(also known as 2nd 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.
18-26 weeks: 100mcg vaginally 6-hourly (x4)
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.
Course of Treatment
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.
The underlying reason for the 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.
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.