Fetal Death In Utero. Intrauterine Prostaglandins. Systemic Prostaglandins

Fetal Death In Utero

Fetal death in utero can be managed with D&E, provided that the surgeon is familiar with the procedure. Vaginal prostaglandin E2 is highly effective for this problem, usually producing fetal abortion in about 10 hours, but often with significant vomiting, diarrhea, and fever as side effects. Beyond 28 weeks of gestation the full dose of vaginal prostaglandin E2 should not be used, or overstimulation and uterine rupture may occur. The standard suppository can be cut into quarters and administered 5 mg at a time for better control of uterine activity. The same low-dose regimen can be used cautiously in patients with asthma if immediate respiratory support (inhalation) is available. Blood or amniotic fluid may impair vaginal absorption of the prostaglandin. Coagulation studies should be obtained preoperatively because disseminated intravascular coagulopathy is a significant risk after either D&E or vaginal prostaglandin E2 for management of fetal death.

Intrauterine Prostaglandins

Intraamniotic prostaglandin is an effective abortion regimen, but it has several disadvantages, including incomplete abortion, the need for a second injection in many cases, the risk of cervical rupture in the primigravida, and the lack of a direct toxic effect on the fetus. Results with intraamniotic prostaglandin F2ca are much improved if overnight treatment with laminaria is used before infusion. Mean times to abortion are reduced from 29 hours to 14 hours, and fewer patients require a second dose. Cervical rupture is very rare. Incomplete abortion is common with prostaglandin abortion, and routine curettage is advised. This can be accomplished easily under local anesthesia in a properly equipped treatment room and reduces rates of postabortal hemorrhage and infection to low levels. Failed prostaglandin abortions can be managed by D&E or by intramuscular or vaginal prostaglandin. To avoid uterine rupture, oxytocin should not be used until after fetal expulsion because prostaglandin and oxytocin are synergistic.

Systemic Prostaglandins

Three different prostaglandins are available for systemic administration: prostaglandin E2 vaginal suppositories; carboprost tromethamine for intramuscular injection; and misoprostol, an analogue of prostaglandin E1. Prostaglandin E2 is given as a 20-mg vaginal suppository every 3 hours. The mean time to abortion is 13.4 hours, with 90% of patients aborting by 24 hours. When 250 mcg of carboprost tromethamine is given intramuscularly every 2 hours, the mean time to abortion is 15-17 hours, with about 80% of patients aborting by 24 hours. Misoprostol is given vaginally as a single 0.200-mg tablet every 12 hours. Mean time to abortion is comparable to that of the other two prostaglandin regimens.
Vomiting and diarrhea are common with prostaglandin E2 and carboprost, but are rare with misoprostol.

About one third of patients treated with prostaglandin E2 will have a temperature elevation of 1 EC or more. This temperature elevation is not seen with carboprost or misoprostol. An ultrasound-guided fetal intracardiac injection of either potassium chloride or digoxin may be given. Alternatively, hypertonic sodium chloride can be given as an intraamniotic injection

Retained placenta is common with all prostaglandin-induced abortions. If spontaneous expulsion has not occurred within 30 minutes or heavy bleeding occurs, instrumental evacuation should be done to prevent further blood loss. Thiscan be accomplished with low-dose intravenous sedation in a treatment room equipped with a uterine aspirator.

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