First Trimester Medical Pregnancy Termination: When Bleeding and Pain are not Caused by Expulsion. A Case Report of Uterine Rupture
Matthey Page C* and Nessi A
Department of Gynecology & Obstetrics, CHUV, Switzerland
Submission: June 05, 2019; Published: June 26, 2019
*Corresponding author: Matthey Page Caroline, Gynecology & Obstetrics Service, Department of woman-mother-child department, CHUV, Ave Pierre Decker 2, 1011 Lausanne, Switzerland
How to cite this article: Matthey Page C, Nessi A. First Trimester Medical Pregnancy Termination: When Bleeding and Pain are not Caused by
Expulsion. A Case Report of Uterine Rupture. JOJ Case Stud. 2019; 10(2): 555785. DOI: 10.19080/JOJCS.2019.10.555785.
Introduction: Uterine rupture is a rare complication of misoprostol when used to induce first trimester medical termination of pregnancy.
Case: A 35-year-old patient gravida 5, para 3, known for a scarred uterus and hospitalised for onsite first trimester termination at 8 weeks and 2 days of pregnancy. After receiving her first dose of 400mcg of oral misoprostol, the patient developed acute abdominal pain associated with heavy vaginal bleeding. Vaginal ultrasound showed the retention of the pregnancy without sign of uterine rupture. A second dose of 400mcg of oral misoprostol was administered. We noticed persistent moderate vaginal bleeding and moderate abdominal pain without expulsion. We then proceeded to remove the pregnancy surgically. Following dilatation and curettage, a perforation of the anterior uterine wall was suspected. During laparoscopy, the complete rupture of the uterine scar covered with peritoneum was diagnosed.
Conclusion: Uterine rupture is a rare complication of misoprostol use, especially during first trimester pregnancy termination. We suggest a low threshold of suspicion in patients presenting abdominal pain with a known scarred uterus.
Keywords: First trimester medical pregnancy termination; Misoprostol; Uterine rupture
Misoprostol is used off label in gynecology to induce uterine contractions. Its use in association with mifepristone is considered to be a safe method for pregnancy termination in the first trimester .
Most frequent side effects of misoprostol involve the digestive system (abdominal pain, diarrhea) or fever . Uterine rupture has also been described in the literature in association with the use of misoprostol . The incidence is low. The risk is known to increase throughout the pregnancy and in scarred uterus. Nevertheless, seldom cases of uterine rupture have been reported after the use of misoprostol in the first trimester. Here, we report the case of a patient, known for 3 prior caesareans, who suffered a uterine rupture after the use of misoprostol, even though the pregnancy was described by ultrasound to be located away from the uterine scar.
A 35-year-old patient, gravida 5, para 3, with three prior C-sections underwent a first trimester medical termination at 8 weeks and 2 days. The patient was known for a prior first trimester medical termination, first caesarean for fetal distress more than 6 years ago, a second caesarean in an emergency setting for uterine rupture and 2 years ago a third elective caesarean with an asymptomatic dehiscence of the uterine scar discovered during the surgery. The intra-uterine localisation was confirmed by vaginal ultrasound. The lower uterine segment was not described Figure 1.
Following our hospital protocol and in accordance to
international guidelines , we proceeded with delivering one
dose of Mifepristone 200mg followed two days later by two doses
of 400mcg of oral misoprostol at 3 hours interval. The patient
entered our hospital for the first dose of misoprostol with a
hemoglobin of 111G/l. She received the first dose of misoprostol
in association with 500mg paracetamol, 30mg of Codeine
and 600mg of Ibuprofen. One hour later, she suffered from
acute abdominal pain (pain scale 9/10) associated with heavy
vaginal bleeding (300ml in total). No change in hemodynamic
parameters was reported. A uterine rupture was suspected.
An emergency vaginal ultrasound showed the retention of the
pregnancy without sign of intra-abdominal bleeding. A control
blood count showed a stable hemoglobin of 109G/l. The pain
and the bleeding spontaneously decreased (pain scale 5/10).
The favorable development without medical intervention led us
to decide for a stationary observation in the hospital.
After 3 hours of expectant management, without any new
reappearance of acute pain, we administered a second dose
of 400mcg of misoprostol. After the second dose, persistent
moderate bleeding associated with moderate abdominal pain
was observed, without resurgence of acute pain, for which we
suggested an oversight in the hospital. At this time, the total
blood loss was estimated to be 450ml.
Constant pain (5/10), increasing bleeding, associated with
a drop of hemoglobin up to 73G/L motivated the decision of
an emergency surgical removal of the pregnancy. A repeated
ultrasound before the surgery showed the persistence of the
pregnancy without any sign of intra-abdominal fluid.
In the operating room, we confirmed moderate to heavy
vaginal bleeding. The cervix dilatation was spontaneously
evaluated ad Hegar 10. The aspiration of the pregnancy was
uncomplicated. The introduction of a curette lead to the suspicion
of an anterior uterine wall dehiscence. We converted the surgery
to laparoscopy. As we entered the camera in the abdomen, there
was no sign of uterine rupture. Only a small amount of blood in
the vesico-uterine pouch was visible.
A curette was inserted again intra-vaginaly which allowed us
to see a covered perforation of the uterine wall by the peritoneum.
The incision of the peritoneum revealed the complete rupture of
the uterine scar Figure 2.
Cystoscopy was undertaken to exclude an extension of
the tear to the bladder. The rupture was sutured during the
laparoscopy procedure Figure 3.
In the post-operative setting, the patient was transfused with
2 units of blood before being discharged home the next day. An
ultrasound two months later confirmed a healing scar Figure 4.
The clinical symptoms associated with a complete rupture
of the uterine scar, suggest that the uterine rupture took place
after the first dose of misoprostol. This hypothesis explains
the persistent pain presented by the patient and the absence
of expulsion (no uterine contraction possible). Uterine rupture
can present itself with intra-abdominal heavy bleeding. As
demonstrated in this case, only moderate signs such as constant
vaginal bleeding associated with one acute episode of abdominal
pain and the absence of expulsion can also be the only symptoms
Misoprostol is considered safe during first trimester
termination of pregnancy. Nevertheless, this case is a good reminder that a medical pregnancy termination should never be
undertaken lightly. First and foremost, intra-uterine pregnancy
needs to be confirmed. For patient who underwent a previous
caesarean, the location of the pregnancy and trophoblast away
from the uterine scar must be asserted. Ultrasonographic
criteria for a definitive diagnostic have been postulated in
different studies. The presence of a healthy myometrium
between the bladder and the gestational sac must be established
. For patients who underwent multiple anterior caesarean,
to our knowledge, there is no study showing a threshold in size
for the inferior uterine wall. It is debatable whether the risk of
misoprostol use is greater than a surgical aspiration for these
When uterine dehiscence or rupture is suspected in a stable
patient, ultrasonography may be a useful tool to confirm the
diagnosis . As shown in our patient, the ultrasonography can
also be misleading, showing no sign of intra-abdominal fluid and
falsy suggesting that the pain experienced by the patient was
connected to uterine contractions and not rupture.
The recommended dose of misoprostol in first trimester
pregnancy termination does not differ depending on the route
of administration. Similarly, there is no required adaptation
necessary for patients with previous caesarean under 26
weeks of gestation . The recommended dose for misoprostol
in first trimester termination in the new FIGO guidelines is
800mcg sublingual, per vaginal or buccal every 3 hours for 2 to
3 doses. Our hospital protocol delivers two doses of 400mcg of
misoprostol. The symptoms suggest that the rupture occurred
already after the first dose. This fact suggests that the risk of
rupture could be better linked to the use of misoprostol than the
actual dosage. Uterine rupture has also been described in the
literature after the use of misoprostol in unscarred uterus .
It is therefore critical before any pregnancy termination in
the first trimester to evaluate the risk of uterine rupture for
each patient (previous caesarean, number of anterior uterine
surgery, uterine wall disease). Most of all, this case is a good
reminder that even though the risk of uterine rupture is low, it is
inherent to the prescription of drugs inducing contractions such
Uterine rupture is a rare complication associated with the
use of misoprostol in first trimester pregnancy termination.
Nevertheless, it is necessary to have a low suspicion threshold
for patient with a scarred uterus. There is no consensus as to
whether it is necessary to measure the inferior uterine wall
for patient with prior caesarean who undergo a first trimester
pregnancy termination. We suggest that these patients should
receive medical abortion in the hospital setting or a surgical
removal of the pregnancy under ultrasound.