PP-038 Medical management of intrauterine fetal demise in women with a scarred uterus

To evaluate the management strategies used locally and existing guidance to develop a local protocol on managing IUFD with scarred uterus (SU).

Eleven women diagnosed with IUFD over 13weeks gestation with a history of previous caesarean section (CS) or uterine surgery were identified through Northern Ireland Electronic Care Records. Following the review of notes, four women were excluded due to spontaneous onset of labour or opting for elective CS. Four out remaining 7 were under 24 weeks while 3 were over 24 weeks.

The number of previous CSs ranged from 1 to 3 all were lower segment (LS) CSs. All women under 24 weeks had 2-3 previous LSCSs. Two women over 24 weeks had 1-2 LSCSs while remaining one had one LSCS and a myomectomy. Combined regime of mifepristone and misoprostol was used in all women. There was a wide variation in the dosage and frequency of misoprostol used. No scar dehiscence was reported although, 50% of the women suffered postpartum haemorrhage with the woman who had a history of LSCS and myomectomy requiring hysterotomy due to failed medical management following six cycles of low dose misoprostol.
 
FIGO23 (1) recommends the safe usage of combined regimen in women with SU, less than 28 weeks, with no reference to the dosage of misoprostol. RCPI (2) recommends half misoprostol dosage for less than 24 weeks without any reference to number of CSs while IPAS (3) recommends no change in routine misoprostol dosage for less than 24 weeks with one previous CS. RCPI (2) recommends the ultrasound examination to localise the placenta prior to IOL. IPAS (3) recommends half routine dosage of misoprostol with no change in frequency for women over 24 weeks with one CS, as well as for all gestations with multiple previous CSs.

Medical management of IUFD in women with SU is challenging and evidence is scarce for women over 28 weeks. Senior involvement with individual risk assessment including ultrasound examination for placental localisation is vital with consideration to half the dosage of misoprostol recommended in FIGO23 (1) for all women with multiple LSCSs or one LSCS in 24-28 weeks. In the absence of safety data on using medical management over 28 weeks with SU, adequate counselling and consideration for mechanical methods is advisable.