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3/1/2016

Management of Second Trimester Fetal Loss

Second trimester fetal loss complicates 1% to 2% of pregnancies and occurs between 14 and 27 weeks gestation and may encompass spontaneous abortion, stillbirth, and early preterm labor. Risk factors include non-Hispanic black race, nulliparity, advanced maternal age, obesity, diabetes, chronic hypertension, cigarette smoking, alcohol use, use of assisted reproductive technology, multiple gestation, male fetal sex, and obstetric history.

In 50% of cases of second trimester fetal loss, no direct cause is identified despite a complete postmortem assessment. Fetal causes commonly include chromosomal and congenital abnormalities. Maternal causes include anatomic factors (insufficient cervix and uterine anomalies), immunologic factors, placental abnormalities, infection, thrombophilia, and uncontrolled maternal medical comorbidities, the most common of such include diabetes mellitus and hypertension.

Most cases of second trimester loss are diagnosed by ultrasonography, where absence of fetal cardiac activity is identified. Further investigation includes amniocentesis, fetal karyotyping, fetal autopsy, and cytogenetic evaluation of placental tissue. Painless, spontaneous cervical dilation (with or without membrane protrusion) is consistent with cervical insufficiency and is sufficiently diagnosed by history and physical examination.

Delivery should be initiated soon after the diagnosis of fetal loss to decrease the risk of disseminated intravascular coagulation. Delivery options are dilatation and evacuation (D&E) or medical induction of labor (IOL). Compared with IOL, D&E is associated with fewer obstetric complications with the added benefit of predictability of delivery timing. The procedure is faster and may be more cost-effective if there are suitable resources for procedure completion.

When considering surgical management, providers should only offer D&E if there are appropriate resources and clinical conditions conducive to a safe and feasible procedure including:

• Clinical staff trained and knowledgeable in both performing and assisting with D&E procedures
• Institutional availability and familiarity with pre-surgical preparation requirements (i.e. cervical preparation with osmotic dilators such as laminaria)
• Appropriate fetal conditions (i.e. fetal weight, structural factors, etc.)

Risks include hemorrhage, uterine perforation, and cervical laceration. Social considerations include the fact that D&E does not allow for the patient to view or hold an intact fetus or have an autopsy performed, although a diagnosis is usually possible through cytogenetic evaluation of placental tissue via chromosomal microarray technology. Therefore, shared-decision making and concurrent grief counseling are paramount as a pre-surgical planning consideration.

When considering medical management, oral mifepristone 200mg given once followed by misoprostol is the most effective regimen for medical induction of labor with a 24-hour expulsion rate of 91%. Vaginal misoprostol alone, however, is also very effective. Doses range from 100 to 600 mcg every 3 to 12 hours with a maximum cumulative dose of 1400 mcg in 24 hours. High-dose oxytocin can be used when prostaglandins are not available, are contraindicated, or have not been successful.

Misoprostol use in the context of second trimester fetal loss is more widely acceptable in maternal conditions than otherwise viable pregnancies. Patients with a history of one cesarean delivery may be safely induced with misoprostol with 0.28% risk of uterine rupture. Guidelines generally support medical abortion in women with one prior cesarean delivery, with multiple cesarean deliveries requiring a more individually-based risk versus benefits assessment. Patients with placenta previa may be induced with misoprostol up to 24 weeks’ gestation or undergo D&E. Patients with second trimester losses with abnormal placentation and a previous cesarean delivery are best treated with D&E due to risk of possible accreta, as long as they are in a setting with access to blood products, interventional radiology, and the ability to perform a hysterectomy (in addition to the other aforementioned prerequisite conditions as well.)

Retained placenta complicates 21% of misoprostol inductions. Ten units of intramuscular oxytocin has a 90% expulsion rate within 60 minutes of administration. When oxytocin is ineffective, carboprost, 250 mcg every 20 minutes for 3 doses, and misoprostol, 600 mcg orally or 800 mcg rectally, are effective secondary options. Caution must be used in patients with asthma and hypertension. Surgical removal is indicated if the placenta is undelivered after 4 hours.

After delivery, mothers should be given the opportunity to bond with the fetus when possible and be asked prior to delivery what their intentions are regarding the desire to bond with the fetus, to pursue autopsy, burial specifics, etc. This process should additionally include planning for short-term psychological care/grief counseling for expected acute stress disorder should the patient be amenable to such arrangements, given the usual and appropriate impact of maternal status, which can be further worsened by postpartum conditions.

Interim evaluation of patients includes a thorough maternal history, family history, pelvic ultrasonography to evaluate uterine anatomy, and serum testing for phospholipid antibodies and inherited thrombophilias. Evaluation results are used to assess recurrence risk and the need for intervention for subsequent pregnancies.

Further Reading:

Diedrich JT, Drey EA, Newmann SJ. Society of Family Planning clinical recommendations: Cervical preparation for dilation and evacuation at 20–24 weeks’ gestation. Contraception. 2020 May 1;101(5):286-92.

American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine in collaboration with Metz TD, Berry RS, Fretts RC, Reddy UM, Turrentine MA. Obstetric Care Consensus #10: management of stillbirth: (replaces Practice Bulletin Number 102, March 2009). Am J Obstet Gynecol. 2020;222(3):B2-B20. PMID: 32004519

ACOG Practice Bulletin No. 135: second-trimester abortion. Obstet Gynecol. 2013;121(6):1394-1406. PMID: 23812485

Robbins SM, Thimm MA, Valle D, Jelin AC. Genetic diagnosis in first or second trimester pregnancy loss using exome sequencing: a systematic review of human essential genes. Journal of Assisted Reproduction and Genetics. 2019 Aug 15;36:1539-48.

Initial approval: January 2016; Revised: July 2017, January 2019, November 2020, Reaffirmed July 2023

 

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