Second Trimester Pregnancy Loss

Table 2Diagnostic Approach to the Patient with a Second Trimester Pregnancy Loss

CLINICAL CLUES POSSIBLE CAUSES FURTHER EVALUATIONPOTENTIALACTION

Recurrent firsttrimester losses

Chromosomalabnormalities

Fetal autopsy; karyotype analysis Genetic counseling

Fetal malformation;stillbirth

Chromosomalabnormalities;maternal teratogenexposure; maternalillness

Fetal autopsy; karyotype analysis;maternal blood tests (i.e., glucose,thyroid, liver); maternal history

Geneticcounseling;avoidance ofteratogens;treatment ofmaternal illness

Painless rupture ofmembranes

Cervicalinsufficiency

Ultrasonography; hysterography Cervical cerclage

Unexplained loss Maternal anatomicfactors (müllerianduct anomalies,intrauterineadhesions)

Physical examination;ultrasonography;hysterosalpingography; hysteroscopy;pelvic magnetic resonance imaging

Metroplasty orother uterinesurgicalprocedures

Placental abruption Maternalhypertension;cocaine use;smoking;thrombophilias;physical abuse,trauma

Directed history and physicalexamination; laboratory evaluation(e.g., blood tests for factor V Leiden,activated protein C resistance,prothrombin G20210A mutation,protein S deficiency); pelvicultrasonography; toxicology screen

Treatment ofmaternal illness;substance abusecounseling orintervention

Maternal systemiclupus erythematosusor primary Sjögren'ssyndrome;cutaneousthrombosis

Antiphospholipidantibody syndrome

Blood tests for lupus anticoagulantand anticardiolipin antibody

Referral;combinationaspirin and heparintherapy

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CLINICAL CLUES POSSIBLE CAUSES FURTHER EVALUATIONPOTENTIALACTION

Normal fetus,possible maternalhistory ofthrombosis

Thrombophilias Blood tests for factor V Leiden,activated protein C resistance,prothrombin G20210A mutation,protein S deficiency

Referral;combinationaspirin and heparintherapy

Maternal fever,preterm labor,pathologic evidenceof placentalinflammation

Maternal infection Maternal (and fetal, if possible)cultures; assays for infectious agents

Antimicrobialagents; avoidanceof cat litter andsexuallytransmittedinfections; rubellaimmunization

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