Since November 2018, the American College of Obstetricians and Gynecologists has recommended a combination of two drugs for pregnant women who have a miscarriage before 13 weeks of gestation.
According to a Vanderbilt University Medical Center study published in JAMA, only 1% of 22,116 commercially insured women ages 15-49 with medically managed miscarriages received the recommended combination of mifepristone, a progesterone blocker, and misoprostol, a synthetic lipid compound that causes contractions, between Jan. 1, 2016, and Dec. 31, 2020, while 99% received misoprostol, which is the less effective option.
“The combination treatment is both more effective in removing the miscarriage pregnancy tissue and more cost-effective than misoprostol alone,” said Ashley Leech, PhD, MS, assistant professor of Health Policy and co-author of the study. “However, mifepristone is highly regulated, which dissuades clinicians from stocking and using it.”
According to the study, most women are receiving ineffective miscarriage management in the U.S., though the numbers of women receiving the combination protocol have increased slightly over time.
“Due to the growing divide of reproductive health care in the U.S., the availability issues surrounding mifepristone might only get worse,” Leech said. “When women don’t receive the most effective care for miscarriage management, this could result in additional medical visits or undesired surgical procedures to remove the pregnancy tissue. This not only imposes considerable financial burden to our already constrained health care system, but more importantly, it poses risks to the patient and negatively impacts women’s health outcomes.”
When a miscarriage is detected before the body expels the tissue, most first-trimester patients have three options: have a procedure; manage it medically (as in this study); or allow the body to recognize the loss, which could take up to eight weeks.
“The loss of a pregnancy can be a very emotional and vulnerable time for many people,” said Elise Boos, MD, MSc, assistant professor of Clinical Obstetrics and Gynecology and lead author of the study. “When a patient chooses one form of management over another, they do so for a reason, and that autonomy is important. As clinicians, we should be doing everything in our power to optimize a safe and successful outcome for our patients.
“Our study highlights that many people undergoing medical management of miscarriage are not receiving the most effective medications and thus will require additional visits, unscheduled procedures, and a prolongation of the miscarriage process. We owe our patients only the evidenced-based care,” Boos said.
This research was supported by the National Institutes of Health (grant DA050740) and a pilot award from the Department of Obstetrics and Gynecology at VUMC.