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Pregnant. Have shortened cervix, bulging membranes and enlarged kidney. On progesterone. What are the risks?

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I am currently 24w4d pregnant with my first baby. I have been admitted to hospital on strict bedrest for a short cervix, full details below:
At my 19w4d morphology scan my CL varied with each measurement = 24.74mm, 25.30mm, 23.80mm.
I was referred for a follow up scan at 23w where my CL appeared to change with measurements = 18.09mm, 12mm. The Sonographer didn't mention funnelling to me during the scan, however the scan looks like there was funnelling present.
I was admitted to hospital immediately and am currently on strict bed rest, taking 100mg of progesterone pessaries twice daily. I am also on 40mg of Clexane due to the inactivity and I am schedule to have weekly scans.
My next scan at 24w1d showed the following CL measured 10.54mm, you could quite clearly see a U shaped funnel the width of which measured 15.82mm. The other measurement that was taken was from the intact portion of the cervix to where the cervix should have been (top of the U shaped funnel) this measured – 19.85mm. So to summarise the CL should have been 30.39 (intact cervix length 10.54 + shortened portion 19.85) the funnel width = 15.82mm (making this a 52% funnel). The Sonographer also mentioned prolapsed membranes within the funnel.
It’s pertinent to note that I do not have a cervical stitch and my Obs told me that at this stage it was too risky to implement due to a chance or rupturing my membranes.
I have also had 2 x lletz procedures approximately 4 years ago, a previous D&C, a hysteroscopy and this baby was conceived by IVF. So there have been numerous cervical manipulations.
The questions I would like answered around this condition is to understand the average delivery date I can expect and what the baby outcome will look like at that gestation (mortality and mobity stats along with likely health problems). I also would like to know if the current management of my condition in your opinion is correct and anything else pertinent you think I should know.
The other issue I want to discuss surrounds my baby itself. From the 19 week morphology scan my babies kidneys look enlarged – measurements below for each scan:
19w – L= 4.72mm R = 5.36mm
23w – L= 4.54mm R = 4.54mm
24w – L= 5.41mm R = 8.81mm
The amniotic fluid was measured only at the 24w scan measurements below:
Q1 - 23.48mm
AFI - 23.50mm
Q1 – 34.37mm
AFI – 57.90mm
Q1 – 26.38mm
AFI – 84.20mm
Q1 – 35.34mm
AFI – 119.60mm
Obviously the enlarged kidneys are concerning especially the right one. I want to know what the potential condition(s) could be and what treatment would be required. Also if my baby is born prematurely, how will this condition affect his/her outcome.
Let me know if there is any further information required in order for you to respond.
Posted Wed, 28 Nov 2012 in Women's Health
Answered by Dr. Timothy Raichle 1 hour later
Hello, I would be happy to help you with your question.

So from what I am hearing, you are a 35 year old with a pregnancy conceived using IVF, with a history of 2 prior excisional procedures (and other procedures) involving the cervix, now admitted to the hospital with cervical incompetence as demonstrated by a shortened cervix and bulging membranes. They have you on strict hospital bedrest and are treating you with progesterone and enoxaparin. You are currently 24 4/7 wks pregnant. In answer to your questions about this part of the question:

1. It is completely uncertain WHEN you will deliver. You are going to deliver preterm, and every day that you gain is a benefit to the baby. There is obviously progressive change in the cervix suggesting that things are progressing, but there is absolutely no way to tell whether you will gain one day, one week, or one month!
2. I agree, the risk of placing an emergency cerclage in your cervix is too risky. This will be a discussion next pregnancy whether to place one at the end of the first trimester - I would say that this will be highly probable.
3. At 24 0/7 weeks, the survival is 50% with a 50% chance of long-term problems. Most of the problems relate to lung problems, but there can be problems with the brain and bowels as well. If you have not met with a neonatologist to discuss these issues, then you deserve this information. It is really hard to say what the risk to fetus is until delivery is imminent as these statistics are changing daily. There is a dramatic improvement in survival and long-term outcomes by 28 weeks.
4. You did not mention if you were given steroids for fetal lung maturity. This can be done at 24 0/7 weeks and would definitely be indicated now if not already done (this improves lung maturity, decreases the risk for bleeding in the brain, and decreases risks related to the bowels and something called necrotizing enterocolitis).

As far as the second part of your question, you are describing bilateral hydronephrosis. The numbers that you are describing are not overly concerning. It can be associated with genetic problems, such as Down's syndrome, but in most cases it is a normal finding (in the absence of other findings). As an isolated finding, it is usually of low clinical significance and would usually be followed up after delivery with an ultrasound of the collecting system of the kidneys. Again, you have had an ultrasound that should have been explained to you in terms of the significance of these findings in the setting of facing a preterm birth.

Finally, the amniotic fluid numbers are a little confusing. Usually the measurement of vertical pockets in 4 quadrants are measured and added together. It would be useful to have these numbers clarified a bit more to give you a better answer.

So for you:
1. Have you met with a Neonatologist?
2. Were there other findings on ultrasound?
3. Please clarify the amniotic fluid numbers?

Thank you.
Above answer was peer-reviewed by
Follow-up: Pregnant. Have shortened cervix, bulging membranes and enlarged kidney. On progesterone. What are the risks? 2 hours later
Thanks so much for your response. Please see further information below as requested.
1.     I haven't met with a Neonatologist yet, but it was discussed that perhaps in the next week or so I would have the opportunity to do so. I haven’t been given any steroids yet. I think my Obs thinks I am stable at present and will give me steroids when there is a more imminent sign that I am going into labour or the Cervix diminishes further. He also mentioned Magnesium Sulphate. If I did start having contractions he would try to halt labour with Nifedipine (Adalat).
Is it better to administer steroids now or have them administered as close to the babies arrival as possible.

2.     There were no other findings on the ultrasound (no further soft markers for DS). I did undergo the 12w NT scan to assess the likelihood of DS and the risk assessment came back as 1:5484 - so I am hoping that although the enlarged kidneys are a soft marker for DS the risk of this would be relatively low. It has been recommended that I do not undergo an amniocentesis - as the risk of miscarriage is greater than the risk of DS - your thoughts?

Whilst you mentioned bilateral hydronephrosis as being of low clinical significance and I have read that this is something that can rectify itself by birth or even within the first year, I have also read that post birth and further assessment sometimes surgery is required. I am obviously assuming that this is something that would be difficult with a premmie. My Obs doesn’t seem overly concerned at the moment but is reassessing weekly which is when I will also have the cervix measured.

3.     Regarding the amniotic fluid numbers – the numbers I typed are exactly what appear on the scan (it’s a shame there is no attachment facility so I can send them to you).
I will try and describe what I am seeing. The scan shows my uterus split into 4 quadrants. Each of these quadrants have been measured and are reflected against the Q1,2,3 or 4 values. Then under the quadrant measurements there is an AFI (amniotic fluid index) value. My googling told me that there overall value is then determined by adding the 4 AFI values together – this would make mine = 285.2mm. Obviously I could be totally mistaken but this is my best guess from the limited knowledge I have.
Q1 - 23.48mm AFI - 23.50mm
Q1 – 34.37mm AFI – 57.90mm
Q1 – 26.38mm AFI – 84.20mm
Q1 – 35.34mm AFI – 119.60mm
Answered by Dr. Timothy Raichle 39 minutes later
First, I think that a meeting with a Neonatologist would be ideal sooner than later. You obviously have a lot of questions about the fetus and risks of prematurity now, and it would put your mind at ease to know what the risks are now and later should you get more days or weeks out of the pregnancy. It is reasonable to ask for this.

I think it is reasonable to hold on the steroids until delivery is imminent. But, delivery is somewhat unpredictable, and the benefit is maximized if you get 48 hours from the first dose until you deliver. This is hard to predict in some cases. This would be a good question for the Neonatologist as well. At least it would get the Neonatologist and the OB's on the same page.

If there are no contractions, then Magnesium Sulfate is not indicated.

Given the "normal" first trimester screen and isolated mild hydronephrosis, I agree that the risks of amniocentesis outweighs any benefits.

Here is a quote from a reputable source regarding hydronephrosis (in your case, the measurement is in the "mild" range:
"Although antenatal hydronephrosis is most often transient or clinically insignificant, urinary tract obstruction or vesicoureteral reflux (VUR) are important causes that should be diagnosed soon after birth because they are risk factors for pyelonephritis and renal impairment"

Finally, an AFI of 28 at 24-25 weeks is considered excessive, or what we would call "polyhydramnios". The most common cause of polyhydramnios is gestational diabetes. We usually screen for this at 28 weeks, but this would be good to do now. It would be especially good to do before administration of steroids, as steroids tend to increase your blood sugars temporarily.

So, from what you are telling me, it sounds like things are stable. Ask about talking to a Neonatologist. Get their opinion about steroids now versus waiting. Ask your OB/GYN about the polyhydramnios and if they think that screening for diabetes would be indicated.

I hope this helps! Remember to leave feedback!!

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