A Late Midtrimester Loss

On August 12, 2007 Anonymous said...

Hi, approximatly 5 weeks ago I went into preterm labour and my son was 23 weeks gestation. He was too small to survive and passed away 10 minutes after the birth. I have a healthy 20 month old and I never had complications in my first pregnancy. My question is, what are my chances of having this happen again, and why do these things happen? According to my ultrasounds and right until the he was born he was fine? My o.b says that the cause is not known yet. I had to do some bloodwork something about antibodies? I need help trying to understand this, I am lost!

Kenneth F. Trofatter, Jr., MD, PhD said...

To Anonymous Aug 12: I am so sorry for your loss. That is a very difficult time to lose a baby - so near, yet so far. To answer your questions more accurately, it would help to know how long you contracted before coming to the hospital, how dilated was your cervix when you arrived, did you have a fever, was there evidence of a bladder or intrauterine infection (chorioamnionitis, or infection of the cord or baby), were the baby and placenta normally grown, did he have any congenital abnormalities, was your white blood count elevated, had you had any bleeding during the pregnancy, had you been leaking fluid...?

The most common causes of late midtrimester losses are 1) cervical incompetence or uterine abnormalities, 2) intrauterine infection, 3) unrecognized bladder infections, 4) fetal chromosomal abnormalities, 5) fetal or placental abnormalities, 6) on rare occasions severe early onset preeclampsia, and 7) maternal substance abuse (like cocaine). I hope the baby or at least the placenta were sent for evaluation to help answer some of your questions.

If you really had no problems with your first pregnancy and carried to term, then cervical incompetence is unlikely unless you had a cervical laceration at the time of delivery (most often these are caused by forceps or from a precipitous delivery prior to complete dilation). However, if no other cause is found, you should be evaluated for possible cervical incompetence during a subsequent pregnancy. It is also unlikely that you have a congenital uterine abnormality such as a septate uterus. You could have an intrauterine or cervical fibroid or polyp that acted as a site for chronic inflammation or infection. Evaluating the placenta and umbilical cord will usually answer the question if an intrauterine infection precipitated the early labor. Your doctor probably screened you for a bladder infection at the time of admission so that will be an easy factor to rule in or out. Fetal abnormalities that lead to increased amniotic fluid (usually obstructions of the upper gastrointestinal tract) can lead to uterine overdistention, but it doesn't sound like this was an issue either. If the baby was normal size and had normal fluid, an "antibody problem" or thrombophilia are also unlikely causes. It also does not sound like there was any evidence of preeclampsia or placental abruption.

The hardest question to answer is the one related to risk of recurrence. Part of the counseling in that regard depends on the answers obtained related to the loss of this pregnancy. Unfortunately, history tends to repeat itself in this business, but the best thing you've got going for you is the normal first pregnancy. Please let me know what they find out about your son and maybe I can provide some more thoughts. Again, I am sorry for your loss. Thanks for your questions. Dr T

Labels: cervical incompetence, preterm labor

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