jmomma's reply - BRAVA! I couldn't agree more, and subscribe every word.

24 week mark is excellent, and from this day on every day counts! Everything seems to be ok, so go ahead, take a deep breath and start enjoying your pregnancy!

Only thing I'd insist on is doing a growth check - 28w, 32w, whatever they feel confortable. But waiting until 36 weeks can be a bit late for detecting growth problems. I'm all for measuring the belly, but recent Brittish studies have shown that clinical evaluation only detects 30-40% of small-for-gestational-age babies, vs 80-90% with ultrasound. Just saying

[littlemissamanda]

Thank you, OBmom and Jmomma! I am definitely going to go back and insist on an earlier growth scan.

Thanks everyone for your words. One week later and I'm definitely feeling more relaxed about the whole situation. I think I still expect the worst to happen - maybe it's that self-preservation thing. Trying not to get my hopes up for fear of them crashing down. But I also know that I have made it to a huge milestone and I am allowed to breathe and enjoy my pregnancy like other moms!

I genuinely feel very thankful to have "met" so many wonderful people on here. If you had told me, three months ago, that I would be chatting so openly, with women all over the world, about my deepest fears and anxieties, and to feel so connected to them, I wouldn't have believed you! I admire you all for your strength as you progress along your personal journey, as well as the support and compassion you show to others on theirs.