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P048Risk of uterine rupture in second-trimester medication abortions using mifepristone and misoprostol after cesarean section birth: A systematic review and meta-analysis

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      Objectives

      To assess the risk of uterine rupture when using current mifepristone and misoprostol regimens for second-trimester abortion among those who had a prior cesarean section birth.

      Methods

      After prospectively registering on PROSPERO (CRD42022302626), we systematically searched PubMed, EMBASE, POPLINE, ClinicalTrials.gov, and Cochrane Library using search terms “second-trimester,” “induction,” “mifepristone,” and “abortion” from inception until January 2022. We limited our sample to studies including pregnancies of 14–28 weeks’ gestation, studies with a mixed cohort with and without uterine scar, and studies available in English. We excluded case reports and narrative reviews. Two authors independently reviewed studies. Absolute risk with binomial confidence intervals was calculated from pooled data. Using R software, total risk difference was estimated by the Mantel-Haenszel random effects method without continuity correction. For studies with zero events, a continuity correction of 0.5 was applied in the forest plot for individual risk differences. Statistical heterogeneity was assessed with Higgins I2 statistics. Funnel plot assessed for publication bias.

      Results

      Of 198 articles identified, 19 met inclusion criteria: seven randomized trials (n=923) and 12 observational studies (n=2,589). Uterine rupture risk with prior cesarean birth was 1.8% (7/385) (95% CI, 0.7–3.7) and without was 0.1% (2/3,127) (95% CI, 0.0–0.2). The risk difference was 0.01 (95% CI, 0.00–0.03; I2=0%). Minor funnel plot asymmetry demonstrated low evidence of publication bias.

      Conclusions

      Uterine rupture during second-trimester abortion is a rare event but risk does appear to increase among those with a prior cesarean section birth. In the context of patient-centered counseling, this may be acceptable to both patients and providers.
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