Is induction of labour (IOL) recommended in cases of intrauterine death (IUD)?

Induction of Labour in Intrauterine Death (IUD)

Yes, induction of labour is recommended in cases of intrauterine fetal death (IUFD), and intravaginal misoprostol is the preferred agent for this indication based on ACOG guidelines. 1

Recommended Induction Agents for IUFD

Second Trimester IUFD

• High-dose PGE2 vaginal suppositories are recommended by ACOG for management of intrauterine fetal demise in the second trimester 1
• Misoprostol is highly effective in second trimester cases, with most patients using this agent during this gestational period 2

Third Trimester IUFD

• Intravaginal misoprostol is recommended by ACOG for induction of labor in third-trimester intrauterine fetal demise (Level C recommendation based on consensus and expert opinion) 1
• Dinoprostone gel is commonly used in third trimester IUFD cases and shows the shortest induction-to-delivery interval (12.52 hours) 2

Specific Dosing Protocols

Misoprostol Regimens

• Lower dosages (25 µg every 3-6 hours) are effective for cervical ripening and induction of labor 1
• Higher dosages (50 µg every 6 hours) may be appropriate in some situations, though they carry increased risk of uterine hyperstimulation 1
• Research supports 100 µg intravaginally every 12 hours as safe and effective, with mean induction-to-delivery time of 12.6 hours 3
• Alternative protocols use 50 µg every 4 hours with high success rates (98% vaginal delivery) and mean induction-delivery interval of 11.8 hours 4

Combination Therapy Option

• Mifepristone 200 mg followed by misoprostol is more effective than misoprostol alone, particularly at earlier gestational ages (21-25 weeks) 5, 6
• This combination reduces total misoprostol dose needed and shortens induction-to-delivery time 5, 6
• Pre-treatment with mifepristone eliminates the need for oxytocin augmentation 6

Safety Profile and Monitoring

All Induction Methods Are Safe in IUFD

• Dinoprostone gel, misoprostol, and Foley catheter are all safe for induction in IUFD cases, even in women with previous cesarean section 2
• This is a critical distinction: the contraindication to misoprostol in women with previous uterine surgery applies to live births, not IUFD 1

Monitoring Requirements

• Fetal heart rate monitoring is not applicable in IUFD cases 1
• Standard monitoring for maternal vital signs and uterine activity should continue 1

Expected Outcomes

Success Rates

• Vaginal delivery success rate is 98% with misoprostol protocols 4
• Only 2-3% of cases require cesarean section 2, 4
• Failure rate is approximately 3% across all methods 2

Complications

• Minor complications include nausea/vomiting (12%), shivering (6%), fever (2%), postpartum hemorrhage (4%), and chorioamnionitis (2%) 4
• No significant complications are associated with any of the standard induction methods 2
• Hypercontractility, severe gastrointestinal effects, and need for analgesics are rare 3

Clinical Algorithm for IUFD Induction

1. Confirm IUFD diagnosis with ultrasound 4
2. Assess gestational age: Second trimester cases may benefit from high-dose PGE2 or mifepristone-misoprostol combination; third trimester cases typically use dinoprostone or misoprostol 1, 2
3. Check for previous uterine surgery: This is NOT a contraindication in IUFD cases 2
4. Select agent: Misoprostol (25-100 µg intravaginally every 3-12 hours) or dinoprostone gel, with option for mifepristone pre-treatment in early gestational ages 1, 5, 6
5. Monitor maternal status and uterine activity throughout induction 1

Important Caveats

• The Bishop score is less predictive of success in IUFD compared to live births, though lower scores still correlate with longer induction times 3
• Cost considerations strongly favor misoprostol ($0.36-$1.20 per tablet) over dinoprostone ($65-$165 per kit) 1
• Misoprostol is stable at room temperature, unlike dinoprostone which requires refrigeration 1