What is the best management for a 26-week pregnant woman with a history of previous cesarean section (CS) who is diagnosed with intrauterine fetal death (IUFD) at 24 weeks of gestation and is no longer feeling fetal movement?

Management of IUFD at 26 Weeks with Previous Cesarean Section

Given the history of previous cesarean section, misoprostol is absolutely contraindicated due to the extremely high risk of uterine rupture (13%), making oxytocin (Option A) the safest choice for labor induction in this case. 1, 2

Critical Contraindication: Misoprostol and Prior Cesarean

The most important consideration in this clinical scenario is the scarred uterus:

• Misoprostol carries a 13% risk of uterine rupture in women with previous cesarean delivery 1
• Both ACOG and the American Academy of Family Physicians explicitly recommend completely avoiding misoprostol in women with prior cesarean in the third trimester 1, 2
• This contraindication extends to second trimester IUFD cases where the uterus is already significantly enlarged 2

Recommended Management Approach

First-Line: Oxytocin (Option A)

Oxytocin is the preferred agent for this patient because:

• The risk of uterine rupture with oxytocin is approximately 1.1%, which is significantly lower than with prostaglandins 3
• It provides controlled, titratable uterine stimulation that can be stopped immediately if complications arise 3
• It is the safest uterotonic option in high-risk uterine scenarios 3

Alternative Consideration: Mifepristone-Misoprostol Combination

If the clinical team determines that prostaglandins must be used despite the scarred uterus:

• Lower doses of misoprostol must be used (25-50 μg every 4-6 hours maximum) 4
• Doses should never be doubled in women with previous cesarean 4
• At 24-26 weeks gestation, the recommended dose would be 100 μg every 6 hours in an unscarred uterus, but this must be reduced to 25-50 μg in a scarred uterus 4

Why Not Mifepristone Alone (Option C)

• Mifepristone is used as a priming agent, not as sole therapy for labor induction 5, 6, 7
• It requires subsequent misoprostol administration to achieve delivery 5, 7
• The combination reduces induction-to-delivery time by approximately 6.86 hours compared to misoprostol alone 6

Why Not Dinoprostone (Option D)

• While dinoprostone (PGE2) is not explicitly discussed in the evidence for IUFD management, prostaglandins generally carry higher uterine rupture risk than oxytocin in scarred uteri 3
• The evidence base strongly supports either oxytocin or carefully dosed misoprostol regimens for IUFD 4, 5, 6

Clinical Monitoring Requirements

Regardless of the agent chosen, continuous monitoring is essential:

• Continuous fetal heart monitoring is not applicable in IUFD, but uterine activity monitoring is critical to detect tachysystole or signs of uterine rupture 1
• Monitor for signs of uterine rupture: sudden severe abdominal pain, vaginal bleeding, hemodynamic instability
• Postpartum monitoring for atony and placental retention is required after delivery 4

Common Pitfalls to Avoid

• Never use standard-dose misoprostol protocols in women with prior cesarean - this is the single most dangerous error in this scenario 1, 2
• Do not delay delivery once IUFD is diagnosed, as maternal coagulopathy risk increases with retained dead fetus, though most women will spontaneously labor within 3 weeks 4
• Ensure cross-matched blood products are available given the risk of hemorrhage with both IUFD and scarred uterus 4