Second trimester pregnancy loss Tehran university of medical sciences Mahboobeh.Shirazi@yahoo.in

Introduction Spontaneous abortion is the most common complication of early pregnancy incidence : 8 to 20 percent History Live Birth : 5 percent after 15 weeks is low (about 0.6 percent)

Risk Factors advanced maternal age previous spontaneous abortion maternal smoking

The most important risk factor for spontaneous is maternal age age 20 to 30 years (9 to 17 percent), age 35 years (20 percent), age 40 years (40 percent), and age 45 years (80 percent)

History of Abortion The risk of miscarriage in future pregnancy is approximately 20 percent after one miscarriage 28 percent after two consecutive miscarriages, and 43 percent after three consecutive miscarriages

Other Risk Factors Prolonged time to conception Smoking Alcohol Gravidity short inter pregnancy intervals in multi gravid women Prolonged time to conception  Smoking Alcohol

Other Risk Factors Cocaine Prolonged ovulation to implantation interval :>10 days between ovulation and implantation : result from 1-fertilization of an aging ovum, 2-delayed tubal transport, 3- abnormal uterine receptivity

Other Risk Factors Non steroidal anti inflammatory drugs (not acetaminophen) Caffeine  Based upon systematic reviews, very high levels (ie, 1000 mg, or 10 cups of coffee, over 8 to 10 hours).

Second-Trimester Pregnancy Loss What do we know? What is a late miscarriage? miscarriage as one that happens after 12 weeks and before 24 weeks

Second-Trimester Pregnancy Loss 1-Spontaneous delivery Cervical insufficiency/incompetence abnormal shape, fibroids (NHS Choices 2009b) Preterm Labor/PPROM 2-Fetal Demise

Diagnosis It’s never really easy to cope with any pregnancy loss born alive before passing away.

Cervical insufficiency previous cervical damage, LEEP, laser ablation and cold knife conization. (A standard cervical biopsy does not cause insufficiency.) It can also occur in women with congenital uterine malformations, such as bicornuate uterus or unicornuate uterus, DES. Some research indicates that cervical insufficiency may be more likely in women who have had multiple D & C procedures

Symptoms: Unfortunately, cervical insufficiency usually has no symptoms in the first affected pregnancy. The cervix dilates without any contractions the waters break and the baby is born Women may have some spotting or bleeding, but usually by the time the condition is detected, it is too late to stop the preterm birth

Diagnosis Methods: Cervical insufficiency is not common not do routinely screen for the condition during pregnancy, except strong risk factors (such as a known uterine malformation previous second-trimester miscarriage In women at high risk, doctors can monitor the cervix by using vaginal ultrasound, but ultrasound does not always accurately detect cervical changes

Other Risk Factors •Listeriosis from food poisoning. group B streptococcus Toxoplasmosis •A viral infection, fever

Other Risk Factors chorionic villus sampling (CVS). Amniocentesis twin pregnancies,

Second-Trimester Pregnancy Loss Fetal Demise Intrauterine fetal demise (Unexplained fetal death after 10 weeks)

Fetal Demise: Fetal Risk Factors –Anomalies •Structural •Chromosomal –Infection/inflammation •Ascending bacterial infection triggers cytokine cascade –Multi fetal •Fetal death rate 18.5 vs6.2/1000

Fetal Demise: Placental/Umbilical Cord Risk factors –Abruption –Cord accident –Utero placental insufficiency

Fetal Demise: Maternal Risk Factors –Vascular disease •Diabetes •SLE •HTN •Renal and thyroid disease –Thrombophilia •Inherited •Acquired

Fetal Demise: Maternal Risk Factors –Social habits •Weight (>87kg -OR 2.1) •Smoking (OR 1.5) •Marital status (single -OR 1.6) –Age •>35yo (OR 3.5) –Race •Black (OR 1.6)

Inherited Thrombophilia •Factor V Leiden mutation •ProthrombinG20210A gene mutation (heterozygous) •Plasminogen activator inhibitor-1 4G/4G mutation (homozygous) • Methylene- tetrahydrofolateReductase(C677T MTHFR) •Anti thrombin III deficiency •Protein S deficiency •Protein C deficiency

Second trimester pregnancy loss Contribution of inherited thrombophiliato pregnancy loss and the role of prophylaxis to prevent recurrence is controversial

Acquired Thrombophilia: Anti phospholipid Syndrome •Autoimmune disorder characterized by moderate- to-high levels of circulating antiphospholipid antibodies •Clinical features include venous or arterial thrombosis, autoimmune thrombocytopenia, and fetal loss •It can occur as a primary condition, or with other autoimmune diseases such as lupus

In the loss of a stillbirth pathologic examination of the fetus and placenta is advocated; chromosomal analysis should also be performed, if possible. Cultures should be ordered only if the patient has clinical symptoms of a specific infection. Particularly, asymptomatic patients should not be treated for bacterial vaginosis

Pre procedure preparation Prophlactic antibiotic >>>no Cervical preparation with osmotic dilators>>>>no Induced fetal demise>>>>yes Anesthesia>>>>yes

Misoprostol range of 200 – 800 micrograms Induction to abortion interval : 12-16 hours Better to be used with Mifepristone - cervical dilatation - decidua necrosis - increased PG production - increased sensitivity to PG

ACOG protocols Mifepristone, 200 mg, administered orally followed by •Misoprostol, 800 mcg, administered vaginally, followed by 400 mcg administered vaginally or sublingually every three hours for up to a maximum of five doses. OR •Misoprostol, 400 mcg, administered buccally every three hours for up to a maximum of five doses also may be used.

ACOG protocols If mifepristone is not available •Misoprostol, 400 mcg, administered vaginally or sublingually every three hours for up to five doses. Vaginal dosage is superior to sublingual dosage for nulliparous women. OR •A vaginal loading dose of 600 to 800 mcg of misoprostol followed by 400 mcg administered vaginally or sublingually every three hours may be more effective.

ACOG protocols If misoprostol is not available •Oxytocin, 20 to 100 units, infused intravenously over three hours, followed by one hour without oxytocin to allow diuresis. Oxytocin dosage may be slowly increased to a maximum of 300 units over three hours.

Complications Incomplete abortion 1-7% Retained placenta Uterine rupture Cervical laceration Infection hemorrhage

and12wks in spontaneous abortion Hospitalization In most practices, second trimester abortion over 16 weeks is completed with misoprostol and12wks in spontaneous abortion Some parents want to see their baby but are worried about what he or she might look like

Next Pregnancy The history should include symptoms and signs of pregnancy loss, chronic maternal medical conditions that may contribute to pregnancy loss, family history that suggests genetic problems, medication use as an indication of underlying illness, environmental exposures, substance abuse, trauma,.

Next Pregnancy and obstetric history. A detailed review of the pregnancy should be performed, including vital signs, weight gain, dating parameters, ultrasonography, and laboratory tests.

Next Pregnancy diabetes, thyroid disease, or hypertension. Nutritional education and folic acid supplementation can improve maternal illness and help prevent neural tube defects. Patients who have had an unexplained pregnancy loss should be offered genetic counseling with an option for karyotype analysis, even though these interventions have few measurable outcomes.

Next Pregnancy Smoking, alcohol consumption, and substance abuse trauma is an uncommon

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