Preventive Betametasone injection at 24w, history of PROM

Hi. I am 24w pregnant for #3.
My last pregnancy, I had bleeding at ~25w, contractions everyday afterward, was put to rest at home and I had PROM at 29 weeks after one day I had some more bleeding and contractions right after being examined in L&D. I was 1cm since 25w with a long cervix then (also evaluated by ultrasound before). I got betametasone injection and medication to stop labor with antibiotics of course. I delivered 8 days after. I never understood exactly why I had PROM and got into premature labor because I don't have an incompetent cervix. Doctors don't know either. We thought my chances of having the same issues would be quite low. (My first was born at 37w).

Unfortunately, it is all the contrary. I have cramps since one week after conception! And got follow ups with a high risk doctor right away and found out there was two bb with great heart beats at 5w. At 7w, only one was growing with heart beat. The cramps diminished for at least 3 weeks, to start again afterward. I started noticing that it was contractions at 13w, increasing every week. I had spotting at 17w, then 22w. I am in home rest since 17w. I have menstrual type cramps, pelvic pressure and/or contractions as soon as I get out of the house or start picking up things on the floor or if I have a full bladder, if I walk too much (more than 5 min), if I forget to drink a lot, when I get stressed out with the care/homeworks and fighting with my older girls (6 and 7) etc. so I do as less as I can. I lie down all day and when I start contracting, I do the trick of drinking 3 glasses of water, emptying bladder, then trying to sleep. This happened a couple of times at 22w. I did a week of antibiotics last week because they found a small bacterial infection that might be causing spotting and other symptoms. I am not so bad this week but still have contractions (no more spotting and much less pelvic pressure and cramps). I am being checked every week or 2 by vaginal ultrasound and my cervix is still long and closed. I was thinking of staying quiet a couple more weeks and if I didn't dilate and was still long, I would try to go back to work and take it easy there.

But 2 days ago, my doctor told me she wanted to give me the corticosteroid injection next week (at 24w5 days) as a prevention, with the second injection the following day. I realized she should really believe that my condition is real and that I am in really high risk of delivering early or soon! The thing is that I read online that betametasone was really effective from day 2 to 7 after the first injection. In the case of PROM, it is crutial to have it right away but I didn't rupture (yet), I am not even dilated... Although I did rupture at 1cm only and really long cervix before. My doctor acknowledged that my contractions were real. Did I mention they were getting really uncompfortable together with my cramps? I also started to have low and high back ache. I am being examined every week and I will go to L&D if I go into labor and bleed. Wouldn't it be more wise to give the corticosteroids only then? Am I too confident that they would be able to stop labor? Or that I would last more than two days after PROM if it happens?
Wouldn't we increase the risks of pulmonary trouble later on if we accelerate lung maturation by forcing production of surfactant this early? Especially that it is not imperative yet. I really believe that betametasone can save a lot of babies and it is super important. I am worried to give it only as a preventive measure though. Did someone read also about it's none efficiency if received too early before birth. For example, if I receive the injection at 24w and deliver at 29? Will the effect of the drug still be present? If I start labor at 28 for example or PROM there, wouldn't it be better to receive the injection at that moment rather than have received it at 24w?

My doc just said there was no risk for the bb to receive it now. But I am still worried and I will get the injection by the nurse first thing at my appointment and won't have time to discuss or think then.
Please, did someone experienced similar before? receiving preventive corticosteroids this early and delivered much later?

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I received the shots at 27.5 weeks, but didn't deliver until 29.5 weeks. My understanding is that the shots are most effective w/i 7 days after being given, so - while I can't be certain - I never figured that my daughter was still feeling the impact at her birth. Now I suppose that depends on what I meant by "feeling the impact". That must have been some benefit from them, even 2 weeks before her birth, because DD was never vented. She went straight to cpap.

What does current research show as most beneficial? I have seen some studies that showed that three or more rounds are detrimental to the baby. One round has proven benefits that offset potential negatives. What is shown about 2 rounds (of 2 shots)? That's one thing I would ask.

I think that personally, I would probably opt for the shots sooner rather than later. Yes, the effects may wear off, and many 28-30 weekers do end end up vented, but for typically much shorter periods of time than earlier gestations.

Don't be rushed into anything, though. You're being seen weekly, but surely they can get you in between appointments if you want a few extra days to make up your mind. Good luck!

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I haven't looked up the numbers recently, but my memory is what you said, that the benefits cover roughly days 2-7 after the steroid dose. General opinion seems to be that two courses are fine to do (http://www.ncbi.nlm.nih.gov/pubmed/21678343). So as you say, if you *knew* you could delay labor you would hold off on the steroid to avoid "wasting" one course. I heard a stat of what % of women who come into L&D in premature labor deliver within 24 hours, it was significant, but I don't remember the number. Your doctor probably knows, and may even have thought through the "if-then" cases as clearly as you have. :)

You are, in a way, choosing whether to give the steroids to the possible 24-weeker, or maybe miss him/her to give the dose to the possible 28-weeker, etc. Where I ended up myself was, nobody really knows the probabilities of these different things that could happen. So to me there's a lot to be said for guaranteeing the steroids to the 24-weeker (if born then), since they need them the most.

"Wouldn't we increase the risks of pulmonary trouble later on if we accelerate lung maturation by forcing production of surfactant this early?"

Interesting question, I've never heard that asked or answered, or seen studies of children who are born many weeks after the last steroid dose. One thing is, even if there is an effect like that, it may be quite small compared to the benefits of those many weeks of gestation?

"But I am still worried and I will get the injection by the nurse first thing at my appointment and won't have time to discuss or think then."

If you want to call before your appointment and say you need to talk to your doctor before getting it, I would *hope* nobody would hold it against you. They certainly shouldn't. Up to your judgment of course.

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Thank you. I was thinking of writting an email to my doctor, she answers but always very briefly (non informative much). But I am worried that she decides to hold the injection. I don't know what will happen to me and if I go in labor in a week and didn't get the injection Monday, that would be sooo bad! But if I get the injection, I would be less stressed for a while, then stressed later,.. But then, my bb will be more mature than 24-28!
I am so looking forward to be 28! And more!

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I received two shots of steriods at 24 weeks and our twins were delivered at 27+6. Both twins were ventilated for less than 24 hours. Sadly we lost one of them due to a pulmonary hemorrhage on the 2nd day however our surviving twin continued to do well respiratory wise which I'm convinced is down to the steriods. I know of a lot of the babies that didn't get the shots and not only were they ventilated for much long periods, they have also struggled a lot with respiratory illnesses since leaving the NICU. I'd definitely get the injections now. My understanding is that each steriod shot helps mature the lungs by a week. Wishing you the best of luck with your pregnancy.

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Wow, thanks 4EvaHopeful!

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You might want to tell your doctor your concern that you believe your bed rest is stabilizing your pregnancy to some degree, except for challenges from raising your two other children, and that you'd like to know how getting the shots next week will affect your pregnancy if you do not go into labor until week 29 or later. It sounds like you need to know what all of her contingency plans are for the different scenarios possible, and that you need to know that she is taking into consideration the risks to your baby by giving them too early. These are excellent questions and your doctor should be able to give you an explanation.

I had one steroid shot 11 hours before I was pushing my baby out at 28+3. He was on the vent for 5 hours and then on CPAP for 7 weeks. Luckily, he has not needed any respiratory support since coming off of CPAP during week 35.

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Follow up:
I talked to my doctor before my betamethasone injection. She agreed that I was not in super high risk of pre-term labor at the moment but argued that the treatment, as a precaution, is highly recommended. I told her about my research and discussed about the duration of the effect and she said that in the original studies, they found evidence for an effect of seven days but now after 20 years of practice using this treatment, she told me its effect was seem for approximately one month. In 4-7 weeks (btw 28w5 and 31w5), if I show up in Labor and Delivery with a high risk of pre-term labor, they might give me an other 2 shots 24h appart for an other month of effectiveness. I would not have more than that. She looked like she knew exactly what she was doing. So I am really glad there is no ambiguity. I concentrate now on keeping baby inside. My cervix is good (long and closed) but I am still at high risk of PROM because of my frequent contractions. I spent a couple of hours with them 3-5 minutes appart with no possibility to sleep all night yesterday! It slowed down gradually during the day and I could sleep last night. Crossing my fingers.

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"after 20 years of practice using this treatment, she told me its effect was seem for approximately one month."

It's great that this is now known (or at least suspected). It will give a little more leeway on when to give the shots, assuming that delivery is not imminent. I hope that you are able to hold off on needing the shots for a lot longer!

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It's great that you were persistent and that your doctor was able to give you solid answers to your questions.

If you aren't already on this site, http://www.keepemcookin.com/ , you should check it out. I've seen many references to it and apparently there are women on that site that have beaten prematurity. I am in awe. Many others have also managed to hold out for much longer than expected. I am in awe of that too. I was never told there was anything besides steroids and MgSO4 that could have slowed my labor. Perhaps in my case nothing would have worked, but I hope you continue to stay pregnant many, many more weeks and continue to have success with your regimen. Wishing you the best!

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I am 34 weeks today and still going!! I didn't receive any more betametasone since the ones at 24w, even when I went for false labor at 29w5 (I had contractions every 5 min. for 2h) because my foetal fibronectin test was negative and the contractions got irregular and wasn't dilating. Since, I got into this kind of pattern once and I decided last minute not to go to L&D because my contractions started to space out after 2h. But even if they are not regular, my contractions are more and more uncomfortable. In addition to the wave that get me short of breath, I have sharp menstrual like cramps, especially if I move or walk. I have read that some people get that just for Brakston-Hicks so I don't panic. But I still wonder if I am not starting to shorten or dilate a little.

The doctors told me that from 35weeks, they wouldn't stop my labor and let me deliver. So there is really much nothing I can do now to avoid delivering. The good thing is that I'm in the safe zone and I am hoping for a term normal an natural delivery now! Yeah!

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