Second and Third Trimester Pregnancy Loss
Few events are more devastating than a pregnancy loss, especially later in the pregnancy. You are so emotionally invested. You may have bought furniture and clothes, had a baby shower, chosen a name. If you have suffered a second or third trimester pregnancy loss, this post is for you.
Most pregnancy losses happen early, in the first 3 months. I talked about possible causes and treatments for this in a previous post (http://box2153.temp.domains/~drtracyp/recurrent-early-pregnancy-loss/). When there is a fetal demise in the second or third trimester, there may be a different set of possible causes. Unfortunately, these are largely unforeseeable with a first pregnancy, because we don’t routinely screen for most of these conditions. Just as with many other pregnancy complications, we usually don’t explore causes of pregnancy loss until you have already had one or more losses.
When we evaluate you, the goal is to find a reason for your pregnancy loss if possible, so that we can prevent this from happening again if possible. Some of the possible causes are the same as with first trimester loss: birth defects, genetic or chromosome abnormalities, etc. But in the case of a stillbirth (a fetal death after 20 weeks of gestation), there are additional potential contributors:
• Infections: When an expectant mom becomes sick, the fetus can be harmed in two ways: because mom is sick enough that her body is not able to send enough blood flow to the baby, or because the fetus is directly infected by the virus or bacteria. Examples of serious maternal infections include flu and chickenpox. Infections with syphilis or Listeria may cause both mom and fetus to become sick. Some fetuses become infected with a virus that may cause few if any symptoms in mom; good examples of this are cytomegalovirus (CMV) and parvovirus, or fifth disease. The majority of us have been exposed to these viruses at some time, and carry antibodies that protect us and our babies. But if we are not immune, these viruses can cause serious fetal infections or death.
• Placental separation: Abruption is the term used to describe the separation of the placenta from where it is attached to the inner wall of the uterus. This can happen for no apparent reason, but it is more common in women with hypertension, blood clotting abnormalities, previous pregnancy with abruption, multiples (twins, triplets, etc.), extra amniotic fluid (polyhydramnios), or a history of drug use. If enough of the placenta separates from the uterus, fetal death can result.
• Maternal medical conditions: Diabetes, preeclampsia, kidney or thyroid problems, or autoimmune diseases like lupus can worsen in pregnancy and lead to a loss. If diabetes is not well controlled, the risk of a bad outcome is much higher. Likewise, if mom has kidney disease or lupus, flares can lead to a fetal or newborn loss because of hypertension, prematurity, or poor growth of the fetus. Recent studies show that obesity and maternal age >35 increase the risk of stillbirth. These women are now being offered increased surveillance in the last half of pregnancy.
• Inherited or acquired blood clotting abnormalities: Some of us inherit an increased tendency to form blood clots, and some of us acquire antibodies that increase the likelihood of forming blood clots. When these clots form in the placenta, blood flow to the fetus is reduced, which may lead to poor fetal growth or fetal death.If you have had a stillbirth, what’s next? How do we determine what caused this to happen, and what can be done to prevent another loss?
• Autopsy should be done if possible, to look for undetected birth defects or infections. The placenta should also be examined, to look for evidence of blood clotting or placental abruption.
• Chromosome analysis should also be done. This is not always possible, especially if the fetus died more than a few days prior to delivery. But if cells can be successfully analyzed, we can look for abnormal chromosomes, translocations, and genetic syndromes.
• Blood should be drawn from you to look for inherited or acquired blood clotting abnormalities. If any of these are found, you may need to receive an anticoagulant with future pregnancies.
• With subsequent pregnancies, you will need to be monitored as a high risk patient. This means regular ultrasounds for fetal growth and increased surveillance of fetal well-being in the third trimester (see my post http://box2153.temp.domains/~drtracyp/the-fifth-m-of-gestational-diabetes-monitor/).
This should not have happened to you. But if we can find a cause for your loss, it makes more sense. Answers are comforting, at least to me. And if there is a problem that is treatable, then the outlook for future pregnancies is much better. You may not ever really be able to relax with another pregnancy. You are no longer naïve; you will never take an uneventful pregnancy for granted again. Most people who have a stillbirth go on to have healthy babies. Grief and joy – these are the experiences that remind us of our humanity, in all its imperfection and fragility and beauty. My love and best wishes are with you.