Obstet Gynecol Sci.  2020 Apr;63(3):323-329. 10.5468/ogs.2020.63.3.323.

Misoprostol complications in second-trimester termination of pregnancy among women with a history of more than one cesarean section

• Jamali M
• Bakhtiyari M
• Arab F
• Mirzamoradi M

• KMID: 2500422
• DOI: http://doi.org/10.5468/ogs.2020.63.3.323

Abstract

Objective
This study aims to investigate the complications due to misoprostol administration for second-trimester termination of pregnancy among women with history of 2 or more cesarean scarring.
Methods
The cohort of this retrospective study included 678 subjects who required second-trimester pregnancy termination, from 2013 to 2015 and treated with vaginal misoprostol of 100 to 400 μg. The subjects were divided into 3 groups based on their history of cesarean sections: without a history of cesarean section, with a history of one cesarean section, and with a history of more than one cesarean section and uterine scaring.
Results
The results showed that the success rate of misoprostol administration for pregnancy termination was 95.72%. The rate of bleeding as a complication was significantly higher in subjects with a history of more than one cesarean section than in other participants (risk ratio [RR], 2.24; 95% confidence interval [CI], 1.11–4.0). The incidence of uterine rupture was higher in the group with a history of more than one cesarean section than in other groups. However, no significant difference was observed between the groups (RR, 1.44; 95% CI, 0.27–7.6). There was a significant relationship between the need for other auxiliary treatments in the pregnancy termination and the history of uterine scarring (RR, 3.3; 95% CI, 1.23–9.1).
Conclusion
The present study showed that pregnancy termination using smaller divided dose of misoprostol in patients with previous history of cesarean scarring may be associated with lower incidence of uterine rupture.

Keyword

Misoprostol; Cesarean section; Pregnancy complications

Figure

• 

  Fig. 1 Total and divided misoprostol dosage among the different groups in this study.

Reference

1. Hamza HS, Gaber KR, Raouf WA, Dohain AM, Mohsen GSA, Elfattah ANA, et al. Fetal echocardiography for early detection of conotruncal anomalies in high risk pregnancies: one year follow-up. J Clin Neonatol. 2016; 5:35.

2. Stubblefield PG, Carr-Ellis S, Borgatta L. Methods for induced abortion. Obstet Gynecol. 2004; 104:174–185. PMID: 15229018.

3. Özden S, Delikara MN, Avci A, Fiçicioglu C. Intravaginal misoprostol vs. expectant management in premature rupture of membranes with low Bishop scores at term. Int J Gynaecol Obstet. 2002; 77:109–115. PMID: 12031560.

4. Trussell J, Guthrie K. Choosing a contraceptive: efficacy, safety, and personal considerations. In : Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D, editors. Contraceptive technology. 19th revised ed. New York (NY): Ardent Media, Inc.;2007. p. 19–47.

5. Lalitkumar S, Bygdeman M, Gemzell-Danielsson K. Mid-trimester induced abortion: a review. Hum Reprod Update. 2007; 13:37–52. PMID: 17050523.

6. Walters KM, Simon RA, Woessner KM, Wineinger NE, White AA. Effect of misoprostol on patients with aspirin-exacerbated respiratory disease undergoing aspirin challenge and desensitization. Ann Allergy Asthma Immunol. 2017; 119:71–76. PMID: 28668243.

7. Allen R, O'Brien BM. Uses of misoprostol in obstetrics and gynecology. Rev Obstet Gynecol. 2009; 2:159–168. PMID: 19826573.

8. Stephenson ML, Wing DA. Misoprostol for induction of labor. Semin Perinatol. 2015; 39:459–462. PMID: 26601733.

9. Grady K, Johnston T. Maternal collapse, including massive obstetric haemorrhage, amniotic fluid embolism and cardiac arrest. In : MacLennan K, O'Brien K, MacNab WR, editors. Core topics in obstetric anaesthesia. Cambridge: Cambridge University Press;2015. p. 191.

10. Green L, Knight M, Seeney FM, Hopkinson C, Collins PW, Collis RE, et al. The epidemiology and outcomes of women with postpartum haemorrhage requiring massive transfusion with eight or more units of red cells: a national cross-sectional study. BJOG. 2016; 123:2164–2170. PMID: 26694742.

11. Nankali A, Jalilian N, Keshavarzi F, Rezaei R, Rezaei M. Comparison of efficacy and side effects of different administration routes of misoprostol (oral, vaginal, and sublingual) for second-trimester abortion. Int J Pediatr. 2017; 5:5887–5895.

12. Ercan Ö, Köstü B, Özer A, Serin S, Bakacak M. Misoprostol versus misoprostol and foley catheter combination in 2nd trimester pregnancy terminations. J Matern Fetal Neonatal Med. 2016; 29:2810–2812. PMID: 26452400.

13. Daskalakis GJ, Mesogitis SA, Papantoniou NE, Moulopoulos GG, Papapanagiotou AA, Antsaklis AJ. Misoprostol for second trimester pregnancy termination in women with prior caesarean section. BJOG. 2005; 112:97–99.

14. Cuellar Torriente M, Steinberg WJ, Joubert G. Misoprostol use for second-trimester termination of pregnancy among women with one or more previous cesarean deliveries. Int J Gynaecol Obstet. 2017; 138:23–27. PMID: 28378361.

15. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, et al. Williams obstetrics. 25th ed. New York (NY): McGraw Hill Professional;2018.

16. Munro MG, Mainor N, Basu R, Brisinger M, Barreda L. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized controlled trial. Obstet Gynecol. 2006; 108:924–929. PMID: 17012455.

17. World Health Organization. Health worker role in providing safe abortion care and post abortion contraception. Geneva: World Health Organization;2015.

18. Borgatta L, French A, Vragovic O, Burnhill MS. Early medical abortion with methotrexate and misoprostol: outcomes and satisfaction among women aged 15–21 years. J Pediatr Adolesc Gynecol. 2001; 14:9–16. PMID: 11358701.

19. Zikopoulos KA, Papanikolaou EG, Kalantaridou SN, Tsanadis GD, Plachouras NI, Dalkalitsis NA, et al. Early pregnancy termination with vaginal misoprostol before and after 42 days gestation. Hum Reprod. 2002; 17:3079–3083. PMID: 12456606.

20. Marwah S, Gupta S, Batra NP, Bhasin V, Sarna V, Kaur N. A comparative study to evaluate the efficacy of vaginal vs oral prostaglandin E1 analogue (misoprostol) in management of first trimester missed abortion. J Clin Diagn Res. 2016; 10:QC14–8.

21. Nath J, Jain M, Najam R, Sharma R. To compare the effectiveness and tolerability of misoprostol as a cervical ripening agent in the first trimester abortion through sublingual and vaginal routes of administration. Bangladesh J Obstet Gynaecol. 2016; 27:63–66.

22. Küçükgöz Güleç U, Urunsak IF, Eser E, Guzel AB, Ozgunen FT, Evruke IC, et al. Misoprostol for midtrimester termination of pregnancy in women with 1 or more prior cesarean deliveries. Int J Gynaecol Obstet. 2013; 120:85–87. PMID: 23195293.

23. Naguib AH, Morsi HM, Borg TF, Fayed ST, Hemeda HM. Vaginal misoprostol for second-trimester pregnancy termination after one previous cesarean delivery. Int J Gynaecol Obstet. 2010; 108:48–51. PMID: 19781700.

24. Karaçor T, Yalınkaya A, Görük N, Özler A, Turgut A. Misoprostol-induced termination of secondtrimester pregnancy in women with a history of cesarean section: a retrospective analysis of 56 cases. Ginekol Pol. 2013; 84.

25. Dickinson JE, Evans SF. The optimization of intravaginal misoprostol dosing schedules in second-trimester pregnancy termination. Am J Obstet Gynecol. 2002; 186:470–474. PMID: 11904609.

26. Iftikhar R, Burney WA. Role of misoprostol in inducing abortion in previous cesarean section. J Surg Pak. 2009; 14:3.