Clinical Care

Pregnancies after a previous pregnancy loss have a significantly higher risk of a poor outcome than other pregnancies. The risk is even more pronounced for African American women. Despite these risks, the majority of families who experience a pregnancy loss will enter another pregnancy, with most of them occurring within 18 months of the loss. Until recently, no standardized guidelines existed for providing care during these pregnancies.

The Rainbow Clinic in Manchester, England has been a leader in creating a program to address the physical and emotional needs of families in a pregnancy subsequent to loss. Their approach is multidisciplinary and focuses on continuity of care. Each plan is individualized based on obstetric history, maternal medical conditions,
and pathology or other test results. In addition to showing a positive impact on pregnancy outcomes, this program has demonstrated a social return on investment primarily from the birth of a live baby, reduced negative psychological symptoms, and fewer contacts with health professionals.

Open communication is essential to develop a trusting and effective relationship between the provider and family. Common topics of concern for families include recurrence risk, providers for each visit, accessibility of providers to address concerns, cadence of prenatal appointments and tests, specialists and others involved in the care plan, emotional support, potential triggers, desired testing and monitoring, plan for managing concerns, and timing of delivery. These and many other conversations should be discussed with families early and often throughout the pregnancy.

Recommendations

Preconception Visit:

• Detailed medical and obstetric history
• Eval/workup of previous loss
• Determination of recurrence risk
• Discuss risk of other obstetrical complications
• Smoking cessation
• Weight loss for obese women (preconception only)
• Genetic counseling if indicated
• Diabetes screen
• Acquired thrombophilia testing (lupus anticoagulant, IgG and IgM for anticardiolipin and β2-glycoprotein antibodies
• Support
• In situations of recurrent pregnancy loss, consider uterine cavity evaluation, thyroid function tests including the presence of TPO antibodies, sperm DNA fragmentation analysis, and endometrial biopsy

First Trimester:

• Complete Preconception Visit items if not done before conception
• Schedule first visit/ultrasound for immediately after pregnancy identification
• Use an identifier in the chart to communicate to staff members that this is a pregnancy subsequent to a loss
• Dating ultrasound
• First trimester screen (PAPP-A, hCG, nuchal translucency, cell-free fetal DNA testing)
• Low-dose ASA if risk of preeclampsia or placental insufficiency
• Support

Second Trimester

• Fetal anatomic survey at 18-20 weeks
• Quad screen (MSAFP, hCG, estriol, inhibin-A)
• Fetal movement assessment starting at 20-24 weeks
• Uterine artery Doppler study at 22-24 weeks
• Serial growth ultrasounds starting at 24-28 weeks
• Early GDM screening at 26-28 weeks
• Support

Third Trimester

• Continue serial growth ultrasounds and fetal movement monitoring
• Antepartum fetal surveillance starting at 32 weeks or 1-2 weeks before gestational age of stillbirth if loss occurred before 32 weeks (twice weekly NST, AFI, BPP)
• Discuss maternal sleep position and encourage side sleep after 28 weeks
• Encourage Pregnancy After Loss – specific Childbirth Education Class
• Support

Delivery

• Induction at 37 – 39 weeks if desired based on clinical situation and emotional status of parents