What is the next step in managing a pregnant woman at 24 weeks gestation (GA) with intrauterine fetal death (IUFD) and a history of previous cesarean section (CS)?

Management of Intrauterine Fetal Death at 24 Weeks with Prior Cesarean Section

In this patient with intrauterine fetal death at 24 weeks and a history of cesarean section, oxytocin is the appropriate next step for labor induction, as misoprostol carries an unacceptably high risk of uterine rupture (13% versus 1.1% with oxytocin) in women with prior cesarean delivery. 1, 2

Critical Safety Consideration: Avoiding Misoprostol

Misoprostol is absolutely contraindicated in this patient due to her prior cesarean section. The evidence is unequivocal:

• The risk of uterine rupture with misoprostol in women with prior cesarean is 13% compared to only 1.1% with oxytocin 1, 2
• Both the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians recommend completely avoiding misoprostol in women with prior cesarean section in the third trimester 2
• This contraindication applies regardless of the fetal viability status 1, 2

Recommended Management Algorithm

First-Line Approach: Oxytocin Induction

Oxytocin is the safest and most appropriate choice for labor induction in this clinical scenario 1, 2:

• Significantly lower uterine rupture risk (1.1%) compared to prostaglandins 1, 2
• Well-established safety profile in women with prior cesarean delivery 3
• Trial of labor after cesarean (TOLAC) in the setting of fetal demise has a high success rate of 86.7% 3

Why Not the Other Options?

Misoprostol (Option B): Absolutely contraindicated due to 13% rupture risk with prior cesarean 1, 2

Mifeprostone (Option C): While mifeprostone combined with misoprostol may shorten induction time in nonviable pregnancies at 24-28 weeks 4, the misoprostol component remains contraindicated in this patient with prior cesarean 1, 2

Dinoprostone (Option D): Although not as extensively studied as misoprostol in this context, prostaglandins generally carry higher rupture risk than oxytocin in scarred uteri 2

Clinical Monitoring Requirements

During oxytocin induction in this patient, ensure:

• Continuous fetal heart monitoring is not required (fetal demise confirmed), but continuous uterine activity monitoring is essential to detect abnormal contraction patterns 5
• Close observation for signs of uterine rupture including abnormal pain patterns, vaginal bleeding, or maternal hemodynamic instability 3
• The uterine rupture rate in women with prior cesarean and IUFD undergoing labor induction is 2.4%, with 3.4% in those specifically being induced 3

Expected Outcomes

With oxytocin induction in this clinical scenario:

• VBAC success rate is approximately 86.7% in women with prior cesarean and IUFD 3
• Mean gestational age at delivery in similar cases is 31.3 ± 6.5 weeks, though this patient is at 24 weeks 3
• Labor induction or augmentation occurs in 83.3% of attempted VBAC cases with IUFD 3

Important Pitfall to Avoid

Do not delay definitive management waiting for spontaneous labor. While the majority of women will spontaneously labor within three weeks of intrauterine death 5, expectant management in this patient carries significant risks:

• Maternal morbidity rate of 60.2% with expectant management versus 33.0% with active intervention 6
• Intraamniotic infection occurs in 38.0% with expectant management 6
• Risk of developing disseminated intravascular coagulation increases with prolonged retention 5

Post-Delivery Considerations

After delivery, remain vigilant for:

• Postpartum atony and hemorrhage risk (occurs in 23.1% of cases) 6, 5
• Retained placenta requiring manual removal 5
• Signs of infection requiring broad-spectrum antibiotics 6
• Anti-D immunoglobulin administration if patient is Rh-negative (50 mcg dose) 6