Abstract

PIP: This paper describes a case of spontaneous uterine rupture following induction of labor for intrauterine death with intravaginal PGE2 suppositories. A 32-year-old gravida 9, para 2-1-5-3 woman who had chronic hypertension during pregnancy (32 to 33 weeks gestation) presented with an intrauterine death confirmed by real-time ultrasonography. A vaginal suppository of 20 mg PGE2 was inserted. Pelvic examination 5 1/2 hours later revealed a 2-cm dilated and 50%-effaced cervix. A 2nd PGE2 suppository was inserted in spite of uterine contractions 1 to 1 1/2 minutes apart. A slightly macerated infant weighing 1520 gm was delivered. Profuse vaginal bleeding ensued after placental delivery. Uterine exploration revealed bilateral uterine wall tears. Total abdominal hysterectomy was performed. The patient was discharged on the 11th postoperative day in satisfactory condition. The dose of uterotonic drugs should be titrated to the frequency and intensity of uterine contractions, especially in the 3rd trimester. Use of PGE2 suppositories during the 2nd half of pregnancy should be accompaned by careful monitoring of uterine contractions with an external tocodynamometer and frequent abdominal palpation and placement of an intrauterine pressure catheter. A 2nd suppository should not have been used in this case as the patient was already in established labor and having strong contractions 1 1/2 minutes apart. Even in cases of uterine death, administration of more drugs to produce hypercontractility is contraindicated and dangerous. Should hypercontractility ensue, the new B2-selective sympathomimetic drugs can be used to reverse this effect.