Management of Fetal Death In Utero

Initial Assessment and Management

The American College of Family Physicians recommends labor induction with misoprostol for FDIU in the second and third trimesters, using intravaginal misoprostol 400 μg every 3-6 hours, with mifepristone 200 mg pretreatment 24-48 hours prior to optimize cervical ripening and reduce induction time 1, 2
Confirm fetal demise using transvaginal ultrasound showing absence of cardiac activity with crown-rump length ≥7 mm or mean sac diameter ≥25 mm without embryo 3
Assess for signs of infection immediately: maternal tachycardia, purulent cervical discharge, uterine tenderness, or fever—do not wait for fever to develop before treating 3
Initiate broad-spectrum antibiotics urgently if any signs of infection are present and proceed with immediate evacuation 3

For first trimester (≤12-13 weeks), surgical evacuation (aspiration/D&C) is preferred due to lower complication rates: hemorrhage 9.1% vs 28.3% with medical management, infection 1.3% vs 23.9%, and retained tissue 1.3% vs 17.4% 3, 4
For second trimester (14-26 weeks), misoprostol 400 μg intravaginally every 3 hours on day 3 in labor and delivery unit under analgesia is recommended 1
For third trimester (≥26 weeks), intravaginal misoprostol remains the primary agent for labor induction 1, 2
Lower doses (25 μg every 3-6 hours) are effective and may reduce hyperstimulation risk 1

Avoid misoprostol entirely in women with prior cesarean delivery due to significant risk of uterine rupture 1, 2
Use oxytocin-based protocols or mechanical methods (Foley catheter with extra-amniotic saline infusion) in women with prior cesarean delivery 1, 2
Suspected chorioamnionitis is an absolute contraindication to expectant management 3, 4
Start IV broad-spectrum antibiotics immediately: ampicillin plus gentamicin, add clindamycin or metronidazole for anaerobic coverage 3
Proceed with urgent evacuation regardless of gestational age 3

Continuous maternal vital signs monitoring for tachycardia, fever, hypotension suggesting sepsis 3
No fetal heart rate monitoring required (fetus is deceased), but uterine activity monitoring recommended to assess contraction pattern and avoid hyperstimulation 1, 2
Monitor for hemorrhage: establish large-bore IV access, type and screen blood 4
Administer uterotonics (oxytocin, methylergonovine) to prevent postpartum hemorrhage 4
Rh immunoglobulin 300 μg IM for all Rh-negative women within 72 hours 3, 4

Never use expectant management for confirmed FDIU—active evacuation is always indicated due to infection and coagulopathy risks 3, 4
Never use misoprostol in women with prior cesarean due to 1-2% uterine rupture risk 1, 2
Never delay treatment waiting for fever if other signs of infection present—maternal sepsis can progress to death within 18 hours of symptom onset 5, 6, 3
Never discharge patient until complete expulsion confirmed by ultrasound—retained tissue increases infection risk dramatically 4

Sepsis is the leading cause of maternal death with FDIU, with median time from infection signs to death being only 18 hours 5, 6
Hemorrhage is the second leading cause, particularly with medical management methods 4