Intravaginal gemeprost and second-trimester pregnancy termination in the scarred uterus

ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery

Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.

Maternal outcomes in first and second trimester termination of pregnancy: which are the risk factors?

AIMS

To evaluate maternal complications of first trimester and second trimester termination of pregnancy (TOP) performed after first or second trimester positive prenatal diagnosis (PD).

RESULTS

We performed a retrospective study from January 2007 to December 2011, on 844 patients, who underwent a TOP after positive amniocentesis or chorionic villus sampling (CVS) for foetal aneuploidies, performed for maternal age ≥35 years of age, positive prenatal screening (PS) or for genetic reasons. Exclusions criteria were gestational age >22+0 weeks, twin pregnancy and co-existing maternal pathologies. We compared maternal complications of first trimester and second trimester TOP and we established which risk factors were correlated to higher maternal complications (haemorrhages, transfusion, repeated uterine curettage and infections). Maternal complications were significantly higher in second trimester TOP. Previous uterine surgery is a significant risk factor for maternal complications in second trimester TOP, but not in first trimester TOP. Six uterine ruptures and three hysterectomies occurred, all in multiparous women with second trimester TOP. All uterine ruptures occurred in women with previous caesarean sections.

CONCLUSIONS

First trimester TOP in women with risks factors for maternal complications guarantees better maternal outcomes and less health costs. Thus, in these women we should prefer a first trimester PS and PD.

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.

Analysis of the efficacy of resveratrol treatment in patients with scarred uterus

Scarred uterus is caused by cesarean section surgery, and this condition affects further gestation and delivery in patients. Previous evidence suggested that resveratrol, a polyphenol compound, presents beneficial outcomes for patients with scarred uterus. Therefore, the aim of the present study was to analyze the efficacy of resveratrol in the treatment of patients with scarred uterus. The efficacy of resveratrol in the formation of new vessels and re-epithelialization of the endometrium was analyzed. The present results demonstrated that resveratrol treatment reduced uterus scarring in the majority of patients (87.36%) compared with the control. It was also observed that the plasma levels of β-human chorionic gonadotropin were downregulated by resveratrol treatment in patients with scarred uterus. Furthermore, resveratrol treatment promoted the remodeling of the scarred uterus, the regeneration of the endometrium and improved pregnancy outcomes. In conclusion, the findings of the current study indicate that resveratrol treatment may be a potential strategy for the treatment of scarred uterus patients, which contributes to the improvement of pregnancy outcomes.

Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery

Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (1-3). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (4-6). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.

Misoprostol use for second-trimester termination of pregnancy among women with one or more previous cesarean deliveries

OBJECTIVE

To establish the safety and efficacy of misoprostol for second-trimester termination of pregnancy among women with one or more previous cesarean deliveries.

METHODS

In a retrospective study, data were reviewed from women attending a reproductive health clinic in Bloemfontein, South Africa, for second-trimester termination between 2010 and 2013. The study group, comprising women with one or more previous cesareans, was compared with a control group, comprising women with no previous cesarean or uterine scarring. Procedure-specific information was compared, including misoprostol use, termination duration, need for other methods (e.g. oxytocin), placenta delivery, termination outcome, and bleeding.

RESULTS

The study group comprised 268 women: 231 (86.2%) with one and 37 (13.8%) with two previous cesareans. The control group comprised 266 women. Incomplete abortion was recorded in 223 (85.4%) of 261 women in the study group and 213 (80.4%) of 265 in the control group. The number of women with retained placenta was higher in the study than in the control group (158/261 [60.5%] vs 146/265 [55.1%]; P<0.001). Severe bleeding was observed only in the control group (7/266 [2.6%]). No uterine rupture was observed.

CONCLUSION

Misoprostol was safe for second-trimester termination among women with previous cesareans; however, the efficacy of the local regimen was reduced owing to high placental retention.

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.

Silent uterine rupture with the use of misoprostol for second trimester termination of pregnancy : a case report

Uterine rupture is an uncommon, but a life-threatening, complication following second trimester medical termination of pregnancy (TOP). The reported cases have been in both the scarred and unscarred uterus (Rajesh et al. 2002, Drey et al. 2006, and Dickinson). A 27-year-old with two previous deliveries, no previous caesarean section, no history of induced abortions, and no gynaecological operations. She presented with amenorrhoea, and according to her last normal menstruation, she was 10 weeks and 5 days. Ultrasound was done, and it reported 16 weeks and 5 days. She asked for TOP. According to the clinic's protocol, misoprostol 800 mcg (4 tabs) were given to be used vaginally as a loading dose and another three to be taken orally after that. In the following day when she attended the clinic for follow up, a manual vacuum aspiration (MVA). A manual vacuum aspiration was indicated as an incomplete abortion. During the procedure, a uterine rupture was found in the uterine lower segment. A laparotomy was done and a lineal uterine rupture was found and sutured. The patient had a good postoperative recovery and was discharged from hospital after four days. The clinician dealing with second trimester terminations should be aware of the possibility of having a uterine rupture, especially in patients with a uterine scar in order to make an early diagnosis.

Midtrimester termination of pregnancy using gemeprost in combination with laminaria in women who have previously undergone cesarean section

AIM

We aimed to assess the efficacy and safety of midtrimester termination of pregnancy using gemeprost in combination with laminaria in women who had previously undergone cesarean section and in women who had not.

METHODS

Between January 1999 and December 2006, we carried out a retrospective study of termination of pregnancy at 12-21 weeks of gestation at the University of Tsukuba Hospital. Termination of pregnancy was carried out by three-step uterine cervical dilation using laminaria followed by vaginal administration of 1 mg gemeprost every 3 h for up to four doses over 24 h.

RESULTS

A total of 173 women underwent midtrimester termination of pregnancy. The women were categorized into two groups: those who had previously undergone cesarean section (n = 26) (previous cesarean section group) and those who had not (n = 147) (control group). Seven women had undergone cesarean section at least twice. The gemeprost dose administered was 2.8 +/- 1.4 mg for the previous cesarean section group and 2.4 +/- 1.6 mg for the control group (difference in doses not significant). Although abnormal vaginal bleeding (>500 mL) was more likely to occur in the previous cesarean section group than in the control group (odds ratio, 2.61; 95% confidence interval, 0.63-10.82), none of the woman required blood transfusion. Uterine rupture and failed abortion were not observed.

CONCLUSION

The efficacy and safety of our laminaria-gemeprost protocol for termination of pregnancy during the midtrimester are similar for women who have previously undergone cesarean section and those who have not.

Recent advances in second-trimester abortion: an evidence-based review

The proportion of US abortions performed in the second trimester has varied little since 1992. Although 30 years of cumulative data corroborate the safety of dilation and evacuation (D&E), the most commonly used method of second-trimester abortion in the United States, both D&E and alternative induction regimens continue to evolve such that the traditional safety gap between medical and surgical regimens has narrowed. Providers now have options that allow them to either expedite D&E by diminishing the cervical-ripening period or reduce induction abortion intervals during medical induction.