Uterine scar rupture after a previous cesarean section and induction of labor with prostaglandins

Abstract

In April 2003, a disciplinary court of the Dutch Medical Council ruled in a case of uterine rupture in a woman with a prior cesarean delivery, which took place in February 2001. The woman was gravida 2, para 1, whose first child was delivered by cesarean section because of breech presentation. In the present pregnancy she had prolonged rupture of membranes (PROM) at term. Priming with 1 mg of prostaglandin E2 gel (PGE2) was started 36 h after PROM. A second application of 2 mg was given six hours later. Three hours later contractions started and four hours after the onset of labor the woman suffered a uterine rupture, had an emergency cesarean section, and an asphyxiated child was born. The child died 10 days later. Several complaints were put forward by the mother, but perhaps the most intriguing issue is whether she should have been induced with PGE2 or not. In the court’s ruling of the case, a study from Washington State (USA), which indicates a higher incidence of uterine scar rupture after PGE2 induction, played a major role (1). Finally the court acquitted the obstetrician of liability during appeal in April 2004, taking into consideration that the US study and the accompanying editorial was published in July 2001 as the lead article in the renowned New England Journal of Medicine, five months after uterine rupture occurred (2). The verdict, however, suggested that if rupture had have happened after the publication, the Court’s ruling might have been different. Until the 1980s the rule ‘once a cesarean, always a cesarean’ was common practice, especially in the USA. Since then a trend has been seen towards vaginal birth after cesarean (VBAC), peaking in the mid 1990s, as one of the ways to curb the increasing cesarean section rate. The VBAC rate in the USA at that time was, however, never higher than 29%, while in Europe the rate was above 50%. Although the incidence of uterine scar rupture in VBAC is low (B/1%) and several large multicenter studies have confirmed the relative safety of VBAC, concern persists that uterine rupture may occur during a trial of labor (TOL) after a prior cesarean section (3 /6). VBAC is therefore still a controversial topic, which has been subjected to intense scrutiny. The quoted paper from the USA with related editorials and correspondence reignited this discussion. Several findings of this study are consistent with results of other studies. The incidence of uterine scar rupture in a TOL without induction (0.52%), and the slightly higher incidence when labor is induced without prostaglandins (0.77%) are in line with the results of other studies (5). However, the finding of a 2.45% risk of uterine rupture when PGE2 is used for * Present address: Atrium Medical Centre, Heerlen, The Netherlands.