Intrauterine fetal death

(also known as 2nd/3rd trimester missed abortion)

The full guidance on missed abortion has been published in the International Journal of Gynecology and Obstetrics 2007;99(supp 2):S190-3, and is available as a read-only pdf file here.

Recommended Dosages

13-17 weeks: 200 mcg vaginally 6-hourly (x4)

18-26 weeks: 100mcg vaginally 6-hourly (x4)

26-43 weeks: 25-50mcg vaginally 4-hourly (x6)

Regimen

A. IUFD from 13 to 17 weeks

Vaginal misoprostol 200 mcg every 6 to 12 hours for a total of 4 doses
- If the first dose does not lead to effective contractions the subsequent dose could be doubled to 400 mcg. The maximum daily dosing should not exceed 1600 mcg

B. IUFD from 18 to 26 weeks

Vaginal misoprostol 100 mcg every 6 to12 hours for a total of 4 doses.
- If the first dose does not lead to effective contractions the subsequent dose could be doubled to 200 mcg. The maximum daily dosing should not exceed 800 mcg.

C. IUFD beyond 26 weeks

If the cervix is unripe (Bishop score <6), vaginal misoprostol 25-50 mcg is given every 4 hours (up to 6 doses). If the cervix is already ripe (Bishop Score ≥6) providers will need to evaluate and decide between oxytocin or misoprostol based on the setting and availability of the drugs. The gold standard, however, remains oxytocin.

If the first dose does not lead to effective contractions the subsequent dose could be doubled to 50 or 100 mcg. The maximum daily dosing should not exceed: 600 mcg
If expulsion has not occurred after 24 hours, the same treatment course can be repeated a second time.
Oxytocin administration, if necessary, may begin 4 hours following administration of the last dose of misoprostol.

Course of Treatment

Repeated dosing

Before administering a repeated dose for IUFD beyond 26 weeks, uterine activity should be evaluated. If the patient has 2 or more contractions in 10 minutes, the dose should not be repeated, because of the risk of uterine hyperstimulation. If the uterine contraction frequency diminishes, a repeat dose may be given. If, however, the uterine contraction frequency persists or the patient has demonstrated sufficient progress in cervical dilatation, intravenous oxytocin can be administered. We recommend that oxytocin should not be initiated until four hours following administration of the last dose of misoprostol.

Monitoring

Clinical monitoring of the women should continue after delivery or expulsion because of the risk of postpartum atony and/or placenta retention. Both may cause postpartum hemorrhage.

Etiologies for IUFD should be sought as appropriate for the institution. Similarly, bereavement and psychological support services should also be provided to women before, during and after delivery of an IUFD.

Effectiveness

Regardless of the route of misoprostol administration, the vast majority of women (67-83%) with late IUFD will deliver vaginally within 24-hours. The remainder will deliver within the ensuing additional 24-hours. If delivery or abortion has not occurred after this time, options include surgical termination, expectant management, or repeating the induction attempt 24 hours after the first failed attempt. These options should be weighed in the context of the urgency in evacuation of the uterus and the patient’s desires for expediency. Variables that influence success (defined as vaginal delivery within 24 hours) are: favorability of the cervix (Bishop score >6), parity and gestational age.

Approximately 25% of women will have retained placental fragments; this is a complication that is seen more frequently with second trimester inductions for IUFD than those in the third trimester.

These recommendations are produced by an expert group on misoprostol brought together by WHO in Bellagio, Italy in Feb 2007. These recommendations do not reflect official WHO guidelines, but have been released early so as to provide guidance to clinicians worldwide. The excerpt above is taken from:

R Gómez Ponce de León, D Wing, C Fiala. Misoprostol for intrauterine fetal death. International Journal of Gynecology and Obstetrics 2007;99(supp 2):S190-3.

Alternative Guidelines

Intrauterine Fetal Death (> 24 wks)
Group	Gestational age	Route	Dose	Time period	Max. Dose	Levels of Evidence	Notes
Bellagio/FIGO	13-17 wks 18-26 wks 27-43 wks	Vaginal Vaginal Vaginal	200µg 100µg 25-50µg	6-hrly 6-hrly 4-hrly	4 x 4 x 6 x	I B	Reduce doses in women with previous caesarean section
WHO	37-42 wks	Vaginal Vaginal	25µg 50µg	6-hrly 6-hrly	2 x 4 x	I A I A	First Line Only use IF two doses of 25µg has not succeeded in expelling fetus in 4 wks
NICE	-	-	-	-	-	-	No guidelines
RCOG	<26 wks 27 wks +	Vaginal Vaginal	100µg 25-50µg	6-hrly 4-hrly	4 x 6 x	I A	Can be used with previous caesarean section may have to reduce doses
SOGC	-	-	-	-	-	-	No guidelines
ACOG	-	-	-	-	-	-	No visible guidelines
Gynuity	-	Oral Sub	600 µg 400 µg	3-hrly 3-hrly	2 x	I B
POPPHI	-	-	-	-	-	-	-
FLASOG p47	13-17 wks 18-26 wks 3^rd trimester (unripe cervix) 3^rd trimester (unresponsive after above treatment)	Vaginal Vaginal Vaginal Vaginal	200µg 100µg 25µg 50µg	12-hrly 12-hrly 6-hrly 6-hrly	4 x 4 x 2 x 4 x	I B	Do not use oxytocin within 6 hours of misoprostol Higher the dose higher chance of uterine rupture

Alternate guidelines for intrauterine fetal death are available here.