What is the most appropriate management for a 24-year-old woman, gravida (number of times pregnant) 2, para (number of viable births) 1, at 28 weeks gestation with suspected fetal demise, as evidenced by absence of fetal cardiac activity on ultrasonography?

From the Guidelines

The most appropriate management recommendation for this patient is induction of labor with misoprostol 25-50 mcg vaginally every 4-6 hours, given the confirmed fetal demise at 28 weeks gestation, to prevent maternal complications such as disseminated intravascular coagulation (DIC) and psychological trauma from carrying a non-viable fetus. The patient's laboratory values are currently normal with no signs of coagulopathy, but the risk increases with retained fetal demise 1.

Key Considerations

• The patient has a previous vaginal delivery, which suggests she is likely to respond well to induction.
• The use of misoprostol for induction of labor in cases of fetal demise is supported by guidelines from the American College of Obstetricians and Gynecologists (ACOG) 1.
• The patient and her husband will need emotional support throughout this process, including grief counseling and discussion about the option for autopsy and genetic testing to determine the cause of fetal death.
• Pain management should be offered during labor, and the couple should be given time with their baby after delivery if desired.
• Follow-up care should include screening for postpartum depression and planning for future pregnancies.

Management Approach

• Induction of labor with misoprostol 25-50 mcg vaginally every 4-6 hours, as this regimen is effective for cervical ripening and induction of labor in the setting of fetal demise 1.
• Continuous monitoring of fetal heart rate and uterine activity is not necessary in this case, as the fetus is demised, but monitoring of the patient's vital signs and labor progress is essential.
• Oxytocin augmentation may be considered if labor does not progress adequately after cervical ripening with misoprostol.

Emotional Support and Follow-up Care

• The patient and her husband should receive emotional support and counseling throughout the process, including grief counseling and discussion about the option for autopsy and genetic testing to determine the cause of fetal death.
• Follow-up care should include screening for postpartum depression and planning for future pregnancies, as the risk of complications and emotional trauma is increased in cases of fetal demise.

From the Research

Management of Intrauterine Fetal Demise

The patient presents with a diagnosis of intrauterine fetal demise at 28 weeks gestation. The most appropriate management recommendation for this patient would be induction of labor.

• Induction of Labor: Induction of labor is a common procedure undertaken whenever the benefits of prompt delivery outweigh the risks of expectant management 2.
• Methods of Induction: Several pharmacologic and mechanical methods are available for induction of labor, each with associated advantages and disadvantages 2, 3.
• Intrauterine Fetal Demise: Specifically, in the case of intrauterine fetal demise, intravaginal misoprostol has been shown to be a safe, effective, practical, and inexpensive method for induction of labor 4.
• Low-Dose Misoprostol: Low-dose oral misoprostol has also been studied for induction of labor and has been found to be associated with fewer caesarean sections and lower rates of hyperstimulation with fetal heart rate changes compared to other methods 5.
• Vaginal Misoprostol: Low-dose vaginal misoprostol has also been used for induction of labor and has been found to be safe and effective, with good fetomaternal outcomes 6.

Considerations for This Patient

Given the patient's presentation and the absence of any contraindications, induction of labor with misoprostol would be an appropriate management recommendation. The patient's closed and long cervix may require a longer duration of induction, and close monitoring of the patient's progress and fetal well-being would be necessary.

• Monitoring: Close monitoring of the patient's vital signs, fetal heart tones, and progress of labor would be necessary to ensure a safe and effective induction of labor 2, 4.
• Support: The patient and her husband should be provided with emotional support and counseling throughout the induction process, given the diagnosis of intrauterine fetal demise.