Comparison of the safety and efficacy of intravaginal misoprostol (prostaglandin E1) with those of dinoprostone (prostaglandin E2) for cervical ripening and induction of labor in a community hospital

OBJECTIVE

This clinical trial evaluated the efficacy of intravaginal misoprostol (prostaglandin E1) and compared it with that of dinoprostone (prostaglandin E2) for cervical ripening and induction of labor in a community hospital.

STUDY DESIGN

This study involved a retrospective analysis of 81 patients undergoing cervical ripening and induction of labor with prostaglandin E2 from May 1, 1996, to May 1, 1997. A comparison prospective analysis of 145 patients undergoing the same procedure with prostaglandin E1 from May 1, 1997 to May 1, 1998, was performed.

RESULTS

The mean time to delivery was significantly shorter with misoprostol (19.8 +/- 10.4 hours) than with prostaglandin E2 (31.3 +/- 13.0 hours, P <.001). Delivery within 24 hours of induction was significantly more frequent with misoprostol (71.9% of subjects vs 31.3%, P <.001). There was no difference in the cesarean delivery rate with misoprostol (25.6% vs 22.2%, P <.67). The incidence of uterine hyperstimulation was higher with prostaglandin E2 (7.4% vs 0.7%, P <.007). There were no uterine ruptures with prostaglandin E2. There were 2 uterine ruptures and 1 dehiscence with prostaglandin E1 in 3 patients with previous cesarean deliveries and 1 rupture in a patient without a history of uterine scarring. There was no difference in neonatal outcome, with the exception of a fetal death related to uterine rupture in the misoprostol group.

CONCLUSIONS

Compared with prostaglandin E2, misoprostol is more effective in cervical ripening and induction of labor, is as safe for patients who do not have a history of cesarean birth, may carry a higher incidence of uterine rupture, and should not be used for patients attempting vaginal birth after previous cesarean delivery.

Spontaneous uterine rupture with fatal hemoperitoneum due to placenta accreta percreta: a case report and review of the literature

Placenta accreta percreta is an unusual cause of hemoperitoneum. Less than 50 such cases have been reported in the English-language literature over the past 100 years. A 22-year-old pregnant multigravida woman who had spontaneous uterine rupture with exsanguination caused by this entity is described. She had abdominal pain and cardiovascular collapse and died without a premortem diagnosis.

[Spontaneous and complete uterine rupture on a scarred gravid uterus]

Uterine rupture is a complication occurring mostly during labour. Spontaneous rupture on gravid uterus is rare. We report the 1st case observed on a scarred uterus in 32 week gestation in Gyn/Obs clinique at Dakar University Hospital. Favorable factors found were: segmento-corporeal scar time, poor technical repair. Then, we pose the problems of follow up of these pregnancy involving scarred uterus and discuss the interest of evaluating prognosis of the quality of the uterine scar.

Rupture of the pregnant uterus--a 21-year review

OBJECTIVES

To review the incidence of ruptured uteri at the Women's Hospital, Hamad Medical Corporation (HMC) and to analyze the causative factors of uterine rupture with a view to its prevention and to highlight the management approach taken to preserve the patient's reproductive potential.

METHODS

Case notes were reviewed for all patients (except for eight which were not available) with a ruptured uterus at the Women's Hospital in Doha for a period of 21 years from 1 July 1977 to 30 June 1997, relevant data relating to the clinical features characteristics of labor, operative procedures, and maternal perinatal outcome were assessed.

RESULTS

There were 31 cases of ruptured uteri. The incidence of ruptured uteri was calculated to be 0.017%, 23 cases being available for the study. Ten cases (43.5%) occurred in patients with previous cesarean scars, while 13 cases (56.5%) were grand multiparous (para 5 or more). In 10 cases (43.5%) uterine rupture was associated with oxytocin use, and four cases (18.2%) were associated with PGE2 use. The ruptures occurred in the lower segment of 19 cases (90.9%). Fetal heart abnormalities were observed in all cases except one in which the uterus ruptured during labor. Abdominal hysterectomy was performed in 15 cases (65.2%). The remaining eight patients had suture repair, two of them had suture repair with sterilization and the other six cases (26.1%) had suture repair without sterilization. Five of them became pregnant and were delivered by cesarean section.

CONCLUSIONS

Even though rupture of the uterus was rare in our study, its occurrence should be suspected when there are sudden fetal heart abnormalities during labor or unexpected postpartum shock. Suture repair should be considered whenever possible in order to maintain the patient's future fertility.

Uterine rupture in women attempting a vaginal birth following prior cesarean birth

OBJECTIVE

To determine (1) if there are any common features to fetal heart rates (FHR) and uterine activity patterns before uterine rupture, (2) if neonatal outcomes as reflected by cord blood gases are associated with the length of fetal bradycardia, and (3) if there is an increase in maternal and/or neonatal length of stay in women who experience uterine rupture during labor as compared with women following repeat cesarean section.

METHODS

Maternal and fetal records of 11 women identified by the ICD-9 code as having had a uterine rupture between 1990 and 1995 were retrospectively reviewed.

RESULTS

No one common feature in FHR patterns or uterine activity existed before uterine rupture other than bradycardia, although variable and/or late decelerations commonly preceded the bradycardia. Of the neonates, 91% had cord blood pH of <7.0 and 45% had base excess greater than 15 meq/l. Of those fetuses experiencing bradycardia, 55% had placental abruption. Maternal length of stay 5 days or greater occurred in 36% of those with uterine rupture. Seventy-three percent of the neonates required admission to the Neonatal Intensive Care Unit (NICU). Despite acidemia as shown by cord pH, none of the neonates experienced seizures or multiorgan dysfunction.

CONCLUSION

There is no one specific FHR or uterine activity pattern that indicates the onset of a uterine rupture, although variable and/or late decelerations occur before the onset of an FHR bradycardia. In the present study, neonatal admissions to the NICU were increased and pH values were below 7.0 in 91% when uterine rupture occurred. A decrease or cessation of uterine tone was not observed. Maternal length of stay was slightly increased following uterine rupture.

Gunshot uterine rupture: a case report

A case report of gunshot uterine rupture from which the mother and fetus survived is presented for the first time. Management was guided by pre-operative ultrasound diagnosis of traumatic anhydramnios.

Vaginal delivery after previous caesarean section for failure of second stage of labour

OBJECTIVE

To determine the outcome of subsequent labour in primiparous women after a caesarean section for delay in descent in the second stage of labour in cephalic presentations with or without trial of instrumental vaginal delivery.

DESIGN

Retrospective follow up study.

SETTING

Medical Centre Leeuwarden, The Netherlands.

PARTICIPANTS

All primiparous parturients who delivered after prior caesarean section during the second stage of labour in the period 19861998.

METHODS

Data concerning the outcome of the first subsequent delivery were gathered from delivery notes and patients charts. The group of women was subdivided into those with or without trial of instrumental vaginal delivery during the previous labour.

RESULTS

Of 132 women, 29 (22%) underwent a planned repeat caesarean section. Of the 103 women who were allowed a trial of labour, 82 (80%) were successful in having a vaginal delivery, and 21 (20%) had a second caesarean section. Of the 74 women with a failed trial of instrumental delivery during the previous labour, 19 had a planned repeat caesarean section and 41 of the remaining 55 (75%) had a successful trial of labour.

CONCLUSIONS

In women with a cephalic presentation who had an arrest of descent in the second stage of labour during their first delivery, the chances of vaginal delivery in their next pregnancy are high, even after a failed instrumented vaginal delivery, and a trial of labour can usually be pursued.

Lower segment uterine rupture related to early pregnancy by in vitro fertilization and embryo transfer after a previous cesarean delivery

A 31-year old woman with secondary infertility after a previous Cesarean delivery underwent in vitro fertilization and embryo transfer (IVF-ET). She was pregnant by IVF-ET. In the first trimester, however, she began to have genital bleeding and lower abdominal pain. This led to intrauterine fetal death, which was terminated by curettage of the uterine cavity. Later, magnetic resonance imaging (MRI) showed the uterine pregnancy on the lower segment scar and the rupture, which was abdominally repaired. It is very likely that the uterine rupture was associated with the implantation in the Cesarean section's scar in this case.

Pregnancy outcome after laparoscopic electromyolysis

Laparoscopic myolysis, a procedure designed to shrink uterine myomas by coagulating their blood supply, is an alternative to myomectomy or hysterectomy in women who do not contemplate childbearing. Three patients conceived within 3 months after myolysis against the surgeon's advice. In two of these women the uterus ruptured at 32 and 39 weeks' gestation, respectively, associated with death of the 32-week fetus. The third patient had an uneventful elective cesarean section at 39 weeks' gestation. Until the risk of uterine rupture after myolysis has been accurately compared with that after myomectomy, women should not undergo myolysis if they wish to conceive. Should pregnancy occur after myolysis, caution and intensive surveillance of mother and fetus must be applied, and cesarean section should be performed at earliest signs and symptoms of uterine rupture and at term before onset of labor.

Delayed postpartum uterine dehiscence. A case report

BACKGROUND

Delayed postpartum uterine dehiscence with hemorrhagic shock may be caused by inadequate treatment of postpartum endomyometritis.

CASE

A woman developed a delayed uterine dehiscence six weeks postpartum. Inadequate antibiotic treatment for postpartum endomyometritis was thought to be the etiology. The patient required a hysterectomy for definitive treatment because of associated hemorrhagic shock.

CONCLUSION

Only one other case of uterine dehiscence that resulted from endomyometritis has been reported. Broad-spectrum antibiotic therapy is indicated in postpartum endomyometritis to avoid uterine dehiscence with hemorrhagic shock.

Rupture of the uterus at the Lagos University Teaching Hospital, Lagos, Nigeria

Rupture of the gravid uterus remains one of the most disastrous complications of labour. Eighty cases of uterine rupture managed at Lagos University Teaching Hospital, Lagos over an eight year period were therefore reviewed to evaluate the characteristic of ruptured uterus in Lagos. The incidence of ruptured uterus was 5.01 per 1000 deliveries and unbooked patients accounted for 80%. Spontaneous rupture occurred in 73.8% while traumatic rupture was responsible for 26.3%. Diagnosis was not made in 25% of the cases until surgery. Poor antenatal care, foeto-pelvic disproportion, previous Caesarean section scar, grand-multiparity were major aetiological factors. Repair of the rupture with or without sterilization was carried out in 70% of the cases. Booking status and the type of surgical procedure did not significantly affect the maternal outcome. Ruptured uterus was responsible for 16.9% of the total maternal deaths in the period of review. The commonest cause of death in this series was hypovolaemic shock (64.3%). The overall perinatal mortality was 86.3% but the registered patients fared better. It was concluded that the incidence of ruptured uterus is still very high and probably on the increase in Lagos. Suggestions are made to improve the situation since the identified aetiological factors are largely preventable.

Spontaneous rupture of the uterus caused by placenta percreta at 28 weeks of gestation: a case report

Placenta percreta is a rare complication of pregnancy. Rupture of the uterus due to placenta percreta is one of the most urgent obstetrical catastrophes. Recently, we observed a patient who developed placenta percreta accompanied by spontaneous uterine rupture at 28 weeks of gestation. A 29-year old gravida 3, para 1, who had a history of one cesarean section and one miscarriage with dilatation and curetage, was seen at 28 weeks of gestation. An acute abdomen and shock were diagnosed. Immediate laparotomy revealed a transverse rupture on the fundus of the uterus. A hysterectomy was performed. Pathological examination of the uterus showed placenta percreta. Rupture of the uterus due to placenta percreta before the onset of labor is extremely rare.

[Vaginal birth after cesarean delivery: can the trial of labor be extended]

Based on a retrospective analysis of 1000 cases of scared uteri following cesarean section(s) (one cesarean, n = 857, 85.7%); two n = 129, 12.9%; three n = 14, 1.4%), we tried to answer two questions. Is trial of labor in case of low segment uterine-scar (excepting pelvic abnormalities, corporeal scar and more than two scars) free of risk for the mother and child? Can trial of labor be extended to cases of breech presentation, two previous cesarean sections, twin pregnancy and suspected macrosomia? In this series, the cesarean was indicated before labor in 138 cases (13.8%). Trial of labor was conducted in 862 cases (86.2%), and led to vaginal birth in 728 (84.5%). Successful trial of labor was observed in 75% of twin pregnancies, in 100% of breech presentations and in 69.6% of macrosomic infants. Uterine rupture occurred in 23 cases (2.7%), especially in cases with unknown corporeal scars (15 cases). No case of perinatal death related to uterine rupture was observed in this series.

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.

Rupture of rudimentary horn pregnancy: a case report

A rare case of rupture of a noncommunicating rudimentary horn pregnancy is presented. The pregnancy continued to 16-weeks' gestation, when the rudimentary horn ruptured. The patient had signs and symptoms of massive hemoperitoneum. An emergency exploratory laparotomy revealed a ruptured rudimentary horn and an intact amnionic sac. Prompt excision of the rudimentary horn was performed. The relative literature and factors associated with a rudimentary horn pregnancy are reviewed and discussed.

Vaginal birth after cesarean delivery: results in 310 pregnancies

OBJECTIVE

To assess and compare the risk associated with a trial of vaginal birth after cesarean section (VBAC) with the risk of an elective repeat cesarean section.

METHODS

A retrospective review of the records of 310 consecutive women who, at the Jichi Medical School Hospital in the 6-year period of 1990 through 1995, had previously undergone a primary cesarean section and gave birth to a singleton infant weighing > or = 2,000 g at > or = 36 weeks of gestation in a subsequent pregnancy.

RESULTS

Elective cesarean sections were performed on 96 (31%) of 310 women, and VBACs were attempted by 214 women (69%). Vaginal deliveries were successful in 132 (43%) of the 310 pregnancies. No maternal death or perinatal deaths occurred in either group. A uterine rupture occurred in 2 (0.9%) of the 214 women who attempted a VBAC, and 5 women (2.3%) gave birth to neonates with a 1-minute Apgar score < or = 6. None of the 96 women who underwent an elective cesarean section had such complications, although the difference in these complication rates did not reach a significant level.

CONCLUSIONS

A trial of a VBAC significantly reduced the rate of cesarean sections. Although the rates of uterine rupture and neonatal asphyxia were slightly higher in women who attempted a VBAC than in women who underwent an elective cesarean section, obstetricians should offer the option of a trial of labor, because more than one-half of the women with a previous cesarean delivery might have successful vaginal deliveries, and the VBAC-related maternal mortality rate does not reportedly differ between women undergoing a trial of labor and women undergoing an elective repeat cesarean section.

Spontaneous rupture of a primigravid uterus secondary to placenta percreta. A case report

BACKGROUND

Uterine rupture secondary to placenta percreta has been observed in multiparous patients. These cases are typically associated with a prior history of uterine trauma or infection: hysterotomy, myomectomy, cornual resection, dilatation and curettage, manual removal of the placenta or endometritis. Spontaneous rupture of the primigravid uterus without a history of trauma or infection is an exceedingly rare occurrence. This case represents the second reported in the medical literature and the first to result in a live-born infant.

CASE

A 23-year-old, African American primigravida at 26 weeks' gestation presented with acute-onset abdominal pain, severe hypotension, tachycardia and fetal heart rate decelerations. Blood product replacement was initiated, and an emergency laparotomy was performed for a presumptive diagnosis of intraabdominal hemorrhage. A significant hemoperitoneum was encountered, with the fetus floating freely in the peritoneal cavity. The uterus had a fundal rupture with a clinically apparent placenta percreta that necessitated performing a total abdominal hysterectomy. The patient recovered uneventfully, and the infant survived without significant morbidity.

CONCLUSION

Spontaneous rupture of the primigravid uterus can occur in the absence of a history of uterine trauma or infection. If a gravid woman presents with hypotension, abdominal pain and fetal distress, the differential diagnosis should include rupture of the uterus, regardless of parity or gynecologic history. Rapid diagnosis, blood product replacement and emergency laparotomy are the key steps in successful management.

[Eighty cases of uterine rupture at the maternity service of the National Hospital Center of Ouagadougou , Burkina Faso]

In this retrospective study, we recall the frequency of uterine ruptures within a national health center of West Africa and propose solutions in order to reduce the incidence. This very high frequency was 23/1000, i.e. one uterine rupture for 44 deliveries. The feto-maternal prognosis was poor with a high stillbirth rate and maternal mortality. Maternal mortality which was 35% of cases represented 22.7% of the causes of maternal mortality observed within the unit during the survey. The stillbirth rate was 95% representing 145/1000 of the hospital stillbirth rate recorded during the survey. Maternal morbidity was also high because 14% of those who survived presented a parietal suppuration with the release of suture during the immediate postsurgical period. The seriousness of the feto-maternal prognosis is linked to a lack of adequate patient management. The importance of uterine ruptures in the obstetrical activity of the unit needs a joint and urgent action of all intervening parties within the sanitary system in order to contend with this scourge, which is the sign of poor quality health care in Obstetrics.