Rupture of Cesarean-Section Scar in Second Trimester Following Misoprostol Induction of Labor for Fetal Demise

Background: Rupture of a cesarean-section scar during labor is a rare condition. However, induction of labor in a patient with previous cesarean-section delivery has been associated with higher incidence of scar rupture. Case: The patient was a 30-year-old, married Caucasian female, gravida 6, para 3-0-2-3, who presented with an 18-weeks' gestation pregnancy. Intrauterine fetal demise was diagnosed with an ultrasound evaluation. She was treated with misoprostol and delivered the deceased infant intact. Ten days postdelivery she reported having black blood and clots coming from her vagina. Exploratory surgery revealed tearing and bleeding arising from a defect from her previous cesarean section. The defect was repaired surgically. Results: The patient's abdomen was closed. Her estimated blood loss was 200 mL. She was taken to the recovery room and did well. She was discharged on postoperative day 4. Conclusions: Second-trimester misoprostol induction has known risks that could be managed in the proper setting. The desire to have an intact infant for evaluation and bonding makes this a better option than dilation and excision. Dosing regimens are varied, study sizes are small, and studies are lacking to evaluate the success after prior successful vaginal birth after cesarean sections (VBAC). This is an area in need of further research. This case demonstrates the need to be vigilant when caring for such patients, because subtle, perhaps occult, uterine rupture does occur and necessitates a high index of suspicion and rapid repair in order to preserve life and fertility.