Induction of labour for women with second-trimester spontaneous abortion who have a uterine scar present is a contentious issue due to the potential risk of uterine scar rupture which is well documented.
This case report regards a lady who had an intrauterine death at 23+6 weeks of gestation. She had four Caesarean sections in the past.
The following options were discussed with the patient: conservative management, induction of labour with prostaglandins, and abdominal surgery (hysterotomy).
The patient was keen for medical induction. This was performed with 200 mg of mifepristone orally, followed by 100 mg of misoprostol per vaginum the next morning. She had a rapid vaginal delivery 3 h later.
A literature search showed no reviews or case reports involving misoprostol for second trimester induction in a woman with four previous Caesarean sections. However, this case report shows that mifepristone and misoprostol resulted in a labour which was quick and safe in a woman who had four previous Caesarean sections and had never laboured previously.
Precautions were taken for the eventuality of haemorrhage or uterine rupture by performing a high risk delivery on delivery suite with the availability of experienced staff and theatre personnel at hand. A small dose of prostaglandin was used and oxytocics were avoided in order to reduce the risk of uterine rupture. In case of failure with the low-dose regimen of prostaglandins a hysterotomy would have been performed. Also importantly, all options and decisions were discussed with the woman and her opinions and wishes taken into consideration.