What counseling is appropriate for a patient undergoing induction of labor in the second trimester due to fetal demise with evident bone formation?

From the Guidelines

Counseling for a second trimester miscarriage requiring induction due to fetal bone formation should prioritize a combination of mifepristone followed by misoprostol for induction, considering the medical and emotional aspects of the patient's care. The standard regimen involves 200mg oral mifepristone, followed 24-48 hours later by misoprostol (400mcg buccally or vaginally every 3 hours until expulsion occurs) 1. Due to the presence of fetal bone formation in the second trimester, the induction process may take longer and be more physically challenging than first trimester losses.

Key Considerations

• Pain management should include ibuprofen 600-800mg every 6-8 hours and potentially stronger analgesics like codeine or tramadol if needed.
• The patient should be prepared for potential complications including incomplete expulsion requiring surgical intervention (D&E) in approximately 20-30% of cases.
• Emotional support is crucial during this process, as second trimester losses can be particularly traumatic.
• The physical process may involve visible fetal parts during expulsion, which can be distressing.
• Follow-up care should include monitoring for signs of infection, excessive bleeding, and assessment of emotional wellbeing.

Patient-Centered Approach

As emphasized in the Society for Maternal-Fetal Medicine consult series, prioritizing patient values and facilitating a values-based decision is essential for improved decision satisfaction and long-term outcomes, including coping and grief resolution 1. This approach involves active listening, self-reflection, and awareness of the patient's cultural background and preferences regarding shared decision-making.

Medical Effectiveness and Emotional Sensitivity

This approach balances medical effectiveness with emotional sensitivity during this difficult experience, acknowledging the unique needs and preferences of each patient. By prioritizing both medical and emotional aspects of care, healthcare providers can provide comprehensive support to patients undergoing induction for second trimester miscarriage due to fetal bone formation.

From the FDA Drug Label

In second trimester abortion, oxytocin infusion will often be successful in emptying the uterus. The answer to counselling for a 2nd trimester miscarriage for induction due to bone already formed is that oxytocin infusion can be used to induce labor in this situation, as it is often successful in emptying the uterus in second trimester abortion cases 2.

• Key considerations for the use of oxytocin in this context include the need for continuous observation by trained personnel and the potential risks of hypertonic contractions and other complications. It is essential to carefully weigh the potential benefits against the potential risks and to have a physician qualified to manage any complications immediately available 2.

From the Research

Induction of Second-Trimester Miscarriage

• The use of mifepristone followed by misoprostol or oxytocin for second-trimester abortion has been studied in several trials 3, 4, 5.
• A randomized controlled trial compared the efficacy of mifepristone followed by misoprostol or oxytocin for second-trimester abortion, and found that both regimens had comparable efficacy, but the mifepristone-misoprostol regimen had a shorter time to expulsion 3.
• Another study found that the combination of mifepristone, misoprostol, and oxytocin was effective for inducing late second-trimester abortion, with a complete abortion rate of 90.4% 4.

Factors Affecting Time to Expulsion

• Factors associated with a shorter time to expulsion include missed miscarriage compared to therapeutic abortion, increased ultrasonographic gestational age, and increased parity 3.
• Nulliparous women and women with gestation more than 16 weeks required opiate analgesia more often 5.
• Women with previous live births aborted more often within 8 hours than women with no previous births 5.

Safety and Acceptability

• The use of mifepristone and misoprostol for medical abortion has been found to be safe and effective in low- and middle-income countries, with an average effectiveness rate of 95% up to 63 days gestation 6.
• A systematic review found that mifepristone and misoprostol is highly effective, safe, and acceptable to women in low- and middle-income countries, making it a feasible option for reducing maternal morbidity and mortality worldwide 6.
• The addition of mifepristone to medical treatment regimens for first trimester miscarriage significantly decreased the need for repeat medical dosing and surgical curettage, and hospital admissions were also significantly decreased 7.