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Walter JR, Barnhart KT, Koelper NC, Santoro NF, Zhang H, Thomas TR, Huang H, Harvie HS. Cost-effectiveness analysis of expectant vs active management for treatment of persistent pregnancies of unknown location. Am J Obstet Gynecol 2024:S0002-9378(24)00471-X. [PMID: 38552817 DOI: 10.1016/j.ajog.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/08/2024] [Accepted: 03/24/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Persistent pregnancies of unknown location are defined by abnormally trending serum human chorionic gonadotropin with nondiagnostic ultrasound. There is no consensus on optimal management. OBJECTIVE This study aimed to assess the cost-effectiveness of 3 primary management strategies for persistent pregnancies of unknown location: (1) expectant management, (2) empirical 2-dose methotrexate, and (3) uterine evacuation followed by methotrexate, if indicated. STUDY DESIGN This was a prospective economic evaluation performed concurrently with the Expectant versus Active Management for Treatment of Persistent Pregnancies of Unknown Location multicenter randomized trial that was conducted from July 2014 to June 2019. Participants were randomized 1:1:1 to expectant management, 2-dose methotrexate, or uterine evacuation. The analysis was from the healthcare sector perspective with a 6-week time horizon after randomization. Costs were expressed in 2018 US dollars. Effectiveness was measured in quality-adjusted life years and the rate of salpingectomy. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were generated. Sensitivity analyses were performed to assess the robustness of the analysis. RESULTS Methotrexate had the lowest mean cost ($875), followed by expectant management ($1085) and uterine evacuation ($1902) (P=.001). Expectant management had the highest mean quality-adjusted life years (0.1043), followed by methotrexate (0.1031) and uterine evacuation (0.0992) (P=.0001). The salpingectomy rate was higher for expectant management than for methotrexate (9.4% vs 1.2%, respectively; P=.02) and for expectant management than for uterine evacuation (9.4% vs 8.1%, respectively; P=.04). Uterine evacuation, with the highest costs and the lowest quality-adjusted life years, was dominated by both expectant management and methotrexate. In the base case analysis, expectant management was not cost-effective compared with methotrexate at a willingness to pay of $150,000 per quality-adjusted life year given an incremental cost-effectiveness ratio of $175,083 per quality-adjusted life year gained (95% confidence interval, -$1,666,825 to $2,676,375). Threshold analysis demonstrated that methotrexate administration would have to cost $214 (an increase of $16 or 8%) to favor expectant management. Moreover, expectant management would be favorable in lower-risk patient populations with rates of laparoscopic surgical management for ectopic pregnancy not exceeding 4% of pregnancies of unknown location. Based on the cost-effectiveness acceptability curves, the probability of expectant management being cost-effective compared with methotrexate at a willingness to pay of $150,000 per quality-adjusted life year gained was 50%. The results were dependent on the cost of surgical intervention and the expected rate of methotrexate failure. CONCLUSION The management of pregnancies of unknown location with a 2-dose methotrexate protocol may be cost-effective compared with expectant management and uterine evacuation. Although uterine evacuation was dominated, expectant management vs methotrexate results were sensitive to modest changes in treatment costs of both methotrexate and surgical management.
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Affiliation(s)
- Jessica R Walter
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL.
| | - Kurt T Barnhart
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Nathanael C Koelper
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Nanette F Santoro
- Divisions of Reproductive Endocrinology and Infertility and Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado, Aurora, CO
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT
| | - Tracey R Thomas
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Hao Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT
| | - Heidi S Harvie
- Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Neill S, Hoe E, Fortin J, Goldberg AB, Janiak E. Management of early pregnancy loss among obstetrician-gynecologists in Massachusetts and barriers to mifepristone use. Contraception 2023; 126:110108. [PMID: 37394110 DOI: 10.1016/j.contraception.2023.110108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVES To measure the prevalence of early pregnancy loss management types among obstetrician-gynecologists in Massachusetts, and delineate barriers, facilitators, demographic and practice-related factors associated with mifepristone use for early pregnancy loss. STUDY DESIGN We surveyed a census of obstetrician-gynecologists in Massachusetts. Descriptive statistics measured the prevalence of offering expectant, misoprostol-alone, mifepristone and misoprostol, dilation and curettage in the office and operating room, and multivariate logistic regression analysis evaluated barriers and facilitators to mifepristone use. Data were weighted to account for nonresponders. RESULTS 198 obstetrician-gynecologists responded to the survey (response rate=29%). Participants most commonly offered expectant management (98%), dilation and curettage in the operating room (94%), and misoprostol-only medication management (80%). Fewer offered mifepristone-misoprostol (51%) or dilation and curettage in an office setting (45%). Those in private practice or other practice types had lower odds of offering mifepristone-misoprostol than those in academic practice (private practice: aOR 0.34, 95% confidence interval [CI] [0.19, 0.61]). Female physicians had higher odds of offering mifepristone-misoprostol (aOR 1.97, 95% CI [1.11, 3.49]). Obstetrician-gynecologists who included medication abortion in their practice had much higher odds of using mifepristone for early pregnancy loss (aOR 25.06, 95% CI [14.52, 43.24]). The Food and Drug Administration Risk and Evaluation Management Strategies Program was a primary barrier among those not using mifepristone (54%). CONCLUSIONS Many obstetrician-gynecologists do not offer mifepristone-based regimens for early pregnancy loss, which are more efficacious than misoprostol-only regimens. The Food and Drug Administration Risk Evaluation and Mitigation Strategies Program is a major barrier to mifepristone use. IMPLICATIONS Half of obstetrician-gynecologists in Massachusetts do not use mifepristone for early pregnancy loss management. Major barriers include lack of experience with mifepristone and the Food and Drug Administration Risk Evaluation and Mitigation Strategies Program regulations. Removing medically unnecessary regulations and increasing education on mifepristone via access to abortion care experts may increase uptake of this practice.
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Affiliation(s)
- Sara Neill
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Emily Hoe
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA; Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jennifer Fortin
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, MA, USA
| | - Alisa B Goldberg
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, MA, USA
| | - Elizabeth Janiak
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Harvard T.H. Chan School of Public Health, Boston, MA, USA; ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, MA, USA
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3
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Bettencourt-Silva B, Rego MT, Miranda C, Cunha AI, Brás F, Lopes-Guerra C, Miguelote R, Sousa-Santos R, Furtado JM. The role of mifepristone on first trimester miscarriage treatment - A double-blind randomized controlled trial - MiFirsT. Eur J Obstet Gynecol Reprod Biol 2023; 289:145-151. [PMID: 37678127 DOI: 10.1016/j.ejogrb.2023.08.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVES To evaluate the efficacy of combined mifepristone and misoprostol compared to misoprostol alone in outpatient medical treatment of first trimester miscarriage. Additionally, the study intends to compare the rate of complications, adverse effects, and treatment acceptability between groups. STUDY DESIGN Single-center double-blind randomized placebo-controlled trial including women with diagnosis of missed first trimester miscarriage up to 9 weeks of gestation. RESULTS Between April 2019 and November 2021, 216 women diagnosed with first trimester miscarriage up to 9 weeks of gestation were randomly assigned to mifepristone group or to misoprostol-alone group. Data from 105 women in mifepristone group and 103 women in misoprostol-alone group were analyzed, with no differences in baseline characteristics. The median time between medications (oral mifepristone/placebo and vaginal misoprostol) was nearly 43 h in both groups (p = 0.906). The median time to first follow-up was 2.6 weeks (IQR 1.0) in mifepristone group and 2.4 weeks (IQR 1.0) in misoprostol-alone group (p = 0.855). The overall success rate of medical treatment was significantly higher in the mifepristone-group comparing to misoprostol-alone group (94.3% vs. 82.5%, RR 1.14, 95% CI, 1.03-1.26; p = 0.008). Accordingly, the rate of surgical treatment was significantly lower in the mifepristone-group (5.7% vs.14.6%, RR 0.39, 95% CI, 0.16-0.97; p = 0.034). The composite complication rate was similar and lower than 4% in both groups. No case of complicated pelvic infection, hemodynamic instability or inpatient supportive treatment was reported. There were no significant differences in the rates of adverse events, median score for vaginal bleeding intensity or analgesics use. Despite the same median value, the score of abdominal pain intensity was significantly higher in the mifepristone-group (p = 0.011). In both groups, more than 65% of the women classified the treatment as "good" and 92% would recommend it to a friend on the same clinical situation. CONCLUSION The mifepristone plus vaginal misoprostol combined treatment for medical resolution of first trimester miscarriage resulted in significant higher success rate and lower rate of surgical uterine evacuation comparing to misoprostol-alone treatment, with no relevant differences in adverse events or treatment acceptability.
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Affiliation(s)
- Beatriz Bettencourt-Silva
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal.
| | - Maria Teresa Rego
- School of Health Science, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal
| | - Cláudia Miranda
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal
| | - Ana Isabel Cunha
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal
| | - Filipa Brás
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal
| | - Cláudia Lopes-Guerra
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal
| | - Rui Miguelote
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal; School of Health Science, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal; Life and Health Sciences Research Institute (ICVS), Campus de Gualtar, 4710-057 Braga, Portugal
| | - Ricardo Sousa-Santos
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal; Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine of Porto University, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - José Manuel Furtado
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal
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Banwarth-Kuhn B, McQuade M, Krashin JW. Vaginal Bleeding Before 20 Weeks Gestation. Obstet Gynecol Clin North Am 2023; 50:473-492. [PMID: 37500211 DOI: 10.1016/j.ogc.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Conditions that often present with vaginal bleeding before 20 weeks are common and can cause morbidity and mortality. Clinically stable patients can choose their management options. Clinically unstable patients require urgent procedural management: uterine aspiration, dilation and evacuation, or surgical removal of an ectopic pregnancy. Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids. Available data on prognosis with expectant management of pre-viable rupture of membranes in the United States are poor for mothers and fetuses.
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Affiliation(s)
| | | | - Jamie W Krashin
- Department of Obstetrics & Gynecology, University of New Mexico Health Sciences Center, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
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5
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Boos EW, Horta M, Thompson I, Dusetzina SB, Leech AA. Trends in the Use of Mifepristone for Medical Management of Early Pregnancy Loss From 2016 to 2020. JAMA 2023; 330:766-3. [PMID: 37477929 PMCID: PMC10445186 DOI: 10.1001/jama.2023.13628] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/01/2023] [Indexed: 07/22/2023]
Abstract
This study assesses the use of mifepristone plus misoprostol for miscarriage management among commercially insured adults in the US.
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Affiliation(s)
- Elise W. Boos
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Manuel Horta
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ivana Thompson
- Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ashley A. Leech
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
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6
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Barghazan SH, Hadian M, Rezapour A, Nassiri S. Comparison of the clinical efficacy of surgical versus medical method for first trimester pregnancy termination in Iran: A quasi-experimental research. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2023; 12:132. [PMID: 37397113 PMCID: PMC10312415 DOI: 10.4103/jehp.jehp_582_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/19/2022] [Indexed: 07/04/2023]
Abstract
BACKGROUND The surgical and medical options for management of pregnancy termination procedures are acceptable in practice but differ in clinical efficacy, costs, and patient experiences, and deciding what the best method is not clear always. This study aimed to compare clinical efficacy, outcomes, and patient acceptance of dilatation and curettage (D and C) versus medical abortion using misoprostol for first trimester of gestation in Iranian context. MATERIALS AND METHODS A prospective, multicenter, quasi-experimental research conducted from July 2021 to January 2022. The primary outcomes were the rate of composite complications or complete abortion. Data were analyzed with SPSS 18 using descriptive statistics, independent t-test, analysis of variance and non-parametric tests. Secondary outcomes were quality of life using EQ5D questionnaire, estimated blood loss, pelvic infection, pain level, hospital stay, and acceptability of intervention and relative risk as the effect size. RESULTS Finally, 168 patients were included in this study. The composite complication rate among medical abortion patients is significantly more than that of surgical abortion patients (39.3% vs. 4.76%). The relative risk calculated 8.25 (3.05-22.26 CI). Medical abortion patients have experienced higher levels of ongoing bleeding, pain, and symptoms of pelvic infection. The higher level of acceptance has been reported by surgical group patients in comparison to the medical group patients (85.7% vs. 59.5%). Quality of life scores for surgical and medical group estimated 0.6605 and 0.5419, respectively. CONCLUSION Surgical method of abortion using D and C is a very safe and highly successful option in comparison to the medical method using misoprostol alone and is associated with better clinical outcomes, acceptance, and quality of life in first trimester of pregnancy among Iranian women.
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Affiliation(s)
- Saeed Husseini Barghazan
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Hadian
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Setare Nassiri
- Endometriosis Research Center, Iran University of Medical Sciences, Tehran, Iran
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Early Pregnancy Assessment Clinics: Expanding Patient-Centered and Equitable Early Pregnancy Care. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2023. [DOI: 10.1007/s13669-023-00353-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
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8
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Meisel ZF, Schreiber CA. Variations in Care for Early Pregnancy Loss Across Clinical Settings. JAMA Netw Open 2023; 6:e232645. [PMID: 36920399 DOI: 10.1001/jamanetworkopen.2023.2645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Affiliation(s)
- Zachary F Meisel
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Courtney A Schreiber
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of Family Planning, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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McKenna K, Sheridan G, Murray L. Compliance with a guideline on outpatient medical management of miscarriage in a gynaecology ED. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:202-208. [PMID: 36828566 DOI: 10.12968/bjon.2023.32.4.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
This article describes the clinical audit of the Outpatient Medical Management of Miscarriage Guideline (Guideline 2) within the Gynaecology Emergency Department (GED) at a single site dedicated Gynaecology and Maternity Hospital in the UK, the Liverpool Women's NHS Foundation Trust. Clinical audits are quality improvement processes used to identify areas of improvement against a set criterion and, as a result, implement any required change(s) (National Institute for Health and Care Excellence, 2002). An audit ensures that the guidelines have been followed to certify safe, effective treatment for women who have suffered a first trimester missed miscarriage and the audit described in this article analysed the success of treatment in avoiding admission to hospital and further intervention, such as surgery. The main findings of the audit were that the GED fell short on compliance rates against some standards, mainly standard 1 (performing a baseline point of care test to measure haemoglobin) and standard 5 (providing the patient with a follow-up phone call, with higher compliance levels to standards 3 and 4, which are in relation to prescribing and administering the treatment. The audit found that 15% of patients required further intervention such as admission to hospital for observation (9%) and surgical intervention to complete the miscarriage (6%). Further training in the clinical setting is required to ensure improved compliance with all standards. A checklist will also be created to ensure all standards are being met.
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Affiliation(s)
- Kerry McKenna
- Advanced Nurse Practitioner, Liverpool Women's NHS Foundation Trust
| | - Gemma Sheridan
- Clinical Supervisor, Liverpool Women's NHS Foundation Trust
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10
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Nagendra D, Gutman SM, Koelper NC, Loza-Avalos SE, Sonalkar S, Schreiber CA, Harvie HS. Medical management of early pregnancy loss is cost-effective compared with office uterine aspiration. Am J Obstet Gynecol 2022; 227:737.e1-737.e11. [PMID: 35780811 PMCID: PMC10302401 DOI: 10.1016/j.ajog.2022.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/17/2022] [Accepted: 06/26/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Early pregnancy loss, also referred to as miscarriage, is common, affecting approximately 1 million people in the United States annually. Early pregnancy loss can be treated with expectant management, medications, or surgical procedures-strategies that differ in patient experience, effectiveness, and cost. One of the medications used for early pregnancy loss treatment, mifepristone, is uniquely regulated by the Food and Drug Administration. OBJECTIVE This study aimed to compare the cost-effectiveness from the healthcare sector perspective of medical management of early pregnancy loss, using the standard of care medication regimen of mifepristone and misoprostol, with that of office uterine aspiration. STUDY DESIGN We developed a decision analytical model to compare the cost-effectiveness of early pregnancy loss treatment with medical management with that of office uterine aspiration. Data on medical management came from the Pregnancy Failure Regimens randomized clinical trial, and data on uterine aspiration came from the published literature. The analysis was from the healthcare sector perspective with a 30-day time horizon. Costs were in 2018 US dollars. Effectiveness was measured in quality-adjust life-years gained and the rate of complete gestational sac expulsion with no additional interventions. Our primary outcome was the incremental cost per quality-adjust life-year gained. Sensitivity analysis was performed to identify the key uncertainties. RESULTS Mean per-person costs were higher for uterine aspiration than for medical management ($828 [95% confidence interval, $789-$868] vs $661 [95% confidence interval, $556-$766]; P=.004). Uterine aspiration more frequently led to complete gestational sac expulsion than medical management (97.3% vs 83.8%; P=.0001); however, estimated quality-adjust life-years were higher for medical management than for uterine aspiration (0.082 [95% confidence interval, 0.8148-0.08248] vs 0.079 [95% confidence interval, 0.0789-0.0791]; P<.0001). Medical management dominated uterine aspiration, with lower costs and higher confidence interval. The probability that medical management is cost-effective relative to uterine aspiration is 97.5% for all willingness-to-pay values of ≥$5600/quality-adjust life-year. Sensitivity analysis did not identify any thresholds that would substantially change outcomes. CONCLUSION Although office-based uterine aspiration more often results in treatment completion without further intervention, medical management with mifepristone pretreatment costs less and yields similar quality-adjust life-years, making it an attractive alternative. Our findings provided evidence that increasing access to mifepristone and eliminating unnecessary restrictions will improve early pregnancy care.
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Affiliation(s)
- Divyah Nagendra
- Department of Obstetrics and Gynecology, Cambridge Health Alliance, Cambridge, MA; Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sarah M Gutman
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Nathanael C Koelper
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sandra E Loza-Avalos
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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11
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Hagey JM, Givens M, Bryant AG. Clinical Update on Uses for Mifepristone in Obstetrics and Gynecology. Obstet Gynecol Surv 2022; 77:611-623. [PMID: 36242531 DOI: 10.1097/ogx.0000000000001063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
IMPORTANCE Mifepristone (RU-486) is a selective progesterone receptor modulator that has antagonist properties on the uterus and cervix. Mifepristone is an effective abortifacient, prompting limitations on its use in many countries. Mifepristone has many uses outside of induced abortion, but these are less well known and underutilized by clinicians because of challenges in accessing and prescribing this medication. OBJECTIVES To provide clinicians with a history of the development of mifepristone and mechanism of action and safety profile, as well as detail current research on uses of mifepristone in both obstetrics and gynecology. EVIDENCE ACQUISITION A PubMed search of mifepristone and gynecologic and obstetric conditions was conducted between January 2018 and December 2021. Other resources were also searched, including guidelines from the American College of Obstetricians and Gynecologists and the Society of Family Planning. RESULTS Mifepristone is approved by the Food and Drug Administration for first-trimester medication abortion but has other off-label uses in both obstetrics and gynecology. Obstetric uses that have been investigated include management of early pregnancy loss, intrauterine fetal demise, treatment of ectopic pregnancy, and labor induction. Gynecologic uses that have been investigated include contraception, treatment of abnormal uterine bleeding, and as an adjunct in treatment of gynecologic cancers. CONCLUSIONS AND RELEVANCE Mifepristone is a safe and effective medication both for its approved use in first-trimester medication abortion and other off-label uses. Because of its primary use as an abortifacient, mifepristone is underutilized by clinicians. Providers should consider mifepristone for other indications as clinically appropriate.
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Affiliation(s)
- Jill M Hagey
- Fellow, Division of Complex Family Planning, Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Matthew Givens
- Fellow, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Amy G Bryant
- Associate Professor, Division of Complex Family Planning, Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, NC
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12
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Barghazan SH, Hadian M, Rezapour A, Nassiri S. Economic evaluation of medical versus surgical strategies for first trimester therapeutic abortion: A systematic review. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2022; 11:184. [PMID: 36003248 PMCID: PMC9393924 DOI: 10.4103/jehp.jehp_1274_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 09/21/2021] [Indexed: 06/15/2023]
Abstract
Pregnancy termination and abortion-related complications are well-established problems among women at reproductive age and resulted in significant morbidity and mortality. Accordingly, a systematic study was performed to investigate the economic evaluation studies results on costs and benefits of medical and surgical abortion methods. PubMed, Web of Science, Scopus, Embase, Cochrane library, ProQuest, and ScienceDirect databases as well as Google scholar were searched through June 2021. Original full-text English language studies that performed an economic evaluation analysis comparing medical and surgical methods of pregnancy termination were included in this review. A critical quality assessment was conducted utilizing the Consolidated Health Economic Evaluation Standards checklist. The latest web-based tool adjusted the estimates of costs expressed in one specific currency and price year into a specific target currency (the year 2020 $US). Overall, 538 records were retrieved, and 20 studies were deemed eligible for qualitative synthesis. Among the reviewed studies, three studies investigated cost-minimization analysis, three studies investigated cost-utility analysis, and 14 studies investigated cost-effectiveness analysis. The directly comparison of medical with surgical abortion was most frequently studied. Medical abortion saved US$ 6 to US$ 2373 per patient's costs. Medical abortion was cost-effective and cost-saving option in compare to the surgical abortion across all perspectives (the incremental cost effectiveness ratio ranged from US$ 419 to US$ 4,044). Quality scores of included studies ranged from 54% to 100%, and 70% of studies received a score of above 85% and had "excellent" quality. According to the results, based on various economic and clinical effectiveness decision-making criteria used in different studies of health economic evaluation, the majority of research provided evidence on the advantage of pharmaceutical methods compared to surgical methods, as well as the advantages of using combinations therapy compared to single therapeutic interventions.
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Affiliation(s)
- Saeed Husseini Barghazan
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Hadian
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Setare Nassiri
- Endometriosis Research Center, Iran University of Medical Sciences, Tehran, Iran
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Hamel CC, Snijders MPLM, Coppus SFPJ, Vandenbussche FPHA, Braat DDM, Adang EMM. Economic evaluation of a randomized controlled trial comparing mifepristone and misoprostol with misoprostol alone in the treatment of early pregnancy loss. PLoS One 2022; 17:e0262894. [PMID: 35139105 PMCID: PMC8827447 DOI: 10.1371/journal.pone.0262894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 01/05/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In case of early pregnancy loss (EPL) women can either choose for expectant, medical or surgical management. One week of expectant management is known to lead to spontaneous abortion in approximately 50% of women. Medical treatment with misoprostol is known to be safe and less costly than surgical management, however less effective in reaching complete evacuation of the uterus. Recently, a number of trials showed that prompt treatment with the sequential combination of mifepristone with misoprostol is superior to misoprostol alone in reaching complete evacuation. In this analysis we evaluate whether the sequential combination of mifepristone with misoprostol is cost-effective compared to misoprostol alone, in the treatment of EPL. METHODS AND FINDINGS A cost-effectiveness analysis (CEA) from a healthcare perspective was performed alongside a randomised controlled trial (RCT) in which standard treatment with misoprostol only was compared with a combination of mifepristone and misoprostol, in women with EPL after a minimum of one week of unsuccessful management. A limited societal perspective scenario was added. This RCT, the Triple M trial, was a multicentre, randomized, double-blinded, placebo-controlled trial executed at 17 hospitals in the Netherlands. The trial started on June 27th 2018, and ended prematurely in January 2020 due to highly significant outcomes from the predefined interim-analysis. We included 351 women with a diagnosis of EPL between 6 and 14 weeks gestation after at least one week of unsuccessful expectant management. They were randomized between double blinded pre-treatment with oral mifepristone 600mg (N = 175) or placebo (N = 176) taken on day one, both followed by misoprostol orally. In both groups, an intention-to-treat analysis was performed for 172 patients, showing a significant difference in success rates between participants treated with mifepristone and misoprostol versus those treated with misoprostol alone (79.1% vs 58.7% respectively). In this cost-effective analysis we measured the direct, medical costs related to treatment (planned and unplanned hospital visits, medication, additional treatment) and indirect costs based on the IMTA Productivity Cost Questionnaire (iPCQ). Quality Adjusted Life Years (QALY's) were calculated from participants' scores on the SF-36 questionnaires sent digitally at treatment start, and one, two and six weeks later. We found medical treatment with placebo followed by misoprostol to be 26% more expensive compared to mifepristone followed by misoprostol (p = 0.001). Mean average medical costs per patient were significantly lower in the mifepristone group compared to the placebo group (€528.95 ± 328.93 vs €663.77 ± 456.03, respectively; absolute difference €134.82, 95% CI 50,46-219,18, p = 0.002). Both indirect costs and QALY's were similar between both groups. CONCLUSION The sequential combination of mifepristone with misoprostol is cost-effective compared with misoprostol alone, for treatment of EPL after a minimum of one week of unsuccessful expectant management.
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Affiliation(s)
- Charlotte C. Hamel
- Radboud University Medical Centre, Department of Obstetrics and Gynaecology, Nijmegen, GA, The Netherlands
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Nijmegen, GS, The Netherlands
| | - Marcus P. L. M. Snijders
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Nijmegen, GS, The Netherlands
| | - Sjors F. P. J. Coppus
- Maxima Medical Centre, Department of Obstetrics and Gynaecology, Veldhoven, DB, The Netherlands
| | - Frank P. H. A. Vandenbussche
- Radboud University Medical Centre, Department of Obstetrics and Gynaecology, Nijmegen, GA, The Netherlands
- Department of Obstetrics and Gynaecology, Helios Klinikum Duisburg, Duisburg, Germany
| | - Didi D. M. Braat
- Radboud University Medical Centre, Department of Obstetrics and Gynaecology, Nijmegen, GA, The Netherlands
| | - Eddy M. M. Adang
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, GA, The Netherlands
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14
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Devall A, Chu J, Beeson L, Hardy P, Cheed V, Sun Y, Roberts T, Ogwulu CO, Williams E, Jones L, Papadopoulos JLF, Bender-Atik R, Brewin J, Hinshaw K, Choudhary M, Ahmed A, Naftalin J, Nunes N, Oliver A, Izzat F, Bhatia K, Hassan I, Jeve Y, Hamilton J, Deb S, Bottomley C, Ross J, Watkins L, Underwood M, Cheong Y, Kumar C, Gupta P, Small R, Pringle S, Hodge F, Shahid A, Gallos I, Horne A, Quenby S, Coomarasamy A. Mifepristone and misoprostol versus placebo and misoprostol for resolution of miscarriage in women diagnosed with missed miscarriage: the MifeMiso RCT. Health Technol Assess 2021; 25:1-114. [PMID: 34821547 DOI: 10.3310/hta25680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
TRIAL DESIGN A randomised, parallel-group, double-blind, placebo-controlled multicentre study with health economic and nested qualitative studies to determine if mifepristone (Mifegyne®, Exelgyn, Paris, France) plus misoprostol is superior to misoprostol alone for the resolution of missed miscarriage. METHODS Women diagnosed with missed miscarriage in the first 14 weeks of pregnancy were randomly assigned (1 : 1 ratio) to receive 200 mg of oral mifepristone or matched placebo, followed by 800 μg of misoprostol 2 days later. A web-based randomisation system allocated the women to the two groups, with minimisation for age, body mass index, parity, gestational age, amount of bleeding and randomising centre. The primary outcome was failure to pass the gestational sac within 7 days after randomisation. The prespecified key secondary outcome was requirement for surgery to resolve the miscarriage. A within-trial cost-effectiveness study and a nested qualitative study were also conducted. Women who completed the trial protocol were purposively approached to take part in an interview to explore their satisfaction with and the acceptability of medical management of missed miscarriage. RESULTS A total of 711 women, from 28 hospitals in the UK, were randomised to receive either mifepristone plus misoprostol (357 women) or placebo plus misoprostol (354 women). The follow-up rate for the primary outcome was 98% (696 out of 711 women). The risk of failure to pass the gestational sac within 7 days was 17% (59 out of 348 women) in the mifepristone plus misoprostol group, compared with 24% (82 out of 348 women) in the placebo plus misoprostol group (risk ratio 0.73, 95% confidence interval 0.54 to 0.98; p = 0.04). Surgical intervention to resolve the miscarriage was needed in 17% (62 out of 355 women) in the mifepristone plus misoprostol group, compared with 25% (87 out of 353 women) in the placebo plus misoprostol group (risk ratio 0.70, 95% confidence interval 0.52 to 0.94; p = 0.02). There was no evidence of a difference in the incidence of adverse events between the two groups. A total of 42 women, 19 in the mifepristone plus misoprostol group and 23 in the placebo plus misoprostol group, took part in an interview. Women appeared to have a preference for active management of their miscarriage. Overall, when women experienced care that supported their psychological well-being throughout the care pathway, and information was delivered in a skilled and sensitive manner such that women felt informed and in control, they were more likely to express satisfaction with medical management. The use of mifepristone and misoprostol showed an absolute effect difference of 6.6% (95% confidence interval 0.7% to 12.5%). The average cost per woman was lower in the mifepristone plus misoprostol group, with a cost saving of £182 (95% confidence interval £26 to £338). Therefore, the use of mifepristone and misoprostol for the medical management of a missed miscarriage dominated the use of misoprostol alone. LIMITATIONS The results from this trial are not generalisable to women diagnosed with incomplete miscarriage and the study does not allow for a comparison with expectant or surgical management of miscarriage. FUTURE WORK Future work should use existing data to assess and rank the relative clinical effectiveness and safety profiles for all methods of management of miscarriage. CONCLUSIONS Our trial showed that pre-treatment with mifepristone followed by misoprostol resulted in a higher rate of resolution of missed miscarriage than misoprostol treatment alone. Women were largely satisfied with medical management of missed miscarriage and would choose it again. The mifepristone and misoprostol intervention was shown to be cost-effective in comparison to misoprostol alone. TRIAL REGISTRATION Current Controlled Trials ISRCTN17405024. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 68. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Adam Devall
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Justin Chu
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Leanne Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Versha Cheed
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yongzhong Sun
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Tracy Roberts
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Chidubem Okeke Ogwulu
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Eleanor Williams
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Laura Jones
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | | | | | - Kim Hinshaw
- Sunderland Royal Hospital, South Tyneside & Sunderland NHS Foundation Trust, Sunderland, UK
| | - Meenakshi Choudhary
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Amna Ahmed
- Sunderland Royal Hospital, South Tyneside & Sunderland NHS Foundation Trust, Sunderland, UK
| | - Joel Naftalin
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Natalie Nunes
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Isleworth, UK
| | - Abigail Oliver
- St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Feras Izzat
- University Hospital Coventry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Kalsang Bhatia
- Burnley General Hospital, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - Ismail Hassan
- Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Yadava Jeve
- Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Judith Hamilton
- Guy's and St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Shilpa Deb
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Cecilia Bottomley
- Chelsea and Westminster Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Jackie Ross
- King's College Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Linda Watkins
- Liverpool Women's Hospital, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Martyn Underwood
- Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | - Ying Cheong
- Department of Reproductive Medicine, University of Southampton, Southampton, UK
| | - Chitra Kumar
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Pratima Gupta
- Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rachel Small
- Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stewart Pringle
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Frances Hodge
- Singleton Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Anupama Shahid
- Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Ioannis Gallos
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Andrew Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Siobhan Quenby
- Biomedical Research Unit in Reproductive Health, University of Warwick, Coventry, UK
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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15
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Okeke Ogwulu CB, Williams EV, Chu JJ, Devall AJ, Beeson LE, Hardy P, Cheed V, Yongzhong S, Jones LL, La Fontaine Papadopoulos JH, Bender-Atik R, Brewin J, Hinshaw K, Choudhary M, Ahmed A, Naftalin J, Nunes N, Oliver A, Izzat F, Bhatia K, Hassan I, Jeve Y, Hamilton J, Debs S, Bottomley C, Ross J, Watkins L, Underwood M, Cheong Y, Kumar CS, Gupta P, Small R, Pringle S, Hodge FS, Shahid A, Horne AW, Quenby S, Gallos ID, Coomarasamy A, Roberts TE. Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial. BJOG 2021; 128:1534-1545. [PMID: 33969614 DOI: 10.1111/1471-0528.16737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. DESIGN Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS). SETTING Twenty-eight UK NHS early pregnancy units. SAMPLE A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage. METHODS Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. MAIN OUTCOME MEASURES Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). RESULTS For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. CONCLUSIONS The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. TWEETABLE ABSTRACT The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.
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Affiliation(s)
- C B Okeke Ogwulu
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - E V Williams
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - J J Chu
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - A J Devall
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - L E Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - P Hardy
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - V Cheed
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - S Yongzhong
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - L L Jones
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - J H La Fontaine Papadopoulos
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | | | - K Hinshaw
- Sunderland Royal Hospital, South Tyneside & Sunderland NHS Foundation Trust, Sunderland, UK
| | - M Choudhary
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - A Ahmed
- Sunderland Royal Hospital, South Tyneside & Sunderland NHS Foundation Trust, Sunderland, UK
| | - J Naftalin
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - N Nunes
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Isleworth, UK
| | - A Oliver
- St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - F Izzat
- University Hospital Coventry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - K Bhatia
- Burnley General Hospital, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - I Hassan
- Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Y Jeve
- Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - J Hamilton
- Guy's and St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - S Debs
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C Bottomley
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - J Ross
- Kings College Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - L Watkins
- Liverpool Women's Hospital, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - M Underwood
- Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | - Y Cheong
- Department of Reproductive Medicine, University of Southampton, Southampton, UK
| | - C S Kumar
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - P Gupta
- Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R Small
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Pringle
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - F S Hodge
- Singleton Hospital, Swansea Bay University Health Board, Swansea, UK
| | - A Shahid
- Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - A W Horne
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - S Quenby
- The Biomedical Research Unit in Reproductive Health, University of Warwick, Warwick, UK
| | - I D Gallos
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - A Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - T E Roberts
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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16
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Ghosh J, Papadopoulou A, Devall AJ, Jeffery HC, Beeson LE, Do V, Price MJ, Tobias A, Tunçalp Ö, Lavelanet A, Gülmezoglu AM, Coomarasamy A, Gallos ID. Methods for managing miscarriage: a network meta-analysis. Cochrane Database Syst Rev 2021; 6:CD012602. [PMID: 34061352 PMCID: PMC8168449 DOI: 10.1002/14651858.cd012602.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option. OBJECTIVES To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods. MAIN RESULTS Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods. AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.
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Affiliation(s)
- Jay Ghosh
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Hannah C Jeffery
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Leanne E Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Vivian Do
- University of Birmingham, Birmingham, UK
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Antonella Lavelanet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
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The burden of the Risk Evaluation and Mitigation Strategy (REMS) on providers and patients experiencing early pregnancy loss: A commentary. Contraception 2021; 104:29-30. [PMID: 33895123 DOI: 10.1016/j.contraception.2021.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 11/22/2022]
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Berkley HH, Greene HL, Wittenberger MD. Mifepristone Combination Therapy Compared With Misoprostol Monotherapy for the Management of Miscarriage: A Cost-Effectiveness Analysis. Obstet Gynecol 2020; 136:774-781. [PMID: 32925621 DOI: 10.1097/aog.0000000000004063] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess whether mifepristone pretreatment adversely affects the cost of medical management of miscarriage. METHODS Decision tree analyses were constructed, and Monte Carlo simulations were run comparing costs of combination therapy (mifepristone and misoprostol) with monotherapy (misoprostol alone) for medical management of miscarriage in multiple scenarios weighing clinical practice, patient income, and surgical evacuation modalities for failed medical management. Rates of completed medical evacuation for each were obtained from a recent randomized controlled trial. RESULTS In every scenario, combination therapy offered a significant cost advantage over monotherapy. Using a Monte Carlo analysis, cost differences favoring combination therapy ranged from 6.3% to 19.5% in patients making federal minimum wage. The cost savings associated with combination therapy were greatest in scenarios using a staged approach to misoprostol administration and in scenarios using in-operating room dilation and curettage as the only modality for uterine evacuation, a savings of $190.20 (99% CI 189.35-191.07) and $217.85 (99% CI 217.19-218.50) per patient in a low-income wage group, respectively. A smaller difference was seen in scenarios using in-office manual vacuum aspiration to complete medical management failures. As patients' wages increased, the difference in cost between combination therapy and monotherapy increased. CONCLUSION Mifepristone combined with misoprostol is, overall, more cost effective than monotherapy, and therefore cost should not be a deterrent to its adoption in the management of miscarriage.
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Affiliation(s)
- Holly H Berkley
- Department of Obstetrics & Gynecology at Naval Medical Center San Diego, San Diego, California; and the Uniformed Services University, Bethesda, Maryland
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Affiliation(s)
- Kurt Barnhart
- The Perelman School of Medicine, University of Pennsylvania, Penn Fertility Care, Philadelphia, PA 19104, USA.
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