A 28-year-old female Gravida 2 Parity 1 living 1 at 18 weeks of gestation with a history of previous cesarean section presenting to Gynecology Emergency of Goldis Hospital, affiliated with Isfahan University of Medical Sciences, Isfahan, Iran. She took 1000 µg of misoprostol tablet 1 day prior to her admission and due to unsuccessful abortion, presented to the hospital.
On physical examination, her vital signs were a pulse rate of 80 beats per minute, blood pressure of 110/70 mmHg, respiratory rate of 18 cycles per minute, and temperature was 36.8ºC. Her gestational age was estimated according to the last normal menstrual period. On abdominal examination, bowel sounds were heard, and a mild tenderness was present. On vaginal examination, we found vaginal odor and cervical motion tenderness were negative. Other systemic examinations were normal. On admission laboratory examination, we found leukocytosis with mild proteinuria. Ultrasonography of the abdomen and pelvic cavity presented a macerated fetus in the inferior intrauterine cavity without cardiac activity. However, the evidence of uterine perforation was not identified in the ultrasonography investigation. Therefore, 200 µg misoprostol tablet was administered as a loading dose sublingually and thereafter 200 µg every three hours. However, after the first maintenance dose, patients reported the symptoms of vertigo and dizziness. After neurology consultation, we continued misoprostol at 200 µg every three hours. Due to unsuccessful abortion, patients underwent ultrasonography to assess the possibility of accreta placenta which was negative. Moreover, no evidence of uterine rupture was detected in the ultrasonography investigation. Then, 400 µg misoprostol every three hours was administered sublingually, and after 4 doses it was discontinued due to unfavorable outcomes. Next, misoprostol was discontinued, and oxytocin was administered to induce an abortion. In this method, 50 IU of oxytocin was infused with 500 mL of saline for three hours. After 1–2 hours of rest, the next 500 mL of saline was infused with 100 IU of oxytocin for three hours. However, even after an infusion of 200 IU oxytocin with 500 mL of saline, the fetus was not aborted. Meanwhile, we also inserted a trans-cervical Foley catheter to improve the efficacy of oxytocin; however, it was disposed of. The next day, we administered 800 µg misoprostol rectally in two separate doses and after 2–3 hours of resting, we started to infuse oxytocin from 50 IU up to 150 IU. However, due to an unsuccessful abortion, the patient was transferred to the operating room.
Finally, she was sent to the operating room for the dilation and evacuation (D & E) procedure. We failed to reach out to the fetus through the D & E procedure and therefore underwent exploratory laparotomy. The uterus was torn, and the fetus and placenta were found in the abdominal cavity with omentum sealing the rupture of the uterus. The fetus and placenta were removed and after proper toileting and controlling of bleeding, the uterus was closed. The Hb during the surgery dropped to 9.1 g/dL owing to massive bleeding. Therefore, two units of blood were infused and Hb was raised to 10.12 g/dL. After surgery, the patient was good without any complications, and she was discharged 3 days later. The patient’s health was good, and she was doing fine after a month of follow-up.
The data that support the findings of this study are available from Goldis Hospital data base, but restrictions apply to the availability of these data, which were used under license for the current study and so are not publicly available. The data are, however, available from the authors upon reasonable request and with the permission of Goldis Hospital data base.
Informed consent to publish was obtained from the participant/s involved in the current study.