Uterine rupture with the use of PGE2 vaginal inserts for labor induction in women with previous cesarean sections

OBJECTIVE: To analyze the rate of uterine rupture in women with previous cesarean sections undergoing a trial of labor in which a prostaglandin E2 (PGE2) vaginal insert was used. STUDY DESIGN: The study was based on a computerized search and review of pharmacy records, medical records and the pertinent literature. Pharmacy records were correlated with the medical records of all women undergoing a trial of labor after cesarean section over a 33-month period. RESULTS: Between January 1998 and September 2000, 13,544 patients delivered. Of these cases, 790 were vaginal trials of labor after previous cesarean section. A PGE2 vaginal insert was used in 58 of the patients. A total of 6 of these 58 patients (10.3%) experienced uterine rupture. This compares to a rupture rate of 1.1% (8/732) in deliveries not using PGE2 vaginal inserts. CONCLUSION: The risk of uterine rupture was significantly increased in patients undergoing a trial of labor after previous cesarean section when a PGE2 vaginal insert was used. Physicians need to be aware that using a PGE2 vaginal inserts for cervical ripening and/or induction of labor in women with a previous cesarean section might increase the risk of uterine rupture above the standard risk for vaginal birth after cesarean (VBAC) candidates. We recommend that all VBAC patients using a PGE2 vaginal insert be closely monitored for evidence of uterine rupture.