CLINICAL ROUNDS
Management Options for Women with Midtrimester Fetal
Loss: A Case Report
Tamara Belkin, CNM, and Jessica Wilder, CNM
CASE PRESENTATION
L.R., a 34-year-old gravida 2, para 1001, presented to labor and
delivery at 22 weeks’ gestation following a prenatal visit at
which no fetal heart rate was heard. The patient’s obstetric,
medical, surgical, family, and social histories were unremark-
able. She reported no medication, drug, or alcohol use, and
denied illnesses for herself or her immediate family during the
pregnancy. A sonogram performed in triage confirmed an intra-
uterine pregnancy with no fetal heart activity, and fetal size was
consistent with dates. Although she desired a surgical dilation and
evacuation (D&E) procedure, she agreed to admission for induction
of labor with the prostaglandin E1 analog misoprostol (Cytotec; GD
Searle & Co., Chicago, IL). The hospital policy included D&E
procedures for termination of midtrimester pregnancy; however,
there were no nurses on staff willing to participate in the
procedure. The patient chose not to go to another institution, as
she wanted to remain in the care of her midwife who managed
her case in collaboration with a consulting physician.
Following admission, an intravenous dose of lactated ringers
running at 125 cc/hour was established. Blood was drawn for the
purpose of establishing baseline values of hemoglobin and
hematocrit, complete blood cell count, prothrombin time, partial
thromboplastin time, platelets, fibrinogen, and D-dimer. The
patient’s vital signs were monitored every 4 hours, and remained
within normal limits. She was placed on bed rest. Pain relief
options were discussed, including butorphanol (Stadol; Geneva
Pharmaceuticals, Inc., Dayton, NJ) with promethazine (Phenergan;
Wyeth Pharmaceuticals, Inc., Philadelphia, PA) morphine, and an
epidural. Reporting a pain level of 4 out of 10 on a pain scale, she
stated that she did not require pain medication. An initial dose of
one tablet of 100 ␮g misoprostol was placed in the posterior
fornix of the vagina, with a second dose, also of 100 ␮g, placed
6 hours later. Fourteen hours following initiation of the induc-
tion, L.R. reported strong cramping and the feeling that “some-
thing came out.” An intact, macerated female fetus was noted
between the bed sheets. L.R. did not wish to see the fetus. Ten
minutes later, she delivered an intact placenta. According to
hospital protocol for fetal demise, the fetus was wrapped and
photographed before being sent with the placenta to pathology.
As per hospital practice, a social worker was called in to see the
patient. During this meeting, L.R. expressed no desire to discuss
the experience or view the photos. L.R. experienced no compli-
cations, and was discharged the following day. The pathologist’s
report was inconclusive, and chromosomal analysis revealed no
abnormality. The fetal weight was 503 grams.
Address correspondence to Tamara Belkin, CNM, 39 Angelus Drive,
Greenwich, CT 06831. E-mail: tlb2105@columbia.edu
164
© 2007 by the American College of Nurse-Midwives
Issued by Elsevier Inc.
INTRODUCTION
According to the World Health Organization, the defini-
tion of fetal death (which has also been adopted by the
United Nations and the National Center for Health
Statistics) is a “death before the complete expulsion or
extraction from its mother of a product of conception,
irrespective of the duration of pregnancy; the death is
indicated by the fact that after such separation, the fetus
does not breathe or show any other evidence of life, such
as beating of the heart, pulsation of the umbilical cord,
or definite movement of voluntary muscles.”1 For the
purpose of statistics, however, fetal deaths are classified
according to gestational age, and only pregnancy losses
that occur at ⱖ20 weeks’ gestation are categorized as
fetal deaths.1 The fetal death rate in the United States
varies among races, but overall, it is 6.8 deaths per 1000
total births. Fetal deaths account for approximately half
the perinatal mortality rate (fetal and neonatal deaths).2 A
careful prenatal history and routine screening for gesta-
tional diabetes and pregnancy-induced hypertension al-
lows for the identification of women at risk for intrauter-
ine fetal demise (IUFD) and also allows for appropriate
treatment, surveillance, and referral. However, up to 50%
of IUFDs are of an undetermined etiology.3 Thus, the
occurrence of midtrimester fetal death is not isolated to
populations of obstetrically, medically, or socially high-
risk women.
The management of fetal death in utero has changed
dramatically from earlier recommendations, when 75%
of women delivered within 2 weeks after fetal demise;
the event was regarded as a medically benign condition
to be managed conservatively except under life-threaten-
ing circumstances.3 After coagulopathy was observed in
pregnancies complicated by fetal death in utero,4 the
management of stillbirth became more proactive with the
development of cervical ripening and uterotonic agents.
In 1977, Grimes et al.5 published the results of their study
showing that D&E was a safe alternative to the then
widely accepted instillation methods of midtrimester
terminations. Since the 1980s, misoprostol use has be-
come increasingly more common.
Today, the primary management options for women
with IUFD are either medical induction of labor or
surgical D&E. The decision of method is influenced by
Volume 52, No. 2, March/April 2007
1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2006.08.015
service availability and obstetric history, as well as
provider and patient preference. The D&E procedure is
not available in every institution, being primarily limited
by the training and skill levels of the available providers.
The availability of the procedure may also be affected by
interpretation of legislation or institutional policy limit-
ing late-term abortions, regardless of the indication and
the status of the fetus.
Misoprostol, an E1 prostaglandin analog, is commonly
used off-label for termination of pregnancy after fetal
demise, while D&E in midtrimester is still used primarily
for therapeutic termination.2
MANAGEMENT OPTIONS FOR MIDTRIMESTER FETAL LOSS
D&E and medical induction are both safe methods for
termination of pregnancy in midtrimester; each have low
complication rates.2 D&E is a scheduled procedure,
which is performed under intravenous-conscious seda-
tion and local anesthesia, managed much like an elective
termination, and often occurs in a surgical gynecology
setting (ambulatory or inpatient). The ambulatory setting
is reserved for those women who have no coagulopathy
or comorbid conditions. Viewing of the intact fetus is not
possible because it is removed in pieces during the
procedure. Medical induction, in comparison, may be
managed more like childbirth, with the woman on the
labor and delivery ward or inpatient gynecology unit. In
this case, the woman will remain conscious but may have
pain medication, and she has the option of viewing her
fetus.
The physical health risks and benefits of D&E versus
induction of labor with misoprostol in midtrimester
terminations were compared in a study by Autry et al.2
These authors found that while both procedures are safe,
the overall complication rate was significantly lower in
patients undergoing D&E than in those who underwent a
medical induction (4% vs. 29%, respectively; P ⬍ .001).
As a surgical procedure, risk related to D&E is also
heavily influenced by the skill and experience of the
provider. Complications associated with D&E included
hemorrhage, infection, cervical laceration, and uterine
perforation. Additionally, several other studies con-
ducted by one group of researchers found no increased
risk of midtrimester loss or preterm birth in future
pregnancies for women who have a midtrimester
D&E.6 – 8
Best practices for the use of misoprostol are not
available. The Cochrane Collaboration is undertaking a
review protocol. The medication is not approved by the
Food and Drug Administration (FDA) for use in induc-
Tamara Belkin, CNM, is part of the midwifery service of Bronx-Lebanon
Hospital Center in the Bronx, NY.
Jessica Wilder, CNM, was a student at Columbia University School of
Nursing at the time the article was written.
Journal of Midwifery & Women’s Health • www.jmwh.org
tion of labor, although it is widely used in the United
States for this purpose. Misoprostol induction for IUFD
involves different dosing than the doses used for induc-
tion at term of a viable fetus. Though high doses and
several different regimens are used, there is limited
research regarding dosage, timing, and route (vaginal,
oral, or rectal) for termination of pregnancy after midtri-
mester fetal death. Autry et al.2 found that the most
common complication of medical induction was retained
products of conception requiring readmittance to the
hospital for a subsequent dilation and curettage. Other
complications included infection, hemorrhage, and uter-
ine rupture.
Inevitably, cost considerations are factors in the avail-
ability of management options. Misoprostol is inexpen-
sive compared with other agents used for medical abor-
tion, but the expense associated with inpatient treatment
and length of hospital stay adds to the cost. The total cost
of inpatient treatment with misoprostol is comparable to
that of D&E, which can be performed in an ambulatory
surgical center.8 The cost related to an increased rate of
necessary follow-up for complications such as retained
products of conception with misoprostol induction may
also be a consideration.
Emotional and Psychological Implications
The emotional and psychological implications of D&E
versus induction of labor can be complex. It is not simply
that one experience is traumatizing and the other sup-
portive, but rather, that each requires the woman to
confront the loss differently. Because not all women cope
in the same way, either option could potentially facilitate
healing or cause additional psychological and emotional
damage. Therefore, when considering the options, it is
critical to remember that the devastation surrounding the
loss of a fetus can be compounded by a management plan
at odds with the needs of the grieving woman. If this
results in an impaired ability to cope, the woman’s entire
life, her relationship with her partner, her ability to care
for her children, and her ability to work will be nega-
tively impacted.
The psychological impact of these very different
choices in midtrimester terminations were compared in a
study by Burgoine et al.3 The subjects in this study
self-selected into two groups following counseling about
the options. This study followed the women for 12
months after the procedure and found no significant
difference at any point within this time period in the
bereavement or incidence of depression between women
choosing D&E or labor induction. One important factor
in this outcome, as noted by the authors of this study, was
that each woman was given the power to choose which
procedure was best for her. While some women may
desire a rapid and detached experience with no exposure
to the fetus, other women may feel better undergoing the
165
experience of labor and birth to end this pregnancy, with
the option of seeing and holding her infant. If a woman
who wished to give birth were made to have a D&E, she
would then have to grieve not only for her lost fetus, but
also for her lost birth experience. Conversely, if D&E is
not available or offered to a woman who desires that kind
of detached surgical procedure, she would then have to
undergo a lengthy induction and birth, with exposure to
her dead fetus, possibly adding more pain and grief to her
already devastating situation.3
It is not uncommon for women to blame themselves for
the demise and to search for answers as to why it occurred.
As stated previously, up to 50% of IUFDs have an unknown
etiology, leaving half of all women experiencing this loss
without desperately wanted answers, which can facilitate
self-blame. It is crucial for the provider to allow the woman
the space to voice her grief and ask questions, even if the
provider does not have the answers. In a study using
questionnaires and interviews of women who had experi-
enced a fetal loss, researchers discovered several common-
alities among the women in the study. Most notable were
the woman’s need for a follow-up visit, her need for more
information and answers, and her guilt and incorrect as-
sumptions about why the loss had occurred.9 It is during this
critically important follow-up visit that the midwife can
allay the woman’s guilt by reassuring her that she did not
cause the demise.
In another study focusing on women’s satisfaction
with their experience following a fetal loss, the most
commonly reported complaint was that the woman was
not given significant opportunity to discuss her loss with
her health care provider. The women in this survey were
most satisfied with the care they received when there was
a follow-up appointment soon after the loss. Most im-
portantly, the women wanted time to talk about their
feelings related to their loss, be able to ask why the loss
occurred, and ask whether it would happen again.10
Midwifery Role In Supporting Women With A Midtrimester
Fetal Loss
The role of the midwife may include assuring that the
woman makes an informed decision based on her needs,
beliefs, physical and emotional status, and available re-
sources. The midwife should know the indications, contra-
indications, and general procedures for both management
options. Contraindications to misoprostol use include pre-
vious uterine surgery and allergy to prostaglandins.
Misoprostol induction may be managed collabora-
tively with a physician, with the midwife still centrally
involved in the hands-on care; referral to a physician is
necessary for D&E. It may be an additional stressor for
a woman in this situation to see an unfamiliar and as
yet untrusted medical provider, especially if the pa-
tient has to be referred to a different institution.
Ideally, the midwife in this case would already have a
166
relationship with a physician to whom she could refer
the patient, quickly resuming care of the patient after
the procedure, or even comanaging the patient, main-
taining continuity of care and allowing the woman to
have the procedure she desires without having to give
up her provider entirely. If this is not possible, the
midwife should continue to be involved as a support
person and advocate, whether during the actual termi-
nation of pregnancy experience or at an early fol-
low-up appointment.
CONCLUSION
D&E and labor induction are both safe procedures
with low risk of complications for a woman with a
midtrimester IUFD. D&E is shown to have lower
complication rates than medical induction when per-
formed by skilled operators, and is associated with a
reduced incidence of retained products of conception,
bleeding, and readmittance to the hospital for fol-
low-up procedures.2 In the absence of significant risk
factors in the patient, providers must make the wom-
an’s choice paramount. In a situation where a woman
already feels she has very little control over what has
happened to her body and this pregnancy, it is impor-
tant to allow her to feel she can regain some of the
decision making to aid in her healing. To best facilitate
this, midwives must keep close to heart the commit-
ment to be “with women” and whatever the choice
made, work to protect her spirit and dignity.
REFERENCES
1. Centers for Disease Control and Prevention, National Center
for Health Statistics Web site. Definitions: Fetal death. Available
from: http://www.cdc.gov/nchs/datawh/nchsdefs/fetaldeath.htm
[Accessed June 30, 2006].
2. Autry AM, Hayes EC, Jacobson GF, Kirby RS. A compar-
ison of medical induction and dilation and evacuation for second-
trimester abortion. Am J Obstet Gynecol 2002;187:393–397.
3. Burgoine GA, Van Kirk SD, Romm J, Edelman AB, Jacob-
son S, Jensen JT. Comparison of perinatal grief after dilation and
evacuation or labor induction in second trimester terminations for
fetal anomalies. Am J Obstet Gynecol 2005;192:1928 –1932.
4. Jain JK, Kuo J, Mishell DR Jr. A comparison of two dosing
regimens of intravaginal misoprostol for second trimester preg-
nancy termination. Am J Obstet Gynecol 1999;93:571–575.
5. Grimes DA, Schulz KF, Cates JrCW. Tyler JrW, Methods of
midtrimester abortion: Which is safest? Int J Gynaecol Obstet
1977;15:184 –188.
6. Chasen ST, Kalish RB, Gupta M, Kaufman JE, Rashbaum
WK, Chervenak FA. Dilation and evacuation at ⱖ20 weeks:
Comparison of operative techniques. Am J Obstet Gynecol
2004;190:1180 –1183.
Volume 52, No. 2, March/April 2007
 7. Chasen ST, Kalish RB, Gupta M, Kaufman JE, Chervenak
FA. Obstetric outcomes after surgical abortion at ⱖ20 weeks’
gestation. Am J Obstet Gynecol 2005;193(Suppl 1):1161–1164.
8. Kalish RB, Chasen ST, Rosenzweig LB, Rashbaum WK, Cher-
venak FA. Impact of midtrimester dilation and evacuation on subse-
quent pregnancy outcome. Am J Obstet Gynecol 2002;187:882– 885.
9. Wong MK, Crawford TJ, Gask L, Grinyer A. A qualitative
investigation into women’s experiences after a miscarriage: Impli-
cations for the primary healthcare team. Br J Gen Pract 2003;53:
697–702.
10. Brier N. Understanding and managing the emotional reac-
tions to a miscarriage. Obstet Gynecol 1999;93:151–155.

NOTICE
Share With Women

All Share With Women columns are available for download from www.jmwh.org These
patient handouts cover more than 20 women’s health topics, from Genital Warts to
Down Syndrome Testing. Share With Women handouts are copyright-free, which means
they can be reproduced and Shared With Women!

Journal of Midwifery & Women’s Health • www.jmwh.org 167