From the Guidelines
The most appropriate management recommendation for this patient is induction of labor with misoprostol, given the confirmed fetal demise at 28 weeks gestation, to prevent potential maternal complications. The patient's current laboratory values are normal, with no signs of coagulopathy, but this can develop over time with retained fetal demise 1. Induction of labor is preferred over expectant management because waiting for spontaneous labor after fetal demise can lead to maternal coagulopathy (DIC) and psychological distress.
Given the patient's closed, long cervix, cervical preparation will be necessary before active labor can begin. The use of misoprostol for cervical ripening and induction of labor is supported by evidence, with lower dosages (25 µg every three to six hours) being effective for cervical ripening and induction of labor 1.
Some key points to consider in the management of this patient include:
- The need for continuous monitoring of fetal heart rate and uterine activity during the induction process, although fetal heart tones are not present in this case
- The importance of comprehensive emotional support and counseling for both the patient and her husband throughout this process
- The option for memory-making after delivery, if desired
- The potential risks and benefits of different induction methods, including the use of oxytocin if needed to establish active labor
The patient's previous successful vaginal birth, despite the breech presentation, supports the feasibility of vaginal delivery in this situation, as fetal positioning concerns are not relevant in the context of fetal demise 1. Overall, prompt induction of labor with misoprostol is the most appropriate management recommendation for this patient, prioritizing her physical and emotional well-being.
From the Research
Management of Fetal Demise
The patient presents with a diagnosis of fetal demise at 28 weeks gestation. The management of fetal demise involves several considerations, including the method of delivery and the timing of intervention.
- Induction of Labor: Induction of labor is a common procedure undertaken whenever the benefits of prompt delivery outweigh the risks of expectant management 2. In this case, the patient has a closed and long cervix, which may require pharmacologic or mechanical methods to induce labor.
- Methods of Induction: The choice of induction method depends on several factors, including the patient's medical history, the presence of any contraindications, and the patient's preference 3. The use of misoprostol, a prostaglandin analog, has been shown to be effective in inducing labor in women with fetal demise 4.
- Analgesic Considerations: The patient may require analgesia during the induction process, particularly if she experiences pain or discomfort 5. The choice of analgesic agent will depend on the patient's medical history and the presence of any contraindications.
- Timing of Intervention: The timing of intervention will depend on several factors, including the patient's medical history, the presence of any contraindications, and the patient's preference 3. In general, induction of labor is recommended as soon as possible after the diagnosis of fetal demise, to minimize the risks of complications such as infection or disseminated intravascular coagulation.
Key Considerations
- The patient's closed and long cervix may require pharmacologic or mechanical methods to induce labor.
- The use of misoprostol has been shown to be effective in inducing labor in women with fetal demise.
- The patient may require analgesia during the induction process, particularly if she experiences pain or discomfort.
- The timing of intervention will depend on several factors, including the patient's medical history, the presence of any contraindications, and the patient's preference.