Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section

Objective: Our purpose is to report our experience with uterine rupture in patients undergoing a trial of labor after previous cesarean delivery in which labor was induced with misoprostol. The literature on the use of misoprostol in the setting of previous cesarean section is reviewed. Study Design: This report was based on case reports, a computerized search of medical records, and literature review. Results: Uterine rupture occurred in 5 of 89 patients with previous cesarean delivery who had labor induced with misoprostol. The uterine rupture rate for patients attempting vaginal birth after cesarean section was significantly higher in those who received misoprostol, 5.6%, than in those who did not, 0.2% (1/423, P = .0001). Review of the literature reveals insufficient data to support the use of misoprostol in the patient with a previous cesarean delivery. Conclusion: Misoprostol may increase the risk of uterine rupture in the patient with a scarred uterus. Carefully controlled studies of the risks and benefits of misoprostol are necessary before its widespread use in this setting. (Am J Obstet Gynecol 1999;180:1535-42.)     

First-trimester uterine rupture from a placenta percreta. A case report

BACKGROUND: Cesarean scar pregnancy complicated by placenta percreta and uterine rupture is an uncommon gynecologic emergency. CASE: A woman presenting with abdominal pain and shock was found to have a cesarean scar pregnancy complicated by placenta percreta and uterine rupture. CONCLUSION: Implantation within a cesarean scar may cause placenta percreta, leading to uterine rupture in the first trimester and mimicking other gynecologic emergencies.     

Placenta percreta with subsequent uterine rupture at 15 weeks of gestation after two previous cesarean sections

A 25-year-old gravida 3 para 2 woman was referred to our hospital at 15 weeks' gestation with an acute abdomen and free fluid in the peritoneal cavity. On admission she was somnolent. She had a history of two cesarean sections. Fetal cardiac activity was detectable by ultrasound preoperatively. Intraoperatively, a lower uterine-segment rupture was identified in the area of the presumed prior uterine incision. The great blood loss with consecutive coagulopathy required an emergency hysterectomy and multiple blood transfusions. The placenta was located on the lower anterior uterine wall. Intervening decidual cells between placenta and maternal scar tissue were absent in the area of the prior uterine incision. Placental villous tissue deeply invaded and perforated the scar tissue. Histological examination revealed a placenta percreta. Placenta percreta with subsequent uterine rupture is a rare but dramatic complication after previous cesarean section. This should be kept in mind as the rate of elective cesarean sections is rising continuously. Our patient recovered completely.     

Second trimester medical abortion in a woman with prior classical caesarean section and a uterine leiomyoma – A case report

Abstract

Background Medical abortion in women with the scar of a classical caesarean section (CS) and a large uterine leiomyoma is rarely attempted; it carries the risk of uterine rupture and haemorrhage.

Case A 34-year-old multiparous woman with prior classical CS and a 14 × 10 × 9 cm leiomyoma arising from the uterine isthmus had an induced abortion at 14 weeks’ gestation. Mechanical cervical priming with Dilapan^®-S followed by vaginal misoprostol administration resulted in the uncomplicated expulsion of the uterine contents.

Conclusions An early second trimester medical abortion with misoprostol was successfully performed in a woman with prior classical CS and a large uterine leiomyoma.     

Fetal survival despite unrecognized uterine rupture resulting from previous unknown corporeal scar

Cesarean scar rupture of a gravid uterus with unknown corporeal scar is common. Our case was a 35 year woman, gravida 2, para 1 presented at 38 weeks gestation. She was admitted to our hospital for routine follow up. She had no signs or symptoms of labor. However eight hours after the initial examination, she came back to hospital with the signs of shock and acute abdomen. Immediately she was referred to surgery. Intraoperatively a complete rupture of the classical corporeal incision was observed, but the fetus was enclosed within the anterior lying plasenta. The fetus was delivered with one minute apgar score 3, and five minute apgar score 8. According to this case, we conclude that spontaneous uterine rupture of the classical uterine scar can be observed even without uterine contractions. So women with the possibility of previous classical uterine incision should be delivered once fetal maturity is documented.     

Disruption of Prior Uterine Incision following Misoprostol for Labor Induction in Women with Previous Cesarean Delivery

Background: Although induction of labor in women with prior cesareans is controversial, we compared misoprostol to oxytocin in such women in a randomized trial. The investigation was terminated prematurely because of safety concerns.Cases: Disruption of the prior uterine incision was found in two of 17 misoprostol-treated women. The first woman underwent repeat cesarean delivery at 42 weeks because of fetal tachycardia and repetitive late decelerations. A 10-cm vertical rent in the anterior myometrium was discovered. The second woman underwent induction for fetal growth restriction. Loss of fetal heart tones and abnormal abdominal contour prompted emergent cesarean for suspected uterine rupture. An 8-cm longitudinal uterine defect was found.Conclusion: When misoprostol is used in women with previous cesareans, there is a high frequency of disruption of prior uterine incisions.     

Fetal survival following posterior uterine wall rupture during labour with intact previous caesarean section scar

Introduction Posterior wall rupture of the uterus in presence of previous caesarean scar is an extremely rare and unpredictable event. Case report A 26-year old lady in her second pregnancy went into spontaneous labour at 41 weeks gestation. She had emergency caesarean section in her previous pregnancy. She made slow progress in labour to full dilatation without augmentation, but was noted to have fresh vaginal bleeding and breakthrough pain despite an epidural. Uterine scar rupture was suspected and an emergency lower segment caesarean section was carried out. Fresh intraperitoneal bleeding was noted but with an intact previous scar. The baby was delivered in good condition. A vertical posterior uterine wall rupture of the lower segment, 5 cm in length, was found to be bleeding profusely and was successfully repaired. Discussion Uterine rupture is a rare but serious complication. Usually the rupture occurs through the previous uterine scar. There are only four reported cases in the literature of posterior uterine rupture in labour through “healthy” uterine tissue in women with previous caesarean section. This is the first instance of fetal survival. The exact mechanism is unknown but likely to be a combination of factors including prostaglandin use, element of obstruction and strong inelastic scar. Conclusion Strict vigilance is required during labour in women with previous scar. Early recognition of imminent scar rupture should speed delivery and improve the outcome for mother and baby.     

Uterine Rupture After Induction of Labour for Intrauterine Death Using the Prostaglandin E2 Analogue Sulprostone

A 30-year old pregnant woman who had had an earlier stillbirth and 2 children, the oldest of whom was delivered by Cesarean section, presented at the National University Hospital in Singapore at 32 weeks because she had not felt fetal movements for 3 days. Doptone did not detect a fetal heart beat and ultrasound confirmed intrauterine death. She did not have any soreness at the previous lower segment Cesarean scar. After she opted to have labor induced, health workers injected 0.5 mg of the prostaglandin E2 analogue, sulprostone, into a muscle every 6 hours. Painful uterine contractions did not start until after the 2nd injection of sulprostone. 20 hours after the 1st injection, her pulse increased to 100/minute, blood pressure fell from 120/70 to 80/50, and she began to perspire. She noted tenderness at the lower segment scar. Abdominal examination did not reveal any free fluid. There was no blood in the urine. 20 minutes after her blood pressure increased to 100/70, the woman had steady abdominal pain and vaginal bleeding. Her abdomen swelled and rebound tenderness occurred. Physicians diagnosed uterine rupture and performed a laparotomy promptly. They found 800 ml of free blood in the peritoneal cavity and a complete rupture all along the Cesarean scar. The removed the dead fetus and repaired the scar. They also applied Filshie clips on her Fallopian tubes since she wanted to be sterilized. She was discharged 7 days after laparotomy and recovered uneventfully. This case report confirms that vaginal delivery at term after lower segment Cesarean section is no guarantee against scar rupture in subsequent pregnancies, particularly when health workers use prostaglandins. Nevertheless, prostaglandins are still a reasonably safe and predictable method of terminating pregnancy even in cases of previous Cesarean section. It is important that health workers supervise closely women who have had a Cesarean section and are being administered a prostaglandin to terminate a pregnancy because of the possibility of uterine rupture.     

Risk of uterine rupture in labor induction of patients with prior cesarean section: an inner city hospital experience

OBJECTIVE: This study was undertaken to determine the risk of uterine rupture in patients induced with oxytocin or misoprostol after 1 or more previous cesarean sections. STUDY DESIGN: Patients with 1 or more previous cesarean sections who delivered after 28 weeks' gestation between 1996 and 2002 were identified by database. Among 3533 total patients, rates of uterine rupture were compared among 4 groups: oxytocin induction (n = 430), misoprostol induction (n = 142), spontaneous labor (n = 2523), and repeat cesarean section without labor (n = 438). Statistical analysis included chi(2) test, Fisher exact test, unpaired t test, and Mantel-Haenszel test. RESULTS: Rate of rupture was increased in all inductions compared with that of the spontaneous labor group. Among patients with 1 prior cesarean, rupture rates with misoprostol and oxytocin induction were 0.8% and 1.1%, respectively. CONCLUSION: Induction of labor with oxytocin or misoprostol is associated with a higher rate of uterine rupture compared with those who deliver after spontaneous labor. After 1 prior cesarean, rupture rate with misoprostol induction is not increased compared with oxytocin induction.     

A trial of labor after cesarean section in patients with or without a prior vaginal delivery.

OBJECTIVE: To determine the outcome of labor in women with a previous cesarean section, with or without prior vaginal delivery. METHOD: Records were reviewed for 1065 women with a previous cesarean section at 'Virgen Macarena' Hospital who were attended for a subsequent labor. RESULTS: Chi-squared tests demonstrated that women with previous vaginal delivery (n = 346) had a significantly higher rate of vaginal delivery after a trial of labor (95.24%) than those without previous vaginal delivery (n = 719) (82.95%). All the ruptures of uterine scar (n = 4) were found in women without previous vaginal delivery. CONCLUSION: It appears that a cesarean section in a multiparous woman is not a determinant fact in her reproductive history and the risk of rupture of uterine scar did not appear to be present.     

Early medical termination pregnancy with methotrexate and misoprostol in lower segment cesarean section cases

AIM: The aim of the study was to investigate the efficacy of methotrexate and misoprostol for the medical termination of early pregnancy with previous cesarean section. METHODS: Sixty-six pregnant women of 60 days or less in duration with previous one or two cesarean sections were selected. Each woman received intramuscularly a dose of methotrexate (50mg). Two to 3 days later, 800 microg of misoprostol was administered intravaginally. Repeat doses were used if there was no significant bleeding. An ultrasonography was done in each case after seven days. Subjects with continuing pregnancies or excessive bleeding had a surgical abortion. A successful medical abortion was defined by vaginal bleeding without surgical intervention and a negative transvaginal ultrasound. Side-effects were noted. RESULTS: Complete abortion occurred in 87.9% cases after first dose of misoprostol, and 6.1% cases had complete abortion after second dose, so out of 66 cases 62 (94%) had a successful medical abortion. Four (6%) subjects required surgical intervention; one for continued pregnancies, one for missed abortion, and two for excessive bleeding. The complete abortion rate was higher for early gestations: 30/30 (100%) at < or = 45 days gestation, 28/30 (93.3%) at 46-50 days gestation, and 2/6 (33.3%) from 50 to 63 days gestation. Vaginal bleeding lasted 15 +/- 7 days. Gastrointestinal side-effects were uncommon, mild, and brief. There was no case of uterine rupture. CONCLUSION: Medical abortion using methotrexate with misoprostol is safe, cheap, and effective for early pregnancy termination through 8 weeks' gestation even with previous cesarean section.     

Successful pregnancy, achieved by ovulation induction using a human menopausal gonadotropin low-dose step-up protocol in an infertile patient with Kallmann's syndrome

A 25-year-old woman, diagnosed with Kallmann's syndrome and wanting to become pregnant, visited our hospital. Because her serum gonadotropin levels indicated hypogonadotropic hypogonadism, a main symptom of Kallmann's syndrome, we attempted to induce ovulation using a low-dose human menopausal gonadotropin (hMG) step-up protocol. In this protocol, 75 IU of hMG was used as an initial dose and this was continued for the first 14 days because adequate follicular development was not achieved. The dose of hMG was subsequently increased to 150 IU for the next 7 days. After 22 days from the start of stimulation, two follicles had developed, and were ovulated using an injection of human chorionic gonadotropin. She became pregnant, and her pregnancy was uneventful during the first trimester; however, in the second trimester both uterine contractions and blood pressure could not be controlled, and at 27 weeks' gestation she delivered a male infant weighing 830 g by cesarean section.     

Vaginal misoprostol for second-trimester pregnancy termination after one previous cesarean delivery

Objective

To determine the safety and efficacy of using misoprostol vaginally for second-trimester abortion in women with a single previous cesarean delivery.

Method

This prospective observational study was carried out at a university hospital in Egypt with 50 pregnant women with 1 previous cesarean delivery; a gestation of at least 16 weeks but less than 20 weeks (group 1) or 20 or more weeks (group 2); and a need to terminate the pregnancy. The regimen was 4 doses of 200 μg of misoprostol applied vaginally every 4 hours daily, with a 12-hour nightly rest from misoprostol applications, until contractions appeared but not for more than 72 hours. The primary outcome was the induction-to-abortion interval.

Results

There were no cases of uterine rupture. Abortion within the study protocol occurred in 45 of the 50 women, for a 90% success rate. There was no significant difference in the induction-to-abortion interval between the 2 groups.

Conclusion

Inducing abortion with lower misoprostol doses appear to be safe and effective throughout the second trimester in women with a single previous cesarean delivery. Larger randomized trials are needed to validate these results.     

Uterine rupture associated with misoprostol labor induction in women with previous cesarean delivery

OBJECTIVE: To review our experience with uterine rupture in patients undergoing a trial of labor with a history of previous cesarean delivery in which labor was induced with misoprostol. STUDY DESIGN: A retrospective chart review was used to select patients who underwent induction of labor with misoprostol during the period from February 1999 to June 2002. Women with a history of cesarean delivery were retrospectively compared with those without uterine scarring. RESULTS: Uterine rupture occurred in 4 of 41 patients with previous cesarean delivery who had labor induced with misoprostol. The rate of uterine rupture (9.7%) was significantly higher in patients with a previous cesarean delivery (P<0.001). No uterine rupture occurred in 50 patients without uterine scarring. Women with a history of cesarean delivery were more likely to have oxytocin augmentation than those without uterine scarring (41% versus 20%; P=0.037). CONCLUSION: Misoprostol induction of labor increases the risk of uterine rupture in women with a history of cesarean delivery.     

妊娠晚期瘢痕子宫隐性破裂六例分析

目的　探讨隐性子宫破裂发生的原因、诊断、预防及处理方法。　方法　回顾性分析1978年 1月至 1998年 12月 ,在我院剖宫产后再次妊娠住院的产妇 141例 ,共发现隐性子宫破裂 6例。结果　 6例产妇均经入院后检查、B超检查 ,并复习前次剖宫产病历及时作出了诊断而行剖宫产术 ,母婴无一死亡。　结论　前次剖宫产的术式与缝合技术、前次剖宫产术后切口愈合情况、宫壁的压力不均匀、妊娠晚期子宫自发性的收缩等均为子宫隐性破裂的诱因。提高剖宫产术中的手术技巧和缝合技术 ,预防感染可预防下次妊娠时子宫破裂 ,对于怀疑有子宫隐性破裂的产妇 ,应高度警惕。     

Induced second trimester abortion by extra-amniotic prostaglandin infusion in patients with a cesarean scar: is it safe?

BACKGROUND: One result of the advancement in prenatal diagnosis is an increase in the need for second trimester pregnancy terminations. Extra-amniotic infusion of prostaglandins is a common technique used for such pregnancy termination. Since prostaglandins cause strong uterine contractions, many practitioners are hesitant to use this technique on women with a uterine scar. In this study we tried to evaluate the effectiveness and safety of the technique for women with a previous uterine scar. METHODS: This retrospective study included all women with a complete medical record who underwent a second trimester pregnancy termination at our institution by extra amniotic prostaglandin E2, during a 6 year period. The study group included all women with a previous uterine scar. The group of women without such a scar served as the control group. RESULTS: Three hundred and forty women had their pregnancy terminated, but only in 282 cases was the medical information complete (research population). The study group (35 women) characteristics were similar to those of the control group (247 women). We found no difference in the abortion interval, the need to use an additional method, the need for curettage and in bleeding complication between the two groups. There was no case of uterine rupture. The group of women with multiple uterine scars was too small for analysis. CONCLUSIONS: Our results suggest that extra amniotic prostaglandin infusion is an effective and safe technique in women with a uterine scar.     

Induction of labor in women with a uterine scar

Objective: To evaluate the frequency of uterine rupture following induction of labor in women with a previous cesarean section. Misoprostol was compared to other methods of induction.

Methods: A retrospective cohort study of 208 women attempting induction of labor after one previous cesarean section. Delivery data were collected retrospectively and compared. Group 1(2009–2010) was compared with Group 2 (2012–2013). In Group 1, the main method of induction was vaginal PGE₂ (prostaglandin-E₂), amniotomy, oxytocin or a balloon catheter. In Group 2, the dominant method of induction was an oral solution of misoprostol. Main outcome measures: frequency of uterine rupture in the two groups.

Results: Nine cases (4.3%) of uterine rupture occurred. There was no significant difference in the frequency of uterine rupture following the change of method of induction from PGE₂, amniotomy, oxytocin or mechanical dilatation with a balloon catheter to orally administered misoprostol (4.1 versus 4.6%, p?=?0.9). All ruptures occurred in women with no prior vaginal delivery.

Conclusion: The shift to oral misoprostol as the primary method of induction in women with a previous cesarean section did not increase the frequency of uterine rupture in the cohort studied.     

Hypertonic saline as an abortifacient in a select group of patients

The clinical course of 40 patients with a uterine scar who were undergoing second-trimester abortion induced with either hypertonic saline or prostaglandin F2 alpha, was reviewed. In the 38 patients with a previous cesarean scar, and in the 2 patients with a hysterotomy scar, the uterine contents were evacuated with no evidence of uterine rupture. A review of the literature dealing with uterine rupture subsequent to induced midtrimester abortion revealed that the typical multiparous uterus was more prone to rupture if oxytocin was used in conjunction with or a few hours after instillation of the abortifacient, or if oxytocin was used continuously for more than 12 hours. Although rupture after use of prostaglandin in a previously scarred uterus has been reported, there is no case reported of rupture after use of hypertonic saline. This review and the authors' experience lead them to conclude that hypertonic saline is a safe abortifacient during the second trimester, especially between 18 and 22 weeks' gestation, in a previously scarred uterus when careful monitoring is employed and oxytocic agents are used judiciously.     

Uterine rupture of cesarean scar related to spontaneous abortion in the first trimester

We report the case of a 31-year-old Japanese female diagnosed by transvaginal ultrasonography to have a spontaneous uterine rupture in the first trimester. Her condition was complicated by diabetes mellitus type 1. Her previous pregnancy had resulted in an emergency cesarean section by transverse incision of the lower uterine segment with single-layer suture at 37(+4) weeks of gestation. Transvaginal ultrasonography displayed both a gestational sac located in the anterior lower uterine segment and a defect in the uterine wall located at the site of the previous cesarean delivery scar. Pelvic magnetic resonance imaging showed that the uterine muscle layer was discontinuous and the gestational sac was almost outside the uterine cavity, accompanied by mild hemorrhaging within the endometrial cavity. The defect in the lower uterine wall was round in shape and was 3 cm in diameter. Since uterine ruptures can occur during all gestational periods, it is important to pay attention to the uterine wall where any cesarean incision was previously made.     

Dehiscencia de herida tras intento de versión externa y cesárea previa

We present a case of cesarean uterine scar dehiscence after an unsuccessful attempt at external cephalic version. The scar dehiscence was not suspected before the start of the second cesarean section. Despite the occurrence of scar dehiscence in the case reported herein, we defend the use of the external cephalic version in patients with previous cesarean section.