- Women who present with bleeding +/- pain or other signs of miscarriage in the second trimester of pregnancy where miscarriage is subsequently confirmed, either by ultrasound diagnosis or by speculum examination or following birth of fetus+/-placenta from 12+0 to 23+6 weeks gestation
- Women who are diagnosed with an intrauterine fetal death on ultrasound scan from 12+0 to 23+6 weeks gestation
- Women for whom termination of pregnancy for fetal anomaly or medical reason has been planned within the second trimester (12+0 to 23+6 weeks gestation)
- This guideline does not relate to the management of labour from 22+0 to 23+6 weeks where the baby remains viable and the parents have expressed a wish for survivor-based care. In that situation, please involve Consultant Obstetrician and Consultant Neonatology support urgently and manage as per the Preterm Birth NHS GGC clinical guideline. In this situation where labour is likely, women should be transferred urgently to the Labour Ward and alert senior Neonatologist on call.
Labour Ward Management of 2nd Trimester Miscarriage and Termination of Pregnancy for Fetal Anomaly (TOPFA) 12+0 to 23+6 (329)
Warning
Objectives
This guideline is intended for use by healthcare professionals working within maternity and gynecology in Greater Glasgow and Clyde.
This guideline applies to the management of confirmed pregnancy loss within the second trimester, defined as between 12 + 0 – 23 + 6 weeks gestation, including spontaneous miscarriage, induction of labour for intrauterine death and management of termination for fetal anomaly/medical reasons (TFMR).
Scope
This guideline was previously called: Termination of Pregnancy or IOL with IUD 18+0 weeks to 23+6 weeks (329)
Audience
This guideline is for use by healthcare professionals working within obstetrics and gynecology throughout GGC.
Staff have a responsibility to ensure they have accessed recent bereavement care training and are familiar with the National Bereavement Care Pathways.
Please report any inaccuracies or issues with this guideline using our online form
This guideline is for guidance only. Where there are clinical grounds to deviate from the guideline good practice dictates that senior input is required in the decision making
The loss of a baby can be a devastating event for parents with enduring psychosocial consequences.
The purpose of this guideline is to aid staff involved in the management of women experiencing second trimester loss/TOPFA/TFMR. While the scope of this guidance is for singleton pregnancies, it should be noted that intrauterine fetal death occurs more frequently in multiple pregnancies than singleton pregnancies and will require the same support through delivery and bereavement care. Parents want to talk about the baby that has died and to acknowledge that they were twins. Some parents may wish to take photographs of the babies together so this should be discussed and offered.
The Butterfly Project has produced materials to educate staff so that the experience of families who have single fetal demise in a multiple pregnancy can be improved. Please see http://www.neonatalresearch.net/butterflystaff-resources.html
The National Bereavement Care Pathway Scotland provides dedicated, evidence-based care pathways designed for all healthcare professionals and staff who are involved in the care of women, partners and families at all stages of pregnancy and baby loss. The miscarriage/TOPFA pathway recognises that bereavement care is a continuing process and is provided by everyone who encounters women, partners and families who are experiencing a loss. https://www.nbcpscotland.org.uk/stillbirth/
Mifepristone, an antiprogestogenic steroid, sensitises the myometrium to prostaglandin-induced contractions and ripens the cervix
- Chronic adrenal failure
- Long term corticosteroid therapy
- Known hypersensitivity to mifepristone, misoprostol, prostaglandins
- Inherited porphyria
- Hemorrhagic disorder (bleeding disorder)
- Concurrent anticoagulant therapy
- Caution
- Renal impairment
- Previous cesarean (see alternative regime)
- Previous uterine surgery
- Known hypersensitivity to misoprostol, prostaglandins.
The RCOG recommends that all women who attend for TOPFA >22+0 should have feticide performed prior to induction of labour commencing. Please ensure on the day of procedure
- Certificate A is completed and signed by 2 doctors
- Ensure consent form signed
- Lorazepam 4mg orally 2 hours prior to procedure
- Morphine 5mg and 12.5mg Prochloperazine IM given 1 hour prior to procedure
- Women should remain an inpatient for at least 4 hours following the administration of morphine
IF THERE ARE NO CONTRAINDICATIONS TO MIFE/MISO PROCEED TO PART ONE
Initial Management following diagnosis of miscarriage / decision for TOPFA / TFMR
- Transfer woman to an appropriate private setting
- If woman unaccompanied, offer to call support person
- Woman given time to process diagnosis
- Full discussion with consultant obstetrician around management options when appropriate
- If opts for medical management, inform LW Co-Coordinator
- Ensure consent form signed by patient
- IF MTOP ensure certificate A signed by 2 consultants
- Obtain FBC and G+S
- Administer 200mg Mifepristone orally and advise to remain in hospital for 1 hour
- Patient advised to avoid NSAIDs
- Patient advised to call Triage if any vaginal bleeding /SROM/ abdominal pain or any other concerns
- Arrange admission for 36-48 hours later to Labour Ward
- 36-48 hours following Mifepristone administration, admit to Labour Ward
Administer 800mcg Misoprostol PV (Sublingual route can be considered if woman is unhappy with vaginal route, women should be informed about bad taste and slightly increased side effects of Misoprostol associated with SL route)
- Subsequently administer Misoprostol 400mcg pv 3 hourly Max 5 doses
IF ONE PREVIOUS SECTION
Research suggests reducing the misoprostol dosage with previous section may reduce uterine rupture, however this hypothesis requires ongoing research.
- Administer half initial dose of initial Misoprostol (400mcg PV)
- Subsequently administer 400mcg Misoprostol 3 hourly Max 5 doses
IF MORE THAN ONE PREVIOUS SECTION
If woman has had more than one previous section discussion should be had with consultant obstetrician regarding management and misoprostol regime/dosage.
If Misoprostol regime is unsuccessful after 5 doses
- Consultant review
- After 3 hours from last misoprostol dose, repeat mifepristone 200mg orally
- Following 12 hours rest, repeat misoprostol regime
DISCUSS WITH CONSULTANT IF TWO COURSES FAIL
In cases of TOPFA/ where loss is obvious abnormality some investigations may not required – discuss with consultant
- Baseline observations T, HR, BP and RR.
- FBC and G+S for all women
- Kleihaur if >20 weeks for all women (regardless of rh status)
- Coag screen (if abruption suspected)
- TFT’s, U’s and E’s LFT’s Hba1c (Not required for TOPFA)
- Maternal serology for CMV, toxoplasmosis and Parvovirus if clinically indicated
- MSSU and LVS if ? Infection
Investigations following delivery can provide essential information as to why the loss has occurred and assist management plans in future pregnancies
- Repeat bloods as required
- Postmortem examination if consents
- Placental sent for histopathology
- Genetic testing. A full post-mortem examination includes genetic testing. If parents do not consent to a PM a small piece of placenta should be sent.
- Thrombophilia screening (performed a minimum of 6 weeks post-delivery)
- Maternal/Fetal placental swabs (not required for MTOPs)
- Fetal ear swab (not required for MTOP)
All women should be given the information leaflet Post-Mortem examination of a child NHS Scotland Publication. Medical staff should discuss PM with parents. If wishes PM, woman must complete Authorisation of hospital postmortem examination of a child under 12 years of age form.
Information leaflets and consent forms can be found on the Scottish Pathology Network website.
Following delivery, check rhesus status and ensure Anti-D given if appropriate.
See GGC Guideline Anti-D Immunoglobulin Administration Following Potentially Sensitizing Events and Routine Antenatal Anti-D Prophylaxis in RhD Negative Women 559
Discuss breast care with women and offer advice/medication as per guidance. See GGC Guideline Breast care lactation management when your baby has died
- Perform thromboprophylaxis risk assessment in line with GGC guideline
- Arrange for IDL including pain relief and iron if required
- The woman's named consultant, community midwife and GP/HV should be informed
- All antenatal appointments should be cancelled
- Offer counselling service and signpost to support group information
- Give bereavement midwife support details and advise will contact
- Discuss/arrange contraception
- Clear contact details for Labour Ward to be given in case any concerns
- If over 22 weeks, should be given written information regarding Perinatal Mortality Review Process (leaflet MI 351551-Understanding what happened the perinatal review process) so they can contribute any specific questions.
- Offer NHS Scotland Certification and Baby Loss Prior to 24 weeks leaflet
- Datix should be completed for all losses over 22 weeks
- Complete both maternal and fetal bereavement pathway on badgernet
All women should be offered a follow up appointment with their named consultant to discuss their care, receive results from any investigations, make recommendations for future pregnancies and an opportunity to ask questions. Consideration should be given to ensure the appropriate timing and location of this appointment.