What is the recommended management for fetal demise at 10 weeks in the emergency department (ED)?

Emergency Department Management of Fetal Demise at 10 Weeks

For fetal demise at 10 weeks gestation in the emergency department, expectant management or medical management with misoprostol are the recommended approaches, with surgical management reserved for specific indications. 1

Initial Assessment

• Confirm fetal demise through transvaginal ultrasound, looking for absence of cardiac activity in an embryo of appropriate size for gestational age 1
• Assess maternal hemodynamic stability (vital signs, bleeding quantity) 1
• Evaluate for signs of infection (fever, uterine tenderness) 1
• Check for history of prior cesarean section or uterine surgery which may influence management options 2

Management Options

1. Expectant Management

• Appropriate for hemodynamically stable patients with minimal bleeding and no signs of infection 1
• Approximately 80% of early pregnancy losses will pass spontaneously within 2-4 weeks 1
• Provide patient education about expected bleeding, cramping, and when to return to the ED 1

2. Medical Management

• Misoprostol is the medication of choice for medical management of early fetal demise 2
• Dosing: 800 mcg vaginally as a single dose 2
• Contraindications:
  • Hemodynamic instability 1
  • Signs of infection 1
  • History of cesarean section or major uterine surgery (relative contraindication due to increased risk of uterine rupture) 2
  • Known allergy to prostaglandins 2

3. Surgical Management (Reserved for specific indications)

• Indications for surgical management in the ED setting:
  • Hemodynamic instability 1
  • Heavy bleeding 1
  • Signs of infection 1
  • Patient preference after counseling 1
• Consult obstetrics for potential surgical evacuation (dilation and curettage) 1

Special Considerations

• Rh-negative women should receive Rh immunoglobulin (RhoGAM) to prevent alloimmunization 1
• Patients should be counseled about the emotional impact of pregnancy loss 3
• Arrange follow-up with obstetrics within 1-2 weeks 1
• Provide clear return precautions: heavy bleeding (soaking >2 pads/hour), severe pain, fever, or signs of infection 1

Discharge Instructions

• Explain the expected course of bleeding and cramping 1
• Prescribe appropriate pain management (NSAIDs are first-line) 1
• Advise patients to avoid tampons, douching, and sexual intercourse until bleeding stops 1
• Provide emotional support resources and referrals 3
• Document confirmed fetal demise in medical record 1

Common Pitfalls to Avoid

• Failure to confirm fetal demise with ultrasound before initiating management 1
• Not considering ectopic pregnancy in the differential diagnosis when ultrasound is indeterminate 1
• Neglecting to administer Rh immunoglobulin to Rh-negative women 1
• Inadequate pain management for patients experiencing miscarriage 1
• Insufficient follow-up planning and return precautions 1