Management of Intrauterine Fetal Demise at 25 Weeks
Active evacuation with dilation and evacuation (D&E) is the recommended management for this stable patient with confirmed fetal demise at 25 weeks gestation. Expectant management is absolutely contraindicated in this scenario due to the significant risks of intrauterine infection, coagulopathy, and maternal sepsis with prolonged retention of fetal tissue 1.
Immediate Diagnostic Confirmation
- Transvaginal ultrasound confirms fetal demise when there is absence of cardiac activity at this gestational age, and the term "fetal demise" (rather than "missed abortion") should be used since gestational age is ≥11 weeks 2, 3.
- The ultrasound should also assess fetal anatomy for structural abnormalities that may have caused the demise, evaluate placental appearance, and measure amniotic fluid volume 2.
Why Expectant Management is Contraindicated
- Expectant management carries significantly higher maternal morbidity (60.2% vs 33.0% with active abortion care) and should be avoided 1.
- Intraamniotic infection occurs in 38.0% of cases with expectant management compared to 13.0% with abortion care 1.
- Postpartum hemorrhage occurs in 23.1% of cases with expectant management compared to 11.0% with abortion care 1.
- The risk of intrauterine infection, coagulopathy, and maternal sepsis increases with prolonged retention of conception products 1, 2.
Recommended Management: Surgical Evacuation
Dilation and evacuation (D&E) is the procedure of choice for fetal demise at 25 weeks gestation 1, 3.
- D&E and induction of labor (IOL) have equivalent composite complication rates at this gestational age (14-24 weeks), but D&E offers significant practical advantages 4.
- Hospital time for D&E is significantly shorter than for IOL 4.
- D&E should be performed under ultrasound guidance to reduce the risk of uterine perforation 3.
- Uterotonic agents should be administered during and after the procedure to reduce bleeding risk 3.
Medical Management Options (Less Preferred)
While misoprostol or oxytocin can be used for medical induction at this gestational age, surgical evacuation is preferred because:
- Medical management has higher rates of hemorrhage (28.3% vs 9.1% with surgical) 1.
- Medical management has higher rates of infection (23.9% vs 1.3% with surgical) 1.
- Medical management has higher rates of retained tissue requiring additional procedures (17.4% vs 1.3% with surgical) 1.
Critical Pre-Procedure Assessments
- Obtain complete blood count with platelets to assess for anemia and thrombocytopenia 3.
- Blood type and Rh status must be assessed immediately - all Rh-negative women must receive anti-D immunoglobulin (50 mcg dose for abortion) to prevent alloimmunization, which occurs in 32% of spontaneous abortions 1, 3.
- Assess for signs of infection (maternal tachycardia, purulent cervical discharge, uterine tenderness) - do not wait for fever to diagnose infection 1.
- If infection is suspected, initiate broad-spectrum antibiotics immediately and proceed with urgent evacuation 1.
Common Pitfalls to Avoid
- Do not delay treatment waiting for spontaneous expulsion - the risks increase substantially with time 1, 2.
- Do not wait for fever to diagnose infection - clinical symptoms may be less overt at earlier gestational ages, and signs like maternal tachycardia and uterine tenderness should prompt immediate action 1.
- Do not forget Rh immunoglobulin - this is essential for all Rh-negative women to prevent future pregnancy complications 1, 3.
Post-Procedure Management
- Serial hCG monitoring until levels return to non-pregnant state 3.
- Ultrasound evaluation to confirm complete evacuation of products of conception 3.
- Histopathologic examination of tissue to confirm intrauterine pregnancy and rule out gestational trophoblastic disease 3.
- Contraceptive counseling should be provided immediately, as ovulation can resume within 2-4 weeks post-procedure 1.