How to manage fetal demise at 24 weeks gestation?

Management of Fetal Demise at 24 Weeks Gestation

For this patient with confirmed fetal demise at 24 weeks gestation, the answer is C: Misoprostol vaginal pessaries. This is the most effective, safest, and evidence-based approach for labor induction at this gestational age, with 100% success rates within 48 hours and significantly shorter induction-to-delivery intervals compared to oxytocin. 1, 2

Immediate Assessment Required

Before initiating any management, urgently assess for signs of intrauterine infection, as this is the leading cause of maternal death with fetal demise:

• Check for maternal tachycardia (do not wait for fever to develop) 1
• Examine for purulent cervical discharge 1
• Assess for uterine tenderness 1
• Monitor vital signs for early sepsis (maternal sepsis can progress to death within 18 hours of symptom onset) 3, 1

If any signs of infection are present, immediately start IV broad-spectrum antibiotics (ampicillin plus gentamicin, add clindamycin or metronidazole for anaerobic coverage) and proceed with urgent evacuation. 1

Why Misoprostol is the Correct Answer

Efficacy Data

Misoprostol vaginal pessaries achieve 100% success rates within 48 hours for fetal demise at this gestational age, with 66.7% delivering within 12 hours and 87.5% within 24 hours. 2 The mean induction-to-delivery interval is approximately 8.5-12.4 hours. 4, 5

Recommended Regimen

For gestations of 24-34 weeks, use intravaginal misoprostol 400 mcg every 3-6 hours. 1 Pretreatment with mifepristone 200 mg given 24-48 hours prior to misoprostol further optimizes cervical ripening and reduces induction time. 1, 4

Safety Profile

Misoprostol at this gestational age has an excellent safety profile with only 8.3% experiencing mild side effects and 3.1% requiring treatment for presumed or proven pelvic sepsis. 4 No cases of uterine tachysystole, hemorrhage, or coagulopathy were recorded in major studies. 4

Why NOT Oxytocin (Option A)

IV oxytocin is significantly less effective than misoprostol for fetal demise at 24 weeks. The mean induction-to-delivery interval with oxytocin is 23.3 hours compared to 12.4 hours with misoprostol (p=0.004). 5 At gestations before 28 weeks specifically, the induction-to-delivery interval with oxytocin is more than twice as long as with misoprostol. 5

Additionally, oxytocin is substantially more expensive (7.86 USD vs 0.65 USD for misoprostol) and requires continuous IV infusion with titration, making it less practical. 5

Why NOT D&C (Option B)

Dilation and curettage is inappropriate and unsafe at 24 weeks gestation. D&C is only suitable for first trimester losses (≤12-13 weeks). 1, 6 At 24 weeks, the fetal size and uterine dimensions make surgical evacuation via D&C technically impossible and extremely dangerous, with high risks of uterine perforation, hemorrhage, and incomplete evacuation. 6

The appropriate surgical method at this gestational age would be dilation and evacuation (D&E), but medical management with misoprostol remains the preferred first-line approach. 1

Critical Management Steps

Before Initiating Misoprostol

• Establish large-bore IV access 1
• Type and screen blood for potential hemorrhage 1
• Confirm Rh status (administer 300 μg Rh immunoglobulin IM within 72 hours if Rh-negative) 1, 6
• Rule out prior cesarean delivery (misoprostol is absolutely contraindicated due to 1-2% uterine rupture risk) 1

During Induction

• Monitor maternal vital signs continuously for tachycardia, fever, hypotension suggesting sepsis 1
• Monitor uterine activity to assess contraction pattern and avoid hyperstimulation 1
• No fetal heart rate monitoring required (fetus is deceased) 1

Post-Delivery

• Administer uterotonics (oxytocin, methylergonovine) to prevent postpartum hemorrhage 1
• Confirm complete expulsion with ultrasound before discharge (retained tissue dramatically increases infection risk) 1

Special Contraindication: Prior Cesarean Delivery

If this patient has a prior cesarean delivery, DO NOT use misoprostol under any circumstances. Instead, use oxytocin-based protocols or mechanical methods such as Foley catheter with extra-amniotic saline infusion. 1 The risk of uterine rupture with misoprostol in scarred uteri is 1-2%, which is unacceptably high. 1

Critical Pitfalls to Avoid

• Never use expectant management for confirmed fetal demise—active evacuation is always indicated due to infection and coagulopathy risks 1, 6
• Never delay treatment waiting for fever if other signs of infection are present 3, 1
• Never discharge the patient until complete expulsion is confirmed by ultrasound 1
• Never use misoprostol in women with prior cesarean delivery 1