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Misoprostol for second trimester pregnancy termination in women with prior caesarean: a systematic review
V Berghella1, J Airoldi, A M O'Neill
1Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, USA. vincenzo.berghella@jefferson.edu
Background:
Second trimester pregnancy induction with misoprostol in women with prior caesarean delivery is not well studied.
Objective:
To estimate the risk of uterine rupture using misoprostol as an induction agent for pregnancy termination in the second trimester of pregnancy in women with prior caesarean delivery.
Search Strategy:
Cases of women with a history of prior caesarean delivery and subsequent misoprostol induction for pregnancy termination in the second trimester (16-28 weeks) were obtained from two main data sources. First, a retrospective chart analysis was performed at Thomas Jefferson University Hospital and Christiana Hospital between 1998 and 2004. Second, multiple Medline, Scopus and POPLINE literature searches were performed.
Selection Criteria:
Case series and cohort studies of women with one or more prior caesarean delivery (of any type), and with a subsequent pregnancy with induction of labour for pregnancy termination at 16-28 weeks using misoprostol as the initial primary agent were included. Case reports were analysed separately.
Data Collection And Analysis:
Total cases were analysed by type and number of prior caesarean delivery, for the primary outcome of uterine rupture.
Main Results:
The incidence of uterine rupture associated with second trimester misoprostol termination was 0.4% (2/461) in women with one prior low transverse, 0% (0/46) in those with two prior low transverse and 50% (1/2) in those with a prior classical caesarean delivery. One of the cases of uterine rupture in a woman with a prior low transverse caesarean required transfusion. None of the total eight cases (including case reports) of uterine rupture was associated with hysterectomy.
Conclusions:
Second trimester misoprostol termination appears safe among women with one prior low transverse caesarean birth, as it is associated with incidences of uterine rupture of 0.4% (95% confidence interval 0.08-1.67%), of hysterectomy of 0% and of transfusion of 0.2%. There are insufficient data on risk with more than one prior caesarean birth or with prior classical caesarean birth.
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