Uterine rupture and misoprostol

We had one patient referred to us from a private hospital. She had intrauterine fetal death at 16 weeks of gestation. They had also diagnosed a cervical fibroid by ultrasonography. They had inserted 200 microgram misoprostol vaginally twice and given it orally once, before sending her to us for further management. She came to us some time in the night. When I saw her in the morning, she was receiving a blood transfusion, and had already received oxygen for breathlessness. "Sir, she has ascites and hepatomegaly too" the Registrar said. "The pulmonologist has seen her and advised to give her nebulization" the Assistant Professor said. "I will examine her" I said. So a screen was arranged somehow in that overcrowded ward and I checked her up. "I think she has a uterine rupture" I said. "The fibroid you feel by the cervix is in my opinion the fetal head which has escaped the uterus." They did not believe me. "Get an ultrasonography done by a senior person" I advised "as early as possible." An hour later they informed me that the uterus had indeed ruptured. But the fetus was within the uterus and there was hemoperitoneum." "Arrange for an immediate exploratory laparotomy" I advised. That was done. When we opened her abdomen, it was full of blood. The membranes were bulging out of the uterus and the fetus was in the sac. The placenta had also been expelled. The top of the uterus had sort of blown off and was looking like a wild flower in full bloom. There was a white fibrous ridge all around the rupture site. We repaired the uterus, but could not put back the part of the uterus that was already lost. "How did you think of uterine rupture, Sir?" asked one Assistant Professor. "We were thinking of septicemia because she was breathless." "She was breathless because she was anemic" I said. "She had abdominal pain because the uterus had ruptured. On bimanual examination she had the fetus felt very superficially in the fornices, and there was no uterus above the cervix, that should have been there holding the baby." After some time the other Assistant Professor asked me the same question. He must have been concentrating on the uterine suturing when I had answered the same question a little while ago. I gave the same answer. "What was the cause of the rupture?" someone asked. "She probably had a uterine fundal weakness due to past perforation which she did not reveal to us. The precipitating factor was misoprostol" I said.