Mifepristone use low for early pregnancy loss management

Mifepristone use low for early pregnancy loss management | Image Credit: © Carl - © Carl - stock.adobe.com.

Mifepristone is underutilized for the management of early pregnancy loss (EPL), according to a recent study published in JAMA Network Open.¹

EPL is reported in over 1 million US individuals annually, making it the most common complication of early pregnancy. Treatment methods include medication management, expectant management, and procedural management.²

All 3 options have efficacy in patients who are hemodynamically stable, and approximately 10% of these patients use medication management in the United States.¹ This method often includes misoprostol administration with or without mifepristone.

Data has indicated increased efficacy from the use of mifepristone in combination with misoprostol vs misoprostol alone, leading the American College of Obstetricians and Gynecologists to recommend combination therapy in their 2018 guidelines. However, mifepristone use for EPL management remains low.

To evaluate differences in clinical outcomes after EPL management with mifepristone plus misoprostol vs misoprostol alone, investigators conducted a retrospective cohort study. Data of US patients with EPL between October 1, 2015, and December 31, 2022, was obtained from the IBM MarketScan Research Database.

Dates and locations of services, demographic characteristics, diagnosis codes, procedure codes, and medication prescriptions were collected from the database. Patients with a diagnosis of ectopic or molar pregnancy, induced abortion, or stillbirth, as well as those with recent EPL management, were excluded from the analysis.

Mifepristone use alongside misoprostol vs misoprostol use alone was the primary exposure. Covariates included age, encounter years, US geographic region, metropolitan statistical area status, location of service, and insurance policy status.

The need for subsequent procedural management, return visits to clinic settings, hospitalizations, and complications within 6 weeks following EPL diagnosis were reported as primary outcomes. These outcomes were determined based on International Classification of Diseases, Tenth Revision, Clinical Modification codes.

There were 31,977 individuals aged a mean 32.7 years with medication management after an EPL diagnosis. The rate of mifepristone plus misoprostol use was 0.7% in 2015 and 8.6% in 2022, with mifepristone use more common in patients who were older, in urban settings, and in the Northeast and West.

Missed abortion was reported in 72.3% of patients, spontaneous abortion in 26.9%, and both in 0.8%. Mifepristone was used by 3.3% of patients with a missed abortion and 2.5% with a spontaneous abortion.

Most patients received their initial EPL diagnosis in an outpatient setting, with these patients having a higher prevalence of mifepristone use than those diagnosed at an emergency department or other setting. Subsequent procedural management increased from misoprostol only use vs mifepristone inclusion, at 14% vs 10.5%, respectively.

The odds of EPL-related care were 7.1% among patients with an initial EPL diagnosis in the outpatient clinic using misoprostol only vs 3.1% for patients in this setting using mifepristone. Low complication rates of 0.9 in the misoprostol-only group and 0.4% in the mifepristone plus misoprostol group were reported.

An adjusted odds ratio (AOR) of 0.71 was reported for subsequent procedural management after mifepristone use, indicating a decreased risk. An initial visit in the emergency department and being a dependent policy holder were also linked to reduced risks, with AORs of 0.62 and 0.81, respectively.

These results indicated underutilization of mifepristone for EPL management despite the reduced odds of requiring additional care. Investigators concluded additional efforts are needed to reduce barriers to mifepristone use as medication management of EPL.

References

1. Benson LS, Gunaje N, Holt SK, Gore JL, Dalton VK. Outcomes after early pregnancy loss management with mifepristone plus misoprostol vs misoprostol alone. JAMA Netw Open. 2024;7(10):e2435906. doi:10.1001/jamanetworkopen.2024.35906
2. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 200: early pregnancy loss.Obstet Gynecol. 2018;132(5):e197-e207. doi:10.1097/AOG.0000000000002899