Understanding the Medical Management of Stillbirth
When a fetus has died in utero, medical management often becomes necessary to ensure the safety of the pregnant person and to facilitate the grieving process. The primary medical approach is the induction of labor, using medications to ripen the cervix and stimulate uterine contractions. The goal is a vaginal delivery, as a Caesarean section is generally reserved for unusual or emergency circumstances. The specific medications and protocol used are tailored to the individual's situation, primarily depending on gestational age and medical history.
Primary Medications for Inducing Labor After Stillbirth
Medical induction for stillbirth relies on drugs that help ripen the cervix and trigger uterine contractions. The most common medications are prostaglandins and hormone analogues.
Misoprostol
Misoprostol is a synthetic prostaglandin E1 analogue widely used for stillbirth induction across various gestational ages due to its effectiveness, low cost, and stability. It softens the cervix and causes uterine contractions. It can be administered vaginally, orally, or sublingually, with vaginal administration often preferred in later trimesters. Dosage varies based on individual factors. Side effects can include nausea, vomiting, diarrhea, shivering, and fever, which are managed by healthcare providers. Monitoring for complications like uterine rupture, especially with prior C-sections, is important.
Mifepristone
Mifepristone is a progesterone receptor antagonist that enhances the effects of prostaglandins, improving misoprostol's effectiveness. Its use in late second and third-trimester stillbirth management is supported by recent evidence. When used before misoprostol, it shortens the time to delivery and reduces the required misoprostol dosage. It's typically given as a single oral dose before starting misoprostol. This combination therapy is very effective in speeding up delivery.
Oxytocin
Oxytocin is a synthetic hormone that induces uterine contractions and is commonly used for labor induction. It is more effective after 28 weeks of pregnancy when the uterus is more responsive. In late-term stillbirths, standard oxytocin induction protocols may be followed.
Comparison of Stillbirth Induction Regimens
| Feature | Misoprostol Alone | Mifepristone + Misoprostol | Oxytocin Alone |
|---|---|---|---|
| Primary Action | Directly stimulates uterine contractions and cervical ripening. | Mifepristone first sensitizes the uterus to prostaglandins; misoprostol then triggers contractions. | Directly causes uterine contractions; more effective later in pregnancy. |
| Induction-to-Delivery Interval | Effective, but may take longer to achieve delivery compared to combination therapy. | Shorter mean induction-to-delivery interval due to the synergistic effect of the drugs. | May be less effective for cervical ripening, leading to longer inductions in some cases. |
| Total Medication Dose | Requires a full course of misoprostol doses to achieve delivery. | Requires less misoprostol overall due to mifepristone's potentiating effect. | Dosing depends on the protocol and uterine response. |
| Suitability | Suitable for most gestations, widely used and cost-effective. | Highly effective, particularly beneficial for reducing time to delivery. | Primarily used in later gestation due to uterine sensitivity; may be used in conjunction with other agents. |
| Side Effects | Common side effects include nausea, vomiting, diarrhea, and fever. | Fewer systemic side effects like fever and shivering compared to misoprostol alone. | Can cause uterine hyperstimulation; side effects are generally well-managed. |
Choosing the Right Approach and Emotional Support
The choice of medical management for stillbirth is a collaborative decision between the patient and healthcare team. Factors like gestational age, history of uterine scars (e.g., previous C-section), and cervical readiness are key considerations. In the second trimester, dilation and evacuation is an alternative option, though some individuals prefer induction to experience birth.
Beyond medical procedures, comprehensive care includes vital counseling and bereavement support for parents. Healthcare providers offer guidance, respect cultural and religious needs, and connect families with support groups and mental health resources to help them navigate their grief. Emotional support is a critical component of care during this challenging time.
Conclusion
Understanding what medication is used for stillbirth is essential in managing fetal demise. Misoprostol, mifepristone, and oxytocin are the main medications used to induce labor for a safe delivery. The specific regimen, often a combination like mifepristone and misoprostol, is determined by the healthcare provider based on various factors. These medications are part of a broader care plan that includes vital emotional support and resources for parents.
For more clinical information, resources are available from the American College of Obstetricians and Gynecologists (ACOG) on managing stillbirth.
