PRACTICE RECOMMENDATIONS
› Consider vaginal misoprostol for achieving delivery following intrauterine fetal demise (IUFD); it is as effective as other vaginal prostaglandin preparations and more effective than oral misoprostol. A
› Include in your postdelivery evaluation of IUFD autopsy, placental gross and histologic examination, fetal karyotype, and exam for fetomaternal hemorrhage. B
›Offer grieving parents early emotional support and counseling; research indicates it shortens the bereavement process. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE › Louise T, age 26, is pregnant with her first child. She attends all prenatal care visits with her health care team and appears to be doing well. However, at Ms. T’s 28-week visit, her physician is unable to detect a fetal heartbeat, or any movement of the fetus. He orders an ultrasound, which confirms his suspicions. Ms. T opts for immediate induction of labor. In his postdelivery evaluation, Ms. T’s physician does not determine a definitive cause for the intrauterine fetal demise.
Intrauterine fetal demise (IUFD) is fetal death that occurs after 20 weeks gestation but before birth.1 If the gestational age is unknown at the time of death, a fetus that weighs ≥350 g is considered an IUFD. In 2005, IUFD occurred at a rate of 6.22 per 1000 pregnancies, which amounted to 25,894 deaths.1
Family physicians who provide obstetric care are likely to care for women who have experienced an IUFD. This article describes what that care should include.
Keep these risk factors in mind
IUFD has been attributed to an extensive range of risk factors and possible causes, including various maternal medical conditions, obstetric complications, and pathologic fetal or placental conditions (TABLE 1).2-8 The 2 most common risk factors—obesity (body mass index [BMI] >30) and smoking—are modifiable and increase the odds of IUFD approximately three-fold.2 Though less common, 2 other notable risk factors are lupus and chronic renal disease; their impact on IUFD risk varies depending on the severity of the disease.2 However, keep in mind that these factors may not be causal and that most pregnant women with these conditions will deliver healthy infants.
Induce labor, or wait?
A woman experiencing an IUFD is likely to seek care when she notices that the fetus isn’t moving or when she experiences contractions, loss of fluid, or vaginal bleeding. Alternatively, she could be asymptomatic, and it may be the physician who suspects IUFD when he/she is unable to hear fetal heart tones. The diagnosis is confirmed by the absence of fetal cardiac activity on ultrasound; physicians may wish to obtain a second ultrasound for confirmation of the diagnosis.
Once IUFD is confirmed, most women choose to immediately undergo induction of labor. However, some elect to wait for spontaneous labor. Approximately 84% to 90% of women will go into spontaneous labor within 2 weeks of fetal death.9 Unless there is a compelling indication for immediate delivery (eg, coagulopathy, evidence of intrauterine infection, preeclampsia), expectant management may be permitted.
If a mother chooses expectant management, she should undergo periodic followup exams to assess for abdominal pain, fever, bleeding, bruising, labor, and emotional lability.10 Tell patients to seek immediate care if they develop a fever, abdominal pain, foul-smelling or purulent vaginal discharge, moderate bleeding, or bruising, or if they go into labor.
Vaginal prostaglandin effectively induces labor
Options for labor induction include oral or vaginal prostaglandins, continuous oxytocin infusion, or mechanical dilation (cervical placement of laminaria or a Foley bulb). Factors that affect which method to use include concomitant maternal illness, gestational age, Bishop score, or the presence of a uterine scar from a previous Cesarean section or other surgery. A Cochrane review found vaginal misoprostol was as effective as other vaginal prostaglandin preparations (E2 and F2-alpha) and more effective than oral misoprostol in achieving delivery for second- and third-trimester terminations and fetal deaths.11 Due to the risk of uterine rupture, most experts advise against use of misoprostol for a woman with a previously scarred uterus at >24 to 26 weeks gestation.10,12 In this circumstance, consider mechanical dilation followed by oxytocin infusion.
Beyond 28 weeks gestation, misoprostol can be used to induce labor by following the standard protocols utilized for term pregnancies (TABLE 2).10,12 Some patients may require additional doses of misoprostol to complete the third stage of labor. Pain can be managed via narcotic patient controlled analgesia, periodic use of intravenous narcotics, or continuous epidural.