How would you manage a patient at 24 weeks of gestation presenting with decreased fetal movement and confirmed fetal demise on ultrasound?

Management of Fetal Demise at 24 Weeks Gestation

For a patient at 24 weeks gestation with confirmed fetal demise on ultrasound, misoprostol (Option B) is the recommended first-line agent for labor induction. 1

Immediate Management Approach

Initiate labor induction with intravaginal misoprostol 400 μg every 3-6 hours, ideally after pretreatment with mifepristone 200 mg given 24-48 hours prior to optimize cervical ripening and reduce induction time. 1 This combination approach is specifically recommended by the American College of Family Physicians for second trimester fetal demise in utero (FDIU). 1

Critical Pre-Induction Assessment

Before initiating any induction protocol, immediately assess for signs of intrauterine infection: 1

• Maternal tachycardia (often the earliest sign, appearing before fever)
• Purulent cervical discharge
• Uterine tenderness on examination
• Fever (do not wait for fever to develop before treating suspected infection)

If any signs of infection are present, initiate broad-spectrum IV antibiotics immediately (ampicillin plus gentamicin, with clindamycin or metronidazole for anaerobic coverage) and proceed with urgent evacuation. 1 The median time from first signs of infection to maternal death is only 18 hours, making early recognition and treatment critical. 2, 1

Medication Selection Rationale

Why Misoprostol (Option B) is Preferred

• Misoprostol 400 μg intravaginally every 3 hours is the recommended agent for second trimester FDIU (14-26 weeks gestation). 1
• Lower doses (25 μg every 3-6 hours) are also effective and may reduce hyperstimulation risk. 1
• When combined with mifepristone pretreatment, this regimen optimizes cervical ripening and reduces overall induction time. 1

Why Other Options Are Less Appropriate

Oxytocin (Option A): While oxytocin can be used for labor induction, it is not the first-line agent for second trimester fetal demise. 1 Oxytocin-based protocols are primarily reserved for patients with contraindications to prostaglandins, such as prior cesarean delivery. 1

Mifepristone alone (Option C): Mifepristone is used as a pretreatment agent 24-48 hours before misoprostol, not as a standalone induction agent. 1 It enhances the effectiveness of subsequent misoprostol administration but does not induce labor by itself.

Dinoprostone (Option D): While dinoprostone (PGE2) is a prostaglandin that can be used for cervical ripening and labor induction, misoprostol is preferred for fetal demise due to better efficacy, lower cost, and more extensive evidence supporting its use in this specific clinical scenario. 1, 3

Critical Contraindications and Special Circumstances

Prior Cesarean Delivery

Avoid misoprostol entirely in women with prior cesarean delivery due to significant risk of uterine rupture (1-2%). 1 In these cases:

• Use oxytocin-based induction protocols instead 1
• Consider mechanical methods such as Foley catheter with extra-amniotic saline infusion 1

Suspected Chorioamnionitis

Suspected chorioamnionitis is an absolute contraindication to expectant management. 1 Proceed with:

• Immediate IV broad-spectrum antibiotics 1
• Urgent evacuation regardless of gestational age 1
• Do not delay waiting for fever—other signs of infection warrant immediate action 1

Monitoring During Induction

Maternal Monitoring

• Continuous vital signs monitoring for tachycardia, fever, or hypotension suggesting sepsis 1
• Establish large-bore IV access and type and screen blood for potential hemorrhage 1
• Monitor uterine activity to assess contraction pattern and avoid hyperstimulation 1

Fetal Monitoring

• No fetal heart rate monitoring is required (fetus is deceased) 1
• Focus monitoring efforts on maternal well-being and uterine activity 1

Post-Delivery Management

Immediate Post-Delivery Care

• Administer uterotonics (oxytocin, methylergonovine) to prevent postpartum hemorrhage 1
• Confirm complete expulsion with ultrasound—retained tissue dramatically increases infection risk 1
• Never discharge the patient until complete expulsion is confirmed 1

Rh Immunoprophylaxis

Administer Rh immunoglobulin 300 μg IM within 72 hours for all Rh-negative women. 1 Fetomaternal hemorrhage occurs in approximately 32% of spontaneous abortions, making prophylaxis essential. 4

Common Pitfalls to Avoid

1. Never use expectant management for confirmed FDIU—active evacuation is always indicated due to infection and coagulopathy risks. 1

2. Never use misoprostol in women with prior cesarean delivery—the 1-2% uterine rupture risk is unacceptable. 1

3. Never delay treatment waiting for fever if other signs of infection are present—maternal sepsis can progress to death within 18 hours of symptom onset. 2, 1

4. Never discharge without confirming complete expulsion—retained tissue increases infection risk dramatically. 1

Clinical Context at 24 Weeks

At 24 weeks gestation, this falls within the periviable period (20 0/7 to 25 6/7 weeks). 2 With confirmed fetal demise, the focus shifts entirely to maternal safety and minimizing complications. 1 The prolonged latency period between fetal death and delivery increases risks of disseminated intravascular coagulation, infection, and maternal morbidity, making prompt induction essential. 1, 3