Fetal Diagn Ther 2005;20:469–471
Accepted after revision: July 27, 2004
DOI: 10.1159/000087115
Uterine Rupture during Second
Trimester Abortion with Misoprostol
Umit Nayki Cuneyt Eftal Taner Tolga Mizrak Cenk Nayki Gulsen Derin
Aegean Social Security and Maternal Teaching Hospital, Izmir, Turkey
Key Words
Misoprostol  Second trimester abortion  Uterine
rupture
Abstract
Background: Data are limited regarding the use of miso-
prostol in the midtrimester, therefore few cases with
uterine rupture during the second trimester with a previ-
ous uterine scar have been reported in the literature.
Case Report: A 23-year-old woman with a prior low
transverse cesarean section presented at 26 weeks’ ges-
tation for pregnancy termination for a fetal abnormality.
She was given 200 g misoprostol intravaginally every
3 h until regular contractions began. After the fourth
dose, she had vaginal bleeding and severe contractions.
She aborted completely 2 h later after the last dose. Uter-
ine rupture was diagnosed at the previous cesarean
section scar by manual vaginal examination. She under-
went emergency laparotomy and the uterus was re-
paired. Conclusion: Misoprostol use in the second tri-
mester in a woman with a uterine scar can trigger severe
contractions that can lead to uterine rupture.
Copyright © 2005 S. Karger AG, Basel
This study was presented as a poster in the Perinatal Medicine 2003
Congress, Çes¸ me, Izmir, October 9–11, 2003.
© 2005 S. Karger AG, Basel
1015–3837/05/0205–0469$22.00/0
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E-Mail karger@karger.ch Accessible online at:
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Received: February 23, 2004
Introduction
Prostaglandins are the current agents of choice for
both cervical ripening and labor induction. Misoprostol
is a synthetic prostaglandin E1 analogue with potent
uterotonic properties. The risk of uterine rupture after the
use of misoprostol for labor induction at term in women
with a history of uterine scar has been well documented
[1, 2]. However, limited data are available for the use of
misoprostol in the second trimester for preoperative cer-
vical ripening or induced abortion. We report a second
trimester pregnant women with a prior cesarean section
who experienced uterine rupture after vaginal misopros-
tol administration.
Case Report
A 23-year-old woman with a prior low transverse cesarean de-
livery necessitated pregnancy termination at 26 weeks’ gestation
for the prenatal diagnosis of Meckel-Gruber syndrome. Her prior
cesarean delivery was for the cephalopelvic disproportion. She had
no remarkable medical history. The perinatology committee of our
hospital approved the termination of her pregnancy and the patient
also gave written consent. Although termination of pregnancies af-
ter 23 weeks carries the risk of survival of a disabled child, we did
not prefer fetocide since the Meckel-Gruber syndrome has a poor
prognosis. One tablet (200 g) of misoprostol (Cytotec, G.D. Sear-
le Co., Istanbul, Turkey) was applied intravaginally at the begin-
ning. The same dose was repeated every 3 h until regular contrac-
Cuneyt Eftal Taner
Aegean Social Security and Maternal Teaching Hospital
105 Sok No: 3/17 Goztepe
TR–35290 Izmir (Turkey)
Tel. +90 532 2612581, Fax + 90 232 4218276, E-Mail cuneyt_taner@hotmail.com
tions began. After the fourth dose, she began to develop abundant dina [10], misoprostol use in patients with previous ce-
vaginal bleeding and severe contractions with cramping. She sarean delivery was not associated with major complica-
aborted completely 2 h after the last dose. The female fetus with
tions. Pongsatha and Tongsong [11] reported no uterine
Meckel-Gruber syndrome weighed 1,000 g and died within min-
utes. Vaginal bleeding continued after abortion. Initially, blood rupture in their series including 247 pregnant women
pressure was 90/60 mm Hg with a pulse rate of 80/min. Hemoglo- administered different misoprostol regimens for termi-
bin was 9.3 with a hematocrit of 28%. The patient went pale and nation of second trimester pregnancies. However, they
became unconscious. A uterine rupture at the lower segment of the suggested close follow-up for induced abortion in case
uterus was found by manual vaginal examination. She was trans-
ferred to the operating room for immediate laparotomy. At lapa-
of a previous scar. Otherwise the uterine rupture rate
rotomy, a hemoperitoneum and inversed T-shaped rupture at the would probably be high if misoprostol was used rou-
lower segment of the uterus including the previous cesarean scar tinely.
was observed. The uterus was repaired. She required 2 units of Al-Hussaini [12] reported a case of uterine rupture at
blood transfusion intraoperatively. She did not have any problems 23 weeks and 5 days in a 36-year-old grand multiparous
during the early postoperative period and was discharged on post-
operative day 4.
woman. A misoprostol tablet (200 g) was inserted in the
posterior vaginal fornix and induced with oxytocin after
an improved Bishop score.
Misoprostol is not approved for termination of sec-
Discussion ond trimester abortions by health authorities in many
countries. Therefore the use of misoprostol in high-risk
Although many methods have been proposed, prosta- situations such as in cases with previous cesarean sec-
glandins are the current agents of choice for both cervical tions might have medico-legal implications for the re-
ripening and labor induction. Misoprostol, a synthetic sponsible doctor when compared to the use of approved
prostaglandin E1 analogue, has potential use for a wide drugs. There is no universal agreement on patients’ char-
range of indications. It has been shown to be highly effec- acteristics receiving vaginal misoprostol and on the safe
tive in most studies for medical abortion or cervical rip- and effective dose and its frequency. Further research is
ening or induction of labor [3–7]. However, safety re- needed to identify the optimal effective and safe regi-
mains a major concern and clinicians should be aware of men of misoprostol for its use in the second trimester.
the side effects and complications associated with miso- In conclusion, misoprostol can cause uterine rupture
prostol. even in the second trimester when used in patients with
Although misoprostol use in women with a scarred a previous uterine scar. It should therefore be used very
uterus at term has been reported several times, the data carefully to avoid undesirable complications.
regarding its use in midtrimester are limited. Chen et al.
[8] reported uterine rupture at 23 weeks’ gestation in a
woman with two prior cesarean sections who received
200 g misoprostol for labor induction. In another case
report, a woman with two prior cesarean sections who
was given 400 g misoprostol intravaginally and then
400 g buccally for pregnancy termination by dilatation
and evacuation was reported to develop uterine rupture
[9]. In our presentation, a women at 26 weeks’ gestation
had been administered four doses of misoprostol (to-
tally 800 g) for labor induction before regular contrac-
tions began. After the last dose, she had severe contrac-
tions that could eventually have led to uterine rupture.
Therefore, increased doses given for induction of labor
should be carefully followed for the risk of severe con-
tractions.
Since only a limited amount of data is available, the
incidence of uterine rupture with misoprostol use in a
scarred uterus in the second trimester is not widely
known. According to the study by Blumental and Me-

470 Fetal Diagn Ther 2005;20:469–471 Nayki/Taner/Mizrak/Nayki/Derin

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