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Hamel CC, Vart P, Vandenbussche FPHA, Braat DDM, Snijders MPLM, Coppus SFPJ. Predicting the likelihood of successful medical treatment of early pregnancy loss: development and internal validation of a clinical prediction model. Hum Reprod 2022; 37:936-946. [PMID: 35333346 PMCID: PMC9071219 DOI: 10.1093/humrep/deac048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 02/19/2022] [Indexed: 11/26/2022] Open
Abstract
STUDY QUESTION What are clinical predictors for successful medical treatment in case of early pregnancy loss (EPL)? SUMMARY ANSWER Use of mifepristone, BMI, number of previous uterine aspirations and the presence of minor clinical symptoms (slight vaginal bleeding or some abdominal cramps) at treatment start are predictors for successful medical treatment in case of EPL. WHAT IS KNOWN ALREADY Success rates of medical treatment for EPL vary strongly, between but also within different treatment regimens. Up until now, although some predictors have been identified, no clinical prediction model has been developed yet. STUDY DESIGN, SIZE, DURATION Secondary analysis of a multicentre randomized controlled trial in 17 Dutch hospitals, executed between 28 June 2018 and 8 January 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS Women with a non-viable pregnancy between 6 and 14 weeks of gestational age, who opted for medical treatment after a minimum of 1 week of unsuccessful expectant management. Potential predictors for successful medical treatment of EPL were chosen based on literature and expert opinions. We internally validated the prediction model using bootstrapping techniques. MAIN RESULTS AND THE ROLE OF CHANCE 237 out of 344 women had a successful medical EPL treatment (68.9%). The model includes the following variables: use of mifepristone, BMI, number of previous uterine aspirations and the presence of minor clinical symptoms (slight vaginal bleeding or some abdominal cramps) at treatment start. The model shows a moderate capacity to discriminate between success and failure of treatment, with an AUC of 67.6% (95% CI = 64.9-70.3%). The model had a good fit comparing predicted to observed probabilities of success but might underestimate treatment success in women with a predicted probability of success of ∼70%. LIMITATIONS, REASONS FOR CAUTION The vast majority (90.4%) of women were Caucasian, potentially leading to less optimal model performance in a non-Caucasian population. Limitations of our model are that we have not yet been able to externally validate its performance and clinical impact, and the moderate accuracy of the prediction model of 0.67. WIDER IMPLICATIONS OF THE FINDINGS We developed a prediction model, aimed to improve and personalize counselling for medical treatment of EPL by providing a woman with her individual chance of complete evacuation. STUDY FUNDING/COMPETING INTEREST(S) The Triple M Trial, upon which this secondary analysis was performed, was funded by the Healthcare Insurers Innovation Foundation (project number 3080 B15-191). TRIAL REGISTRATION NUMBER Clinicaltrials.gov: NCT03212352.
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Affiliation(s)
- C C Hamel
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - P Vart
- Faculty of Medical Sciences, University Medical Centre Groningen, Groningen, the Netherlands
| | - F P H A Vandenbussche
- Department of Obstetrics and Gynaecology, Helios Klinikum Duisburg, Duisburg, Germany
| | - D D M Braat
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - M P L M Snijders
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - S F P J Coppus
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, the Netherlands
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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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Hamel C, Coppus S, van den Berg J, Hink E, van Seeters J, van Kesteren P, Merién A, Torrenga B, van de Laar R, Terwisscha van Scheltinga J, Gaugler-Senden I, Graziosi P, van Rumste M, Nelissen E, Vandenbussche F, Snijders M. Mifepristone followed by misoprostol compared with placebo followed by misoprostol as medical treatment for early pregnancy loss (the Triple M trial): A double-blind placebo-controlled randomised trial. EClinicalMedicine 2021; 32:100716. [PMID: 33681738 PMCID: PMC7910666 DOI: 10.1016/j.eclinm.2020.100716] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Worldwide, millions of women seek treatment for early pregnancy loss (EPL) annually. Medical management with misoprostol is widely used, but only effective 60% of the time. Pre-treatment with mifepristone prior to misoprostol might improve the success rate of medical management. METHODS This was a multi-centre, double-blind, placebo-controlled randomised trial in 17 Dutch hospitals. Women with a non-viable pregnancy between 6 and 14 weeks of gestation were eligible for inclusion after at least one week of expectant management. Participants were randomised (1:1) between oral mifepristone 600 mg or an oral placebo tablet. Participants took 400 μg misoprostol orally, repeated after four hours on day two and, if necessary, day three. Primary outcome was expulsion of gestational sac and endometrial thickness <15 mm after 6-8 weeks. Analyses were done according to intention-to-treat principles. This trial is registered with ClinicalTrials.gov, NCT03212352. FINDINGS Between June 28th 2018 and January 8th 2020, 175 women were randomised to mifepristone and 176 to placebo, including 344 in the intention-to-treat analysis. In the mifepristone group 136 (79•1%) of 172 participants reached complete evacuation compared to 101 (58•7%) of 172 participants in the placebo group (p<0•0001, RR 1•35, 95% CI 1•16-1•56). Incidence of serious adverse events was significantly lower in the mifepristone group with 24 (14%) patients affected versus 55 (32%) in the placebo group (p = 0•0005) (Table 3). INTERPRETATION Pre-treatment with mifepristone prior to misoprostol was more effective than misoprostol alone in managing EPL. FUNDING Healthcare Insurers Innovation Foundation, Radboud University Medical Centre, Canisius Wilhelmina Hospital.
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Affiliation(s)
- Charlotte Hamel
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
- Department of Obstetrics and Gynaecology, Radboud university medical centre, Nijmegen, the Netherlands
| | - Sjors Coppus
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, the Netherlands
| | - Joyce van den Berg
- Department of Obstetrics and Gynaecology, Gelderse Vallei Hospital, Ede, the Netherlands
| | - Esther Hink
- Department of Obstetrics and Gynaecology, Radboud university medical centre, Nijmegen, the Netherlands
| | - Jacoba van Seeters
- Department of Obstetrics and Gynaecology, Amphia Hospital, Breda, the Netherlands
| | | | - Ashley Merién
- Department of Obstetrics and Gynaecology, Rijnstate, Arnhem, the Netherlands
| | - Bas Torrenga
- Department of Obstetrics and Gynaecology, Ikazia Hospital, the Netherlands
| | - Rafli van de Laar
- Department of Obstetrics and Gynaecology, Vie Curi Medical Centre, the Netherlands
| | | | - Ingrid Gaugler-Senden
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, the Netherlands
| | - Peppino Graziosi
- Department of Obstetrics and Gynaecology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Minouche van Rumste
- Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven, the Netherlands
| | - Ewka Nelissen
- Department of Obstetrics and Gynaecology, Laurentius Hospital, Roermond, the Netherlands
| | - Frank Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud university medical centre, Nijmegen, the Netherlands
- Department of Obstetrics and Gynaecology, Helios Klinikum Duisburg, Duisburg, Germany
| | - Marcus Snijders
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
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Chu JJ, Devall AJ, Beeson LE, Hardy P, Cheed V, Sun Y, Roberts TE, Ogwulu CO, Williams E, 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, Deb S, Bottomley C, Ross J, Watkins L, Underwood M, Cheong Y, Kumar CS, Gupta P, Small R, Pringle S, Hodge F, Shahid A, Gallos ID, Horne AW, Quenby S, Coomarasamy A. Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial. Lancet 2020; 396:770-778. [PMID: 32853559 PMCID: PMC7493715 DOI: 10.1016/s0140-6736(20)31788-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 07/24/2020] [Accepted: 08/06/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The anti-progesterone drug mifepristone and the prostaglandin misoprostol can be used to treat missed miscarriage. However, it is unclear whether a combination of mifepristone and misoprostol is more effective than administering misoprostol alone. We investigated whether treatment with mifepristone plus misoprostol would result in a higher rate of completion of missed miscarriage compared with misoprostol alone. METHODS MifeMiso was a multicentre, double-blind, placebo-controlled, randomised trial in 28 UK hospitals. Women were eligible for enrolment if they were aged 16 years and older, diagnosed with a missed miscarriage by pelvic ultrasound scan in the first 14 weeks of pregnancy, chose to have medical management of miscarriage, and were willing and able to give informed consent. Participants were randomly assigned (1:1) to a single dose of oral mifepristone 200 mg or an oral placebo tablet, both followed by a single dose of vaginal, oral, or sublingual misoprostol 800 μg 2 days later. Randomisation was managed via a secure web-based randomisation program, with minimisation to balance study group assignments according to maternal age (<30 years vs ≥30 years), body-mass index (<35 kg/m2vs ≥35 kg/m2), previous parity (nulliparous women vs parous women), gestational age (<70 days vs ≥70 days), amount of bleeding (Pictorial Blood Assessment Chart score; ≤2 vs ≥3), and randomising centre. Participants, clinicians, pharmacists, trial nurses, and midwives were masked to study group assignment throughout the trial. The primary outcome was failure to spontaneously pass the gestational sac within 7 days after random assignment. Primary analyses were done according to intention-to-treat principles. The trial is registered with the ISRCTN registry, ISRCTN17405024. FINDINGS Between Oct 3, 2017, and July 22, 2019, 2595 women were identified as being eligible for the MifeMiso trial. 711 women were randomly assigned to receive either mifepristone and misoprostol (357 women) or placebo and misoprostol (354 women). 696 (98%) of 711 women had available data for the primary outcome. 59 (17%) of 348 women in the mifepristone plus misoprostol group did not pass the gestational sac spontaneously within 7 days versus 82 (24%) of 348 women in the placebo plus misoprostol group (risk ratio [RR] 0·73, 95% CI 0·54-0·99; p=0·043). 62 (17%) of 355 women in the mifepristone plus misoprostol group required surgical intervention to complete the miscarriage versus 87 (25%) of 353 women in the placebo plus misoprostol group (0·71, 0·53-0·95; p=0·021). We found no difference in incidence of adverse events between the study groups. INTERPRETATION Treatment with mifepristone plus misoprostol was more effective than misoprostol alone in the management of missed miscarriage. Women with missed miscarriage should be offered mifepristone pretreatment before misoprostol to increase the chance of successful miscarriage management, while reducing the need for miscarriage surgery. FUNDING UK National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Justin J Chu
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
| | - Leanne E Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Pollyanna Hardy
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, 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 E Roberts
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - C 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 L Jones
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | | | | | - Kim Hinshaw
- Sunderland Royal Hospital, South Tyneside and 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 and 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 NHS Foundation Trust, London, 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
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jackie Ross
- Kings 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 NHS Trust, Telford, UK
| | - Ying Cheong
- Department of Reproductive Medicine, University of Southampton, Southampton, 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
| | | | - Frances Hodge
- Singleton Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Anupama Shahid
- Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Ioannis D Gallos
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Andrew W Horne
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Siobhan Quenby
- Biomedical Research Unit in Reproductive Health, University of Warwick, Warwick, UK
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Ehrnstén L, Altman D, Ljungblad A, Kopp Kallner H. Efficacy of mifepristone and misoprostol for medical treatment of missed miscarriage in clinical practice—A cohort study. Acta Obstet Gynecol Scand 2020; 99:488-493. [DOI: 10.1111/aogs.13780] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Lisa Ehrnstén
- Department of Clinical Sciences Danderyd Hospital Karolinska Institutet Stockholm Sweden
- Stockholm Urogyn Clinic Solna Sweden
| | - Daniel Altman
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Anton Ljungblad
- Gynecology and Surgery Sophiahemmet Hospital Stockholm Sweden
| | - Helena Kopp Kallner
- Department of Clinical Sciences Danderyd Hospital Karolinska Institutet Stockholm Sweden
- Stockholm Urogyn Clinic Solna Sweden
- Department of Obstetrics and Gynecology Danderyd Hospital Stockholm Sweden
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van den Berg J, Hamel CC, Snijders MP, Coppus SF, Vandenbussche FP. Mifepristone and misoprostol versus misoprostol alone for uterine evacuation after early pregnancy failure: study protocol for a randomized double blinded placebo-controlled comparison (Triple M Trial). BMC Pregnancy Childbirth 2019; 19:443. [PMID: 31775677 PMCID: PMC6880504 DOI: 10.1186/s12884-019-2497-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/09/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Early pregnancy failure (EPF) is a common complication of pregnancy. If women do not abort spontaneously, they will undergo medical or surgical treatment in order to remove the products of conception from the uterus. Curettage, although highly effective, is associated with a risk of complications; medical treatment with misoprostol is a safe and less expensive alternative. Unfortunately, after 1 week of expectant management in case of EPF, medical treatment with misoprostol has a complete evacuation rate of approximately 50%. Misoprostol treatment results may be improved by pre-treatment with mifepristone; its effectiveness has already been proven for other indications of pregnancy termination. This study will test the hypothesis that, in EPF, the sequential combination of mifepristone with misoprostol is superior to the use of misoprostol alone in terms of complete evacuation (primary outcome), patient satisfaction, complications, side effects and costs (secondary outcomes). METHODS The trial will be performed multi-centred, prospectively, two-armed, randomised, double-blinded and placebo-controlled. Women with confirmed EPF by ultrasonography (6-14 weeks), managed expectantly for at least 1 week, can be included and randomised to pre-treatment with oral mifepristone (600 mg) or oral placebo (identical in appearance). Randomisation will take place after receiving written consent to participate. In both arms pre-treatment will be followed by oral misoprostol, which will start 36-48 h later consisting of two doses 400 μg (4 hrs apart), repeated after 24 h if no tissue is lost. Four hundred sixty-four women will be randomised in a 1:1 ratio, stratified by centre. Ultrasonography 2 weeks after treatment will determine short term treatment effect. When the gestational sac is expulsed, expectant management is advised until 6 weeks after treatment when the definitive primary endpoint, complete or incomplete evacuation, will be determined. A sonographic endometrial thickness < 15 mm using only the allocated therapy by randomisation is considered as successful treatment. Secondary outcome measures (patient satisfaction, complications, side effects and costs) will be registered using a case report form, patient diary and validated questionnaires (Short Form 36, EuroQol-VAS, Client Satisfaction Questionnaire, iMTA Productivity Cost Questionnaire). DISCUSSION This trial will answer the question if, in case of EPF, after at least 1 week of expectant management, sequential treatment with mifepristone and misoprostol is more effective than misoprostol alone to achieve complete evacuation of the products of conception. TRIAL REGISTRATION Clinicaltrials.gov (d.d. 02-07-2017): NCT03212352. Trialregister.nl (d.d. 03-07-2017): NTR6550. EudraCT number (d.d. 07-08-2017): 2017-002694-19. File number Commisie Mensgebonden Onderzoek (d.d. 07-08-2017): NL 62449.091.17.
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Affiliation(s)
- Joyce van den Berg
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
| | - Charlotte C. Hamel
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, GA 6525 The Netherlands
| | - Marcus P. Snijders
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
| | - Sjors F. Coppus
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, De Run 4600, Veldhoven, DB 5504 The Netherlands
| | - Frank P. Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, GA 6525 The Netherlands
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van den Berg J, Hamel CC, Coppus SF, Snijders MP, Vandenbussche FP. Current and future expectations of mifepristone treatment in early pregnancy failure: a survey among Dutch gynaecologists. J OBSTET GYNAECOL 2019; 39:1006-1011. [PMID: 31215270 DOI: 10.1080/01443615.2019.1602598] [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: 10/26/2022]
Abstract
To investigate the current and future addition of mifepristone to misoprostol treatment in case of early pregnancy failure (EPF), a digital questionnaire was distributed to a representative sample of all Dutch hospitals (25/79). In non-teaching centres, the presence of a local protocol was significantly lower compared to academic and teaching hospitals (p=.012). If a local protocol was present, the first choice of treatment was medical in 54.5%. Four respondents (16%) always prescribed mifepristone in case of EPF. The most common reason not prescribing mifepristone was the lack of sufficient scientific evidence. An average increase in success rate of 21.7% was desired to prescribe mifepristone in the future for EPF. Completeness of evacuation of products of conception from the uterus was usually assessed after 1 week by ultrasonography combined with clinical signs. If a complete evacuation was not achieved by the initial medical treatment, expectant management was proposed just as often as surgical intervention. Impact Statement What is already known on this subject? In case of early pregnancy failure (EPF), women can choose from both expectant medical (misoprostol, whether or not combined with mifepristone) and surgical (D and C) treatment. In The Netherlands, a national guideline concerning the treatment of EPF is still lacking. A questionnaire performed by Verschoor et al. ( 2014 ) showed there was a large practice variety between Dutch clinics. What the results of this study add? In this study, a representative sample of all Dutch clinics received a questionnaire about the treatment of EPF. The results confirm a large practice variation regarding treatment of EPF. The first choice of treatment, the medical treatment regimen, and the assessment of whether or not the treatment have been variations of successful between clinics. With regards to the addition of mifepristone to the medical treatment regime with misoprostol, gynaecologists are willing to consider mifepristone if an improvement of efficacy of approximately 20% is scientifically proven. What the implications are of these findings for clinical practice and/or further research? In our opinion, these results emphasise the need for a national guideline concerning the treatment of EPF. Our results also demonstrate that, if the addition of mifepristone to medical treatment with misoprostol proves to be more efficient than misoprostol alone, gynaecologists are willing to prescribe mifepristone in the future. Whether the addition is indeed more effective than misoprostol alone, will be the subject of a multicentre, double-blind, placebo-controlled randomised controlled trial, planned to begin in the first half of 2018.
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Affiliation(s)
- Joyce van den Berg
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital , Nijmegen , The Netherlands
| | - Charlotte C Hamel
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital , Nijmegen , The Netherlands
| | - Sjors F Coppus
- Department of Obstetrics and Gynaecology, Maxima Medical Centre , Eindhoven , The Netherlands
| | - Marcus P Snijders
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital , Nijmegen , The Netherlands
| | - Frank P Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre , Nijmegen , The Netherlands
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Dimitrijevic A. Drug Methods for Arteficial Termination of Unwanted Pregnancy. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2018. [DOI: 10.1515/sjecr-2016-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractAll medical and surgical procedures are carried out in order to premature termnination of pregnancy, can be divided on medicament and surgical methods, according to the way of procedure.Medications used today in order to break unwanted pregnancy are inhibitors of the synthetics of progesterone and antiprogesterone, prostaglandini and antimetabolite.Mifepristone is a derivate of norethidrone, binds to the progesterone receptor with an affinity similar progesterone, but it does not activate them so as to act as an antiprogestine.Metotrexat is an antimetabolite and is used in gynecology practice for more indication areas. It is used the most often in conservative treatment of ectopical pregnancy. Because of low price and accessibility in order to mifepristone, it was used for application in drug methods of inducative abortions.Misoprostol is an anlogue PGE1, used in peroral pills.The complication are very rare at aplication of mifepristone and misoprostole in the aim to the termination the early unwanted pregnancy. The appearance of more efficient procedure of drugs called out abortions, it does not mean taht decision for the abortion is more modest. The ease and safety should not help to make a decision.
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Affiliation(s)
- Aleksandra Dimitrijevic
- Clinic of Obstetrics and Gynaecology, Clinical Center Kragujevac
- Department of Ginecology and Obstetrics Faculty of Medical Sciences , University of Kragujevac
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Dunford A, Fyfe R. Combination therapy with mifepristone and misoprostol for the management of first trimester miscarriage: Improved success. Aust N Z J Obstet Gynaecol 2017; 58:438-442. [DOI: 10.1111/ajo.12747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 10/12/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Angela Dunford
- Division of Obstetrics and Gynaecology; John Hunter Hospital; Newcastle NSW Australia
- Department of Gynaecology; The Royal Children's Hospital Melbourne; Vic Australia
| | - Rina Fyfe
- Division of Obstetrics and Gynaecology; John Hunter Hospital; Newcastle NSW Australia
- Maternal and Fetal Medicine Unit; Royal Prince Alfred Hospital; Sydney NSW Australia
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Sinha P, Suneja A, Guleria K, Aggarwal R, Vaid NB. Comparison of Mifepristone Followed by Misoprostol with Misoprostol Alone for Treatment of Early Pregnancy Failure: A Randomized Double-Blind Placebo-Controlled Trial. J Obstet Gynaecol India 2017; 68:39-44. [PMID: 29391674 DOI: 10.1007/s13224-017-0992-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 04/07/2017] [Indexed: 12/01/2022] Open
Abstract
Objective To compare the efficacy and safety of mifepristone followed by misoprostol with misoprostol alone in the management of early pregnancy failure (EPF). Study Design A randomized double-blind placebo-controlled clinical trial. Methods Ninety-two women with EPF ≤12 weeks were recruited and randomly allocated to receive either mifepristone 200 mg (n = 46) or placebo (n = 46). Forty-eight hours later, patients in both the groups were given 800 µg misoprostol per-vaginum. If no expulsion occurred within 4 h, repeat doses of 400 µg misoprostol were given orally at 3-hourly interval to a maximum of 2 doses in women ≤9 weeks by scan and 4 doses in women >9 weeks by scan. Results Pre-treatment of misoprostol with mifepristone significantly increased the complete abortion rate (86.7 vs. 57.8%, p = 0.009) and, hence, reduced the need for surgical evacuation (13.3 vs. 42.2%, p = 0.002), induction to expulsion interval (4.74 ± 2.24 vs. 8.03 ± 2.77 h, p = 0.000), mean number of additional doses of misoprostol required (0.68 vs. 1.91, p = 0.000), and side effects. Conclusion Use of mifepristone prior to misoprostol in EPF significantly improves the efficacy and reduces the side effects of misoprostol alone.
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Affiliation(s)
- Priya Sinha
- 1Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
| | - Amita Suneja
- 1Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
| | - Kiran Guleria
- 1Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
| | - Richa Aggarwal
- 1Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India.,KL-99, Kavi Nagar, Ghaziabad, Uttar Pradesh India
| | - Neelam B Vaid
- 1Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
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van den Berg J, Gordon BB, Snijders MP, Vandenbussche FP, Coppus SF. The added value of mifepristone to non-surgical treatment regimens for uterine evacuation in case of early pregnancy failure: a systematic review of the literature. Eur J Obstet Gynecol Reprod Biol 2015; 195:18-26. [DOI: 10.1016/j.ejogrb.2015.09.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/15/2015] [Accepted: 09/17/2015] [Indexed: 11/15/2022]
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