Embryonic Demise

Embryonic demise is death of an embryo that has developed, with a crown rump length of 7 mm or more and no cardiac activity, in the first trimester. It usually results from chromosomal abnormality. It matters because the diagnosis must be confirmed carefully before intervention, and the retained products can cause bleeding, infection and coagulopathy.

• Risk factors: maternal age above 35 years, thrombophilia, uterine anomaly, diabetes.
• Found at 6 to 12 weeks.
• Occurs even when cardiac activity was seen earlier.

Patients have loss of pregnancy symptoms, spotting or no symptoms. The os is closed and the uterus is smaller than dates.

• Fetal heart not detected on scan.
• Light brown discharge is common.
• Differential diagnosis: wrong dates with early viable pregnancy, anembryonic pregnancy, threatened miscarriage, ectopic pregnancy, molar pregnancy.
• Complications: haemorrhage, infection, retained tissue, disseminated intravascular coagulation when retention exceeds 4 weeks, grief.

The diagnosis is made on transvaginal ultrasound.

• Crown rump length 7 mm or more with no heartbeat; confirm by a second examiner or repeat scan after 7 days if findings are borderline.
• Check that the heartbeat is absent for at least 2 minutes with the probe held still.
• Haemoglobin, blood group and Rhesus status; platelets and clotting tests if retention is prolonged.
• Histology of tissue; karyotype of tissue if loss is recurrent.

The principle is to confirm demise and offer expectant, medical or surgical management.

• Supportive: counsel and allow time to decide; analgesia; safety netting.
• Pharmacological: misoprostol 800 micrograms vaginally, repeat once after 3 hours if no bleeding; repeat the full course after 24 hours if tissue is not passed; mifepristone 200 mg oral then misoprostol 800 micrograms vaginally 24 to 48 hours later where available; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); ibuprofen 400 mg oral 8-hourly with food for 3 days; ferrous sulphate 200 mg oral 8-hourly for 3 months if haemoglobin is below 11 g/dL.
• Procedures: manual vacuum aspiration up to 12 weeks size under paracervical block with lignocaine 1 percent, 20 mL; evacuation under anaesthesia for heavy bleeding or infection.
• Special groups: Rhesus negative women give anti-D immunoglobulin 250 IU IM within 72 hours of evacuation; women with sepsis give ampicillin 2 g IV 6-hourly plus gentamicin 5 mg/kg IV once daily plus metronidazole 500 mg IV 8-hourly before evacuation.
• Red flags: heavy bleeding, fever above 38 degrees Celsius, abdominal rigidity, bleeding from other sites.
• Follow-up: urine pregnancy test at 3 weeks; review histology; plan investigation after 3 losses; contraception counselling.