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Journal of Postgraduate Medicine, Vol. 48, Issue 1, 2002 pp. 71-72 Letter to the Editor Anterior Transverse Cervical Rupture Following Intra-Amniotic Prostaglandin Induced Mid-trimester Abortion Agarwal U, Kriplani A,* Arora V* Departments of Obstetrics and Gynaecology, Pt. B.D. Sharma PGIMS, Rohtak - 124001, Haryana, India and All India Institute of Medical Sciences,* New Delhi - 110029, India. E-mail: umberagarwal_100@rediffmail.com Code Number: jp02022 Sir, A 30 years old 5th gravida with previous four full term normal vaginal deliveries was admitted at 18 weeks period of gestation for termination of pregnancy following ultrasound revealing anencephalic foetus. Physical examination revealed a uterus corresponding to 18 weeks gestational age. After informed consent, amniocentesis was performed under ultrasound guidance. Ten ml of amniotic fluid was removed and same amount of injection of 15 methyl PGE2a containing 2.5mg of the drug was instilled. Uterine contractions started in one hour. Vital signs were recorded. After six hours, per abdomen examination revealed presence of good uterine contractions and vaginal examination demonstrated slight bleeding with 3 cm dilated and fully effaced cervix. Artificial rupture of membranes was done. Fourteen hours following the procedure, she aborted an anencephalic female foetus of 200gms. Patient continued to bleed after placental expulsion in presence of a well contracted uterus. Per-speculum examination revealed a 5cm transverse tear involving the anterior lip of the cervix extending on both sides. Bimanual examination revealed that the defect did not extend through the internal cervical os. Under intravenous sedation the repair of defect was accomplished vaginally after placing a number 8 Hegars dilator through the external os into the uterine cavity. She did not require any blood transfusion. The post-operative course was uneventful. Transverse cervical rupture in association with elective mid-trimester abortion is an uncommon but potentially serious complication. Such lacerations not only increase the immediate post-abortal morbidity but also may adversely influence future reproductive performance. Cervico-vaginal fistulas may form through which women may menstruate, abort or even bear children.1 The exact incidence of such a complication is not known. Wentz et al1 in their series of 102 elective mid-trimester abortions with prostaglandins reported the incidence of transverse cervical rupture to be 2%. In both these cases the posterior lip of cervix was involved. Kajanaja et al2 in their experience of 412 patients with elective mid-trimester abortion with prostaglandins reported the incidence of this complication to be 2.7%. Three cases had posterior cervical rupture, one had anterior rupture and one had lateral wedge shaped tear extending to external os. Similarly, isolated cases of prostaglandin induced cervical rupture have been described.3,4 The mechanism of this aberrant cervico uterine response is debatable. Skajaa5 has suggested that rupture occurs when the external os is relatively inelastic. It has been observed by Wentz et al1 that the cervix feels more rigid during PGF2a induced abortions then with hypertonic saline. It is unknown whether this represents active cervical contractions or an alteration in the status of cervical connective tissue as a result of administered prostaglandins. If PGF2a does cause even a mild degree of cervical contraction then this agent may not be ideal for induction of mid-trimester abortions because of an inability to control the force of uterine contractions in the presence of cervix resistant to dilatation.
Agarwal U, Kriplani A,* Arora V* Departments of Obstetrics and Gynaecology,
References
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