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Reproductive Toxicology 20 (2005) 575577

Case report

Oral misoprostol and uterine rupture in the first trimester of pregnancy:


A case report
Joo Oh Kim b , Jung Yeol Han a,b, , June Seek Choi a,b , Hyun Kyong Ahn a,b , Jae Hyug Yang b ,
Inn Soo Kang b , Mi Jin Song c , Alejandro A. Nava-Ocampo d
a The Korean Motherisk Program, Samsung Cheil Hospital & Womens Health-care Center, Sungkyunkwan University School of Medicine,
Seoul, Republic of Korea
b The Department of Obstetrics and Gynaecology, Samsung Cheil Hospital & Womens Health-care Center, Sungkyunkwan University

School of Medicine, 1-19 Mookjung Dong, Choong Gu, Seoul 100-380, Republic of Korea
c The Department of Radiology, Samsung Cheil Hospital & Womens Health-care Center, Sungkyunkwan University

School of Medicine, Seoul, Republic of Korea


d Department of Clinical Pharmacology, Hospital Infantil de M exico Federico Gomez, Mexico DF, Mexico

Received 28 January 2005; received in revised form 29 March 2005; accepted 30 April 2005
Available online 27 June 2005

Abstract

We are reporting the case of a woman with 8 weeks of amenorrhea who orally received a single dose of misoprostol 400 g at midnight for
ripening of cervix before uterine evacuation of an intrauterine gestational sac containing a single fetus (6.3 weeks of gestation) without cardiac
activity. The patient had severe abdominal pain an hour later. Her blood pressure was 70/40 mmHg and her abdomen was slightly distended
with direct and rebound tenderness. A transvaginal ultrasonography showed a 3-cm depth of a free fluid collection in the rectouterine pouch.
Her hemoglobin and hematocrit levels were of 6.5 g/dL and 18.4%, respectively. A rupture of 1.5 cm at the left uterine horn with a protruding
gestational sac was identified by laparoscopy. The gestational sac was removed and hemoperitoneal collection were successfully drained.
The site of uterine rupture was primarily sutured and postoperative course was satisfactory. In summary, misoprostol administered in the first
trimester of pregnancy may produce uterine rupture.
2005 Elsevier Inc. All rights reserved.

Keywords: Misoprostol; Nonsteroidal abortifacient agents; Oxytocics; Uterine rupture

1. Introduction uterine rupture during second-trimester abortions induced


with misoprostol [68]. However, it is unexpected that
Misoprostol is an orally active prostaglandin E-1 analogue uterine rupture may occur when misoprostol is administered
that has been used widely by vaginal and oral routes for labor in early pregnancy.
induction at term, for cervical ripening for termination of Because there are no previous cases of uterine rupture with
pregnancy in mid-trimester and for dilatation and evacuation misoprostol administered in the first trimester reported in the
in the first trimester of pregnancy [1,2]. Uterine rupture is a literature, we are reporting our experience with a patient who
serious and often life-threatening condition for both mothers orally received misoprostol for cervix dilatation and uterine
and fetuses. It occurs at a frequency of approximately 1% evacuation in the first trimester of pregnancy and had uterine
of pregnancies with a previous scarred uterus during labor rupture.
induction with misoprostol or oxytocin [3]. Isolated reports
of a unscarred uterine rupture following misoprostol use for
cervical ripening have also been reported [4,5], as well as 2. Case

Corresponding author. Tel.: +82 2000 7124; fax: +82 2 2278 4574. A 30-year-old woman with amenorrhea for 8 weeks had
E-mail address: hanjungyeol@yahoo.com (J.Y. Han). vaginal bleeding probably secondary to a missed abortion. In

0890-6238/$ see front matter 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.reprotox.2005.04.014
576 J.O. Kim et al. / Reproductive Toxicology 20 (2005) 575577

her obstetric history, 2 years ago, she had delivered a 4.2 kg


male baby by cesarean section due to cephalopelvic dispro-
portion. Her menstrual cycles were regular with intervals
of 2830 days and 7 days of menstruation. Her pregnancy
was diagnosed by a positive urine hCG test after 5 weeks
of amenorrhea. A clearly defined intrauterine single gesta-
tional sac was detected by transvaginal ultrasonography at 9
weeks of amenorrhea. A 5.2 mm, single fetus of 6.3 weeks
of gestation without cardiac activity was observed within the
gestational sac, with a mean sac diameter of 18.9 mm. Also,
an irregular-shape mixed-echoic mass of approximately 2 cm
in the maximum length was identified in the left uterine
horn. We established the diagnosis of a single intrauterine
pregnancy with embryonic demise as well as a probable
hematoma in the left uterine horn. The patient was sched- Fig. 1. Schematic representation of the uterine rupture at the left horn in
a patient who orally received a single dose of misoprostol 400 g in the
uled for dilatation and evacuation the next day. first trimester of pregnancy for cervix dilatation and uterine evacuation of a
She orally received a single dose of misoprostol 400 g gestational sac. The site of rupture was far from a previous cesarean section.
at midnight for ripening of cervix. However, she had severe
abdominal pain an hour later. She was admitted to the emer- a woman who received oral misoprostol, a prostaglandin-E1
gency room (ER) with a blood pressure of 70/40 mmHg, analogue widely used for elective medical abortion, cervical
pulse rate of 56 beats per minute (b.p.m.), body temperature ripening before surgical abortion, evacuation of the uterus
of 36.8 C and respiratory rate of 20 min1 . During phys- in cases of embryonic or fetal death, labor induction, and
ical examination, her conjunctivas were hypochromic, her treatment of postpartum hemorrhage [9]. In general, the inci-
chest had normal breath and heart sounds, but her abdomen dence of uterine rupture may vary from 1 in 1280 deliveries to
was slightly distended with direct and rebound tenderness. 1 in 18,500 deliveries [10] and more than 90% are associated
No cervical bleeding or motion tenderness was identified. A with a prior cesarean section [11]. Other less common causes
transvaginal ultrasonography performed in the ER showed may include abortions with instrumentation, sounds, silent
no intrauterine gestational sac, an endometrial thickness of rupture in a previous pregnancy, labor stimulation with oxy-
16 mm (expected to be above this value) and a 3-cm depth tocin or prostaglandins, and placenta percreta. Our patient
of a free fluid collection in the rectouterine pouch. At hos- also had a previous delivery by low-flap transverse cesarean
pital admission, her hemoglobin and hematocrit levels were section 2 years ago, which probably predisposed the uterus
of 6.5 g/dL and 18.4%, respectively. Two days before this to rupture during the uterotonic effects of misoprostol. How-
problem occurred, these levels were at 13.2 g/dL and 39.0% ever, uterine rupture in this patient did not occur at the site of
levels, respectively. the scar of previous cesarean section, but at the left uterine
An emergency laparoscopy was performed, and the uterine horn. In addition, uterine rupture probably occurred due to
size was found to be compatible with a pregnancy of 10 weeks the anatomical differences between the uterine horn and the
of gestation. Both ovaries were normal in their appearance. rest of the uterus, including less muscle fiber.
A rupture of 1.5 cm at the left uterine horn with a protruding After oral administration, misoprostol is rapidly absorbed
gestational sac was identified (Fig. 1). The gestational sac was and converted to its pharmacologically active metabolite,
successfully removed by aspiration. A peritoneal blood col- misoprostolic acid, which reaches a maximum plasma con-
lection of approximately 500 mL was drained during surgery. centration approximately 30 min later and declines rapidly
The site of uterine rupture was primarily closed by laparo- thereafter [12]. Misoprostol bioavailability is decreased by
scopic suture. Three units of red blood cells were transfused concomitant ingestion of food or antacids, and is primar-
during the surgery and hemostasis was ensured before clo- ily metabolized in the liver and less than 1% of its active
sure in planes of the laparoscopic incisions. The postoperative metabolite is excreted in urine [13]. If the oral preparation
course was satisfactory and the patient was discharged 4 days of misoprostol is administered vaginally, the effects of miso-
later. Finally, in the postoperative review of the preopera- prostol on the reproductive tract are increased and gastroin-
tive ultrasonography, we noticed that at the rupture site the testinal adverse effects (e.g. nausea, vomiting, and diarrhea)
myometrium was thiner than the rest of the uterus. We did are decreased [14,15]. However, uterine contractility increase
not have any explanation for it. continuously for 4 h when administered vaginally whereas
the maximum effect is reached 1 h after its oral administra-
tion [14], maximum uterine contractility being significantly
3. Discussion higher with vaginal than oral administration. Before surgical
abortion in the first trimester, cervical ripening (the softening,
This seems to be the first case reported in the literature of a effacement, and gradual dilatation of the cervical os) reduces
uterine rupture occurring in the first trimester of pregnancy in the incidence of cervical lacerations and uterine perforation
J.O. Kim et al. / Reproductive Toxicology 20 (2005) 575577 577

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