Management of Second Trimester Fetal Loss
Mentor: Abimbola Famuyide, MD
Editor: Regan Theiler, MD
Second trimester fetal loss occurs between 14 and 27 weeks and may encompass spontaneous abortion, stillbirth, and early preterm labor. It complicates 1-2% of pregnancies and has been associated with black race, nulliparity, advanced maternal age, and obesity.
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.
Most cases of second trimester loss will be diagnosed by ultrasonography. Further investigation may include amniocentesis, fetal karyotyping, and autopsy. Painless, spontaneous cervical dilation (with our 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 DIC. Delivery options are dilatation and evacuation (D&E) or medical induction of labor. D&E is associated with lower morbidity because of decreased need for antibiotic therapy or further surgical intervention.
Providers should only offer D&E if they are skilled in the procedure and the fetal size is appropriate. Risks include hemorrhage, uterine perforation and cervical laceration. D&E does not allow for the patient to view or hold an intact fetus or have an autopsy performed, though a diagnosis may frequently be possible from pathologic analysis.
Oral mifepristone 200 mg followed by misoprostol is the most effective regimen for medical induction with a 24 hour expulsion rate of 91%. Vaginal misoprostol alone is also very effective. Doses range from 100 to 600 mcg every 3-12 hours with a maximum cumulative dose of 1400 mcg in 24 hours. High dose oxytocin is a third, but less effective, option.
Patients with a history of one cesarean may be safely induced with misoprostol with 0.28-0.4% risk of uterine rupture. Safety data in women with a history of more than one cesarean delivery induced with misoprostol showed no uterine ruptures.
Patients with placenta previa may be induced with misoprostol up to 24 weeks or undergo D&E. Women with abnormal placentation and a previous cesarean are best treated with D&E due to risk of possible accreta.
Retained placenta complicates up to 50% of misoprostol inductions. Ten units of IM oxytocin has a 90% expulsion rate within 60 minutes of administration. When oxytocin is ineffective, carboprost 250ug every 20 minutes for 3 doses and misoprostol 600ug orally or 800ug 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 where possible and if requested. Close follow up is recommended to assess grief response.
Interim evaluation of patients includes pelvic ultrasonography to evaluate uterine anatomy and serum testing for anti-phospholipid antibodies and inherited thrombophilias. Evaluation results are used to assess risk of recurrence and need for intervention during the next pregnancy.
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 102. Management of stillbirth. Obstet Gynecol. 2009 Mar;113(3):748-61. doi: 10.1097/AOG.0b013e31819e9ee2.
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 135: Second-trimester abortion. Obstet Gynecol. 2013 Jun;121(6):1394-406. doi: 10.1097/01.AOG.0000431056.79334.cc.
Initial Approval January 2016, Revised July 2017, January 2019
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