Title

18 weeks IUFD with previous 3 C Sections, what would you do?

Objective:

Raise awareness of the NICE recommendation 2021 against the use of dinoprostone /misoprostol with a uterine scar. Detailed counseling for the women about the risks involved with medical termination in a scarred uterus.

 

Case report:

28 years old P3, and only one living child with her. She had 3 previous CS. The first CS was at 36 weeks. The second/ third CS were stillbirths at 26 weeks/20 weeks respectively. Unfortunately, there was no access to operative notes or clues for the cause of death, however, considering how premature the deliveries were, high suspicion was raised about classical CS in the past.

The first-trimester screen revealed a high risk for Trisomies. In Fetal Medicine, she had an amniocentesis and a microarray analysis that was all normal. The patient presented days later with IUFD at 18 weeks + 5 days.

The termination started with Mifepristone 200 mcg then after 36-48 hours vaginal Misoprostol 200 mcg every 6 hours up to 4-5 doses as per local guidance. After the 4th dose of misoprostol, the patient complained of minimal bleeding per vagina, shoulder tip pain, painful contractions that look settled, vasovagal attack, vomiting, unwell, and tachycardia. Bedside scanning was done to assess, no bleeding in the abdomen with the head deeply engaged. On repeat blood, HB dropped from 106 to 80 mg/dl.

The provisional diagnosis was a uterine rupture. The patient was taken to theatre and the diagnosis was confirmed as uterine rupture at the lower segment with 6 litres of blood loss and eventually life-saving hysterectomy with ovarian conservation. Later, histology reported uterine perforation in the lower segment 35 mm from the cervix with evidence of transmural permeation of decidualized endometrium. The patient had blood products 10x RBCS, 4 platelets, FFP and CPP. She was under close observation for 48 hours, recovered well after surgery, and was offered bereavement sessions.

Discussion:

IUFD in a scarred uterus, the balance between risks of surgical options vs medical termination that might result in emergency surgical intervention in case of rupture has left clinicians with a difficult choice especially when it leads to out of hours life-saving procedure. 

Conclusion: 

The NICE recommendation has made it clear that Misoprostol/Dinoprostone is contraindicated in the scarred uterus.
If the patient chose to have the medical option, it must be thoroughly discussed with a senior doctor highlighting national and local trust guidance and properly documented in her notes.