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LaborInductionManagement:Caringfor2nd and3rd TrimesterFetalLosses

Rebecca Cypher, MSN, PNNPrlcjumper@aol.com

Disclosure

In the interest of full disclosure I wish to communicate that I have a professional relationship with

PeriGen: Chief Nursing OfficerLucina Health: Clinical AdvisorProfessional Education Center: Speaker

Objectives

• Describecriteriaofcervicalripeningandlaborinductiontechniques

• Identifyadvantages,disadvantagesanddosingrecommendationsofspecificcervicalripeningandlaborinductiontechniques

• Discussriskmanagementstrategiestoincludeinformedconsent,staffingresources,frequencyofassessmentandmedicalrecorddocumentation

Diagnosis

• Basedonultrasound• Absenceoffetal cardiacactivity

• Inpersonconversation• Empatheticandstraightforward

• Privatearea

SixKeyPhasesofFetalLossCounseling

1. Timeofdiagnosis2. Whenmakingdeliveryplans3. Atdeliveryandimmediatelypostpartum4. Duringtheweeksafter dischargeandpostpartumvisit5. Ata”closure"meetingtoreviewlaboratoryandpathologyresults6. Whenthepatientisconsideringanotherpregnancy

TimingofDelivery

• Patientacceptanceofdiagnosisisvariable• NOrusheddecisionsaboutdelivery

• Absenceofmaternal co-morbidities• Severe pre-eclampsia

• Timingandprocedurediscussedafterpatientacceptance• Interventionsshould beguidedbymaternal/parentaldesires

• Potentiallongintervalbetweenfetaldeathandspontaneouslabor• Limitscauseofdeath informationobtainedonpostmortemexamination

Chakhtoura NA, Reddy UM. Management of stillbirth delivery. Seminars in perinatology 2015;39:501 -5 04 ).

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TimingandAnxiety

• Admittohospitalimmediately• Reasonableoption

• Alsoreasonableandsafetotaketimeindecidingnextsteps• Psychologicalcontroversy:

• Increasedriskoflifelonganxietyanddepression• induction>24hoursafterdiagnosis comparedto<6hours

Radestad I, Steineck G, Nordin C, Sjogren B. Psychological complications after stillbirth—influence of memories and immediate management: population based study. BMJ. 1996 Jun 15;312(7045 ): 15 05 -8.

CoagulationDisorders

• Etiology:• Releaseofthromboplastin fromfetal/placentacirculation tomaternalcirculation

• Thromblastin:• Stimulatesmaternalcoagulationsystemleading to intravascularconsumptionofclotting factorsandplatelets

• Increasedactivityoffibrinolyticpathway• Leadstobreakdownof fibrinogen to formfibrindegradationproductsandD-Dimers

• Leadstostillbirthretentionandcoagulopathy

TimingandRiskofCoagulationDisorders

• Spontaneouslaborusuallystarts1-2weeksafterfetaldeath• Avoids risks associatedwith induction

• Riskofcoagulationabnormalitiesincreaseswithwaiting• Pritchard:Notdetectedatless than5weeks

• Makecertainthefetusisdead.Frequentlyitwilltake3-4weekstoascertainthis”• Maslow: Detectedbeyond4week

• Increasedfrequencyinabruptionoruterineperforation

Mas low AD, Breen TW, Sarna MC, et a l . Prev alenc e of c oagulation abnormal i ties as s oc iated wi th in trauterine fe ta l death. Can J Anaes th 1996; 43:1237.P ri tch ard , Jack A. "Fetal d eath in u tero ."Ob stetrics & Gyn eco lo g y 1 4 .5 (1 9 5 9 ):5 7 3 -5 8 0 .

ExpectantManagement

• Weeklyprenatal visits• Homeassessment

• Temperature,presenceofabdominalpain, bleedingor labor

• Seriallabs• Minimaldataonbenefit• Consider baselinecoagulopathypanel

• Fibrinogen, platelets, PTT,aPTT• Recheckprior toneuraxial anesthesia

• Considerifdemise<4weeksChakhtoura NA, Reddy UM. Management of stillbirth delivery. Seminars in perinatology 2015;39:501 -5 04

Route

• Vaginaldelivery• Alwaysdesirable • Generally saferforwomanthancesareandelivery

• YES evenwithpriorLTCS

• Maternal requestforcesarean delivery• Avoidexperienceof laborandbirth• Informedconsent• Requires counselingonbenefitsandrisksofvaginalversuscesareandelivery

Essentials ofLaborManagement

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Terminology

• CervicalRipening• Complexprocessof softeninganddistensibility• Consistency,position, effacementanddilation

• InductionofLabor• Useofpharmacologicaland/ormechanicalmethods to initiate labor• Includesunsuccessfulattemptsatinitiating labor, initiation oflabor followingspontaneous ruptureofmembraneswithout contractions

• Augmentation• Stimulationofuterinecontractionsusingpharmacologicmethodsorartificialruptureofmembranes toincreasecontractionfrequencyand/or strengthfollowing theonsetof spontaneous labororcontractionsfollowingspontaneous ruptureormembranes

“Indicationsforlaborinductionarenotabsolutebutshouldtakeintoaccountmaternalandfetalconditions,gestationalage,cervicalstatus,andotherfactors.”ACOG

• Abruptio Placentae• Chorioamnionitis

• FetalDemise• Prematureruptureofmembranes• Posttermpregnancy

• MaternalConditions• Hypertension• Diabetes• RenalDisease• Chronicpulmonarydisease• Antiphospholipid syndrome

• Fetalcompromise• Growth restriction• Isoimmunization• Oligohydramnios

AbsoluteContraindications

• Placentaorvasaprevia• Transverse fetallie• Umbilicalcordprolapse• Previousclassicalcesareandelivery• Myomectomy

• Enteredtheendometrial cavity

• Activegenitalherpes

StagesofLabor

• First Stage• Onset of labor until complete dilation• Two phases: latent and active

• Active transition: 8-10 cm• Second Stage

• Complete cervical dilation and effacement to delivery• Third Stage

• Placental Expulsion

FactorsAffectingBirthProcess:“P’s”

4“P’s”• Power:Contractions• Passage:Birthcanal

• Passenger:Fetus• Psyche:Emotions

5“P’s”• Power

• Passage• Passenger

• Position:Maternal• Psyche

PowerForcesrequiredtomovefetusthoughmaternalpelvis

• Primaryuterinepower• Myometriumadvancesfromquiettoactivewithlabor• Uterinemuscle:Composed of upperandlowersegments

• Uppersegment:activeandcontainspacemakerssites• Lowersegment:passivezone

• Physiologicretractionringbetweensegments• Facilitatesdescentanddilation

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Power(continued)

• Effacement/shortening• Thinningofthe cervical canal• Reported inpercentage

• Dilation• Openingofcervical os• Allowspassage offetus

• Cervix• Position:posterior toanterior• Consistency: firmtosoft

Passage:Pelvis

• Bony boundaries • Shape and configuration that allows for delivery

• Conditions impacting passage• Musculoskeletal deformities/ diseases

• Contracted pelvis, dwarfism• Pelvic trauma• Cervical trauma or injury (DES, surgical procedures)

Passenger (Fetus/Placenta)

• Active participant in labor process• Descending, turning through pelvis

• Determined by• Fetal lie• Fetal attitude• Fetal presentation• Presenting part• Fetal position

Psyche• History

• Past/presentbirthexperience• Culturalconsiderations• Expectationsforbirthexperience

• Birthplanrealisticornot• Preparationforbirth• Supportsystem

• Psychosocialresponse• Emotionsduringphases oflabor

• Psychologicalreactionstolabor• Trainedsupportpersonatbedside

UterineActivity

• Importanttoknowuterinephysiology• Relationshiptofetaloxygenation• Doesitapplytofetallosses?NO

• CorrelationbetweenUAandacid-basestatus• Frequencyalonenotenoughfor

• “Passage”and“Passenger

UterineActivityTerminology• Frequency

– Beginning of contraction tobeginning of next one– Measured inminutes

• Duration– Length of contraction frombeginning toend (onsettooffset)– Measured inseconds

• Intensity– Strength of contraction– Assessed via palpation ormmHg (Montevideo units)

• Resting Tone– Intrauterine pressure when uterus isnotcontracting– Assessed via palpation ormmHg

– Relaxation Time– Time fromend of contraction tobeginning of next

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MontevideoUnits

• 10minutetimeframe• Twomethods

• Measure peakintensity,oramplitude,inmmHgforeachcontractionandaddtogether

• Subtractbaselineuterinetonefrompeakcontractionpressureforeachcontractionandaddtogether

ShoulderDystocia• Obstetricemergency

• Mostlyunpredictableandunpreventable• Resultofsizediscrepancybetweenfetalshouldersandthepelvicinlet.

• Delivery offetalbodyispreventedbyimpaction• Fetalshoulderbehindsymphysispubis

• Delivery requiringmaneuversinadditiontogentledownwardtraction• Secondarydefinition

• Delivery withlongerthan60secondsbetweenheadandbody• Requiresuseofancillaryobstetricmaneuvers

PotentialRiskFactors

• Stronglyassociated• EFW>4500grams

• Some use>4000grams• Maternaldiabetes

• Pre-existingandGDM

• Historyofpriorshoulderdystocia• Maternal obesity• Increasedweightgain

• Multiparity• Posttermpregnancy• Disproportionatefetalgrowth

• Abdomen/chestcircumferencecomparedtoocciputofrontaldiameter

IntrapartumRiskFactors

• Laborinduction• Abnormallaborprogress• Prolongedsecondstage• Operativevaginalbirth

Chorioamnionitis:FeverPlusOneoftheFollowing

Clinical Parameters Suggestive of Chorioamnionitis

Maternal Fever T ≥ 100.4 °

Maternal Leukocytosis > 15, 000 cells/mm

Maternal Tachycardia > 100 bpm

Uterine/Fundal or Abdominal Tenderness

Tenderness or pain on palpation

Vaginal Discharge Foul smelling fluid or discharge

Adapted from: Tita AT, Andrews WW. Diagnos is and management of clinical chorioamnionitis . Clin Per inatol. 2010;37:339-354.Greenberg, Mara B., et al. "A firs t look at chorioamnionitis management practice variation among US obs tetricians ." Infectious diseases in obs tetr ics and gynecology 2012

ChorioamnionitisRISK FACTORS

Prolonged membrane rupture (≥ 12 hours )

Prolonged Labor

Meconium s tained fluid (heavy or particulate)

Nulliparity

↑ BMI

Regional anes thes ia (epidural fever)

Immunocompromised patients

Race/ethnic background (e.g. African American)

Urogenital Infections (Group B s trep, UTI, bacterial vaginos is )

Prior his tory of chorioamnionitis

Procedures (> 8 vaginal exams, amnioinfus ion, internal fetal monitoring)

Poor perineal hygiene (includes during labor)

Alcohol and tobacco use

Ad ap ted fro m: Tita AT, An d rews WW. Diag n o sis an d man ag emen t o f clin ical ch o rio amn io n itis. Clin Perin a to l. 2 0 1 0 ;3 7 :3 3 9 -3 5 4

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Every hospital will need to customize the protocol—but the point is every hospital

needs one

CMQCC OB Hemorrhage Emergency Management Plan

!

!

Copyright California Department of Public Health, 2014; supported by Title V funds. Developed in partnership with California Maternal Quality Care Collaborative Hemorrhage Taskforce Visit: www.CMQCC.org for details

Obstetric Hemorrhage Emergency Management Plan: Table Chart Format version 2.0

Assessments Meds/Procedures Blood Bank Stage 0 Every woman in labor/giving birth

Stage 0 focuses on risk assessment and active management of the third stage.

• Assess every woman for risk factors for hemorrhage

• Measure cumulative quantitative blood loss on every birth

Active Management 3rd Stage:

• Oxytocin IV infusion or 10u IM

• Fundal Massage-vigorous, 15 seconds min.

• If Medium Risk: T & Scr • If High Risk: T&C 2 U • If Positive Antibody

Screen (prenatal or current, exclude low level anti-D from RhoGam):T&C 2 U

Stage 1 Blood loss: > 500ml vaginal or >1000 ml Cesarean, or VS changes (by >15% or HR ≥110, BP ≤85/45, O2 sat <95%)

Stage 1 is short: activate hemorrhage protocol, initiate preparations and give Methergine IM.

• Activate OB Hemorrhage Protocol and Checklist

• Notify Charge nurse, OB/CNM, Anesthesia

• VS, O2 Sat q5’ • Record cumulative

blood loss q5-15’ • Weigh bloody materials • Careful inspection with

good exposure of vaginal walls, cervix, uterine cavity, placenta

• IV Access: at least 18gauge • Increase IV fluid (LR) and

Oxytocin rate, and repeat fundal massage

• Methergine 0.2mg IM (if not hypertensive) May repeat if good response to first dose, BUT otherwise move on to 2nd level uterotonic drug (see below)

• Empty bladder: straight cath or place foley with urimeter

• T&C 2 Units PRBCs (if not already done)

Stage 2 Continued bleeding with total blood loss under 1500ml

Stage 2 is focused on sequentially advancing through medications and procedures, mobilizing help and Blood Bank support, and keeping ahead with volume and blood products.

OB back to bedside (if not already there) • Extra help: 2nd OB,

Rapid Response Team (per hospital), assign roles • VS & cumulative

blood loss q 5-10 min • Weigh bloody materials • Complete evaluation

of vaginal wall, cervix, placenta, uterine cavity • Send additional labs,

including DIC panel • If in Postpartum: Move

to L&D/OR • Evaluate for special

cases: -Uterine Inversion -Amn. Fluid Embolism

2nd Level Uterotonic Drugs: • Hemabate 250 mcg IM or • Misoprostol 800 mcg SL

2nd IV Access (at least 18gauge)

Bimanual massage Vaginal Birth: (typical order) • Move to OR • Repair any tears • D&C: r/o retained placenta • Place intrauterine balloon • Selective Embolization

(Interventional Radiology) Cesarean Birth: (still intra-op) (typical order) • Inspect broad lig, posterior

uterus and retained placenta

• B-Lynch Suture • Place intrauterine balloon

• Notify Blood Bank of OB Hemorrhage

• Bring 2 Units PRBCs to bedside, transfuse per clinical signs – do not wait for lab values

• Use blood warmer for transfusion

• Consider thawing 2 FFP (takes 35+min), use if transfusing > 2u PRBCs

• Determine availability of additional RBCs and other Coag products

Stage 3 Total blood loss over 1500ml, or >2 units PRBCs given or VS unstable or suspicion of DIC

Stage 3 is focused on the Massive Transfusion protocol and invasive surgical approaches for control of bleeding.

• Mobilize team -Advanced GYN surgeon -2nd Anesthesia Provider -OR staff -Adult Intensivist • Repeat labs including

coags and ABG’s • Central line • Social Worker/ family

support

• Activate Massive Hemorrhage Protocol • Laparotomy: -B-Lynch Suture -Uterine Artery Ligation -Hysterectomy • Patient support -Fluid warmer -Upper body warming device -Sequential compression stockings

Transfuse Aggressively Massive Hemorrhage Pack • Near 1:1 PRBC:FFP • 1 PLT apheresis pack per 4-6 units PRBCs

Unresponsive Coagulopathy: After 8-10 units PRBCs and full coagulation factor replacement: may consult re rFactor VIIa risk/benefit

Blood Loss:1000-1500 ml

Stage 2Sequentially

Advance throughMedications &

Procedures

Pre-Admission

Time of admission

Identify patients with special consideration:Placenta previa/accreta, Bleeding disorder, or those who decline blood products

Follow appropriate workups, planning, preparing of resources, counseling and notification

Screen All Admissions for hemorrhage risk:Low Risk, Medium Risk and High Risk

Low Risk: Draw blood and hold specimenMedium Risk: Type & Screen, Review Hemorrhage ProtocolHigh Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage Protocol

All women receive active management of 3rd stageOxytocin IV infusion or 10 Units IM, 10-40 U infusion

Standard Postpartum Management

Fundal Massage

Vaginal Birth:Bimanual Fundal MassageRetained POC: Dilation and CurettageLower segment/Implantation site/Atony: Intrauterine BalloonLaceration/Hematoma: Packing, Repair as RequiredConsider IR (if available & adequate experience)

Cesarean Birth:Continued Atony: B-Lynch Suture/Intrauterine BalloonContinued Hemorrhage: Uterine Artery Ligation

To OR (if not there); Activate Massive Hemorrhage Protocol

Mobilize Massive Hemorrhage Team TRANSFUSE AGGRESSIVELY RBC:FFP:Plts Æ 6:4:1 or 4:4:1

IncreasedPostpartum Surveillance

Definitive SurgeryHysterectomy

Conservative SurgeryB-Lynch Suture/Intrauterine BalloonUterine Artery LigationHypogastric Ligation (experienced surgeon only)Consider IR (if available & adequate experience)

Fertility Strongly Desired

Consider ICUCare; Increased

Postpartum Surveillance

Verify Type & Screen on prenatal record;

if positive antibody screen on prenatal or current labs (except low level anti-D from Rhogam), Type & Crossmatch 2

Units PBRCs

CALL FOR EXTRA HELPGive Meds: Hemabate 250 mcg IM -or-

Misoprostol 600-800 SL or PO

Cumulative Blood Loss>500 ml Vag; >1000 ml CS>15% Vital Sign change -or-

HR ≥110, BP ≤85/45 O2 Sat <95%, Clinical Sx

Ongoing Evaluation:

Quantification of blood loss and

vital signs

Unresponsive Coagulopathy:After 10 Units PBRCs and full

coagulation factor replacement,may consider rFactor VIIa

HEMORRHAGE CONTINUES

Blood Loss:>1500 ml

Stage 3

Activate Massive

Hemorrhage Protocol

Blood Loss: >500 ml Vaginal

>1000 ml CSStage 1Activate

Hemorrhage Protocol

NO

Stage 0All Births

Transfuse 2 Units PRBCs per clinical signs

Do not wait for lab valuesConsider thawing 2 Units FFP

YES

YES NO

Ong

oing

Cum

ulat

ive

Blo

od L

oss

Eva

luat

ion

Cumulative Blood Loss>1500 ml, 2 Units Given,

Vital Signs Unstable

YESIncrease IV Oxytocin RateMethergine 0.2 mg IM (if not hypertensive)Vigorous Fundal massage; Empty Bladder; Keep WarmAdminister O2 to maintain Sat >95%Rule out retained POC, laceration or hematomaOrder Type & Crossmatch 2 Units PRBCs if not already done

Activate Hemorrhage ProtocolCALL FOR EXTRA HELP

Continued heavy bleeding

Increased Postpartum Surveillance

NO

NO

CONTROLLED

INCREASED BLEEDING

California Maternal Quality Care Collaborative (CMQCC), Hemorrhage Taskforce (2009) visit: www.CMQCC.org for detailsThis project was supported by funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division

Obstetric Emergency Management Plan: Flow Chart Format Release 2.0 7/9/2014

The Importance of IV Gauge

Gauge Gravity Flow Flow with Rapid Infuser

20 65 mL/min

18 140 mL/min 250 mL/min

16 190 mL/min 350 mL/min

14 300 mL/min 500 mL/min

Get 2nd Line In Before Vasoconstriction Develops!

ClotTube• 5ml in red top tube

• No anticoagulant• No clot activator

• 10 minutes• Failure to clot or dissolution of initial clot

• Coagulopathy present

MethodsofLaborInductionNon-Pharmacologic Surgical Pharmacologic

Complementary orAlternative Medicine

Dilation&Evacuation Prostaglandins

MechanicalDilators Hysterotomy Misoprostol

MembraneStripping Hysterectomy Oxytocin

Amniotomy

Complementary/AlternativeMedicineLackofsafetyandefficacydata

Nospecificrecommendationsinfetaldemise• Herbalsupplements

• Redraspberryleaf ,• Blueandblack cohosh• Evening primroseoil

• Breast stimulation• Sexualrelations• Acupuncture• TranscutaneousNerveStimulation

MechanicalDilators

• Hygroscopic/osmoticdilators• Laminaria

• Balloondevices• Foleycatheters• Doubleballoondevices• Extraamnioticsaline infusion

• Membranestripping/sweeping• Amniotomy

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MechanicalDilators

Advantages• Cost• Stableatroomtemperature• Easystorage• Fewer sideeffects

Disadvantages• Ruptureofmembranes• Infection• Bleeding• Maternal discomfort

Hygroscopic/OsmoticDilators

• “Laminaria”ortypeofseaweed• Technique

• Placedduringspeculumexamination• Progressiveplacement• Sterilegauzepad• Recordnumberofdilators

BalloonDevices

• Foleycatheters/double balloons• Technique

• Speculum orblind placement• Inf lation of balloon

• 30-60ccoff luid• Gently retract and secure

• Traction• Extra-amniotic infusion (EASI)

• 18Ffoley catheter• Inf late balloonwith 30cc• Secure withtraction• NS infusion30drops/min (90cc/hr)• Maximum volume 2liters

MembraneStripping/Sweeping• Digitaldilatationofthecervix• Releasesprostaglandin• Technique

• Vaginalexamination• Membranesseparated frominternalos• Movinginacirculardirection

Amniotomy

• Pressureofpresentingpartoncervix• Bestwithfavorablecervix• Inconjunctionwithlowdoseoxytocin

• Shorten intervals frominduction todelivery

• Commitmenttodelivery

PharmacologicMethods

• Prostaglandins• Prostaglandin E1(PGE1)

• Misoprostol• Prostaglandin E2(PGE2)

• Gel: 0.5mgdinoprostone• Vaginal insert:10mgdinoprostone

• Oxytocin

AWHONN Webinar Series ©2009 42

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SecondTrimesterManagement

• Optimalmethodsnotestablished• Inductionversussurgical

• IOLusedmoreoftenthandilationandevacuation• Maybegestational agerelated• Requires skilledclinicians inperformingD&E• Clinically importanttoobtain intactfetus• Allows forprocessof labor tooccur• Patientpreference

• BUT D&Econsideredsafer13to22-24weeks• Lowercomplication ratesthan IOL

Bry ant AG, Grimes DA, Garrett J M, Stuart GS. Sec ond-trimes ter abortion for fe ta l anomal ies or fe ta l death: labor induc tion c ompared wi th d i la tion and ev ac uation. Obs tetric s & Gy nec ology . 2011;117(4):788-92.

SurgicalProcedure:

• Cervicalripening• Laminariaormisoprostol• Ultrasoundguidedprocedure• Removaloffetusandplacenta

• Cannulaandspecial forceps

• Awarenessbyentireteam ofprocedureresults

SurgicalProcedure:D&E• Medication

• Doxycycline100mgpo1hrprior toprocedureand200mgafterprocedure• ORpostoperativemetronidozole500mgorally twicex5days

• Cervical ripening• Misoprostol 200mgin theposterior fornix4hoursprior toprocedure• OR laminariax12-24hours

• Dilationandevacuationunderultrasoundguidance• Cannulaandspecial forceps

• Dischargeafteranesthesia wornoffandvaginalbleeding isminimal• Administer Rhoghamifpatient isRhnegative• Schedulefollow-up visit in1-2weeks• PrescribeNSAIDs

Bry ant AG, Grimes DA, Garrett J M, Stuart GS. Sec ond-trimes ter abortion for fe ta l anomal ies or fe ta l death: labor induc tion c ompared wi th d i lation and ev ac uation. Obs tetric s & Gy nec ology . 2011 Apr 1 ;117(4):788-92.

Bry ant AG, Grimes DA, Garrett J M, Stuart GS. Sec ond-trimes ter abortion for fe ta l anomal ies or fe ta l death: labor induc tion c ompared wi th d i lation and ev ac uation. Obs tetric s & Gy nec ology . 2011 Apr 1 ;117(4):788-92.

PGE2VaginalSuppositories

• 20mgsuppositoryq4hours• Redoseuntilcontractionscausecervicalchange• <28weeks• Sideeffects

• Fever,nausea,vomitinganddiarrhea• Pretreatmentmedications

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SecondTrimesterManagement

• Drugofchoice• Misoprostol forlate2ndtrimester (≥22weeks)• Optimumregimennotestablished

• Suggested Dose• 200to400mcgvaginally• Repeating doseevery3hours• Maximumcumulativedose=1400mcgin24hours

• Meandeliverytime• 10to11hours

Gomez Ponce de Leon R, Wing D, Fiala C. Misoprostol for intrauterine fetal death. Int J GynaecolObstet 2007; 99 Suppl 2:S190.

Literature

• Systematicreview of14RCT’s• Dosing: 100 to400mcg(butsometimesmore….)• Routes:oral, vaginal, sublingual, buccal• Frequenciesofadministration: q3to12hours

• Vaginaldosingjustaseffectiveasoraldosingwithin48hours• 100% delivery rate

• Vaginaldosingalonecomparedtovaginaldosingandoxytocinlesseffective indelivery<24hours

• Nodifferencein<48hours

Gómez PD, Wing DA. Misoprostol for termination of pregnancy with intrauterine fetal demise in the second and third trimester of pregnancy-a systematic review. Contraception . 2009 Apr;79(4):259 .

Alternatives• Misoprostol100mcgvaginally

• Repeat q6to12hoursforamaximumof4doses• Pregnanciesat18to26weeks

• Seconddosecanbedoubledto200mcg• Maximumcumulativedoseis800mcgin24hours

● Misoprostol 100mcgor200mcgvaginally•q4hours• Mifepristone(RU486)Misoprostolregimen(<20weeks but>20weeks???)

• Mifepristone200mgor600mg• Followedbymisoprostol200or400mcg24to48hourslater

Gomez Ponce de Leon R, Wing D, Fiala C. Misoprostol for intrauterine fetal death. Int J GynaecolObstet 2007; 99 Suppl 2:S190.

Mifepristone

• Antiprogestin• Increasesuterinesensitivitytoprostaglandins

• Allows for lowerdoses• Fewerside effects

• Alternative optionGemeprost• Notavailable inUnitedStates

MifepristoneandMisoprostolReferences

• Chaudhuri P, DattaS.Mifepristone andmisoprostol compared withmisoprostol alone for induction of labor in intrauterine fetaldeath:Arandomized trial. JObstet Gynaecol Res 2015;41:1884.

• Panda S, JhaV, Singh S.Role ofCombination OFMifepristone andMisoprostol Verses Misoprostol alone in Induction ofLabour in LateIntrauterin FetalDeath:AProspective Study.JFamilyReprodHealth 2013;7:177.

• Wagaarachchi PT, Ashok PW, Narvekar NN,etal. Medical management oflate intrauterine death using acombination ofmifepristone andmisoprostol. BJOG 2002;109:443.

MisoprostolSideEffects

• Nauseaandvomiting• Diarrhea

• Associatedmostwithhigherdoses

• Noninfectiousfever• Combinedmethods

• Higher ratescomparedtomisoprostol only

Perritt JB, Burke A, Edelman AB. Interruption of nonviable pregnancies of 24–28 weeks ' gestation us ingmedical methods .Contraception. 2013 Sep 30;88(3):341-9.

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Whyis28weeksacut-off

• Uterus lesssensitivetooxytocin• Prostaglandinsandmechanicaldilatorsmayberequired

• Prostaglandin side-effects

• “Keepinmindthatalthoughsideeffects(uterinetachysystole,nausea,vomiting,diarrhea)andsafetyremainimportantconsiderationsforthepatientinthesecircumstances,thefetalwellbeingisnolongeranissue”(Gabbe)

HighDoseOxytocin

• Effective especiallyifotheroptionsnotavailable• Dosing

• 6mU/min• Increaseby6mU/minat45minuteintervalsuntilcontractionsare effective

• Donotexceed40mU/min

Abed iasl Z, Sheikh M ,P oo ran sari P , Farahan i Z, K alan i F. Vagin al misop ro sto l versu s in travenou s o xyto cin fo r th emanagemen t o f second -trimester p regnan cieswith in trau terin e fetal d eath : A randomized cl in ical trial . Jo u rnal o fOb stetrics and Gynaeco lo gy Research . 2 0 1 5 Jan 1 .

Yapar EG,Senö z S, Ürkü tü r M ,Batio glu S, Gökmen O.Second trimester p regnan cy termination in clud in g fetal d eath : comparison o f five d i fferen t method s.Eu ropean Jou rnal o fOb stetrics &Gyneco lo gy and Rep rodu ctive B io lo gy.1 9 9 6 Nov3 0 ;6 9 (2 ):9 7 -1 0 2 .

AlternativeHighDoseOxytocin

Winkler C L, Gray SE, Hau th JC , Owen J, TUCK ER J. M id -second -trimester l ab o r in du ctio n :co n cen trated o xyto cin compared wi th p ro stagland in E2 vagin al su ppo si to ries. Ob stetri cs &Gyneco lo gy. 1 9 9 1 Feb 1 ;7 7 (2 ):2 9 7 -3 0 0 .

Owen J, Hau th JC , Win klerC L, Gray SE. M id trimester p regn an cy termin atio n : a randomized trial o fp ro stagland in E 2 versu s co ncen trated o xyto cin . American jo u rn al o fo b stetri cs an d gyn eco lo gy. 1 9 9 2 Oct3 1 ;1 6 7 (4 ):1 1 1 2 -6 .

WaterIntoxication• Oxytocinisananti-diuretic

• Highdoses lead tohyponatremia(~40mU/min)• Prostaglandin usehasdecreasedneedforprolongedoxytocin

• Hyponatremiaetiology• Attributed tohemodilution with IVfluids• Increasedexcretionofsodium in theurine• Shiftof sodiumfromextracellular tointracellular fluid

• Relationbetweensymptomsandplasmasodiumconcentration• Critical range:120-125mmol(mEq)/l

Ahmad AJ, Clark EH, Jacobs HS. Water intoxication associated with oxytocin infusion. Postgraduate medical journal. 1975 Apr 1;51(594):2 49 -5 2.

WaterIntoxication• Quantityofinfusedfluidismoreimportantthanoxytocinconcentration

• Lowdose (2-5mU/min)actasantidiuretic• Demonstratedwithin 10-15minutes

• Oxytocin-inducedhyponatremia• Receivedmore than3.5litersof fluid (fluidswithD5)

• Symptoms• Headache,anorexia,nausea,vomiting, tachycardia,abdominalpain, lethargy,drowsiness, unconsciousness, grandmalseizures, andLossofconsciousness orGrandmalseizures “AlteredLOCaredifficult totospot inlaborbuthavebeen retrospectivelynoted in somepatients”

• Differentialdiagnosis: Eclampsia• “Normotensive,noproteinuriawithedema”• Confirmedbyserumelectrolytes

• Potentially irreversible neurologic injury\

Feeney J G. Water in tox ic ation and ox y toc in . Br Med J (Cl in Res Ed). 1982 J u l 24;285(6337):243-Ahmad AJ, C lark EH, Jacob s HS. Water In to xication asso ciation with o xyto cin in fu sion .. Ob stetrical &Gyneco lo gical Su rvey. 1 9 7 6 Mar1 ;3 1 (3 ):1 9 6 -7 ..

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TreatmentforWaterIntoxication• Stoptheseizures• ABC’soflifesupport• DiscontinueIVinfusionofoxytocinandD5

• WenowuseLactatedRingersorNormalSaline foroxytocininfusionJ

• Infuseisotonicsaline• Goal:normal rangeserumsodiumconcentration• Allows forphysiologicdiuresis

• ConsiderLasixorotherrapidlyactingdiuretic

• Nopatientshouldreceivemorethan3Loffluidcontainingoxytocin• Intakeandoutput

ManagementofThirdTrimester

• Idealmanagement>28weeks• Notdetermined

• “Usualmethods”• Unfavorablecervix

• Cervical ripening• Favorablecervix(>6)

• Laborinduction withoxytocin

0 1 2 3

Dilation Closed 1to 2 3to 4 5to 6

Effacement 0to 30% 40 to50% 60 to70% >70%

Station -3 -2 -1 to 0 +1 to+2

Cons is tency Firm Medium Soft

Pos ition Posterior Midpos ition Anterior

PGE2:Dinoprostone

• Suggested technique/dosing• Syringe/catheterplacement• 0.5mginendocervicalcanal• Maximumdosing:3doses in24hours• 6-12hourdelaybeforeusingoxytocin

• Suggested technique/dosing• Mesh insertplaced inposterior fornix• Removeafter12hoursoractivelabor• 30-60minutedelaybeforeusingoxytocin

Oxytocin

• Endogenous• Maternal circulation concentrations

• 2-4mU/min• Fetal contribution

• ~3mU/min• Combined Effect: 5-7mU/min

• Exogenous• Half life: 10-12minutes

• 3-5half livestoachievesteadystateconcentration• Physiologic dosing

• Initialdose1-2mU/min• Increaseby1-2mU/minq30-60minutes

Oxytocin

• Suggested technique• Multiple dilution options• Piggybackintomainline IVline

• Mostproximalport

• 10unitsto1000mlIVfluid• 1mu/min=6ml/hr

• 20unitsto1000mlIVfluid• 1mu/min=3ml/hr

• 60unitsto1000mlIVfluid• 1mu/min=1ml/hr

• 30unitsto500mlIVfluid• 1mu/min=1ml/hr

OxytocinRegimens

Type Initial Dose Increases Intervals

Low Dose 0.5 to 2 mU/min

1-2 mU/min 15-40 minutes

High Dose 6 mU/min 3-6 mU/min 15-40 minutes

Adapted from ACOG, 2009; Simpson, 2013

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Misoprostol

• Well studied in 2nd trimester demises• Insuff icient evidence in 3rd trimester

• 25 to50mcgvaginally• Repeat q4hours ifless than2contractions in 10minutes

• Second dose canbedoubled to50 to100mcg• Maximum of6doses

• Maximum cumulative dose =600mcgin 24hours• Oxytocin

• Initiated 4hours afteradministration of the last dose• Augmentation of labor

LaborInductioninThirdTrimesterStillbirthsGawron&Kiley,2013

• Objective• Managementof3rd trimester stillbirths 28weeks

• Academichospital• Chartreview: 74deliveries

• Demographics• History• Inductionmethodanddeliveryinterval• Adverseoutcome

• Results• ”Safedeliverywithin 24hours” regardlessofmethod

Gawron LM, Ki ley J W. Labor induc tion outc omes in th i rd-trimes ter s ti l lb i rths . In ternational J ournal o f Gy nec ology & Obs tetric s . 2013 Dec 31;123(3):203-6.

Gawron LM, Ki ley J W. Labor induc tion outc omes in th i rd-trimes ter s ti l lb i rths . In ternational J ournal o f Gy nec ology & Obs tetric s . 2013 Dec 31;123(3):203-6.

Gawron LM ,K i ley JW.Labo r in du ction ou tcomes in th i rd -trimester sti l lb i rth s. In tern ational Jou rnal o fGyneco lo gy &Ob stetrics. 2 0 1 3 Dec3 1 ;1 2 3 (3 ):2 0 3 -6 .

PlacentaPrevia

• Earlypregnancy doesnotprecludevaginaldelivery• <24weeksincreasedEBL

• Noincrease in infection,hysterectomy,postoperative transfusion

• Nopublishedstudies• Impactofplacentapreviaat>24– 28weeks

• Probablyhigherbloodlossrates• Insufficientevidencetomakerecommendations

Thomas AG, Alv arez M, Friedman F, Brodman ML, Kim J , Loc k wood C. The effec t o f p lac enta prev ia on b lood loss in s ec ond trimes ter pregnanc y termination. Obs tet Gy nec ol 1994;84:58–60Perri tt JB ,Bu rkeA,Edelman AB . In terrup tion o fn onviab le p regnan cies o f2 4–2 8 weeks' gestation u sin g med ical method s. Con tracep tion . 2 0 1 3 Sep 3 0 ;8 8 (3 ):3 4 1 -9.

PriorCesareanSection:Liveborn

• ProbabilityforSuccessfulInductionhttps://mfmu.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html

• LowRiskofUterineRupture(stillhigherthanunscarreduterus)• ~0.5– 1%(onepriorLTCS);3.7%for2priorLTCS

• UnfavorableCervix• Limiteddataonhowtoapproach

• Methods• MechanicalandPharmacologicMethods

ACOG, 2010; Cahill et al, 2010; Metx et al, 2012; Shanks & Cahill, 2011Hoffman MK, Sciscione A, Srinivasana M, Shackelford DP, Ekbladh L.Uterine rupture inpatients with a prior cesareandelivery: the impact ofcervical ripening. Obstetrical &gynecological survey. 2005 Jan 1;60(1):22-3.

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VBACCalculatorhttps://mfmu.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html

UterineRupture RatesFactors Rates

UnscarredUterus 1/5700 to1/20,000 pregnancies(RARE)0.0175%to0.005%

UnscarredUteruswithOxytocin Uncertain:3.6-43%ScarredUterus(all comers) 325per100,000womenundergoingTOL

0.325%Inductionoflaboratterm(37-40weeks) 1,500per100,000

1.5%Spontaneous labor 800per100,000

0.8%Inductionat>40weeks 3,200per100,000

3.2%Signore C, Spong CY. Vaginal birth after cesarean: new insights manuscripts from an NIH consensus development conference, March 8–10, 2010. In Seminars in perinatology 2010 Oct (Vol. 34, No. 5, p. 309).

BeAlert for Signs of Uterine Rupture• Maternal tachycardiaandhypotension

• Complete rupture=maternal shock

• Hematuria• Vaginalbleeding:May/maynotbepresent• Pain

• Shearing,tearing, subrapubic• Occurswithepidural• Continuesaftercontractions

• Recedingpresentingpart/fetalstationloss• Palpablefetalpartinabdomen

PriorCesareanSectionandMisoprostol• Contraindicatedintermlaborinductionwithlivefetus• SAFEforfirst- andsecond-trimesterdemises(upto28weeks)• Misoprostolonlyregimenindemisecases(Cayrac)

• Noreportedcasesofuterine rupture inwomenwith priorcesarean

• Mifepristone-misoprostolregimens• Uterine rupture:4.8%(Cayrac)

• Successoftheregimenandoverallmorbidity• Similar forwomenwithandwithoutprioruterine incision

Perritt JB, BurkeA,EdelmanAB.Interruption ofnonviablepregnancies of24–28weeks 'gestationus ingmedicalmethods .Contraception.2013Sep30;88(3):341-9.CayracM,FaillieJL,FlandrinA,BoulotP. Second-andthird-trimester managementofmedicaltermination ofpregnancyandfetaldeathinuteroafter prior caesareansection.EuropeanJournalofObstetrics &GynecologyandReproductiveBiology.2011Aug31;157(2):145-9.

MisoprostolinPriorCesareanSection

• Criteria• Priorcesareansection• Misoprostol use16-28weeks

• Initial agent

• 509patients• Uterine rupturerate

• Oneprior: 0.4%• Twoprior: 0%• Priorclassical: 50%

“UniqueGroup”

• Creasy &Resnik• Individualize; use oxytocin protocolsandcervical ripening withfoley

• Gabbe• Candidates forinductionof labor• Does notmention misoprostol inpriorLTCS

• Williams• Outcomes were atf irstdiscouraging butrecent evidence is less pessimistic

• Berghella,2009andGoyal,2009:28weeksorless• UptoDate

• If thecervix isunfavorable, we suggest cervical ripening using a mechanical methodrather thana prostaglandin

• Favorable cervix: oxytocin

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LimitedData….

• Limiteddata• Priorclassicaluterine incision• Myomectomy

• Overalluterinerupturerate• 1-12% in thispopulation• Repeatcesareansection isappropriate

Chakhtoura NA, Reddy UM. Management of stillbirth delivery. Seminars in perinatology 2015;39:501 -5 04 ).

HowLongIsTooLong?

• Nopublishedstudiesonregimensafter24-48hours• Isolatedreportsofrefractorycasesafter 48hours

• Deliveryby72hours

• Considermedicationholiday• Changeregimens• Cesarean formaternalindications

• Arrestdisorders

Perritt JB, Burke A, Edelman AB. Interruption of nonviable pregnancies of 24–28 weeks ' gestation us ingmedicalmethods . Contraception. 2013 Sep30;88(3):341-9

RiskManagementStrategies• Informedconsent• Unitpolicyorprotocol

• Standardized institutionally based• Ripening,induction,augmentation

• Chainofcommand• Methodsanddosages• Complications• Interventions• Multidisciplinary input• Staffexpectations

• Staffing• PharmacologicCervicalRipening: 1:2• OxytocininLabor:1:1• Nothingaddressing fetal loss

• Patientacuity• Availability of supportpersonnel• Doula

• Medicalrecorddocumentation• Checklist???• Charting frequency• Evidenceofinformedconsent• Order set