What is the management for intrauterine fetal demise (IUFD) with fetal hydrops?

From the Guidelines

Management of intrauterine fetal demise (IUFD) with fetal hydrops requires prompt delivery to prevent maternal complications, with the specific approach depending on gestational age and maternal condition. For pregnancies less than 28 weeks, medical induction with mifepristone followed by misoprostol is typically recommended, as seen in guidelines from the American College of Obstetricians and Gynecologists 1. The regimen usually involves 200mg oral mifepristone, followed 24-48 hours later by misoprostol (typically 400mcg vaginally every 3 hours). For pregnancies beyond 28 weeks, induction with oxytocin may be more appropriate, starting at 1-2 mU/min and increasing gradually, as suggested by the Society for Maternal-Fetal Medicine 1. Cervical ripening with a Foley catheter or prostaglandins may be necessary if the cervix is unfavorable. Close maternal monitoring is essential during this process, as fetal hydrops increases the risk of maternal complications including mirror syndrome (preeclampsia-like symptoms), coagulopathy, and infection, as highlighted in the guidelines for nonimmune hydrops fetalis 1. Laboratory assessment should include complete blood count, coagulation studies, and renal function tests. Psychological support is crucial, and parents should be offered the opportunity to see and hold their baby after delivery if desired. Post-delivery, a thorough evaluation including autopsy, placental examination, and genetic testing should be considered to determine the cause of hydrops and guide counseling for future pregnancies, as recommended by the Society for Maternal-Fetal Medicine 1. Rh-negative mothers should receive Rh immunoglobulin if the fetus was Rh-positive or of unknown status. It's also important to consider the etiologies of nonimmune hydrops fetalis, which include cardiovascular, chromosomal, and hematologic abnormalities, as well as structural fetal anomalies and infections, as outlined in the guidelines 1. The prognosis of NIHF depends on the underlying etiology, gestational age at detection and delivery, and the need for prenatal or postnatal treatment, as discussed in the guidelines 1. Overall, the management of IUFD with fetal hydrops requires a multidisciplinary approach, taking into account the gestational age, maternal condition, and underlying etiology of the hydrops, as well as the potential risks and benefits of different management strategies, as emphasized in the guidelines from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine 1.

From the Research

Management of Intrauterine Fetal Demise (IUFD) with Fetal Hydrops

• The management of IUFD with fetal hydrops involves induction of labor, and several studies have compared the efficacy and safety of different regimens 2, 3, 4, 5.
• Misoprostol is a commonly used medication for induction of labor in cases of IUFD, and its dosage and administration route may vary depending on the gestational age and other factors 2, 4, 5.
• A study published in 2007 found that both misoprostol-alone and a combination of mifepristone plus misoprostol are effective and safe in induction of labor after IUFD, with the combination regimen being more effective at earlier gestational weeks 2.
• Another study published in 2013 found that the combination of mifepristone and misoprostol is more effective than misoprostol-only in reducing the induction-to-delivery time and the total dose of misoprostol needed 3.
• A 2022 study compared dilation and evacuation (D&E) and induction of labor (IOL) for the treatment of IUFD between 14 and 24 weeks gestation, and found that both methods are equally safe and effective 6.
• The use of buccal misoprostol has also been studied, and a 2014 trial found that a 200 mcg dose is significantly more effective than a 100 mcg dose in expelling the fetus and placenta within 48 hours 5.

Induction of Labor Regimens

• Misoprostol-only regimen: 100 microg of misoprostol at 4-h intervals 2
• Combination regimen: 200 mg of mifepristone followed by 25 microg of misoprostol at 4-h intervals 2, 3
• Buccal misoprostol regimen: 200 mcg of buccal misoprostol every 6 hours for a maximum of 8 doses 5

Considerations

• Gestational age: The dosage and administration route of misoprostol may vary depending on the gestational age 4
• Previous cesarean: Lower doses of misoprostol should be used, and doubling of doses should not occur 4
• Clinical monitoring: Should continue after delivery or expulsion due to the risk of postpartum atony and/or placenta retention 4