How much misoprostol is safe? - First reported case of second-trimester uterine rupture after a single low dose

With the rising rate of caesarean births, the scenario of fetal demise occurring in a woman with previous caesarean births is becoming more prevalent. The optimal mode of management of intrauterine fetal demise in women with multiple caesarean births presents a challenge for the obstetricians due to absence of a definite protocol with good efficacy, safety and acceptability in these women. The risks of hysterotomy have to be balanced against the risk of uterine rupture with induction. Misoprostol is one of the most common drugs being used in mid-trimester miscarriage but with variable doses. The reports of uterine rupture with previous caesarean scar are rare and have occurred with different doses, making it difficult to counsel women regarding maternal risks. It is difficult to conduct a randomised control trial to address this issue due to limited number of patients and therefore no drug or dosage can be recommended with certainty. We present a unique and first case of second-trimester uterine rupture in a woman with three previous caesarean births and intrauterine fetal demise, after a single low dose of 25 μg vaginal misoprostol. This highlights the need for further research in context of misoprostol dosage in women with more than two previous caesarean births having second-trimester induction of labour.