Last updated: February 12, 2021
Recommendation:
- Less than 22-24 weeks gestation with one uterine scar:Ā No changes to recommended regimens necessary.Ā Ā
- More than 22-24 weeks gestation with one uterine scarĀ or 13-24 weeksĀ gestationĀ with more than one uterine scar:Ā Consider decreasing the misoprostol dose with or withoutĀ lengthening the misoprostol dosing interval. There is insufficient evidence toĀ know if thisĀ impactsĀ the risk of uterine rupture in these women.Ā Ā
Strength of recommendation: WeakĀ
Quality of evidence: Very LowĀ
Risk of uterine rupture with medical abortionĀ
Uterine rupture has been reported during medical abortion at or after 13 weeks gestation in women with and without a uterine scar. The risk of uterine rupture for any woman undergoing aĀ medical abortion at or after 13 weeksĀ gestationĀ is very rare, occurring inĀ fewerĀ than 1 in 1,000 women (Goyal, 2009). In a meta-analysis of 16 studies of 3,556 women undergoing medical abortion at or after 13 weeksĀ gestationĀ with combined or misoprostol-only regimens, three women suffered uterine rupture resulting in a rate of 0.28% with a previous cesarean section and 0.04% without (Goyal, 2009).Ā Ā
One single-center retrospectiveĀ review of 279 women undergoingĀ abortion between 14-26 weeks includedĀ 60 women with one andĀ 26 women with more than oneĀ uterineĀ scarĀ (Küçükgƶz GüleƧ et al., 2013). Women received misoprostol 200mcg vaginally every four hours; three had a uterine rupture.Ā In another retrospective review of 263 women between 12-24 weeks undergoing misoprostol-only abortion,Ā 48 had one andĀ 29 had more than one scar; one rupture was observed in a woman with three prior cesarean sections who received a misoprostol regimen of 200mcg sublingually every three hours (Cetin et al., 2016).Ā A third retrospective review included 231 women with one and 37 women with two prior cesarean deliveries, and used a regimen of 800mcg of misoprostol as a loading dose followed by 200mcg everyĀ twoĀ hours for three doses; no women experienced rupture (Torriente, Steinberg, & Joubert, 2017).Ā Ā
Regimen for women with a uterine scarĀ
Due to the rarity of uterine rupture in women with a previous scar, no clear guidance can be obtained from the published literature (Borgatta & Kapp, 2011; Daponte, Nzewenga, Dimopoulos, & Guidozzi, 2006; Daskalakis et al., 2004; Dickinson, 2005; Morris et al., 2017).Ā Ā
Expert opinion supports:Ā
- No change in medical abortion regimen for women with one uterine scar whose gestation is less than 22-24 weeks.Ā Ā
- After 22-24 weeks gestationĀ with a single uterine scar or 13-24 weeksĀ gestationĀ with more than one uterine scar:Ā
- Consider decreasing the dose of misoprostol with or withoutĀ lengthening the dosing interval (Ho et al., 2007; Küçükgƶz GüleƧ et al., 2013).Ā
There is insufficient evidenceĀ toĀ knowĀ ifĀ changing the dosing regimen will decrease the risk of uterine rupture.Ā
References
Borgatta, L., & Kapp, N. (2011).Ā Society of Family Planning Clinical Guideline 20111:Ā Labor induction abortion in the second trimester.Ā Contraception,Ā 84(1), 4-18.Ā Ā
Cetin, C., Buyukkurt, S., Seydaoglu, G., Kahveci, B., Soysal, C., & Ozgunen, F. T. (2016).Ā Comparison of two misoprostol regimens for mid-trimester pregnancy terminations after FIGOās misoprostol dosage recommendation in 2012.Ā The Journal of Maternal-Fetal & Neonatal Medicine, 29(8), 1314-1317.Ā
Daponte, A., Nzewenga, G., Dimopoulos, K. D., & Guidozzi, F. (2006). The use of vaginal misoprostol for second-trimester pregnancy termination in women with previous single cesarean section.Ā Contraception,Ā 74(4), 324-327.Ā
Daskalakis, G. J., Mesogitis, S. A., Papantoniou, N. E., Moulopoulos, G. G., Papapanagiotou, A. A., & Antsaklis, A. J. (2004).Ā Misoprostol for second trimester pregnancy termination in women with prior caesarean section.Ā BJOG:Ā An International Journal of Obstetrics & Gynaecology,Ā 112(1), 97-99.Ā Ā
Dickinson, J. E. (2005). Misoprostol for second-trimester pregnancy termination in women with a prior cesarean delivery.Ā Obstetrics & Gynecology,Ā 105(2), 352-356.Ā Ā
Goyal, V. (2009). Uterine rupture in second-trimester misoprostol-induced abortion after cesarean delivery:Ā AĀ systematic review.Ā Obstetrics & Gynecology,Ā 113(5), 1117-1123.Ā Ā
Ho, P. C., Blumenthal, P. D., Gemzell-Danielsson, K.,Ā Gómez Ponce de León, R., Mittal, S., & Tang, O. S. (2007). Misoprostol for the termination of pregnancy with a live fetus at 13 to 26 weeks.Ā International Journal of GynecologyĀ &Ā Obstetrics,Ā 99(2), 178-181.Ā Ā
Küçükgƶz GüleƧ, Ć., Urunsak, I. F., Eser, E., Guzel, A. B., Ozgunen, F. T., Evruke, I. C., & Buyukkurt, S. (2013). Misoprostol for midtrimester termination of pregnancy in women with 1 or more prior cesarean deliveries.Ā International Journal of Gynecology & Obstetrics,Ā 120, 85-87.Ā
Morris, J. L., Winikoff, B., Dabash, R., Weeks, A., Faundes, A., Gemzell-Danielsson, K., ⦠Visser, G. H. A. (2017). FIGOās updated recommendations for misoprostol used alone in gynecology and obstetrics.Ā International Journal of Gynecology & Obstetrics,Ā 138(3), 363-366.Ā Ā
Torriente, M. C., Steinberg, W. J., & Joubert, G.Ā (2017). Misoprostol use for second-trimester termination of pregnancy among women with one or more previous cesarean deliveries.Ā International Journal of Gynecology & Obstetrics, 138, 23-27.Ā