Mifepristone pretreatment reduces procedural management, ED visits in early pregnancy loss
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Key takeaways:
- Mifepristone for early pregnancy loss reduced the need for uterine aspiration and subsequent ED visits.
- Data suggest mifepristone remains underutilized for early pregnancy loss.
Women with early pregnancy loss who received misoprostol alone without pretreatment with mifepristone were more likely to receive subsequent procedural management and have visits to the ED, researchers reported.
Pregnancy loss at less than 13 weeks’ gestation is the most common complication of early pregnancy, and recent evidence suggests approximately 10% of U.S. patients with an early pregnancy loss diagnosis receive medication management, Lyndsey S. Benson, MD, MS, an assistant professor in the complex family planning division in the University of Washington Medicine department of obstetrics and gynecology, and colleagues wrote in JAMA Network Open. However, the proportion of patients who were offered their preferred management option is not known.
“Despite updated guidance from the American College of Obstetricians and Gynecologists in 2018, mifepristone remains underutilized for patients with early pregnancy loss,” the researchers wrote. “Mifepristone is highly regulated and there are substantial barriers to its use, in large part due to its use for medication abortion.”
Underutilization of mifepristone
In their retrospective study, researchers analyzed private insurance claims data from 31,977 pregnant women (mean age, 33 years) with an early pregnancy loss diagnosis between October 2015 and December 2022. Researchers reviewed medications used to manage the early pregnancy loss — either mifepristone plus misoprostol or misoprostol alone. Primary outcome was subsequent procedural management (uterine aspiration) and medication management. Other outcomes included hospitalizations and complications during the subsequent 6 weeks after medication management.
Within the cohort, 3% of women received mifepristone pretreatment followed by misoprostol and 97% of women received misoprostol alone. The proportion of women who received both drugs for medication management gradually increased during the study period, from 0.7% in 2015 to 8.6% in 2022. Mifepristone use was higher when the index early pregnancy loss diagnosis occurred in an outpatient setting vs. the ED setting (3.4% vs. 0.9%; P < .001).
“The continued underutilization of mifepristone in the setting of early pregnancy loss is multifactorial, with prior studies identifying multiple barriers to its use, including logistical barriers and uncertainty related to the FDA Risk Evaluation and Mitigation Strategy [REMS] requirements, resistance from institutional leadership and lack of education or prior experience with mifepristone,” the Benson and colleagues wrote.
Researchers found women who received misoprostol with mifepristone pretreatment were less likely to have subsequent uterine aspiration (10.5% vs. 14%; P = .002) and were less likely to have subsequent ED visits related to early pregnancy loss (3.5% vs. 7.9%; P < .001).
Researchers found that combined mifepristone plus misoprostol treatment decreased odds of subsequent procedural management of early pregnancy loss by 29% (adjusted OR = 0.71; 95% CI, 0.57-0.87).
“Continued efforts are needed to reduce barriers to mifepristone use for medication management of early pregnancy loss,” the researchers wrote. “Increasing access to mifepristone for early pregnancy loss management may decrease health care utilization and expenditures.”
Changing patient preferences
In a related editorial published in JAMA Network Open, Sarita Sonalkar, MD, MPH, and Rachel McKean, MD, MPH, both of the division of complex family planning at the University of Pennsylvania Perelman School of Medicine, wrote that a preference for medication management of early pregnancy loss is likely increasing due to an “increased socialization” of medication abortion.
“Compared with procedural management, medication management of early pregnancy loss allows greater control of timing of management, privacy and avoidance of uterine instrumentation,” Sonalkar and McKean wrote. “With the increasing popularity of this management modality, it is essential from both an individual and public health perspective to support strategies that optimize effectiveness and reduce health care utilization. Lifting the REMS restrictions on mifepristone would be a highly effective policy-level strategy to improve these outcomes. Mifepristone has an outstanding safety profile that is not concordant with its level of regulation.”