Second- and third-trimester termination of pregnancy in women with uterine scar — a retrospective analysis of 111 gemeprost-induced terminations of pregnancy after previous cesarean delivery

[Uterine rupture during medical termination of pregnancy or intrauterine death: A risk management study]

OBJECTIVE

To describe and analyze a series of uterine ruptures (UR) that occurred in the context of medical termination of pregnancy (MTP) or intrauterine death (IUD) from a risk management perspective.

METHODS

French retrospective descriptive observational study of all cases of UR occurring during induction for IUD or MTP, reported between 2011 and 2021 by Gynerisq. Cases were recorded on a basis of voluntary reports using targeted questionnaires.

RESULTS

Between November 27, 2011, and August 22, 2021, 12 cases of UR occurring during an induction for IUD or MTP were recorded. 50 % of the patients had never given birth by cesarean section. The term of delivery varied from 17+3 days to 41+2 days. The clinical signs found were pain (n=6), ascending fetal presentation (n=5) and bleeding (n=4). All patients were managed by laparotomy, 5 were transfused. One vascular ligation and one hysterectomy were required.

CONCLUSION

Knowledge of surgical history is involved in the prevention of UR. The signs of detection are pain, ascending presentation and bleeding. The speed of management and good teamwork allow a reduction of maternal complications. The findings of the morbidity and mortality reviews show that prevention and mitigation barriers can be established.

Complete cervical inversion and nearly inappropriate stitching with cesarean section during the second stage of labor: a case report

Cesarean section is a common obstetric operation and an important method for saving the lives of mothers and their neonates in dangerous situations. Nevertheless, cesarean section has a higher risk and might have more complications compared with natural delivery. A reasonable choice of delivery method is important for maternal and neonatal health. The incidence of complications after cesarean section for mothers and neonates during the second stage of labor significantly increases compared with planned cesarean section. During the second stage of labor, the fetal head is deep in the pelvic cavity. If a cesarean section is performed at this stage, it is prone to causing complications, including difficult delivery of the fetal head, delayed uterine incision, and massive hemorrhage, which seriously threaten the health of the mother and her neonate. For the first time, we report a case of cesarean section after complete opening of the uterine orifice, which led to almost mistakenly suturing the cervix to the uterus. This report will hopefully help surgeons anticipate such incidents during cesarean section in the future.

Incidence of uterine rupture in second-trimester abortion with gemeprost alone compared to mifepristone and gemeprost

OBJECTIVES

To compare uterine rupture rates in women having a medical abortion receiving gemeprost alone to those receiving mifepristone plus gemeprost.

STUDY DESIGN

We reviewed the records of women undergoing medical abortion at 13 0/7-23 6/7 weeks from January 2007 to December 2014 at a single center in Italy. Prior to January 2011, we used gemeprost 1 mg vaginally every 3 h up to a maximum of five doses. After January 2011, we added mifepristone 200 mg orally 24 h prior to the same gemeprost protocol. The primary outcome of the study was the incidence of uterine rupture. We compared the outcome between women receiving gemeprost alone with the combination of gemeprost and mifepristone.

RESULTS

One thousand and sixty-one (58.5%) and 753 (41.5%) women underwent medical abortion in the gemeprost-alone and the gemeprost/mifepristone groups, respectively. Five (0.47%) uterine ruptures occurred in the gemeprost and four uterine ruptures occurred in the gemeprost/mifepristone groups, respectively (0.53%) (p=.89). All uterine ruptures occurred in women with prior cesarean delivery.

CONCLUSIONS

We rep orted no difference in the incidence of uterine rupture between the gemeprost-alone and gemeprost and mifepristone groups.

IMPLICATIONS

Uterine rupture is a rare complication of second-trimester medical abortion with gemeprost. Use of mifepristone prior to gemeprost does not affect this risk.

Incidence and contributing factors for uterine rupture in patients undergoing second trimester termination of pregnancy in a large tertiary hospital - a 10-year case series

INTRODUCTION

Uterine rupture is a rare complication in second trimester termination of pregnancy (TOP) with an overall incidence of up to 1.1%. There are concerns that patients with previous caesarean section(s) were at an increased risk of uterine rupture. However, there is no published data in our local population to date. This study aims to identify the incidence and contributing factors for uterine rupture in women undergoing TOP in Singapore.

STUDY DESIGN

This is a retrospective review of all women who had TOP between 14⁺⁰ weeks to 23⁺⁶ weeks gestation from January 2005 to December 2014 in a large tertiary hospital. Patients' characteristics and details of TOP were retrieved from pre-existing hospital databases. The gestation age and dose of gemeprost used were retrieved from an internal hospital audit conducted from December 2012 to July 2016.

RESULTS

A total of 3385 patients underwent TOP from 2005 to 2014. An estimated 339 patients had a scarred uterus. Seven cases of uterine rupture were identified, with an overall incidence of 0.21% (7/3385). The incidence of uterine rupture in patients with scarred uterus was 2.1% (7/339). Contributing factors identified included higher mean dose of abortifacient, usage of multiple abortifacients and methods, advanced gestation age and short interval between last caesarean section and current TOP.

CONCLUSION

Second trimester TOP on scarred uterus warrants careful usage of abortifacient with minimal cumulative dosage and should be carried out in early second trimester gestation whenever feasible. Prostaglandin analogues appeared to be safe for TOP in unscarred uteruses.

Cervical ripening agents in the second trimester of pregnancy in women with a scarred uterus: a systematic review and metaanalysis of observational studies

OBJECTIVE

The aim of this systematic review and metaanalysis was to determine the efficacy and safety of cervical ripening agents in the second trimester of pregnancy in patients with previous cesarean delivery.

STUDY DESIGN

Data sources were PubMed, EMBASE, CINAHL, LILACS, Google Scholar, and clinicaltrials.gov (1983 through 2015). Eligibility criteria were cohort or cross-sectional studies that reported on efficacy and safety of cervical ripening agents in patients with previous cesarean delivery. Efficacy was determined based on the proportion of patients achieving vaginal delivery and vaginal delivery within 24 hours following administration of a cervical ripening agent. Safety was assessed by the risk of uterine rupture and complications such as retained placental products, blood transfusion requirement, and endometritis, when available, as secondary outcomes. Of the 176 studies identified, 38 met the inclusion criteria. Of these, 17 studies were descriptive and 21 studies compared the efficacy and safety of cervical ripening agents between patients with previous cesarean and those with no previous cesarean. From included studies, we abstracted data on cervical ripening agents and estimated the pooled risk differences and risk ratios with 95% confidence intervals. To account for between-study heterogeneity, we estimated risk ratios based on underlying random effects analyses. Publication bias was assessed via funnel plots and across-study heterogeneity was assessed based on the I(2) measure.

RESULTS

The most commonly used agent was PGE1. In descriptive studies, PGE1 was associated with a vaginal delivery rate of 96.8%, of which 76.3% occurred within 24 hours, uterine rupture in 0.8%, retained placenta in 10.8%, and endometritis in 3.9% in patients with ≥1 cesarean. In comparative studies, the use of PGE1, PGE2, and mechanical methods (laminaria and dilation and curettage) were equally efficacious in achieving vaginal delivery between patients with and without prior cesarean (risk ratio, 0.99, and 95% confidence interval, 0.98-1.00; risk ratio, 1.00, and 95% confidence interval, 0.98-1.02; and risk ratio, 1.00, and 95% confidence interval, 0.98-1.01; respectively). In patients with history of ≥1 cesarean the use of PGE1 was associated with higher risk of uterine rupture (risk ratio, 6.57; 95% confidence interval, 2.21-19.52) and retained placenta (risk ratio, 1.21; 95% confidence interval, 1.03-1.43) compared to women without a prior cesarean. However, the risk of uterine rupture among women with history of only 1 cesarean (0.47%) was not statistically significant (risk ratio, 2.36; 95% confidence interval, 0.39-14.32), whereas among those with history of ≥2 cesareans (2.5%) was increased as compared to those with no previous cesarean (0.08%) (risk ratio, 17.55; 95% confidence interval, 3.00-102.8). Funnel plots did not demonstrate any clear evidence of publication bias. Across-study heterogeneity ranged from 0-81%.

CONCLUSION

This systematic review and metaanalysis provides evidence that PGE1, PGE2, and mechanical methods are efficacious for achieving vaginal delivery in women with previous cesarean delivery. The use of prostaglandin PGE1 in the second trimester was not associated with significantly increased risk for uterine rupture among women with only 1 cesarean; however, this risk was substantially increased among women with ≥2 cesareans although the absolute risk appeared to be relatively small.

Programmed intermittent epidural bolus versus continuous epidural infusion for pain relief during termination of pregnancy: a prospective, double-blind, randomized trial

BACKGROUND

Pain is a major concern during medical abortion but no evidence-based recommendations for optimal analgesia during medical termination of pregnancy are available. We compared two methods of epidural analgesia during second trimester termination of pregnancy, with the primary aim of assessing the incidence of motor block.

METHODS

Women were randomly assigned to receive continuous epidural infusion (CEI Group; n=52) or programmed intermittent epidural bolus (PIEB Group; n=52). Assessment of motor block was performed every hour. Patients with a modified Bromage score <6 were considered to have motor block.

RESULTS

Motor block occurred more frequently in the CEI Group compared with the PIEB Group (46.2% vs. 5.8%, P<0.001). Pain scores were low and comparable between groups. Patients in the CEI Group experienced nausea more frequently than those in the PIEB Group (34.6% vs. 13.5%, P=0.022). The degree of satisfaction was higher in the PIEB Group compared with the CEI Group.

CONCLUSIONS

During second trimester termination of pregnancy in our patient groups, a programmed intermittent epidural bolus technique was associated with less motor block and greater patient satisfaction than continuous epidural infusion. Both techniques had similar analgesic efficacy.

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

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.

Ethical considerations on methods used in abortions

There is a fundamental inconsistency in Western society's treatment of non-human animals on the one hand, and of human foetuses on the other. While most Western countries allow the butchering of animals and their use in experimentation, this must occur under carefully controlled conditions that are intended to minimize their pain and suffering as much as possible. At the same time, most Western countries permit various abortion methods without similar concerns for the developing fetus. The only criteria for deciding which abortion method is used centre in the stage of the pregnancy, the size of the fetus, the health of the pregnant woman and the physician's preference. This is out of step with the underlying ethos of animal cruelty legislation, cannot be justified ethically and should be rectified by adjusting abortion methods to the capacity of the fetus to experience nociception and/or pain.

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.