Management of intrauterine fetal death with prostaglandin E2 vaginal suppositories

The recent Food and Drug Administration's approval of prostaglandin E₂ (PGE₂) vaginal suppositories provides the clinician with a technique for the immediate management of missed abortion and intrauterine fetal death (IUFD). During a 4-year period at our institution, 78 of 80 patients with gestations ranging from 13 to 42 weeks had pregnancy successfully terminated with PGE₂ suppositories with a dose schedule of 20 mg every 2 hours. The mean interval from induction to delivery of the fetus was 8.9 hours. Fifty percent of the patients spontaneously expelled the placenta; active intervention to remove the placenta within 2 hours of delivery of the fetus is recommended to avoid excessive vaginal bleeding. The most frequently encountered side effect was a temperature elevation, which was managed by less frequent administration of the prostaglandin. Gastrointestinal side effects were minimized by premedication with antidiarrheal and antiemetic agents, which also were administered during the induction period when indicated by the patient's symptoms. A concomitant oxytocin infusion was utilized in 38 patients. In gestations of less than 24 weeks the oxytocin was administered via intravenous drip at a rate of 10 U/hour. In the case of a patient with IUFD and a gestation of 24 weeks or more, oxytocin should be administered only with a constant-rate infusion pump starting at a dose schedule of 1 mU/minute with careful titration of the dose against the monitored uterine activity. The availability of the vaginal PGE₂ suppositories for missed abortion and IUFD makes it important for the clinician to fully acquaint himself with the drug, its administration, effects, and side effects.     

Cervical priming prior to dilatation and evacuation: A comparison of methods

Vaginal administration of prostaglandin analogues resulted in cervical changes that facilitated dilatation and evacuation in 80 patients in the late first trimester and the second trimester of pregnancy. When 0.5 mg and 1.0 mg of 15(S)-15-methyl-prostaglandin F_2α (15-ME-PGF_2α) was compared to 30 and 60 mg of 9-deoxo-16, 16-dimethyl-9 methylene prostaglandin E₂ (PGE₂ analogue), the PGE₂ analogue appeared to have more cervical ripening effect than did the 15-ME-PGF_2α. Overall, the 30 mg PGE₂ vaginal suppository seemed to offer the most optimal combination of effectiveness, sufficient cervical dilatation, and minimal side effects. With the prostaglandins, maximal cervical effect was observed at 4 to 5 hours; this rapid effectiveness allows administration of the prostaglandin to accommodate a 1-day stay for surgical evacuation. The preoperative cervical priming results with the prostaglandins were compared to those obtained with the use of laminaria tents. Although the number of patients who needed further dilatation at the time of operation was less with the laminaria, the incidence of complications and the time for adequate dilatation were higher in that group.     

Termination of pregnancy with 16,16-dimethyl-trans-delta2 PGE1 methyl ester vaginal suppositories: an analysis of 182 cases]

The results of pregnancy termination with ONO 802 as a vaginal suppository in 182 cases are presented. The drug was tested during the different phases of pregnancy, as well as in abnormal pregnancies (intrauterine fetal death and hydatidiform mole) and normal pregnancy. 1 suppository containing 1 mg of the drug was inserted in the posterior vaginal fornix every 3 hours, with 1 full course consisting of 5 suppositories. Cases which did not terminate spontaneously were administered the same treatment the next day. A success rate of 90.5% was obtained; 91.6% for the 1st trimester, 88.8% for the 2nd, 94.7% for intrauterine fetal death, and 100% for hydatidiform mole and 3rd trimester cases. A dosage of between 1-5 mg was successful in 83.9%. 75% terminated within 24 hours. In the 34 patients who were given 2 suppositories and whose surgical termination followed 6 hours later, the cervix was so soft and dilated that a No. 8 Hegar dilator was easily inserted and blood loss was reduced to an average of 12.5 ml. After termination, vaginal bleeding ceased within 2 weeks and menses resumed in 6 weeks. Few complications and side effects occurred. Of the 8 cases which later became pregnant, 2 have delivered normal fetuses spontaneously. In light of these results, the use of ONO 802 vaginal suppository is 1 of the better methods of pregnancy termiantion. (author's modified)     

应用前列腺素0N0802阴道栓剂引产——182例临床观察

本文报告了182例(早孕、中期妊娠、晚期妊娠、胎死宫内、葡萄胎)应用前列腺素ONO802阴道栓剂引产的临床效果。每隔3小时于阴道后穹窿投药1枚(1毫克/枚)。5枚为一疗程。如不成功,次日再用第二疗程。引产总成功率为90.5%,其中早孕引产成功率为91.6%、中期妊娠88.8%、胎死宫内94.7%。葡萄胎和晚期妊娠100%。在引产成功者中,有83.9%用药1—5毫克;产程在24小时以内者占75%。34例手术终止妊娠者,用药2枚后6小时,宫颈大多已扩张至Hegar 氏10号以上,不需要器械扩宫即能进行手术流产,操作容易,出血量少(平均为12.5毫升)。流产后,一般于二星期内阴道流血停止,6周内月经转复。并发症少,副反应轻。8例再次妊娠者中有2例已足月分娩,新生儿未见异常,故认为前列腺素ONO802阴道栓剂引产是目前较好的引产方法之一。     

Mid-trimester abortion induced by intravaginal administration of prostaglandin E2 suppositories.

Mid-trimester abortion was successfully induced in 70 of 71 patients by administration of vaginal PGE2 suppositories. The one patient who failed to abort with this method was pregnant in the blind horn of a duplex uterus. The mean abortion time for the successful inductions was 11.88 hours. Multiparous patients aborted somewhat faster than nulliparous patients, but the difference was not significant. Among the 70 successful inductions 42 patients aborted in 12 hours or less and only one patient had an abortion time of more than 24 hours. The drug appeared effective throughout the stages of gestation included in this series--from 8 to 27 weeks. Eight patients were monitored throughout the abortion procedure and uterine activity was calculated and analyzed. The development of uterine activity was gradual without the sudden rise in frequency of contractions and intrauterine baseline tonus that characterized prostaglandin administered by other methods. The most frequently encountered side effect of vaginal PGE2 suppositories was a temperature elevation, which returned to normal within a few hours of the last dose of the drug. Gastrointestinal disturbances--vomiting and diarrhea--were also common, despite a low initial dose of PGE2 and premedication with antiemetic and antidiarrheal agents. These side effects were in general well tolerated by the patients and never required termination of therapy. The cardiovascular effects of PGE2 in this series could be considered minimal. In a single patient surgical intervention was required to remove the placenta. In seven patients the placenta was removed by sponge forceps and in five patients the placenta was removed manually. There was an estimated blood loss exceeding 250 ml. in 10 patients, but transfusion was not required. Although white blood cell count rose significantly during the abortion period there were no significant changes in hematocrit or platelet count. Mid-trimester abortion with intravaginal administration of PGE2 suppositories appears to offer a valid alternative to the presently available techniques, with a rapid abortion time, high success rate, and low incidence of complications.     

Myometrial response to prostaglandins enhanced by progesterone

The effect of estrogen and progesterone on prostaglandin-induced uterine contractions was studied in ovariectomized rats fitted with intrauterine recording balloons. The effects of the three prostaglandins, PGE₁, PGE₂, and PGF_2α, injected intravenously were very similar. Pretreatment with estradiol benzoate (1 μg per rat per day) resulted in a considerable reduction of the contractile response to the prostaglandins and was frequently associated with tachyphylactic reactions. Progesterone pretreatment (5 mg. per rat per day), on the other hand, markedly increased the uterine response to prostaglandins and no tachyphylaxis was observed. Intact pregnant rats were studied at mid-gestation; the uterine response in these rats was similar to the response in progesterone-treated rats.     

Vaginal prostaglandin E2 in the management of fetal intrauterine death.

The results of a multicentre clinical trial of prostaglandin E2 (PGE2) administered by the vaginal route in the management of intrauterine fetal death and missed abortion showed an overall efficacy of 97 per cent. The mean induction-abortion interval was 10.7 hours with a mean total dose of 60.4 mg of PGE2. Side effects were tolerated well and there was no evidence of significant alterations in hepatic or renal function.     

Prostaglandins: overview in obstetrics and gynecology

The intention of this discussion is to review recent data on prostaglandins and to speculate on their use in clinical obstetrics and gynecology. The uses of prostaglandins are the induction of term labor, therapeutic abortion, and termination of normal and abnormal pregnancies. Prostaglandins E2 and F2alpha have been used successfully to induce labor at or near term. The oral administration of prostaglandins for the induction of labor has been reported by several investigators. Elias concluded that prostaglandins are efficient and safe for the induction of labor in both intravenous and oral forms. Continuous intravenous infusion of either prostaglandins E2 or F2alpha, when administered by the intravenous route, is capable of inducing abortion. Intravenous doses of prostaglandins that will induce abortion are frequently associated with undesirable side effects such as vomiting, diarrhea, and nausea. Due to the severity of the side effects, intravenous therapy is less clinically acceptable and attention has been directed to the vaginal route of administration. The vaginal route of administration can be used to induce abortion in the 2nd trimester with either prostaglandin E2 or F2alpha. The extra-amniotic intrauterine approach has been found to be highly effective, and the rate of abortion has been about 90% within a 36-hour period. The intra-amniotic administration of prostaglandins in 2nd trimester pregnancy compares most favorably with the extra-amniotic intrauterine method and is the only method found to be acceptable in the United States.     

A randomized trial of oral and vaginal misoprostol to manage delivery in cases of fetal death

OBJECTIVE: To compare the effectiveness and side effects of oral and vaginal misoprostol for the termination of second and third trimester pregnancy with intrauterine fetal death. METHODS: Eighty pregnant women at 16-41 weeks' gestation with intrauterine fetal death were randomized in two groups to receive either 400 micro g of misoprostol orally every 4 hours (n = 40) or 200 micro g of misoprostol vaginally every 12 hours (n = 40) until the termination of pregnancy was completed. The adverse effects, progress, and outcomes of delivery were assessed. RESULTS: The groups were similar in age, weight, height, gestational age, parity, and modified Bishop scores before intervention. The mean induction-to-delivery time in the oral group (13.95 [standard deviation (SD) = 5.63] hours) was significantly shorter than the time in the vaginal group (18.87 [SD = 10.38] hours, P =.001). The number of deliveries within 24 hours after the initial drug administration in the oral group (92.5%) was significantly higher than the number in the vaginal group (67.5%, P <.001), and all delivered within 48 hours after the initial drug administration. However, the gastrointestinal side effects in the oral group was significantly higher than in the vaginal group (P =.005). CONCLUSION: Misoprostol (400 micro g given orally every 4 hours) was more effective than misoprostol (200 micro g given vaginally every 12 hours) for the termination of second and third trimester pregnancy with intrauterine fetal death, but with more gastrointestinal side effects.     

Efficacy and Patient Satisfaction with Outpatient Prostaglandin E2 versus Foley Catheter for Cervical Ripening—A Randomized Trial

Introduction: an important factor in the success of labour induction is the presence of a ripe cervix. The safety and efficacy of outpatient prostaglandin E₂ (PGE₂) administered intracervically compared to extra-amniotic cervical Foley catheter placement to ripen the cervix were studied. Patient satisfaction and overall cost with both methods were reported for the first time.Methods: pregnant women with uncomplicated term pregnancies having an indication for induction of labour were enrolled. Singleton pregnancies with intact membranes and cervical Bishop scores < 5 were randomized blindly to receive .5 mg intracervical PGE2 (n=67) every six to eight hours or intracervical Foley catheter (extra-amniotic) (n=62) insertion overnight. Cervical assessments were carried out prior to treatment and again before induction of labour. Patients filled out a post-treatment Likert questionnaire.Results: overall change in Bishop score did not differ between the two groups. The Foley treatment group were more likely to have Mated to three to four cm (χ²=5.48 DF=1 p=.02). Intrapartum variables, mode of delivery and post-partum complications were similar. For patients completing the questionnaire, pain experienced during insertion was similar, however, fewer patients would recommend the Foley catheter treatment to a pregnant friend (F[1,64]=5.53 p=.02). The price of the Foley catheter is much less than the PGE₂.Conclusion: both methods lead to similar changes in overall Bishop score although the intracervical Foley catheter was more likely to lead to cervical dilatation of three centimetres or more—a dilatation which facilitates amniotomy. There were no differences in the mode of delivery, maternal or neonatal outcomes. Patients reported the same amount of pain with both treatments but patients seem to prefer the more expensive PGE₂.     

A randomized comparison between intravaginal misoprostol and prostaglandin E<Subscript>2</Subscript> for labor induction

Objective The aim of this randomized study was to compare the effectiveness, safety, and side effects of 6 h vaginal misoprostol versus vaginal prostaglandin E₂ (PGE₂) for labor induction. Study design Fifty microgram of misoprostol was given intravaginally in the misoprostol group (204 women), and 3 mg PGE₂ was given intravaginally in the PGE₂ group (211 women). In both groups, the dose was repeated every 6 h for a maximum of three doses, until active labor was achieved. Artificial rupture of membranes and oxytocin infusion was used during labor in both groups where it was indicated. Results The mean interval from the institution of labor induction to delivery was 11.3 ± 8.6 h for the misoprostol group, and 15.7 ± 9.3 h for PGE₂ group (P < 0.05). In the misoprostol group, oxytocin was used less frequently, but there was a higher prevalence of tachysystole. No statistically significant differences were observed between the two groups as regard abnormal patterns of fetal heart rate, the mode of delivery, and the need for neonatal intervention. Conclusion In conclusion, the intravaginal administration of 50 μg misoprostol at 6 h interval (maximum three doses) is comparable in safety, but more effective for induction of labor than 3 mg intravaginal PGE₂.     

Laminaria versus extra-amniotic saline solution infusion for cervical ripening in second-trimester labor inductions

OBJECTIVE: The aim of this study was to determine which cervical ripening method, laminaria placement or extra-amniotic saline solution infusion, was associated with the shorter interval from induction to delivery in the second trimester. STUDY DESIGN: Women admitted for indicated second-trimester labor induction with an unfavorable cervix were randomly assigned to receive either intracervical placement of laminaria (n = 25) or extra-amniotic saline solution infusion (n = 25) with concurrent concentrated oxytocin and vaginally administered prostaglandin E2 (10 mg every 6 hours). Treatment success was defined as an interval from induction to delivery of < or =24 hours. RESULTS: Maternal age, race, parity, gestational age, and initial cervical dilatation were similar between the groups. Indications for uterine evacuation were also similar and included fetal death (n = 7), aneuploidy (n = 20), fetal structural anomaly (n = 18), and maternal indications (n = 4). There was no difference in the mean intervals from induction to delivery (laminaria, 16 +/- 8 hours, vs extra-amniotic saline solution infusion, 17 +/- 10 hours) or the number of treatment successes (laminaria, n = 23, vs extra-amniotic saline solution infusion, n = 21). Retained placenta, live birth, and hemorrhage occurred with similar frequencies in the two groups. CONCLUSION: Relative to laminaria, extra-amniotic saline solution infusion did not shorten the induction-to-delivery interval in women undergoing indicated second-trimester labor induction with concentrated oxytocin and low-dose vaginally administered prostaglandin E2.     

Comparing Foley Catheter to Prostaglandins for Cervical Ripening in Multiparous Women

ObjectiveThis study sought to test the hypothesis that among multiparous women requiring cervical ripening, mechanical ripening with a Foley catheter is more effective than prostaglandin preparations.MethodsThis was a retrospective analysis of multiparous women with a singleton gestation who required cervical ripening in a single tertiary center from 2014 to 2019. Women who underwent cervical ripening with a Foley catheter (Foley group) were compared with women who underwent cervical ripening using a controlled-release dinoprostone vaginal insert (PGE₂-CR group) or dinoprostone vaginal gel (PGE₂-gel group). The primary outcome was the ripening-to-delivery interval.ResultsA total of 229 women met the study criteria (Foley group: 95; PGE₂-CR group: 83; PGE₂-gel group: 51). Women in the Foley group had a significantly shorter ripening-to-delivery interval compared with women in the PGE₂-CR group (16.2 ± 9.2 hours vs. 27.0 ± 14.8 hours; P < 0.001) and were more likely to deliver within 12 hours (47.4% vs. 12.0%; P < 0.001; adjusted relative risk [aRR] 3.87; 95% confidence interval [CI] 2.07–7.26) and within 24 hours (78.9% vs. 49.4%; P < 0.001; aRR 1.61; 95% CI 1.26–2.06). Women in the Foley group were also less likely to require a second ripening method compared with women in the PGE₂-CR group (1.1% vs. 8.4%; P = 0.018; aRR 7.26; 95% CI 2.99–17.62). These differences were not observed when comparing the Foley and the PGE₂-gel groups. The cesarean section rate was similar among the Foley group (9.5%), PGE₂-CR group (9.6%; P = 0.970), and PGE₂-gel group (11.8%; P = 0.664).ConclusionIn multiparous women requiring cervical ripening, all methods of cervical ripening have a similar success rate. However, the use of a PGE₂-CR insert is associated with a considerably longer interval to delivery compared with a Foley catheter or PGE₂ gel.     

Cervical ripening and induction of labor by intracervical and extra-amniotic prostaglandin gel application in cases of intrauterine fetal death

In 42 patients with intrauterine fetal death between the 29th and 43rd week of gestation, a standard, 2-step procedure was employed to deliver the dead fetus. After priming with an intracervical application of PGF2 alpha- or PGE2-gel, labor was induced by extra-amniotic prostaglandin (PG) gel or oxytocin infusion while under epidural anesthesia. Intracervical PG application led to a significant improvement in the modified Bishop score from 1.3 to 7.6 after a mean of 8 h. In 20 patients labor and progressive dilatation of the cervix occurred after intracervical PG gel application alone. The average total therapy time was 18.1 h in patients treated with PGF2 alpha and 13.7 h in the PGE2-treated group. The average induction of labor to delivery intervals were 8.8 h in the PGF2 alpha- and 7.1 h in the PGE2-group. Gastrointestinal side effects were observed in only 5 patients. The combination of cervical ripening with intracervical PG gel application and induction of labor by extra-amniotic PG gel under epidural anesthesia is an efficient and safe method for treatment of intrauterine fetal death.     

Extra-amniotic saline infusion for induction of labour in antepartum fetal death: a cost effective method worthy of wider use

Objective To compare the effectiveness of extra-amniotic saline with intra-amniotic prostaglandin F_2α in inducing labour in pregnancies with intrauterine fetal death.
Design A randomised controlled trial.
Participants One hundred and twenty-one women in the extra-amniotic saline group and 123 women in the intra-amniotic prostaglandin group, performed at Harare Maternity Hospital, Zimbabwe during the period October 1994 to February 1996.
Results The two methods were equally effective in achieving delivery. The number of women not delivering within 48 hours of recruitment was 6% for the extra-amniotic saline group compared with 11% for the intra-amniotic prostaglandin group (relative risk [RR] 0.51, 95% CI 0.21–1.22). The extra-amniotic saline group required augmentation with Syntocinon more frequently than the intra-amniotic prostaglandin group: 22% compared with 7% (RR 3.1, 95% CI 1.5–6.2). There were more complications associated with the intra-amniotic prostaglandin group: five women developed hypertonic contractions compared with none in the extra-amniotic saline group. In addition 23% of women in the intra-amniotic prostaglandin group developed acute vasovagal-like symptoms lasting for about 10 to 15 minutes which were distressing for the women. There was no evidence of any increase in febrile morbidity from extra-amniotic saline (RR 0.8,95% CI 0.75–1.1).
Conclusion Extra-amniotic saline infusion is successful in inducing labour in antepartum fetal deaths after 20 weeks of gestation. This method has been shown to be safe and well tolerated by the women and should be considered in areas with limited resources. This method should be evaluated further for inductions of labour with a live fetus.     

Vaginal misoprostol versus concentrated oxytocin and vaginal PGE2 for second-trimester labor induction

OBJECTIVE: To compare the efficacy, side effects, and complications of high-dose vaginal misoprostol with concentrated intravenous oxytocin plus low-dose vaginal prostaglandin (PGE(2)) for second-trimester labor induction. METHODS: One hundred twenty-six consenting women with maternal or fetal indications for pregnancy termination and no prior cesarean delivery were randomly assigned to receive either vaginal misoprostol 600 microg 1x, 400 microg every 4 hours 5x (misoprostol group, n = 60) or escalating-dose concentrated oxytocin infusions (277-1,667 mU/min) plus vaginal PGE(2) 10 mg every 6 hours 4x (oxytocin group, n = 66). Both groups received concurrent extra-amniotic saline infusion for cervical ripening. Women who failed their assigned regimen received 20 mg of PGE(2) suppositories every 4 hours until delivery. Analysis was by intent to treat. RESULTS: Demographic characteristics were similar between study groups. Median induction-to-delivery interval was significantly shorter in the misoprostol group (12 hours) than in the oxytocin group (17 hours; P <.001). There was a higher induction success rate at 24 hours in the misoprostol group (95%) than in the oxytocin group (85%; P =.06), although this difference did not reach statistical significance. The incidence of live birth (25% versus 17%), chorioamnionitis (5% versus 2%), and postpartum hemorrhage greater than 500 mL (3% versus 3%) were similar between the misoprostol and oxytocin groups, respectively. Diarrhea (2% versus 11%; P =.04), nausea/emesis (25% versus 42%; P =.04), and retained placenta requiring curettage (2% versus 15%; P =.008) were significantly less common in the misoprostol group when compared with the oxytocin group, respectively. Isolated intrapartum fever, however, was more frequent in the misoprostol group (67%) than in the oxytocin group (21%; P <.001). CONCLUSION: Compared with concentrated oxytocin plus low-dose vaginal PGE(2), high-dose vaginal misoprostol is associated with significantly shorter induction-to-delivery intervals, fewer side effects, a lower incidence of retained placenta, and comparable incidence of live birth.     

Second dose of PGE2 vaginal insert versus Foley transcervical balloon for induction of labor after failure of cervical ripening with PGE2 vaginal insert

Purpose: To determine the success rate of induction of labor (IOL) using Foley transcervical balloon (FTB) versus prostaglandin E₂ (PGE₂) vaginal insert, following failure of cervical ripening with PGE₂ vaginal insert.

Materials and methods: A retrospective cohort study of all pregnant women admitted for IOL with either FTB or PGE₂ vaginal insert. Either second dose of PGE₂ vaginal insert or FTB was used as a second line treatment after failure (not giving birth in 24?h from insertion) of first PGE₂ vaginal insert.

Results: During the study period, 1162 women were admitted for IOL. Failure was reported in 322/852 (37.8%) in the FTB versus 162/310 (52.2%) in the PGE₂ group (p?2 as first line who did not deliver after 24?h, 14 had spontaneous rupture of membranes, 15 underwent stripping and 42 were in still in active labor. The remainder were allocated to either second trial of PGE₂ treatment (n?=?58) or FTB (n?=?33) with failure rate higher in the PGE₂ group, not statistically significant (p?=?0.23).

Conclusion: IOL with FTB was not superior to PGE₂ vaginal insert for IOL following failure of cervical ripening with PGE₂ vaginal insert.     

Low-dose vaginal misoprostol in the management of intrauterine fetal death

Objectives.?To assess the effectiveness and side effects of vaginal misoprostol (Vagiprost® tablet) termination of second and third trimester pregnancy complicated with intrauterine fetal death (IUFD).

Design.?A prospective observational cohort study.

Setting.?Tanta University Hospital.

Patients.?The study carried out on 324 women with fetal demise in the second and third trimesters, from January 2008 to December 2009.

Intervention.?All patients were subjected to history taking, physical examination, and the Bishop Scoring. Application of 25?μg misoprostol in the posterior fornix of the vagina, this was repeated every 4 h over 24 h. We assessed the adverse effects, progress, and outcomes.

Results.?The success rate was 90% and 45% in women in the third and second trimesters, respectively. The mean induction-termination interval was 8.95?±?2.63 and 15.3?±?5.37 h for women in the third and second trimesters, respectively. The induction termination interval correlated negatively with the duration of gestation. Approximately, 90% of second trimester and 55% of third trimester women required oxytocin augmentation. The mean value of total required dose of misoprostol was 166.3?±?7.5 and 120?±?28.79?μg for women in the second and third trimesters, respectively.

Conclusion.?Vagiprost appears to be a safe, effective, practical, and inexpensive method for termination of third trimester pregnancy complicated with of IUFD.     

Extraamniotic prostaglandin F2 alpha for intrauterine death and fetal abnormality.

Prostaglandin F2 alpha was administered extraamniotically for termination of pregnancy in 15 cases of intrauterine fetal death between 18 and 39 wk gestation and in 10 cases of fetal abnormality or hydatidiform mole between 16 and 28 wk gestation. Although delivery was achieved with minimal side effects in all cases, the best results were obtained in patients with intrauterine fetal death. It is concluded that discontinuous extraamniotic prostaglandin therapy constitutes a safe and effective approach for the active management of intrauterine fetal death.     

Extra-Amniotic Prostaglandin Gel in the Management of Fetal Death and Fetal Abnormality

Summary: Seventeen cases of fetal death in utero and 3 cases of anencephaly have been managed by the extra-amniotic instillation of prostaglandin F2α in Tylose, followed 12 hours later by amniotomy and the intravenous infusion of oxytocin in escalating doses. The mean amniotomy-delivery interval was 7.4 hours and all patients delivered within 12 hours. There were no complications.