What is the recommended misoprostol (prostaglandin E1 analogue) regimen for a 2nd trimester intrauterine fetal death (IUFD)?

Misoprostol Regimen for Second Trimester Intrauterine Fetal Death (IUFD)

For second trimester IUFD, the recommended misoprostol dosage should be adjusted according to gestational age: 200 mcg vaginally every 6 hours for 13-17 weeks gestation; 100 mcg vaginally every 6 hours for 18-26 weeks gestation; and 25-50 mcg vaginally every 4 hours for gestations beyond 27 weeks. 1

Dosing Recommendations Based on Gestational Age

• For 13-17 weeks gestation: 200 mcg misoprostol vaginally every 6 hours 1
• For 18-26 weeks gestation: 100 mcg misoprostol vaginally every 6 hours 1
• For gestations beyond 27 weeks: 25-50 mcg misoprostol vaginally every 4 hours 1

Special Considerations

• Lower doses should be used in women with a previous cesarean delivery, and doubling of doses should not occur due to risk of uterine rupture 1, 2
• For women with scarred uterus, the dose should not exceed 100 mcg per dose 3
• Vaginal administration is preferred over oral administration as it reduces the induction-expulsion time without increasing side effects 3
• Clinical monitoring should continue after delivery due to risk of postpartum atony and/or placenta retention 1

Efficacy and Advantages

• Vaginal misoprostol has been shown to have a shorter induction-to-delivery interval (10.5 ± 5.3 hours) compared to intravenous oxytocin (14 ± 6.8 hours) 4
• Total hospital stay is significantly lower with misoprostol compared to oxytocin (22.6 ± 9.3 hours vs 35.3 ± 16.4 hours) 4
• Placenta retention occurs less frequently with misoprostol (5%) compared to oxytocin (20%) 4

Enhanced Protocol Option

• Pre-treatment with mifepristone (200 mg orally) 24-48 hours before starting misoprostol can:
  • Reduce the induction-to-delivery interval 5
  • Lower the total dose of misoprostol needed 5
  • Eliminate the need for oxytocin augmentation 5

Potential Side Effects and Monitoring

• Common side effects include nausea, vomiting, diarrhea, fever, and chills 6
• Doses exceeding 800 mcg are likely to cause more side effects, particularly diarrhea 6
• Monitor for signs of uterine hyperstimulation, which may require dose adjustment 3
• Continue clinical monitoring after delivery for potential postpartum hemorrhage 1

Contraindications

• Misoprostol should be avoided or used with extreme caution in women with previous cesarean delivery due to increased risk of uterine rupture 2, 1
• When misoprostol must be used in women with scarred uterus, lower doses should be employed 1, 3