Management of Second-Trimester Intrauterine Fetal Death at 26 Weeks
For a 26-week pregnant woman with confirmed IUFD at 24 weeks, vaginal misoprostol is the best management option (Answer C).
Rationale for Medical Management Over Surgical or Cesarean Delivery
At 26 weeks gestation with IUFD, cesarean section is contraindicated as it exposes the mother to unnecessary surgical risks without fetal benefit 1, 2. Dilation and curettage is inappropriate at this advanced gestational age—this procedure is reserved for first-trimester losses, not second-trimester IUFD 1. The choice is between intravenous oxytocin and misoprostol for labor induction.
Why Misoprostol is Superior to Oxytocin
Misoprostol demonstrates clear superiority over oxytocin for second-trimester IUFD based on direct comparative evidence:
- Shorter induction-to-delivery interval: Misoprostol achieves delivery in 10.5 ± 5.3 hours versus 14 ± 6.8 hours with oxytocin (P = 0.009) 2
- Reduced hospital stay: 22.6 ± 9.5 hours with misoprostol versus 35.3 ± 16.4 hours with oxytocin (P = 0.000) 2
- Lower placenta retention rate: 5% with misoprostol versus 20% with oxytocin (P = 0.03) 2
- Higher success rate: 95% versus 86.7% successful induction, though not statistically significant 2
Optimal Misoprostol Dosing Protocol
For gestational age 18-26 weeks, the evidence-supported regimen is 100 mcg vaginally every 6 hours 1. However, more recent evidence suggests 200 mcg vaginal misoprostol every 12 hours is highly effective for second-trimester IUFD with unripe cervix 2.
Alternative dosing based on systematic review data:
- 400 mcg is more effective than 200 mcg when misoprostol is used alone (RR 0.78; 95% CI 0.66-0.92) 3
- Sublingual route may be as effective as vaginal (RR 0.93; 95% CI 0.85-1.03) 3
Expected Outcomes and Timeline
With vaginal misoprostol 200 mcg every 12 hours:
- 98.9% of women deliver within 72 hours of first misoprostol dose 4
- 66.7% deliver within 12 hours 4
- 87.5% deliver within 24 hours 4
- Mean induction-to-delivery interval is approximately 8-10 hours 2, 4
Important Clinical Caveats
Previous cesarean section requires dose modification: Lower doses must be used and dose-doubling should not occur due to uterine rupture risk 1. In women with prior cesarean, consider 25-50 mcg every 4 hours instead of standard dosing 1.
Monitor for complications:
- Mild side effects occur in approximately 8.3% of women 4
- Temperature elevation is the most common side effect, managed by extending dosing intervals 5
- Gastrointestinal symptoms should be preemptively treated with antiemetics and antidiarrheals 5
- Risk of postpartum atony and placenta retention requires continued monitoring after delivery 1
- Pelvic sepsis occurs in approximately 3.1% of cases 4
Active placental management: If the placenta does not spontaneously expel (occurs in 50% of cases), active intervention within 2 hours of fetal delivery is recommended to prevent excessive bleeding 5.