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Uterine rupture after use of a prostaglandin E2 vaginal insert during vaginal birth after cesarean. A report of two cases.

BACKGROUND
Prostaglandin E2, when used for cervical ripening, often initiates labor. Single dosing and ease of removal contribute to the common use of a commercially available prostaglandin E2 vaginal insert. We describe two cases of uterine rupture among 57 pregnancies undergoing attempted vaginal birth after cesarean section.


CASES
Two cases of women attempting vaginal birth after a single low transverse cesarean section were treated with the insert either at 41 weeks, 4 days, or 39 weeks, 3 days, for postdatism or preeclampsia. Signs of uterine rupture included persistent suprapubic pain and repetitive fetal heart rate variable decelerations followed by bradycardia. Infant outcomes were favorable, and tears along the prior low transverse uterine scar were repaired without additional morbidity.


CONCLUSION
This prostaglandin compound is not exempt from being associated directly or indirectly with uterine rupture and requires informed consent and continuous monitoring.