What is the management of Fetal Death In Utero (FDIU)?

Management of Fetal Death In Utero (FDIU)

For FDIU in the second and third trimesters, labor induction with misoprostol is the recommended approach, using intravaginal misoprostol 400 μg every 3-6 hours, with mifepristone 200 mg pretreatment 24-48 hours prior to optimize cervical ripening and reduce induction time. 1, 2, 3

Initial Assessment and Timing

• Confirm fetal demise using transvaginal ultrasound showing absence of cardiac activity with crown-rump length ≥7 mm or mean sac diameter ≥25 mm without embryo 2
• Do not delay treatment waiting for coagulation studies or other tests unless clinically indicated, as the risk of maternal complications increases with prolonged retention 2, 4
• Assess for signs of infection immediately: maternal tachycardia, purulent cervical discharge, uterine tenderness, or fever—do not wait for fever to develop before treating 2
• Initiate broad-spectrum antibiotics urgently if any signs of infection are present and proceed with immediate evacuation 2

Management by Gestational Age

First Trimester (≤12-13 weeks)

• Surgical evacuation (aspiration/D&C) is preferred due to lower complication rates: hemorrhage 9.1% vs 28.3% with medical management, infection 1.3% vs 23.9%, and retained tissue 1.3% vs 17.4% 2, 5
• Medical management with misoprostol 800 μg vaginally can be offered if patient prefers, but has higher failure rates 2

Second Trimester (14-26 weeks)

• Mifepristone 200 mg orally on day 1 for cervical preparation 3
• Consider laminaria tents on evening of day 2 if membranes are unreachable 3
• Misoprostol 400 μg intravaginally every 3 hours on day 3 in labor and delivery unit under analgesia 1, 3
• High-dose PGE2 vaginal suppositories (20 mg) are an alternative with 96.7% success rate, though with higher side effects than oxytocin 1, 6
• Oxytocin augmentation may be added if needed after prostaglandin priming 1

Third Trimester (≥26 weeks)

• Intravaginal misoprostol remains the primary agent for labor induction 1
• Lower doses (25 μg every 3-6 hours) are effective and may reduce hyperstimulation risk 1
• Oxytocin can be used as primary or adjunctive agent, particularly in women at term 1

Special Considerations

Prior Cesarean Delivery or Uterine Scar

• Avoid misoprostol entirely due to significant risk of uterine rupture 1
• Use oxytocin-based protocols or mechanical methods (Foley catheter with extra-amniotic saline infusion) 7
• Lower threshold for cesarean delivery if labor does not progress 7

Suspected Chorioamnionitis

• Absolute contraindication to expectant management 2, 5
• Start IV broad-spectrum antibiotics immediately: ampicillin plus gentamicin, add clindamycin or metronidazole for anaerobic coverage 2
• Proceed with urgent evacuation regardless of gestational age 2
• Do not wait for fever—tachycardia, foul discharge, or uterine tenderness warrant treatment 2

Coagulopathy Risk

• Check baseline CBC, PT/PTT, fibrinogen if fetal demise has been retained >4 weeks 4
• DIC is rare but increases with prolonged retention beyond 4-6 weeks 4
• Correct coagulopathy with FFP, cryoprecipitate as needed before induction 4

Monitoring During Induction

• Continuous maternal vital signs monitoring for tachycardia, fever, hypotension suggesting sepsis 2, 4
• No fetal heart rate monitoring required (fetus is deceased), but uterine activity monitoring recommended to assess contraction pattern and avoid hyperstimulation 1
• Monitor for hemorrhage: establish large-bore IV access, type and screen blood 5, 4
• Pain management: epidural analgesia is appropriate and recommended for patient comfort 3

Post-Delivery Management

• Manual exploration of uterus may be needed to ensure complete placental removal 7
• Administer uterotonics (oxytocin, methylergonovine) to prevent postpartum hemorrhage 5
• Rh immunoglobulin 300 μg IM for all Rh-negative women within 72 hours 2, 5
• Pathology examination of fetus and placenta to determine cause of death 8
• Genetic testing should be offered (amniocentesis before delivery or tissue after) 8

Critical Pitfalls to Avoid

• Never use expectant management for confirmed FDIU—active evacuation is always indicated due to infection and coagulopathy risks 2, 5
• Never use misoprostol in women with prior cesarean due to 1-2% uterine rupture risk 1
• Never delay treatment waiting for fever if other signs of infection present—maternal sepsis can progress to death within 18 hours of symptom onset 1, 2
• Never discharge patient until complete expulsion confirmed by ultrasound—retained tissue increases infection risk dramatically 5

Maternal Mortality Considerations

• The crude maternal death-to-case rate with FDIU is approximately 4.5 per 100,000 cases 4
• Sepsis is the leading cause of maternal death with FDIU, with median time from infection signs to death being only 18 hours 1
• Hemorrhage is the second leading cause, particularly with medical management methods 5, 4
• Prompt recognition and treatment of complications is essential to prevent maternal mortality 4