Misoprostol for second trimester pregnancy termination in women with prior caesarean: a systematic review

Abstract

Background Second trimester pregnancy induction with misoprostol in women with prior caesarean delivery is not well studied.Objective To estimate the risk of uterine rupture using misoprostol as an induction agent for pregnancy termination in the second trimester of pregnancy in women with prior caesarean delivery.Search strategy Cases of women with a history of prior caesarean delivery and subsequent misoprostol induction for pregnancy termination in the second trimester (16-28 weeks) were obtained from two main data sources. First, a retrospective chart analysis was performed at Thomas Jefferson University Hospital and Christiana Hospital between 1998 and 2004. Second, multiple Medline, Scopus and POPLINE literature searches were performed.Selection criteria Case series and cohort studies of women with one or more prior caesarean delivery (of any type), and with a subsequent pregnancy with induction of labour for pregnancy termination at 16-28 weeks using misoprostol as the initial primary agent were included. Case reports were analysed separately.Data collection and analysis Total cases were analysed by type and number of prior caesarean delivery, for the primary outcome of uterine rupture.Main results The incidence of uterine rupture associated with second trimester misoprostol termination was 0.4% (2/461) in women with one prior low transverse, 0% (0/46) in those with two prior low transverse and 50% (1/2) in those with a prior classical caesarean delivery. One of the cases of uterine rupture in a woman with a prior low transverse caesarean required transfusion. None of the total eight cases (including case reports) of uterine rupture was associated with hysterectomy.Conclusions Second trimester misoprostol termination appears safe among women with one prior low transverse caesarean birth, as it is associated with incidences of uterine rupture of 0.4% (95% confidence interval 0.08-1.67%), of hysterectomy of 0% and of transfusion of 0.2%. There are insufficient data on risk with more than one prior caesarean birth or with prior classical caesarean birth.Keywords Induction, misoprostol, prior cesarean, second trimester.Please cite this paper as: Berghella V, Airoldi J, O'Neill A, Einhorn K, Hoffman M. Misoprostol for second trimester pregnancy termination in women with prior caesarean: a systematic review.

Second Trimester Medical Termination of Pregnancy with Combined Intracervical and Intravaginal Misoprostol: Comparative Analysis with Intravaginal Misoprostol—A Pilot Study

“…Medical induction has become the mainstay in the management of second trimester abortion [1,2]. Reasons for this include the non-requirement of anesthesia or a skilled operator, and the abortus is usually delivered intact which aids in genetic diagnosis.…”

Buccal Versus Vaginal Misoprostol Administration for the Induction of First and Second Trimester Abortions

“…The safety and efficacy of misoprostol in second trimester termination of pregnancy in patients with previous cesarean section have been documented in various studies [11,12]. In our study, five patients had delivery by cesarean section in previous pregnancy.…”

Comparison of Use of Low Dose Vaginal Misoprostol for Second and Early Third Trimester Pregnancy Termination in Women With Prior Caesarean and Unscarred Uteri

“…The pregnancies less than 20 weeks had a higher rate of incomplete abortion and surgical intervention as compared to pregnancies greater than 20 weeks in our study. Uterine rupture is a rare but serious complication of medical induction of abortion in the second trimester of pregnancy, especially in women with a previous uterine scar (20). Although prior hysterotomy is suspected to be a risk factor for uterine rupture during labour induction abortion, approximately one-half of uterine ruptures occur in unscarred uteri.…”

“…This review showed that the uterine rupture rate for women with one prior low transverse caesarean birth and subsequent second trimester misoprostol termination was 0.28%. The other current meta-analysis included 12 studies and 461 patients revealed that the uterine rate among women with one prior low transverse caesarean birth was 0.43% during second trimester pregnancy termination (20). The lowest total misoprostol dose administered prior to uterine rupture was a single dose of 200µg (22), but several women received multiple doses prior to uterine rupture.…”