Sonographic Findings and Surgical Management of a Uterine Rupture Associated With the Use of Misoprostol During Second-Trimester Abortion

Abstract

isoprostol, a synthetic analogue of prostaglandin E 1 , is gaining popularity for use in second-trimester pregnancy termination worldwide, and several studies have reported excellent results with its use in the second trimester of pregnancy.1,2 In women with previous cesarean delivery, the use of prostaglandins for labor induction during the second or third trimester is considered dangerous because of the risk of uterine rupture.3,4 The incidence of this complication after misoprostol administration in women with a scarred uterus in the second trimester is unknown. In a retrospective study examining whether a previous cesarean delivery carries a higher risk of complications in women who undergo pregnancy termination with misoprostol, no increased risk of uterine rupture was found. 5In this report, we describe a case of uterine rupture during a second-trimester pregnancy termination with misoprostol in a woman with a previous cesarean delivery. Apart from the clinical symptoms, the diagnosis was based on the sonographic findings that prompted surgical intervention. Case ReportA healthy 22-year-old woman, gravida 2, was admitted at 23 weeks' gestation, to our hospital for pregnancy termination after prenatal diagnosis of spina bifida. The patient's medical history was unremarkable. The obstetric history included 1 prior cesarean delivery 2 years earlier because of cephalopelvic disproportion, which was uncomplicated. Four hundred micrograms of oral misoprostol and 400 µg of intravaginal misoprostol were given initially. The same dose (400 µg) of intravaginal misoprostol was repeated 8 hours later. Two hours after the second administration, the patient had vaginal bleeding, and digital examination showed 3-cm cervical dilatation with intact membranes. Regular uterine contractions every 5 minutes were also observed.

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

“…(Table 3) Three further cases of uterine rupture in women with one previous caesarean birth were reported as case reports. 13,17,18 Including the cases in case reports, the total rupture rate was 1.1%. The other two uterine rupture cases were reported in a retrospective cohort study 14 where it was difficult to determine the denominator (number of total second trimester misoprostol inductions).…”

“…None of all the eight cases of uterine rupture was associated with maternal mortality. Five 7,8,13,17,18 of the eight cases of uterine rupture occurred during induction of live fetuses.…”

“…Characteristics of the 17 included studies (including ours) are shown in Table 1 (case series and cohort studies) and Table 2 (case reports). [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Additional information from one study 14 could not be obtained, despite numerous email and phone attempts. The cases of uterine rupture analysed by incision number and type are shown in Table 3 (case series and cohort studies).…”

“…The defect was repaired, with an uncomplicated postoperative course. 14 Another three cases 13,17,18 were induced between 17 and 26 weeks, receiving total doses of misoprostol ranging from 800 to 1200 lg (Table 4). No uterine rupture took place in the 46 cases with two prior low transverse caesarean deliveries.…”

Sonographic findings of uterine rupture with expulsion of the fetus into broad ligament

“…There are few case reports of uterine rupture in midtrimester abortion associated with the use of prostaglandins. 3,4 However, this complication is rare with use of ethacridine, and only 1 such case has been reported. 5 Use of ethacridine has been declining significantly in developed nations, but it continues to be routinely used in Asian countries.…”