With rapid confirmation of embryonic or fetal death, surgicalior medical evacuation or expectant observation is an option. As with induced abortion, nonsurgical options balance their noninvasiveness against heavier procedural bleeding, longer completion times, and lower success rates. Of options, expectant care underperforms medical or surgical options, and failure rates range from 15 to 50 percent (Luise, 2002; Trinder, 2006; Zhang, 2005). Also, weeks may pass between pregnancy failure diagnosis and actual spontaneous miscarriage.
Alternatively, misoprostol can be given to hasten uterine evacuation. A single 800-l-1g dose vaginally is a common stan dard (American College of Obstetricians and Gynecologists, 20 16c). It may be repeated in 1 to 2 days, and one large trial reported that 22 percent of women required a second dose (Zhang, 2005). Overall, failure rates range from 15 to 40 per cent (Petersen, 2014; Trinder, 2006). Unlike induced abortion, adding mifepristone does not add value (Stockheim, 2006).
Contraindications mirror those listed in the section describing induced abortion (p. 361).
Confirmation of completion may include a history of heavy bleeding, cramping, and tissue passage followed by ebbing flow; ping serum hCG levels. That said, there is no consensus on intervention.
Pre term premature rupture of membranes (PPRO\1) at a pre viable gestational age complicates 0.5 percent of pregnancies (Hunter, 2012). Rupture may be spontaneous or may follow an invasive procedure such as amniocentesis or fetal surgery.
Risks for spontaneous rupture at a previable gestation are prior
PPROM, prior second-trimester delivery, and tobacco use (Kilpatrick, 2006).
A gush of vaginal fluid that is seen pooling during sterile speculum examination confirms the diagnosis. In suspect cases, amnionic luid will fern on a microscope slide or will have a pH >7, or oligohydramnios will be seen on sonography (Sugibayashi, 2013). lso, amnionic fluid proteins placental alpha microglobulin-1 and insulin growth factor binding protein-I, described in Chapter 22 (p. 235), can be assayed (Doret, 2013).
In iatrogenic cases, defects are typically higher in the uterus and tend to self seal. Also, an occlusive plug-termed an amniopatch-can be created by intraamnionic instillation of autologous platelets and cryoprecipitate. Considered investigational, it is used to seal some surgical leaks (Richter, 2013).
Spontaneous rupture in the first trimester is nearly always followed by either uterine contractions or infection, and termination is typical. In some second-trimester cases not associated with pain, fever, or bleeding, fluid may have collected previously between the amnion and chorion. If this is documented, then diminished activity with observation is reasonable. After 48 hours, if no additional amnionic luid has escaped and if there is no bleeding, cramping, or fever, then a woman may resume ambulation and pelvic rest at home.