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Uterine rupture as a complication of second trimester abortion using intraamniotic prostaglandin E2 and augmentation with other oxytocic agents
PROSTAGLANDINS
UTERINE RUPTURE AS A COMPLICATION OF SECOND TRIMESTER ABORTION USING INTRAAMNIOTIC PROSTAGLANDIN E2 AND AUGMENTATION WIM OTHER OXYTOCIC AGENTS Terry McCarthy+, St Thomas’ Hospital, John Chelsea
Senior Registrar London, England
McQueen, Senior Registrar Hospital for Women, London,
England
ABSTRACT Two cases of ruptured uterus are presented following attempted induction of midtrimester abortion using intraamniotic prostaglandin E2 and augmentation with other With continued uterine stimulation the oxytocic agents. diagnosis of rupture may not be obvious and the diagnostic features are discussed. Patients of high parity appear to be particularly susceptible to uterine rupture during induced midtrimester abortion. INTRODUCT
ION
Intraamniotic prostaglandins have been extensively used for the induction of midtrimester abortion (1, 2). The mean induction delivery interval for the naturally occurring prostaglandins given by this route is 17.2 (5-73) hours for prostaglandin E2 and 37.3 (5-72) hours In order to reduce this for prostaglandin F2a (3). interval and to achieve vaginal delivery in those cases which appear to respond poorly to prostaglandins alone augmentation with intravenous oxytocin (4) and intraamniotic urea (5) has been employed. This following prostaglandin Both cases were only
*Present Department Hospital
JUNE
paper presents two cases of uterine rupture therapeutic abortion where intraamniotic E2 was augmented with other oxytocic agents. showed clinical signs of uterine rupture which fully appreciated retrospectively.
Senior Lecturer and Consultant, Address: of Obstetrics and Gynaecology, Kandang for Women, Hampshire Road, Singapore 0821
1980 VOL. 19 NO. 6
Kerbau
849
PROSTAGLANDINS
Case
Reports
A 35 year old, gravida 6 para 5, was referred for 1: Intraamniotic PGE2 termination at 16 weeks gestation. 10 mg in 10 ml sterile water was given at 08.15 cm on day 1 and an intravenous infusion of syntocinon 278 m units/minute started at the same time and continued for At 18.00 contractions were occurring, “quite 12 hours. However by 20.30 these strongly”, 1 in every 5 minutes. contractions had stopped and the cervix was only 1.5 cm A further 10 mg PGE2 was injected into the dilated. amniotic cavity after removal of 10 ml of liquor and the infusion of syntocinon at 278 m units/minute continued. Contractions and pain were reported at 02.00 on day 2 accompanied by the passage of 200 ml of blood per vaginam Pethidine but the cervix was still only 1.5 cm dilated. 75 mg IM was given for pain at 04.45 but there was no change in the vital signs until 06.00 when the pulse rose to 120 per minute and the blood pressure fell to go/60 Resuscitation with intravenous fluids was started mnHg. and vaginal examination showed that the cervix was drawn up almost out of reach of the examining finger with the OS no further dilated. Clinical signs of tenderness and guarding in the lower abdomen continued to increase and after blood transfusion laparotomy was performed.
Case
A massive haematoma was found on the left side of the pelvis extending from the bladder anteriorly to the The cavity of the uterus was empty sacrum posteriorly. since both the fetus and the placenta had been expelled through an anterolateral tear at the level of the lower Hysterectomy and left salpingoophorectomy was segment. performed with considerable technical difficulty and a further operation for evacuation of a vaginal haematoma A total of 6 units of was necessary 4 hours later. Her postblood was transferred over a 24 hour period. operative recovery was uncomplicated. A 24 year old, gravida 2 para 1 referred for Case 2: termination at 17 weeks gestation. After withdrawal of 120 ml of clear amniotic fluid 2.5 mg PGE2 and 80 gm urea was injected into the amniotic cavity at 14.00 on Only mild contractions were recorded during the day 1. first 24 hours with no cervical dilatation. At 13.00 on day 2 an intravenous infusion of syntocinon was started rising in incremental doses from 50 m units/ minute to 400 m units/minute over the next 24 hours.
850
JUNE
1980 VOL. 19 NO. 6
PROSTAGLANDINS
By 18.00 on day 2 contractions were ‘fairly strong’ occurring 1 in every 2 minutes with slight red vaginal loss but vaginal examination at 21.30 showed no cervical dilatation and the infusion was discontinued overnight. On day 3 a similar regimen of syntocinon was given for 15 hours resulting initially in ‘fairly strong’ contractions 1 in every 3 minutes but without further cervical dilatation and by 18.00 the contractions had ceased so syntocinon was again discontinued. At 11.30 on day 4 syntocinon was recommenced at 100 m units/minute increasing over the next 24 hours to 1200 m units/minute but without effect. During this time the pulse and blood pressure were normal and no mass or tenderness was palpable on abdominal examination, Lasix was given to counter the antidiuretic effect of the syntocinon and IM Velosol 500 mg ads was started at 20.00 because of a fever of 37.6’C. At 18.00 on day 5 examination under anaesthesia was performed, ‘Products’ were removed from the cervical canal with sponge forceps but the cervix was found to be distorted anteriorly, At laparotomy an extraperitoneal haemorrhagic mass was found in the uterovesical angle. The uterus was explored through the fundal incision and found to be empty with the foul smelling fetus and placenta lying anteriorly, The rupture, which was at the level of the isthmus was sutured after removal of the products of conception. The patient’s fever settled on continued Velosol therapy and she was discharged home on the 8th postoperative day. DISCUSSION -The use of intraamniotic prostaglandins has been shown to be effective and safe (6, 7). PGF2w has been widely used in the USA and elsewhere but use of PGE2 has been restricted mainly to specialised centres in the UK, There are cases in most series however which did not respond satisfactorily to one dose of prostaglandin and augmentation with syntocinon (8, 9), intraamniotic urea (10) and other oxytocics (11) has been advocated. Mackenzie et al (3) stated that they had been unable to find any report of uterine rupture as a complication of pharmacologically induced abortion. However cervical lacerations and annular detachment had been reported (12, 13, 14). More recently intraabdominal rupture with extrusion of the fetus had been reported in at least 5 cases (15, 16, 17), 4 of which had combined prostaglandin and oxytocin therapy.
JUNE
1980 VOL. 19 NO. 6
851
PROSTAGLANDINS
Of the 5 reported cases and the two discussed here 3 were gravida 5 or above whilst the other 2 were gravida As Propping et al (16) point out 2 and 3 respectively. it would appear that the young primigravid patient is at risk of a cervical laceration while the multiparous woman is at risk of uterine rupture when other strong oxytocics are used to augment prostaglandin induced uterine contThe very high syntocinon concentrations used ractions. in our two cases were those described by Craft and Musa (8) and were in routine use in the two institutions involved. Stubblefield et al (18) suggested that the solution to the problem in primiparous patients might be in the use of laminaria tents introduced on the night before abortion though this method has not found much favour in the UK perhaps because of the high death rates which had been associated with laminaria tents in the Confidential Enquiries into Maternal Deaths (19). For multiparous patients the danger is of uterine overstimulation (20) and it would seem from the cases presented that the same caution should be exercised in stimulating midtrimester abortion as would be used if the same patient was being induced at term. The decision to terminate pharmacological stimulation and resort to laparotomy and hysterotomy with its recognised dangers will depend on assessment of the Uarim and Amy (21) reported that nearly clinical signs. 100% of patients deliver within 48 hours using multiple dose schedules and prolongation beyond this period particularly with no cervical dilatation would seem to indicate laparotomy even in the absence of clinical Other rare causes of failure of progress in the signs. abortion such as an extrauterine pregnancy, a fibroid mistaken for a pregnancy or an abnormal uterus should always be considered and if available ultrasonography will often help in the differential diagnosis (22). In one of our two cases and in one case each of the three other reports the diagnosis of uterine rupture had not been suspected preoperatively. The diagnosis of uterine rupture should always be considered if established uterine contractions disappear or if there is blood loss vaginally without concomitant progressive cervical dilatation. The clinical sign of elevation of the cervix into the pelvis is diagnostic of an extraperitoneal mass and a haematoma should be suspected even in the absence of the signs of blood loss or abdominal tenderness.
852
JUNE
1980 VOL. 19 NO. 6
PROSTAGLANDINS
Augmentation of prostaglandin induced midtrimester abortion with syntocinon involves a small but definite risk of uterine rupture particularly in patients of Until the newer prostaglandin analogues high parity. with their higher specificity and lesser side effects (2) become readily available augmentation still has a place The purpose in reducing the induction-delivery interval. of this paper is to suggest that care should be taken to avoid uterine overstimulation particularly in highly parous patients at abortion; their increased risk of uterine rupture is not confined to delivery at term.
REFERENCES 1
Brenner
W.E.
American
2
In: Advances in Prostaglandin Research: Karim S.M.M. Practical Application of Prostaglandins and their Synthesis Inhibitors. (Karim S.M.M. ed) MTP Press, Lancaster. 1979 p 375.
3
Mackenzie Medical
4
Embrey M.P., Biosciences. 9:507, 1973.
I.z., Journal.
Hillier 4:683, Hillier (Ruspe
Lancet
i:
Mahendran Pergaman
1115,
WHO Prostaglandin Journal 1:1373,
Task 1976.
7
Bygdeman M. and 7:68 Series G. University iedical
Bergstrom (Conn F Centre
8
Craft
9
Seppala M., Prostaglandins Craft
I.
Musa
B.
Kajanoja 2:311, Lancet
JUNE 1980 VOL. 19 NO. 6
i:1344,
Embrey
K and
6
and
Obstetrics
G ed)
Craft
I.
of
K. and 1974.
5
10
I.
Journal
and
M.P.
British
Advances
P.
in
Vieweg
Press.
1975. Force.
British
Medical
In: Population ReportsS. G ed). George Washington Washington, 1976.
Lancet
g:1058,
D., Widholm 1972.
0.
1971. and
Sara
P.
1973.
853
PROSTAGLANDINS
11
Karim S.M.M. and Amy J.J. In: Advances in Prostaglandin Research: Prostaglandins and Reproduction. (Karim S.M.M. ed) MTP Press, Lancaster, p 114, 1975.
12
Bradley Watson P.J., Beard R.J. and Craft I. of Obstetrics and Gynaecology of the British Commonwealth. %:284, 1973.
13
Wentz A.C., Journal of 1973.
14
Kajanoja P,, Jungner G., Widholm O., Journal of Obstetrics and Seppala M. of the British Commonwealth. %:242,
15
Smith
16
Propping D., Zuckerman J. Gynecology.
A.
Thompson Obstetrics
British
B.H. and
Medical
and King T.M. Gynecology.
Journal.
Stubblefield J., American Journal 128:689, 1977.
M. and Friedman
E.A.
Journal
American
Karjalainen 0. and Gynaecology 1974. 1:205,
1975.
Golub J. and of Obstetrics
and
Prostaglandins
15: 187,
17
Borten 1978.
18
Stubblefield Ryan K.J. Gynecology.
19
Report on Confidential Enquiries into Maternal Deaths in England and Wales 1970-1972. Her Majesty’s Stationery Office, London, 1975 p 46.
20
Karim
21
Karim S.M.M. and Amy J.J. Obstetrics and Gynaecology. Churchill Livingstone 2nd
22
Laversen Saary Z.
854
P.G., Naftolin American Journal 118:284, 1974.
S.M.M.
Personal
N.H., Wilson Obstetrics
F., Frigoletto of Obstetrics
Communication,
F.D. and
and
1979b.
In:
Scientific Basis of (MacDonald R.R. ed) Ed. 1978, p 373.
K.H., Zervoudakis and Gynaecology.
JUNE
I.A. 47:473,
and 1976.
1980 VOL. 19 NO. 6
UTERINE RUPTURE AS A COMPLICATION OF SECOND TRIMESTER ABORTION USING INTRAAMNIOTIC PROSTAGLANDIN E2 AND AUGMENTATION WIM OTHER OXYTOCIC AGENTS Terry McCarthy+, St Thomas’ Hospital, John Chelsea
Senior Registrar London, England
McQueen, Senior Registrar Hospital for Women, London,
England
ABSTRACT Two cases of ruptured uterus are presented following attempted induction of midtrimester abortion using intraamniotic prostaglandin E2 and augmentation with other With continued uterine stimulation the oxytocic agents. diagnosis of rupture may not be obvious and the diagnostic features are discussed. Patients of high parity appear to be particularly susceptible to uterine rupture during induced midtrimester abortion. INTRODUCT
ION
Intraamniotic prostaglandins have been extensively used for the induction of midtrimester abortion (1, 2). The mean induction delivery interval for the naturally occurring prostaglandins given by this route is 17.2 (5-73) hours for prostaglandin E2 and 37.3 (5-72) hours In order to reduce this for prostaglandin F2a (3). interval and to achieve vaginal delivery in those cases which appear to respond poorly to prostaglandins alone augmentation with intravenous oxytocin (4) and intraamniotic urea (5) has been employed. This following prostaglandin Both cases were only
*Present Department Hospital
JUNE
paper presents two cases of uterine rupture therapeutic abortion where intraamniotic E2 was augmented with other oxytocic agents. showed clinical signs of uterine rupture which fully appreciated retrospectively.
Senior Lecturer and Consultant, Address: of Obstetrics and Gynaecology, Kandang for Women, Hampshire Road, Singapore 0821
1980 VOL. 19 NO. 6
Kerbau
849
PROSTAGLANDINS
Case
Reports
A 35 year old, gravida 6 para 5, was referred for 1: Intraamniotic PGE2 termination at 16 weeks gestation. 10 mg in 10 ml sterile water was given at 08.15 cm on day 1 and an intravenous infusion of syntocinon 278 m units/minute started at the same time and continued for At 18.00 contractions were occurring, “quite 12 hours. However by 20.30 these strongly”, 1 in every 5 minutes. contractions had stopped and the cervix was only 1.5 cm A further 10 mg PGE2 was injected into the dilated. amniotic cavity after removal of 10 ml of liquor and the infusion of syntocinon at 278 m units/minute continued. Contractions and pain were reported at 02.00 on day 2 accompanied by the passage of 200 ml of blood per vaginam Pethidine but the cervix was still only 1.5 cm dilated. 75 mg IM was given for pain at 04.45 but there was no change in the vital signs until 06.00 when the pulse rose to 120 per minute and the blood pressure fell to go/60 Resuscitation with intravenous fluids was started mnHg. and vaginal examination showed that the cervix was drawn up almost out of reach of the examining finger with the OS no further dilated. Clinical signs of tenderness and guarding in the lower abdomen continued to increase and after blood transfusion laparotomy was performed.
Case
A massive haematoma was found on the left side of the pelvis extending from the bladder anteriorly to the The cavity of the uterus was empty sacrum posteriorly. since both the fetus and the placenta had been expelled through an anterolateral tear at the level of the lower Hysterectomy and left salpingoophorectomy was segment. performed with considerable technical difficulty and a further operation for evacuation of a vaginal haematoma A total of 6 units of was necessary 4 hours later. Her postblood was transferred over a 24 hour period. operative recovery was uncomplicated. A 24 year old, gravida 2 para 1 referred for Case 2: termination at 17 weeks gestation. After withdrawal of 120 ml of clear amniotic fluid 2.5 mg PGE2 and 80 gm urea was injected into the amniotic cavity at 14.00 on Only mild contractions were recorded during the day 1. first 24 hours with no cervical dilatation. At 13.00 on day 2 an intravenous infusion of syntocinon was started rising in incremental doses from 50 m units/ minute to 400 m units/minute over the next 24 hours.
850
JUNE
1980 VOL. 19 NO. 6
PROSTAGLANDINS
By 18.00 on day 2 contractions were ‘fairly strong’ occurring 1 in every 2 minutes with slight red vaginal loss but vaginal examination at 21.30 showed no cervical dilatation and the infusion was discontinued overnight. On day 3 a similar regimen of syntocinon was given for 15 hours resulting initially in ‘fairly strong’ contractions 1 in every 3 minutes but without further cervical dilatation and by 18.00 the contractions had ceased so syntocinon was again discontinued. At 11.30 on day 4 syntocinon was recommenced at 100 m units/minute increasing over the next 24 hours to 1200 m units/minute but without effect. During this time the pulse and blood pressure were normal and no mass or tenderness was palpable on abdominal examination, Lasix was given to counter the antidiuretic effect of the syntocinon and IM Velosol 500 mg ads was started at 20.00 because of a fever of 37.6’C. At 18.00 on day 5 examination under anaesthesia was performed, ‘Products’ were removed from the cervical canal with sponge forceps but the cervix was found to be distorted anteriorly, At laparotomy an extraperitoneal haemorrhagic mass was found in the uterovesical angle. The uterus was explored through the fundal incision and found to be empty with the foul smelling fetus and placenta lying anteriorly, The rupture, which was at the level of the isthmus was sutured after removal of the products of conception. The patient’s fever settled on continued Velosol therapy and she was discharged home on the 8th postoperative day. DISCUSSION -The use of intraamniotic prostaglandins has been shown to be effective and safe (6, 7). PGF2w has been widely used in the USA and elsewhere but use of PGE2 has been restricted mainly to specialised centres in the UK, There are cases in most series however which did not respond satisfactorily to one dose of prostaglandin and augmentation with syntocinon (8, 9), intraamniotic urea (10) and other oxytocics (11) has been advocated. Mackenzie et al (3) stated that they had been unable to find any report of uterine rupture as a complication of pharmacologically induced abortion. However cervical lacerations and annular detachment had been reported (12, 13, 14). More recently intraabdominal rupture with extrusion of the fetus had been reported in at least 5 cases (15, 16, 17), 4 of which had combined prostaglandin and oxytocin therapy.
JUNE
1980 VOL. 19 NO. 6
851
PROSTAGLANDINS
Of the 5 reported cases and the two discussed here 3 were gravida 5 or above whilst the other 2 were gravida As Propping et al (16) point out 2 and 3 respectively. it would appear that the young primigravid patient is at risk of a cervical laceration while the multiparous woman is at risk of uterine rupture when other strong oxytocics are used to augment prostaglandin induced uterine contThe very high syntocinon concentrations used ractions. in our two cases were those described by Craft and Musa (8) and were in routine use in the two institutions involved. Stubblefield et al (18) suggested that the solution to the problem in primiparous patients might be in the use of laminaria tents introduced on the night before abortion though this method has not found much favour in the UK perhaps because of the high death rates which had been associated with laminaria tents in the Confidential Enquiries into Maternal Deaths (19). For multiparous patients the danger is of uterine overstimulation (20) and it would seem from the cases presented that the same caution should be exercised in stimulating midtrimester abortion as would be used if the same patient was being induced at term. The decision to terminate pharmacological stimulation and resort to laparotomy and hysterotomy with its recognised dangers will depend on assessment of the Uarim and Amy (21) reported that nearly clinical signs. 100% of patients deliver within 48 hours using multiple dose schedules and prolongation beyond this period particularly with no cervical dilatation would seem to indicate laparotomy even in the absence of clinical Other rare causes of failure of progress in the signs. abortion such as an extrauterine pregnancy, a fibroid mistaken for a pregnancy or an abnormal uterus should always be considered and if available ultrasonography will often help in the differential diagnosis (22). In one of our two cases and in one case each of the three other reports the diagnosis of uterine rupture had not been suspected preoperatively. The diagnosis of uterine rupture should always be considered if established uterine contractions disappear or if there is blood loss vaginally without concomitant progressive cervical dilatation. The clinical sign of elevation of the cervix into the pelvis is diagnostic of an extraperitoneal mass and a haematoma should be suspected even in the absence of the signs of blood loss or abdominal tenderness.
852
JUNE
1980 VOL. 19 NO. 6
PROSTAGLANDINS
Augmentation of prostaglandin induced midtrimester abortion with syntocinon involves a small but definite risk of uterine rupture particularly in patients of Until the newer prostaglandin analogues high parity. with their higher specificity and lesser side effects (2) become readily available augmentation still has a place The purpose in reducing the induction-delivery interval. of this paper is to suggest that care should be taken to avoid uterine overstimulation particularly in highly parous patients at abortion; their increased risk of uterine rupture is not confined to delivery at term.
REFERENCES 1
Brenner
W.E.
American
2
In: Advances in Prostaglandin Research: Karim S.M.M. Practical Application of Prostaglandins and their Synthesis Inhibitors. (Karim S.M.M. ed) MTP Press, Lancaster. 1979 p 375.
3
Mackenzie Medical
4
Embrey M.P., Biosciences. 9:507, 1973.
I.z., Journal.
Hillier 4:683, Hillier (Ruspe
Lancet
i:
Mahendran Pergaman
1115,
WHO Prostaglandin Journal 1:1373,
Task 1976.
7
Bygdeman M. and 7:68 Series G. University iedical
Bergstrom (Conn F Centre
8
Craft
9
Seppala M., Prostaglandins Craft
I.
Musa
B.
Kajanoja 2:311, Lancet
JUNE 1980 VOL. 19 NO. 6
i:1344,
Embrey
K and
6
and
Obstetrics
G ed)
Craft
I.
of
K. and 1974.
5
10
I.
Journal
and
M.P.
British
Advances
P.
in
Vieweg
Press.
1975. Force.
British
Medical
In: Population ReportsS. G ed). George Washington Washington, 1976.
Lancet
g:1058,
D., Widholm 1972.
0.
1971. and
Sara
P.
1973.
853
PROSTAGLANDINS
11
Karim S.M.M. and Amy J.J. In: Advances in Prostaglandin Research: Prostaglandins and Reproduction. (Karim S.M.M. ed) MTP Press, Lancaster, p 114, 1975.
12
Bradley Watson P.J., Beard R.J. and Craft I. of Obstetrics and Gynaecology of the British Commonwealth. %:284, 1973.
13
Wentz A.C., Journal of 1973.
14
Kajanoja P,, Jungner G., Widholm O., Journal of Obstetrics and Seppala M. of the British Commonwealth. %:242,
15
Smith
16
Propping D., Zuckerman J. Gynecology.
A.
Thompson Obstetrics
British
B.H. and
Medical
and King T.M. Gynecology.
Journal.
Stubblefield J., American Journal 128:689, 1977.
M. and Friedman
E.A.
Journal
American
Karjalainen 0. and Gynaecology 1974. 1:205,
1975.
Golub J. and of Obstetrics
and
Prostaglandins
15: 187,
17
Borten 1978.
18
Stubblefield Ryan K.J. Gynecology.
19
Report on Confidential Enquiries into Maternal Deaths in England and Wales 1970-1972. Her Majesty’s Stationery Office, London, 1975 p 46.
20
Karim
21
Karim S.M.M. and Amy J.J. Obstetrics and Gynaecology. Churchill Livingstone 2nd
22
Laversen Saary Z.
854
P.G., Naftolin American Journal 118:284, 1974.
S.M.M.
Personal
N.H., Wilson Obstetrics
F., Frigoletto of Obstetrics
Communication,
F.D. and
and
1979b.
In:
Scientific Basis of (MacDonald R.R. ed) Ed. 1978, p 373.
K.H., Zervoudakis and Gynaecology.
JUNE
I.A. 47:473,
and 1976.
1980 VOL. 19 NO. 6