What is the recommended management for early fetal demise diagnosed at 6 weeks, now at 14 weeks and 4 days?

From the Guidelines

For early fetal demise diagnosed at 6 weeks but now at 14 weeks and 4 days, surgical management with dilation and evacuation (D&E) is the recommended first-line approach. This procedure is typically performed under anesthesia and involves dilating the cervix and removing the pregnancy tissue. According to a recent study published in the American Journal of Obstetrics and Gynecology 1, D&E has been shown to have a shorter time to uterine evacuation and lower complication rates compared to medical management, such as induction of labor.

Some key points to consider in the management of early fetal demise at this gestational age include:

• Confirmation of fetal demise should be documented by ultrasound before any management approach is undertaken
• Rh-negative women should receive Rh immunoglobulin to prevent isoimmunization
• Patients should be counseled about the risks and benefits of each approach, including bleeding, infection, and the potential need for emergency care
• Surgical management is preferred at 14+ weeks due to higher completion rates and shorter resolution time compared to medical or expectant management at this advanced stage of a non-viable pregnancy, as supported by the study 1 which found that complications were more frequent after induction of labor than after D&E, including hemorrhage, infection, and retained tissue requiring an additional procedure.

Medical management is an alternative option, but it may not be as effective at this gestational age, and expectant management is generally not recommended due to the higher risk of heavy bleeding or incomplete expulsion. Ultimately, the decision regarding the type of abortion care should prioritize the safety of the pregnant person, with consideration of maternal stability, gestational age, and availability of clinicians able to provide procedural abortion care, as emphasized in the study 1.

From the Research

Management of Early Fetal Demise

The management of early fetal demise diagnosed at 6 weeks and now at 14 weeks and 4 days can be approached in several ways, including medical treatment, surgical evacuation, or expectant management.

• Medical Treatment: Vaginal misoprostol has been shown to be effective in hastening miscarriage and reducing the need for uterine curettage 2, 3. The use of mifepristone in combination with misoprostol may also be effective, although the evidence is limited 3, 4.
• Surgical Evacuation: Dilation and evacuation (D&E) is a common method for managing second-trimester abortion, including fetal demise 4. However, it carries a risk of complications, such as hemorrhage and infection.
• Expectant Management: Expectant management involves waiting for spontaneous miscarriage to occur. This approach may be suitable for women who are stable and have no symptoms, but it carries a risk of delayed miscarriage and infection 5.

Comparison of Treatment Options

Studies have compared the effectiveness and safety of different treatment options for early fetal demise.

• A systematic review and network meta-analysis found that medical treatments, including misoprostol and mifepristone, had similar effectiveness and side effects compared to surgery 5.
• A retrospective cohort study found that vaginal misoprostol was effective in managing retained products of conception after first-trimester miscarriage, with a success rate of 65% 6.
• Another study found that the use of mifepristone and misoprostol for second-trimester labor induction had a lower complication rate compared to other methods 4.

Considerations for Management

When managing early fetal demise, several factors should be considered, including:

• Gestational age: The management approach may vary depending on the gestational age at diagnosis.
• Women's preferences: Women's preferences and values should be taken into account when deciding on a management approach.
• Medical history: Women's medical history, including any previous obstetric complications, should be considered when deciding on a management approach.
• Availability of resources: The availability of resources, including medical facilities and personnel, should be considered when deciding on a management approach.