A 24-year-old woman, gravida 2 para 1, at 28 weeks gestation comes to the office with her husband because she has felt no fetal movement for 3 days. She has no pain, leakage of fluid, or bleeding. All testing during this pregnancy has been normal, including an anatomy ultrasound at 20 weeks gestation. Her first child was delivered vaginally at term. Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, and pulse is 94/min. Fetal heart tones are not heard by Doppler. Ultrasound demonstrated an absence of fetal cardiac activity and a small for gestational age fetus in breech presentation. A digital cervical examination shows the cervix to be long and closed. Laboratory results are as follows: Which of the following is the most appropriate management advice for this patient?

Question

A 24-year-old woman, gravida 2 para 1, at 28 weeks gestation comes to the office with her husband because she has felt no fetal movement for 3 days.  She has no pain, leakage of fluid, or bleeding.  All testing during this pregnancy has been normal, including an anatomy ultrasound at 20 weeks gestation.  Her first child was delivered vaginally at term.  Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, and pulse is 94/min.  Fetal heart tones are not heard by Doppler.  Ultrasound demonstrated an absence of fetal cardiac activity and a small for gestational age fetus in breech presentation.  A digital cervical examination shows the cervix to be long and closed.  Laboratory results are as follows:  Which of the following is the most appropriate management advice for this patient?

Quizplus · Accepted Answer

11ec25c8_da42_a3ad_bc81_e3d4acba1f22_MD0003_00 Intrauterine fetal demise (IUFD) refers to fetal death at ≥20 weeks gestation and before the onset of labor. Although IUFD most commonly occurs in uncomplicated pregnancies, risk factors include fetal growth restriction, abnormal fetal karyotype, and tobacco use. Patients typically present with decreased or absent fetal movement. Fetal heart tones are not heard by Doppler sonography, and ultrasound confirms the absence of fetal cardiac activity. Once the diagnosis is confirmed, it is critical to inform the parents as empathically as possible. The timing and route of an IUFD delivery are dependent on gestational age and patient preference. The diagnosis can be overwhelming for prospective parents, and some patients are unable to make decisions at the time of diagnosis. Patients should be informed that vaginal delivery is the preferred delivery route at ≥24 weeks gestation, regardless of fetal presentation (eg, vertex, breech). Although most patients prefer to begin an induction immediately, it can generally be delayed until the patient is ready. However, retention of the fetus for several weeks can lead to coagulopathy. Therefore, waiting for spontaneous labor (Choice E), which usually occurs 2-3 weeks after the diagnosis, is not recommended. (Choices A and C) Cesarean delivery is associated with an increase in maternal morbidity and mortality compared with vaginal delivery. Cesarean delivery is indicated for a living breech fetus due to an increased risk of neonatal morbidity (eg, hypoxic injury, delivery-related trauma). However, in a patient with a breech IUFD, the maternal risks from a cesarean delivery would not be offset by any fetal benefits. Therefore, neither cesarean delivery nor external cephalic version is appropriate for this patient. (Choice B) A dilation and evacuation is indicated for an IUFD that is diagnosed at <24 weeks gestation. Educational objective: Induction of labor for vaginal delivery is the best option for management of intrauterine fetal demise at ≥24 weeks gestation. The delivery can be delayed to allow time for parental acceptance of the diagnosis; however, retention of the fetus for several weeks can lead to coagulopathy. References: ACOG Practice Bulletin No. 102: management of stillbirth. (http://www.ncbi.nlm.nih.gov/pubmed/19300347)

A 24-Year-Old Woman, Gravida 2 Para 1, at 28 Weeks