What counseling is appropriate for a patient undergoing induction of labor in the second trimester due to fetal skeletal anomalies (bone abnormalities)?

From the Guidelines

Counseling for a second trimester miscarriage with induction due to fetal bone abnormalities should prioritize a multidisciplinary approach, including emotional support and medical information, with a focus on pain management and monitoring for complications, as recommended by recent guidelines 1.

Key Considerations

• The induction process typically involves a combination of medications, such as mifepristone and misoprostol, which may require hospital admission for pain management and monitoring for complications.
• Emotional support is crucial, as second trimester losses can be particularly traumatic, and patients should be advised about what to expect physically and emotionally.
• Follow-up care should include a visit 1-2 weeks after the procedure to assess physical recovery and emotional wellbeing, with referrals to grief counseling or support groups as needed.

Medical Information

• The presence of fetal bone makes expectant management less likely to succeed completely, potentially requiring surgical intervention later if tissue retention occurs.
• Pregnancies with suspected fetal skeletal dysplasia should be referred to appropriate centers with high-level ultrasound expertise and expert evaluation, as recommended by guidelines 1.
• Counseling should include a discussion of possible therapies and new treatments that may be available to the child, as well as the potential risks and complications associated with skeletal dysplasia 1.

Pain Management and Monitoring

• Patients should be informed that the induction process may take 12-24 hours and will require hospital admission for pain management, typically with IV opioids as needed.
• Monitoring for complications, such as infection or hemorrhage, is crucial, and patients should be advised to seek medical attention immediately if they experience any symptoms.

Emotional Support

• Emotional support is crucial, as second trimester losses can be particularly traumatic, and patients should be advised about what to expect physically and emotionally.
• Patients should be offered the opportunity to see and hold the fetus as part of the grieving process if desired, and referrals to grief counseling or support groups should be provided as needed.

From the FDA Drug Label

In second trimester abortion, oxytocin infusion will often be successful in emptying the uterus. Adjunctive therapy in the management of incomplete or inevitable abortion. The answer to counselling for a 2nd trimester miscarriage for induction due to bone is that oxytocin infusion can be used as it is often successful in emptying the uterus in such cases, and it is indicated for adjunctive therapy in the management of incomplete or inevitable abortion 2.

• The dosage and administration of oxytocin for this purpose should follow the guidelines outlined in the drug label, including the use of an intravenous infusion and careful monitoring of the patient's response 2.
• Close monitoring of the patient is necessary to ensure safe administration of oxytocin.

From the Research

Counselling for 2nd Trimester Miscarriage

• The use of misoprostol for termination of second-trimester pregnancy has been studied, with a recommended regimen of 400 μg given vaginally every 3-6 hours 3.
• Combination therapy with mifepristone and misoprostol has been shown to be effective for the management of first trimester miscarriage, with improved success rates and reduced need for hospital admission 4.
• For second-trimester fetal miscarriage, medical treatment with misoprostol-only or mifepristone and misoprostol has been studied, with factors such as history of surgical evacuation and gestational age affecting outcomes 5.
• A randomised, double-blind, placebo-controlled trial found that treatment with mifepristone plus misoprostol was more effective than misoprostol alone in the management of missed miscarriage, with reduced need for surgical intervention 6.

Safety and Side Effects

• The safety and side effects of mifepristone and misoprostol sequential regimen have been studied, with special emphasis on rare but relevant safety issues such as heavy uterine bleeding, pelvic infections, and continuing pregnancies 7.
• The use of misoprostol alone or in combination with mifepristone has been associated with side effects such as diarrhea, and careful consideration should be given to the risks and benefits of treatment 3, 7.

Bone-Related Considerations

• There is limited information available on the specific considerations for counselling 2nd trimester miscarriage for induction due to bone-related issues.
• However, the available studies suggest that medical treatment with misoprostol-only or mifepristone and misoprostol can be effective for the management of second-trimester miscarriage, regardless of the underlying cause 3, 5.