Management of Second and Third Trimester Pregnancy Loss

Contributor: Dr Sharon Keiser
Last Update: 4/1/2015  

Definition – Fetal death prior to delivery, after 20w EGA if dates are known (or EFW >350g if dates unknown)

• Terminology – Stillbirth, IUFD, FDIU

• Prevalence – 6.2/1000 births in the US (2002)

 
Etiology

• Chromosomal abnormalities

• Placental

• Maternal

• Unexplained (25-35%)

 
Diagnosis and Evaluation

• Confirm absence of FCA with 2 examiners

 
Assessment

• Maternal history – Last perceived fetal movement; vaginal bleeding, contractions, ROM, trauma

• Chart review – Problem list, OB history – maternal age; review anatomic survey and testing done; BMI

• Maternal Physical Exam – Temperature, BP, abdominal exam, presence/absence of pruritis

• Labs: CBC, T&S, fibrinogen, Kleihauer Betke, serum glucose, LFTs, urinalysis, urine drug screen, RPR (if not done with prenatal labs), PT/aPTT (for anesthesia if epidural); Antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant, Beta 2 Glycoprotein 1)

• Consider TORCH serology, Thyroid function tests, ANA, Parvovirus serology if applicable (per ACOG, ANA and TORCH are of unproven benefit)

• Offer Karyotype (with reflex testing for microarray) via amniocentesis (if patient declines, amniotic fluid can be obtained via IUPC)

 
Management

Counseling

• Emotional closure for the patient and counseling for future pregnancies depend on an evaluation for the etiology of the IUFD
• Cultural boundaries may limit the patient’s willingness to allow testing of the fetus
• A high number of stillbirths remain “unexplained” despite workup

Offer expectant management vs immediate delivery and document discussion.

If patient opts for expectant management:

1. Most will deliver within 1-2 weeks
2. Time from demise to delivery is longer for earlier gestations
3. Coagulopathy – caused by release of tissue thromboplastin (check CBC and fibrinogen weekly) – rare within the first 4 weeks after demise. 25% will develop DIC after 5 weeks
4. Prolonged time in-utero will make evaluation post-delivery more difficult, making amniocentesis even more critical
5. Patient can opt for delivery at any time

If patient opts for active management:

1. 2nd Trimester Misoprostol:
   • 400micrograms vaginally or sublingually q3 hours for up to 5 doses (if delivery has not occurred after the 5th dose, allow 12hours of rest and re-start cycle). Vaginal dosing is superior to sublingual dosing for nulliparous patients. OR
   • 600-800 micrograms loading dose (vaginal) followed by 400 micrograms vaginally or sublingually every 3 hours
2. High-dose oxytocin (less effective but an acceptable alternative) – standard orders available in L&D
3. Laminaria and transcervical foley insertion can be used to expedite cervical ripening
4. Surgical evacuation of the uterus can be performed (individualized care to be discussed with the practitioner performing the procedure). Laminaria, with or without vaginal misoprostol, should be used to facilitate cervical ripening and dilation – placed the day prior to the procedure. Real-time ultrasound should be utilized throughout the procedure to reduce the risk of uterine perforation.
5. Prior low-transverse scar – Laminaria and transcervical foley insertion can be used to expedite cervical ripening. Guidelines support the safety of misoprostol specifically and medical abortion generally in women with one prior cesarean delivery – 400micrograms vaginally or sublingually q3 hours for up to 5 doses, as above.
6. 28 weeks – Standard obstetric procedures
7. Prior classical incision – individualize management.
8. Indications for Cesarean delivery – complete placenta previa
9. If placenta retained – high-dose oxytocin (misoprostol is an alternative) – DO NOT APPLY TENSION TO UMBILICAL CORD. D&C under ultrasound, if needed.

 

Assessment of fetus after delivery

At Delivery:

1. Appearance of amniotic fluid, membranes, placenta and cord (number of vessels, abnormalities)
2. Document fetal weight, length, head circumference and foot length; gender; any obvious malformations or abnormalities.
3. Dictate a delivery note that includes the above information

 

Options 

1. Autopsy (may provide cause of death in up to 70% of cases; may change preconception counseling and prenatal diagnostic assessment in future pregnancies)
   • a. Autopsies are performed at GHS pathology (NOT Greenwood Genetics) – must be >20 weeks gestation
   • b. Body to be taken to the morgue (call hospital security first so that body can be checked into morgue upon arrival 455-7931). Send a requisition indicating that body is for autopsy; include gestational age.
   • c. Placenta to pathology (obtain specimen(s) for infectious studies or genetics before sending, if applicable)
   • d. If patient declines autopsy, send body to morgue and placenta to Pathology
2. External assessment of fetus
3. X-rays and other imaging studies (eval for skeletal dysplasias and other malformations) as indicated
4. Tissue biopsy for genetics testing
   • a. Placenta – send to surgical pathology, but first obtain 1x1cm full-thickness specimen for culture if infection suspected (Call microbiology for culture medium).
   • b. Cord blood – for karyotype to Greenwood Genetics, if delivery occurs within 24-hours of demise – Need purple-top collected first!! Then green-top (Sodium Heparin) if possible
   • c. Skin Biopsy or abortus tissue – for cytogenetic studies to Greenwood Genetics – 5mm full-thickness biopsy of non-macerated skin/non-macerated tissue, in either tissue culture media or balanced salt solution (such as Hanks solution). Placental tissue is an alternative if tissue is macerated (must have fetal membranes or chorionic villi)
   • d. Products of conception – for cytogenetic studies to Greenwood Genetics – place in a sterile container. Specimen should be kept moist – add sterile tissue culture media or sterile saline if necessary
   • e. Transport of any tissue to Greenwood Genetics –
   • • i. Keep tissue at room temperature if it is to be transported immediately
     • ii. If not for immediate transport, refrigerate but DO NOT FREEZE. Specimen must be sent by courier or overnight mail to arrive at the laboratory within 24 hours.
     • iii. Contact information – Kellie King, MS, Lab Counselor or Barb DuPont, PhD, Cytogenetics Laboratory Director at 800-473-9411.
5. Fetal Examination for obvious malformation (patient declining autopsy) – Can be done at Greenwood Genetics – Patient must be aware that this is NOT an autopsy. Packet available at the following website:https://www.ggc.org/professionals/fetal-pathology-packet.html (this packet is updated frequently so use the online version). For questions or to discuss a potential candidate for fetal examination, call 864-388-1700 (864-227-4111 night/weekend/holiday – Self Memorial). There is no charge to the patient for this option.

DO NOT ALLOW ANY SPECIMEN TO COME INTO CONTACT WITH FORMALIN OR OTHER FIXATIVES – FIXED TISSUE WILL NOT GROW!

 

Postpartum Care

1. Patients go to Women’s Specialty (or to 3rd floor gyn overflow)
2. Children’s Hospital Supportive Care Team consult
3. Offer chaplain services
4. Social Services consult (optional)
5. Follow-up 2 weeks pp at OB/Gyn Center (with residents or with NP who did OB care) – discussion about coping mechanisms and depression, referral to counseling if necessary, review any test results that are available
6. 6 weeks PP visit to discuss all findings, refer to geneticist if applicable, identify opportunities for medical and social intervention that might influence risk of IUFD in the future (i.e. uncontrolled DM, polysubstance abuse, tobacco abuse)

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References

1. ACOG Practice Bulletin 102 (“Management of Stillbirth”).  March 2009, reaffirmed 2012
2. Silver RM, Heuser CC.  Stillbirth workup and delivery management.  Clin Ob Gyn 2010; 53(3); 681-9.
3. Bove KE and the autopsy committee of the College of American Pathologists. Practice guidelines for autopsy pathology: the perinatal and pediatric autopsy. Arch Pathol Lab Med. 1997;121(4):368-376.
4. Cartlidge PH, Dawson A, Stewart J, Vujanic G. Value and quality of perinatal and infant postmortem examination: cohort analysis of 400 consecutive deaths. BMJ. 1995;310(6973):155-158.
5. Chescheir NC. Intrauterine fetal death: what is the right follow-up? OBG Mgt Sept. 2002
6. Faye-Peterson OM, Guinn DA, Wenstrom KD. Value of perinatal autopsy. Obstet Gynecol. 1999; 96:915-20.
7. Markenson, GR. Diagnosing the cause of fetal demise. Female Patient. 2001 (26).
8. Michalski ST, Porter J, Pauli RM. Costs and consequences of comprehensive stillbirth assessment. Am J Obstet Gynecol. 2002;186(5):1027-34.
9. Pauli RM, Reiser CA, Lebovitz RM, Kirkpatrick SJ. Wisconsin Stillbirth Service Program: I. Establishment and assessment of a community-based program for etiologic investigation of intrauterine deaths. Am J Med Genet. 1994;50:116-34.
10. Saal HM, Rodis J, Weinbaum PH, DiMaggio R, Landrey TM. Cytogenetic evaluation of fetal death: the role of amniocentesis. Obstet Gynecol. 1987;70(4):601-603.
11. NM. Broadsheet #56: mechanisms of fetal loss. Pathology. 2000;32(2):107-115.
12. Woodward PJ, Sohaey R, Harris DP, et al. Postmortem fetal MR imaging: comparison with findings at autopsy. AJR AM J Roentgenol. 1997;168(1):41-46.
13. ACOG Practice Bulletin 135 (“Second-Trimester Abortion”).  June 2013
14. ACOG Practice Bulletin (“Medical Management of First Trimester Abortion”), March 2013.