Mifepristone and Oral, Vaginal, or Sublingual Misoprostol for Second-Trimester Abortion: A Randomized Controlled Trial

Prior Cesarean Birth and Risk of Uterine Rupture in Second-Trimester Medication Abortions Using Mifepristone and Misoprostol: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the risk difference of uterine rupture when using current mifepristone and misoprostol regimens for second-trimester abortion among individuals with prior cesarean birth compared with those without prior cesarean birth.

DATA SOURCES

We searched the terms second trimester, induction, mifepristone, and abortion in PubMed, EMBASE, POPLINE, ClinicalTrials.gov , and Cochrane Library from inception until December 2022.

METHODS OF STUDY SELECTION

We included randomized trials and observational studies including a mixed cohort, with and without uterine scar, of individuals at 14-28 weeks of gestation who used mifepristone and misoprostol to end a pregnancy or to manage a fetal death. We excluded case reports, narrative reviews, and studies not published in English. Two reviewers independently screened studies.

TABULATION, INTEGRATION, AND RESULTS

Absolute risks with binomial CIs were calculated from pooled data. Using R software, we estimated total risk difference by the Mantel-Haenszel random-effects method without continuity correction. For studies with zero events, a continuity correction of 0.5 was applied for individual risk differences and plotted graphically with forest plots. Statistical heterogeneity was assessed with Higgins I2 statistics. Funnel plot assessed for publication bias. Of 198 articles identified, 22 met the inclusion criteria: seven randomized trials (n=923) and 15 observational studies (n=6,195). Uterine rupture risk with prior cesarean birth was 1.1% (10/874) (95% CI 0.6-2.1) and without prior cesarean birth was 0.01% (2/6,244) (95% CI 0.0-0.12). The risk difference was 1.23% (95% CI 0.46-2.00, I2 =0%). Of the 12 reported uterine ruptures, three resulted in hysterectomy.

CONCLUSION

Uterine rupture with mifepristone and misoprostol use during second-trimester induction abortion is rare, with the risk increased to 1% in individuals with prior cesarean birth.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022302626.

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

Maternal complications associated with second trimester medical abortion using mifepristone priming and subsequent misoprostol

OBJECTIVES

To assess the frequency of maternal adverse events associated with second trimester medical abortion using sequential mifepristone and misoprostol.

STUDY DESIGN

Retrospective analysis of medical abortions 13 to 28 weeks gestation using sequential mifepristone and misoprostol in a single center from January 2008 to December 2018. The main outcomes evaluated were the nature and incidence of adverse procedural events and the impact of gestation upon these outcomes.

RESULTS

During the study period, 1393 people underwent a medical abortion with sequential mifepristone and misoprostol. The median maternal age was 31 years (IQR 27-36 years) and 21.8% had at least one prior cesarean delivery. The median gestational age at abortion commencement was 19 weeks (IQR 17-21). The main adverse maternal events were complete or partial placental retention greater than 60 minutes triggering removal in the operating room (19%), maternal hemorrhage>1000 cc (4.3%), blood transfusion (1.7%), hospital readmission (1.4%), uterine rupture (0.29%) and hysterectomy (0.07%). There were significant reductions in placental retention rates with increasing gestational age (23.3% at 13-16 weeks gestation declining to 10.1% at>23 weeks gestation, p < 0.001).

CONCLUSIONS

Serious adverse maternal events associated with second trimester medical abortion with sequential mifepristone-misoprostol are uncommon.

IMPLICATIONS

Second trimester medical abortion with mifepristone and misoprostol is generally safe, however, on occasions serious complications may occur. All health care units providing a medical abortion service require the facilities and expertise to deal with these adverse events in a timely manner.

Mifepristone priming and subsequent misoprostol for second trimester medical abortion in women with previous caesarean delivery

AIMS

To assess clinical outcomes and complications in women with ≥1 prior caesarean delivery (CS) during mid-pregnancy medical abortion with misoprostol following mifepristone priming.

MATERIALS AND METHODS

Retrospective analysis of abortions at 13-28 weeks gestation using sequential mifepristone and misoprostol at a single centre from 1/2008-12/2018. Procedural outcomes were compared between cases with no prior CS, one prior and ≥2 prior CS.

RESULTS

There were 1399 consecutive women who underwent a medical abortion, with 304 (21.7%) having ≥1 prior lower segment CS (241 one, 49 two, 12 three, one four) and one a prior classical CS. Median gestation was 19 weeks (interquartile range (IQR) 17-21) among nulliparas, multiparas with no prior CS and multiparas with prior CS, P = 0.505. Compared with nulliparas (median procedural duration 10.8 h, IQR 7.5-16.5; adjusted hazards ratio (aHR) = 1.20 95%CI 1.04-1.40, P = 0.015), multiparas with prior CS had a shorter procedural duration (9.5 h, IQR 6.5-13.5) while multiparas with no CS had the shortest duration (7.0 h, IQR 5.0-9.8; aHR = 2.28 95%CI 2.01-2.58, P < 0.001). Complications were more frequent with prior CS: estimated blood loss (medians: 100 cc no CS vs 150 cc ≥1 CS, P = 0.002), blood loss >1000 cc (3.6% no CS vs 7.2% ≥1 CS; odds ratio (OR) = 2.11 95%CI 1.23-3.62, P = 0.007) and placental retention (17.3% no CS vs 25.3% ≥1 CS; adjusted OR = 1.44 95%CI 1.05-1.99, P = 0.024). Uterine rupture occurred in 4/304 women with ≥1 prior CS (1.3%).

CONCLUSIONS

Mifepristone-misoprostol abortion in women with prior CS is generally safe but associated with an increased risk of procedural complications. Lowering of the misoprostol dosage with prior CS may reduce uterine rupture, although this hypothesis requires ongoing research.

Combined vesicouterine rupture during second-trimester medical abortion for fetal abnormality after prior cesarean delivery: A case report

Introduction

The use of mifepristone and misoprostol for the induction of a second-trimester abortion is common and effective. However, its safety in women with previous cesarean delivery is still controversial, given the potentially higher risk of uterine rupture.

Case presentation

We present the case of a 30-year-old woman (G2P1) who experienced vesicouterine rupture with escape of the dead fetus into the bladder during second-trimester induced abortion after prior cesarean delivery. She was successfully managed with conservative surgery.

Conclusion

This case highlights the challenges of early diagnosis of vesicouterine rupture during second-trimester medical abortion. We argue that a close monitoring of patients with prior cesarean section is mandatory, particularly if uterine contractions suddenly stop or the fetal head fails to descend. A prompt conservative surgical approach allows preservation of fertility.

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The use of mifepristone/misoprostol for the induction of abortion is common and effective.

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For women who have previously had a cesarean delivery, there is a higher risk of uterine rupture.

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Diagnosis of vesicouterine rupture is challenging and close monitoring is mandatory.

Abortion Care Beyond 13 Weeks' Gestation: A Global Perspective

The majority of abortions are performed early in pregnancy, but later abortion accounts for a large proportion of abortion-related morbidity and mortality. People who need this care are often the most vulnerable-the poor, the young, those who experience violence, and those with significant health issues. In settings with access to safe care, studies demonstrate significant declines in abortion-related morbidity and mortality. This review focuses on evidence-based practices for induced abortion beyond 13 weeks' gestation and post-abortion care in both high- and low-resource settings. We also highlight key programmatic issues to consider when expanding the gestational age for abortion services.

Pretreatment With Mifepristone Compared With Misoprostol Alone for Delivery After Fetal Death Between 14 and 28 Weeks of Gestation: A Randomized Controlled Trial

OBJECTIVE

To assess the efficacy of pretreatment with mifepristone before misoprostol, compared with misoprostol alone, for termination of pregnancy after a fetal death in the second trimester.

METHODS

This prospective, double blind, placebo-controlled trial randomized women requiring a termination of pregnancy after fetal death between 14 and 28 weeks of gestation to placebo or 200 mg mifepristone orally 24-48 hours before the termination of pregnancy with misoprostol (400 micrograms every 6 hours vaginally for women at 24 weeks of gestation or less, and 200 micrograms every 4 hours vaginally for women at 24 weeks of gestation or more). Based on a median labor with misoprostol alone in the second trimester of 13 hours, a sample size of 116 women per group was planned to compare the primary outcome of time from administration of misoprostol to delivery. The trial was ceased after 66 women were enrolled secondary to prolonged time to achieve recruitment.

RESULTS

From April 2013 to November 2016, 66 women were randomized (34 to placebo and 32 to mifepristone). There were no differences in the characteristics between the two groups. The median time for the primary outcome of administration of misoprostol to delivery in the placebo group was 10.5 hours, compared with 6.8 hours in the treatment group (hazard ratio 2.41 95% CI 1.39-4.17, P=.002). Women in the placebo group required more doses of misoprostol (3.4 vs 2.1, P=.002) and more misoprostol overall (1,181.8 micrograms, vs 767.7 micrograms, P=.003). There was no difference in maternal complications between the two groups. Women in the mifepristone group reported improved perception of the procedure.

CONCLUSION

The sequential use of mifepristone and misoprostol for the termination of pregnancy after fetal deaths between 14 and 28 weeks of gestation reduces the time to delivery, compared with the use of misoprostol alone, with no worsening of maternal complications.

CLINICAL TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12612000884808.

Medical regimens for abortion at 12 weeks and above: a systematic review and meta-analysis

Background

Mifepristone and misoprostol are recommended for second-trimester medical abortion, but consensus is unclear on the ideal regimen.

Objectives

The objectives were to systematically review randomized controlled trials (RCTs) investigating efficacy, safety and satisfaction of medical abortion at ≥ 12 weeks' gestation.

Data sources

We searched PubMed, Popline, Embase, Global Index Medicus, Cochrane Controlled Register of Trials and International Clinical Trials Registry Platform from January 2008 to May 2017.

Study eligibility participants and interventions

We included RCTs on medical abortion at ≥ 12 weeks' gestation using mifepristone and/or misoprostol. We excluded studies with spontaneous abortion, fetal demise and mechanical cervical ripening and those not reporting ongoing pregnancy (OP).

Study appraisal and synthesis methods

After extracting prespecified data and assessing risk of bias in accordance with the Cochrane handbook, we used Revman5 software to combine data and GRADE to assess certainty of evidence.

Results

We included 43 of the 1894 references identified. Combination mifepristone-misoprostol had lower rates of OP [risk ratio (RR) 0.12, 95% confidence interval (CI) 0.04-0.35] vs. misoprostol only. A 24-h interval between mifepristone and misoprostol had lower OP rate at 24 h than simultaneous dosing (RR 3.13, 95% CI 1.23-7.94). Every 3-h dosing had lower OP rate at 48 h (RR 0.39, 95% CI 0.17-0.88).

Limitations

Direct comparisons of buccal misoprostol to sublingual or vaginal routes after mifepristone were limited. Evidence from clinical trials on how to best manage women with prior uterine incisions was lacking.

Conclusion

Our analysis supports the use of mifepristone 200 mg 1 to 2 days before misoprostol 400 mcg vaginally every 3 h at ≥ 12 weeks' gestation.

Implications

Where available, providers should use mifepristone plus misoprostol for second-trimester medical abortion. Vaginal misoprostol appears to be most efficacious with fewest side effects, but sublingual and buccal routes are also acceptable.

Current and potential methods for second trimester abortion

Medical and surgical methods can both be recommended for second trimester abortion (after 12-weeks of gestational age). Induced abortion with a mifepristone and misoprostol regimen is the preferred approach; where mifepristone is not available, misoprostol alone for medical abortion is also effective. Dilation and evacuation (D&E) is the procedure of choice for surgical abortions, and adequate cervical preparation contributes significantly to safety. Availability of drugs and instruments, ability to provide pain control, provider skill and comfort, client preference, cultural considerations, and local legislation all influence the method of abortion likely to be performed in a given setting. Both surgical and modern medical methods are safe and effective when provided by a trained, experienced provider.

Early medical abortion with self-administered low-dose mifepristone in combination with misoprostol

AIM

The aim of the present study was to investigate the safety and efficacy of low-dose mifepristone combined with self-administered misoprostol for termination of early pregnancy.

METHODS

A total of 533 women seeking medical abortion in early pregnancy (≤49 days since the last menstrual period) were divided randomly into hospital- (H-Mis, 250) and self- (S-Mis, 283) administered misoprostol groups. Women in two groups took 100 mg of oral mifepristone in hospital followed by 200 μg of sublingual misoprostol 24 h later in hospital or home. The primary outcome parameter was complete abortion without surgical intervention. Secondary outcomes were uterine bleeding, return of regular menses, side effects and patient acceptability.

RESULTS

High rates of complete abortion were observed for both the H-Mis group (243/250; 94.8%) and the S-Mis group (266/283; 94.0%). No significant differences in outcomes (complete abortion/failure rates) or side effects were observed between the two groups. General satisfaction rates were similar for the two groups (H-Mis, 231/250, 92.4%; S-Mis, 263/283, 92.9%; P > 0.05). Higher convenience of administration (H-Mis, 211/250, 84.4%; S-Mis, 270/283, 95.4%; P < 0.05) and privacy protection (H-Mis, 214/250, 85.6%; S-Mis, 267/283, 94.3%; P < 0.05) satisfaction rates were obtained for the S-Mis group than for the H-Mis group.

CONCLUSION

Self-administered sublingual misoprostol is as safe and effective as hospital-administered misoprostol following low-dose mifepristone to terminate early pregnancy (≤49 days of amenorrhoea) with fewer side effects.

Update on second trimester medical abortion

PURPOSE OF REVIEW

To review recent literature on second trimester abortion with medical methods.

RECENT FINDINGS

Across studies published in the recent past, it is apparent that women prefer shorter procedures and procedure times. Several randomized controlled trials have confirmed adding mifepristone to the second trimester medication abortion regimen results in shorter abortion intervals from first misoprostol administration to complete fetal expulsion. A study of simultaneous administration of mifepristone and misoprostol yielded shorter mean 'total' abortion times, presenting several logistical advantages. Recent studies on the continuous dosing of misoprostol have produced critical evidence to support continued dosing until expulsion. These studies had a more practical design compared with previous protocols that capped the number of misoprostol doses.

SUMMARY

Second trimester surgical abortion is well tolerated and increasingly expeditious. Further research is needed to refine second trimester medical abortion methods, specific to the mifepristone, misoprostol dosing interval. A 12-hour mifepristone to misoprostol interval may be the optimal interval balancing patient preferences and logistical considerations. Pragmatic dosing, including continuous dosing of misoprostol, could yield results that better inform clinical guidelines and reduce burden on patient, provider, and health facility.

Comparison of sequential vaginal and sublingual misoprostol after a vaginal loading dose for second-trimester abortion

OBJECTIVE

To evaluate the effects of sequential vaginal and sublingual misoprostol after a vaginal loading dose for second-trimester abortion.

MATERIALS AND METHODS

From January 2006 to December 2011, 173 women received an 800-μg vaginal loading dose of misoprostol. After the loading dose, 103 patients received 800 mg of misoprostol vaginally and 70 patients received 400 mg of misoprostol sublingually every 12 h until the delivery of the fetus.

RESULTS

In the vaginal group, the average abortion time was 1.07 ± 1.29 days; that was 0.82 ± 0.66 days in the sublingual group. Sequential sublingual misoprostol after a vaginal loading dose of 800 mg with an administration interval of 12 h had a similar abortion rate and time to abortion. In addition, this protocol reduced unnecessary digital pelvic examinations and speculum examinations.

CONCLUSION

This sequential sublingual misoprostol regimen might be a suitable regimen for mid-trimester abortion.

Update on second-trimester surgical abortion

PURPOSE OF REVIEW

To review the recent literature on surgical second-trimester abortion, with specific attention to cervical preparation techniques.

RECENT FINDINGS

Confirming previous studies, a recent retrospective observational cohort study, including 54 911 abortions, estimated the total abortion-related complication rate to be 0.41% for second-trimester or later procedures. Cervical preparation is known to reduce risks associated with second-trimester dilation and evacuation (D&E). When considering adjuncts to osmotic dilators for cervical preparation prior to D&E after 16 weeks, both misoprostol and mifepristone are effective alone and in combination or as adjuncts to osmotic dilators. Misoprostol consistently has been shown to cause more pain and cramping than placebo, but is an effective adjunct to osmotic dilators after 16 weeks. Although mifepristone has fewer side-effects, at its current price, it may not be as cost-effective as misoprostol.

SUMMARY

Second-trimester abortion is safe. The use of mifepristone and misoprostol for second-trimester abortion has improved safety and efficacy of medical and surgical methods when used alone or in combination and as adjuncts to osmotic dilators. An important aspect of D&E, cervical preparation, is not a one-size-fits-all practice; the approach and methods are contingent on patient, provider and setting and should consider all the evidence-based options.

A Comparative Study of Misoprostol Only and Mifepristone Plus Misoprostol in Second Trimester Termination of Pregnancy

OBJECTIVE

To compare the effectiveness, success rate and induction to abortion interval between administration of misoprostol only and mifepristone with misoprostol in second trimester abortions (14-20 weeks) .

MATERIALS AND METHODS

The study was conducted by dividing women approaching for second trimester termination, into two groups each consisting of 100 women. Group-I received only misoprostol; 600 mcg initial vaginal insertion followed by 400 mcg sublingually every 3 h until termination. Women in Group-II received mifepristone 200 mg and after 24 h started with 600 mcg misoprostol, per vaginal followed by 400 mcg sublingually till abortion was completed, up to a maximum of five doses in both groups.

RESULTS

The success rate in Group-I was 89 %, whereas in Group-II it was 96 %. The mean induction abortion interval in Group-I was 10.67 ± 3.96 h compared to Group-II which was significantly less 6.19 ± 2.70 h (p value < 0.01). The mean dose of misoprostol in Group-I was 1610 ± 511.18 mcg and in Group-II, it was lesser 1046 ± 392.71 mcg (p value < 0.01). There was significant difference in the mean blood loss also, 97.20 ± 36.35 ml in Group-I and 52.55 ± 27.96 ml in Group-II. Also among the individual groups multigravidae and lower gestational age (<17 weeks), women had lesser IAI as well as lesser misoprostol dose was required.

CONCLUSION

Pretreatment with mifepristone significantly reduces the induction abortion interval and the misoprostol dose along with minimal blood loss.

Vaginal Misoprostol Compared With Buccal Misoprostol for Termination of Second-Trimester Pregnancy: A Randomized Controlled Trial

OBJECTIVE

To compare the efficacy of vaginal misoprostol with buccal misoprostol for second-trimester termination of pregnancies.

METHODS

In a randomized trial, we compared 400 micrograms vaginal and buccal misoprostol every 3 hours for up to six doses for induction of labor at 13-24 weeks of gestation with a live fetus and intact membranes. Women who had a uterine scar were excluded from the study. The primary outcome of the study was induction-to-abortion interval. Based on a two-tailed α of 0.05, we planned to include 65 patients per group to detect a 50% difference in the primary outcome with a power of 80%.

RESULTS

From January 2014 to December 2014, 172 women were screened and 130 were randomized: 65 vaginal and 65 buccal misoprostol. Characteristics of patients were similar between groups. Patients administered vaginal misoprostol compared with buccal misoprostol had a shorter induction-to-abortion interval (25±17 hours compared with 40±29 hours, P=.001) and a higher abortion rate within both 24 hours (41 [63%] compared with 27 [42%] P=.014) and 48 hours (59 [91%] compared with 44 [68%], P=.001). Complete abortion rates were similar in both groups (vaginal 51 [78%] compared with buccal 54 [83%]). The incidence of side effects was similar for both groups. The perceived pain was higher in the buccal group, but the small difference did not appear to be clinically meaningful.

CONCLUSION

Vaginal compared with buccal misoprostol administration has a shorter induction-to-abortion interval for second-trimester termination of viable pregnancies. However, both administration routes are equally effective for induction of termination.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT02048098.

LEVEL OF EVIDENCE

I.

The use of prostaglandin E₁ in peripartum patients with asthma

OBJECTIVE

Prostaglandin E₁ (PGE₁) is commonly used in obstetric practice for labor induction and cervical ripening and in treating postpartum hemorrhage; however, its use in pregnant asthmatic patients has not been studied to date. The package insert states there is an unknown causal side effect for dyspnea and bronchospasm. Other pharmacological publications have stated that bronchoconstriction may occur with the use of PGE₁. The study objective was to examine peripartum pregnant asthmatic patients who received prostaglandin E₁.

STUDY DESIGN

Every patient who was administered PGE₁ from January 2010 through December 2013 was prospectively recorded. The charts were retrospectively reviewed. Peripartum patients with asthma were identified and further analyzed for any evidence of an asthma exacerbation following administration of the drug.

RESULTS

A total of 234 of 2629 patients (8.9%) who received PGE₁ were identified as having asthma. None of the patients had any evidence of an asthma exacerbation (0 of 234; 95% confidence interval, 0-0.017). Of the 234 patients, 104 (44%) had active asthma and were receiving daily medication, and the remaining 130 patients had a medical history of asthma for which they used an inhaler on an as-needed basis. A total of 98 patients (42%) received greater than 400 μg of total dose. A post hoc statistical assessment was performed, and the study was sufficiently powered to detect any clinically meaningful increase in asthma exacerbation with PGE₁ usage, if such a risk existed.

CONCLUSION

Based on the 95% confidence interval of these data, the maximum risk for an asthma exacerbation following the use of prostaglandin E₁ is less than 2%. Although all medications administered to asthmatic patients in the peripartum period should be carefully selected, this information supports the use of prostaglandin E₁ in obstetric patients with asthma, if clinically indicated.

Uterine rupture disguised by urinary retention following a second trimester induced abortion: a case report

Background

Uterine rupture classically presents with severe abdominal pain, loss of fetal station, vaginal bleeding, and shock.

Case presentation

We present a case of uterine rupture presenting as significant urinary retention that occurred following a second trimester abortion induced with mifepristone and misoprostol. Uterine rupture was discovered unexpectedly on diagnostic laparoscopy. The uterine rupture was contained by dense adhesions between the omentum and bladder with the previous uterine cesarean hysterotomy scar.

Conclusion

This case highlights the difficulties in diagnosis of abnormal placentation and an unusual presentation of uterine rupture. This case was managed successfully laparoscopically.