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3/1/2016

Management of Second Trimester Fetal Loss

Author: Vanessa Torbenson, MD

Mentor: Abimbola Famuyide, MD
Editor: Regan Theiler, MD

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Second trimester fetal loss occurs between 14 and 27 weeks’ gestation and may encompass spontaneous abortion, stillbirth, and early preterm labor. It complicates 1% to 2% of pregnancies. Stillbirth has been associated with non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes mellitus, chronic hypertension, cigarette smoking, alcohol use, a pregnancy resulting from assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and obstetric history.

Specific causes can be either maternal or fetal; however, in 50% of cases no direct cause is found. Fetal causes include chromosomal and congenital abnormalities. Maternal causes include anatomic factors (insufficient cervix and uterine anomalies), immunologic factors, placental abnormalities, infection, thrombophilia, and uncontrolled maternal illness. Two of the most common conditions are diabetes mellitus and hypertension.

Most cases of second trimester loss are diagnosed by ultrasonography. Further investigation may include amniocentesis, fetal karyotyping, and fetal autopsy. Painless, spontaneous cervical dilation (with or without membrane protrusion) is consistent with cervical insufficiency and is diagnosed by history and physical examination.

Delivery should be initiated soon after the diagnosis of fetal loss to decrease risk of disseminated intravascular coagulation. Delivery options are dilatation and evacuation or medical induction of labor. Compared with medical induction of labor, dilatation and evacuation is associated with fewer complications and the timing is predictable. The procedure is faster and may be more cost-effective.

Providers should only offer dilatation and evacuation if they are skilled in the procedure and if the fetal size is appropriate. Dilatation and evacuation usually requires cervical preparation with osmotic dilators or prostaglandin analogues to reduce the risk of trauma to the cervix. Risks include hemorrhage, uterine perforation, and cervical laceration. Dilatation and evacuation does not allow for the patient to view or hold an intact fetus or have an autopsy performed, although a diagnosis may frequently be possible from pathologic analysis.

Oral mifepristone, 200 mg, followed by misoprostol is the most effective regimen for medical induction of labor with a 24-hour expulsion rate of 91%. Vaginal misoprostol alone 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.

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.

Patients with placenta previa may be induced with misoprostol up to 24 weeks’ gestation or undergo dilatation and evacuation. Women with abnormal placentation and a previous cesarean delivery are best treated with dilatation and evacuation 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.

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 if requested. Close follow-up is recommended to assess grief response.

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 need for intervention during the next pregnancy.

Further Reading:

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

Borgatta L, Kapp N, Society of Family Planning. Clinical guidelines. Labor induction abortion in the second trimester. Contraception. 2011;84(1):4-18. PMID: 21664506

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

 

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