Management Options for Women with Midtrimester Fetal Loss: A Case Report

Tamara Belkin, CNM; Jessica Wilder, CNM

Disclosures

J Midwifery Womens Health. 2007;52(2):164-167. 

In This Article

Management Options for Midtrimester Fetal Loss

D&E and medical induction are both safe methods for termination of pregnancy in midtrimester; each have low complication rates.[2] D&E is a scheduled procedure, which is performed under intravenous-conscious sedation and local anesthesia, managed much like an elective termination, and often occurs in a surgical gynecology setting (ambulatory or inpatient). The ambulatory setting is reserved for those women who have no coagulopathy or comorbid conditions. Viewing of the intact fetus is not possible because it is removed in pieces during the procedure. Medical induction, in comparison, may be managed more like childbirth, with the woman on the labor and delivery ward or inpatient gynecology unit. In this case, the woman will remain conscious but may have pain medication, and she has the option of viewing her fetus.

The physical health risks and benefits of D&E versus induction of labor with misoprostol in midtrimester terminations were compared in a study by Autry et al.[2] These authors found that while both procedures are safe, the overall complication rate was significantly lower in patients undergoing D&E than in those who underwent a medical induction (4% vs. 29%, respectively; P < .001). As a surgical procedure, risk related to D&E is also heavily influenced by the skill and experience of the provider. Complications associated with D&E included hemorrhage, infection, cervical laceration, and uterine perforation. Additionally, several other studies conducted by one group of researchers found no increased risk of midtrimester loss or preterm birth in future pregnancies for women who have a midtrimester D&E.[6,7,8]

Best practices for the use of misoprostol are not available. The Cochrane Collaboration is undertaking a review protocol. The medication is not approved by the Food and Drug Administration (FDA) for use in induction of labor, although it is widely used in the United States for this purpose. Misoprostol induction for IUFD involves different dosing than the doses used for induction at term of a viable fetus. Though high doses and several different regimens are used, there is limited research regarding dosage, timing, and route (vaginal, oral, or rectal) for termination of pregnancy after midtrimester fetal death. Autry et al.[2] found that the most common complication of medical induction was retained products of conception requiring readmittance to the hospital for a subsequent dilation and curettage. Other complications included infection, hemorrhage, and uterine rupture.

Inevitably, cost considerations are factors in the availability of management options. Misoprostol is inexpensive compared with other agents used for medical abortion, but the expense associated with inpatient treatment and length of hospital stay adds to the cost. The total cost of inpatient treatment with misoprostol is comparable to that of D&E, which can be performed in an ambulatory surgical center.[8] The cost related to an increased rate of necessary follow-up for complications such as retained products of conception with misoprostol induction may also be a consideration.

The emotional and psychological implications of D&E versus induction of labor can be complex. It is not simply that one experience is traumatizing and the other supportive, but rather, that each requires the woman to confront the loss differently. Because not all women cope in the same way, either option could potentially facilitate healing or cause additional psychological and emotional damage. Therefore, when considering the options, it is critical to remember that the devastation surrounding the loss of a fetus can be compounded by a management plan at odds with the needs of the grieving woman. If this results in an impaired ability to cope, the woman's entire life, her relationship with her partner, her ability to care for her children, and her ability to work will be negatively impacted.

The psychological impact of these very different choices in midtrimester terminations were compared in a study by Burgoine et al.[3] The subjects in this study self-selected into two groups following counseling about the options. This study followed the women for 12 months after the procedure and found no significant difference at any point within this time period in the bereavement or incidence of depression between women choosing D&E or labor induction. One important factor in this outcome, as noted by the authors of this study, was that each woman was given the power to choose which procedure was best for her. While some women may desire a rapid and detached experience with no exposure to the fetus, other women may feel better undergoing the experience of labor and birth to end this pregnancy, with the option of seeing and holding her infant. If a woman who wished to give birth were made to have a D&E, she would then have to grieve not only for her lost fetus, but also for her lost birth experience. Conversely, if D&E is not available or offered to a woman who desires that kind of detached surgical procedure, she would then have to undergo a lengthy induction and birth, with exposure to her dead fetus, possibly adding more pain and grief to her already devastating situation.[3]

It is not uncommon for women to blame themselves for the demise and to search for answers as to why it occurred. As stated previously, up to 50% of IUFDs have an unknown etiology, leaving half of all women experiencing this loss without desperately wanted answers, which can facilitate self-blame. It is crucial for the provider to allow the woman the space to voice her grief and ask questions, even if the provider does not have the answers. In a study using questionnaires and interviews of women who had experienced a fetal loss, researchers discovered several commonalities among the women in the study. Most notable were the woman's need for a follow-up visit, her need for more information and answers, and her guilt and incorrect assumptions about why the loss had occurred.[9] It is during this critically important follow-up visit that the midwife can allay the woman's guilt by reassuring her that she did not cause the demise.

In another study focusing on women's satisfaction with their experience following a fetal loss, the most commonly reported complaint was that the woman was not given significant opportunity to discuss her loss with her health care provider. The women in this survey were most satisfied with the care they received when there was a follow-up appointment soon after the loss. Most importantly, the women wanted time to talk about their feelings related to their loss, be able to ask why the loss occurred, and ask whether it would happen again.[10]

The role of the midwife may include assuring that the woman makes an informed decision based on her needs, beliefs, physical and emotional status, and available resources. The midwife should know the indications, contraindications, and general procedures for both management options. Contraindications to misoprostol use include previous uterine surgery and allergy to prostaglandins.

Misoprostol induction may be managed collaboratively with a physician, with the midwife still centrally involved in the hands-on care; referral to a physician is necessary for D&E. It may be an additional stressor for a woman in this situation to see an unfamiliar and as yet untrusted medical provider, especially if the patient has to be referred to a different institution. Ideally, the midwife in this case would already have a relationship with a physician to whom she could refer the patient, quickly resuming care of the patient after the procedure, or even comanaging the patient, maintaining continuity of care and allowing the woman to have the procedure she desires without having to give up her provider entirely. If this is not possible, the midwife should continue to be involved as a support person and advocate, whether during the actual termination of pregnancy experience or at an early follow-up appointment.

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