From the Guidelines
In cases of placenta previa with a fetal demise at 15 weeks, a dilation and evacuation (D&E) procedure is the recommended approach. This is based on the most recent evidence from the Society for Maternal-Fetal Medicine consult series #71, which emphasizes the importance of prompt abortion care in the presence of contraindications to expectant management, including fetal demise 1. The D&E procedure is safer than induction of labor when placenta previa is present, as it avoids the risk of severe hemorrhage that could occur with labor induction due to the placenta's low-lying position over the cervical os.
Some key points to consider when performing a D&E procedure in this context include:
- Prior to the procedure, cervical preparation with misoprostol or osmotic dilators may be performed to facilitate cervical dilation
- The procedure should be performed by a provider experienced in second-trimester D&E techniques
- Adequate IV access, blood products availability, and anesthesia support are essential given the increased bleeding risk
- Ultrasound guidance during the procedure may help ensure complete evacuation while minimizing complications
- Following the procedure, close monitoring for hemorrhage is necessary, and patients should receive appropriate post-procedure care, including RhoGAM if Rh-negative. A recent study comparing maternal outcomes after procedural abortion (D&E) and medication abortion (induction of labor) among patients with PPROM from 14 0/7 to 23 6/7 weeks of gestation found that complications were more frequent after induction of labor than after D&E 1.
From the Research
Management of Placenta Previa with Fetal Demise
In cases of placenta previa with fetal demise, the management approach may vary depending on several factors, including the gestational age and the presence of bleeding.
- For a fetus that has demised at 15 weeks, the management approach may involve expectant management, dilation and evacuation (D&E), or other procedures to manage the placenta previa and prevent complications 2.
- D&E is a common method for uterine evacuation in the second trimester, and it can be used to manage fetal demise and placenta previa 3, 4.
- However, the decision to perform a D&E or other procedures should be made on a case-by-case basis, taking into account the individual patient's circumstances and the presence of any complications 5, 6.
- Prophylactic uterine artery embolization and uterine tamponade are other management options that can be used to reduce bleeding and prevent complications in patients with placenta previa 5, 6, 4.
- The choice of management approach will depend on various factors, including the patient's overall health, the presence of bleeding, and the gestational age of the fetus 2.
Considerations for Dilation and Evacuation
- Dilation and evacuation (D&E) is a procedure that involves dilating the cervix and removing the fetal and placental tissue from the uterus 3, 4.
- D&E can be used to manage fetal demise and placenta previa, but it should be performed by an experienced practitioner to minimize the risk of complications 3, 4.
- The procedure can be monitored by ultrasound to ensure that all tissue is removed and to minimize the risk of bleeding 4.
- In some cases, D&E may be combined with other procedures, such as prophylactic uterine artery embolization, to reduce bleeding and prevent complications 4.
Alternative Management Approaches
- Expectant management is another approach that can be used to manage fetal demise and placenta previa, especially if the patient is stable and there is no significant bleeding 2.
- This approach involves monitoring the patient's condition and waiting for the fetus and placenta to be expelled from the uterus naturally 2.
- Expectant management can be used in combination with other procedures, such as prophylactic uterine artery embolization, to reduce bleeding and prevent complications 5, 6, 4.