Q: My wife is pregnant once again and is in the second month of the pregnancy. Last time we lost our baby in the 7th month due to arcuate type of uterus and there was some leakage of the amniotic fluid. A baby boy was born with the weight of 1.7 kg only. As such the USG report done 2-3 days back shows the same kind of uterus this time also. What kind of precautions are required in this kind of pregnancy? Is there any medicine which can help the child to develop faster or the uterus can sustain the whole 9 months of pregnancy. What are the chances of early birth (premature) once again. Which month (4th or 5th moth of pregnancy) is advisable for movement (she has to travel for 24 hours by train to go to her native place for better medical and other facilities).

A:I understand your anxiety but at the outset I want to say that each pregnancy is different and behaves differently. Hopefully, the events of last time will not be repeated this time. As though arcuate uterus is known to cause premature labour it may not actually be the cause in your case as it is often a coincidental finding. So other treatable causes of premature labour like intrauterine infections and urinary infection, which are common causes, should be identified and treated if present. If indeed all possible causes have been ruled out then one can assume that the cause of premature rupture was arcuate uterus (this has to be an exclusion diagnosis after ruling out all possible causes). As this is most plausible and in such cases premature delivery is generally preceded by rupture of membranes and drainage of amniotic fluid, as happened to your wife last time. Unfortunately this could happen again. Especially if the pregnancy is in the same part of the uterus as it was last time. This premature rupture of the bag of waters is postulated to be because there may not be enough space for the baby to grow to a full 9 months size. The growing bag at this stage (beyond 7 months or so) may increase in volume so much that it will be more than the volume of the uterus. This would cause raised liquid pressure (Hydrostatic pressure) causing the rupture of the bag and the leakage of amniotic fluid. This theory is very scientific sounding but is not true in all cases. In a majority of cases there is an associated weakness of the cervix (the mouth of the uterus) which is shorter than normal and weak at the sphincter and gives way once the uterus is large. The prematurity is not completely preventable but some time for fetal growth can be gained by expert medical care. The volume of the uterus cannot be increased at this stage, now that she is pregnant already, and in all fairness she should be allowed to go through this pregnancy. But fortunately, the cervical weakness can be partially countered with a re-enforcing stitch on the cervix around the 14th week of pregnancy. This is in the form of MacDonalds stitch or a similar Shirodkars operation, also called Cervicoplasty. Since this is the commonest problem in a case like yours and the surgery is relatively simple, it should be done in this pregnancy. This may prolong the pregnancy by a few weeks which will make all the difference in the neonatal survival. If the pregnancy goes on to about 26 weeks, she should be given a course if Steroids (Like Betamethasone for accelerated maturity of the organs of the baby including lungs which will improve the babys chances of survival even if there is premature delivery. Of course access to expert neonatal care at the time of delivery is all important in saving the baby in case of a problem. Almost no other measures like bed-rest and drugs to relax the drugs (like Duvadilan and other Beta- mimetics), which are often prescribed without any scientific logic, will not help and may actually be harmful. They are not required. She can travel any time during the pregnancy by train as that or any other means of travel will not cause any harm to this pregnancy. She should try and live s normal a life as possible and hope for the best. What would help you most in this pregnancy would be a lot of reassurance and go through this pregnancy with some confidence and not fear! A good and sympathetic obstetrician who is experienced and competent will go a long way in generating this all important confidence. However, God unwilling, if this time as well she does not carry to a reasonable time to allow normal survival of the baby she should have a repair procedure called meteroplasty to increase the volume of the uterus and tighten the cervix. I am in no way suggesting that this is the standard treatment, in fact it is not usually successful and should be done only in extreme cases and as a last resort. And may help you in subsequent pregnancies. What I am saying is that even if things do not go very well this time it is not a desperate situation and modern medicine has a few more solutions which can be tried. I am sure all this would be not required and she will do well with some confidence and a cervical stitch at the right time.