Management Of Early Pregnancy Loss Research Articles

Medical management of early pregnancy loss with mifepristone and misoprostol in emergency departments compared to a Complex Family Planning office: Implementation of a COVID-19 institutional policy change

ObjectivesTo evaluate the implementation of mifepristone and misoprostol for medical management of early pregnancy loss (EPL) in emergency departments (EDs) by comparing efficacy, complication, and follow-up rates for patients treated in EDs to those in the Complex Family Planning (CFP) outpatient office. Study DesignIn COVID-19's first wave, we expanded medication management of EPL to our EDs. This retrospective study evaluated 72 patients receiving mifepristone and misoprostol for EPL from 4/1/2020-3/31/2021, comparing treatment success, safety outcomes, and follow-up rates by location. We did not perform a power calculation. ResultsThirty-three (46%) patients received care in the ED and 39 (54%) at CFP. Treatment success was lower in the ED (23, 70%) compared to CFP (34, 87.2%), but after adjusting for insurance status and type of pregnancy (miscarriage, uncertain viability, unknown location) this was not significant: aOR 0.48 (95%CI 0.13-1.81), p=0.28. More ED patients underwent emergent interventions (3 vs 0). Complications in the ED cohort included two emergent uterine aspirations, one uterine artery embolization, and two blood transfusions. Among these, two cases were attributed to misdiagnosis (a cesarean scar and a cervical ectopic pregnancy interpreted as incomplete miscarriages) and one to guideline nonadherence (anticoagulated patient). No complications occurred in the CFP group. Follow-up rates were over 80% in both groups. More ED patients engaged in telehealth follow-up (67% vs 18.0%, p≤0.0001). ConclusionsIn this small sample, we observed a trend toward lower rates of treatment success following medication management of EPL in the ED, compared to the CFP office. This analysis highlights that both correctly making uncommon diagnoses and adhering to new guidelines presented challenges during our implementation process. IMPLICATIONSImplementing mifepristone and misoprostol for EPL in our EDs achieved lower rates of pregnancy resolution compared to outpatient management. Complex uncommon diagnoses and implementing new care pathways in EDs may have contributed to complications and highlight opportunities for improvement. Additional studies are needed to further quantify safety outcomes for EPL management in EDs. TWEETABLE ABSTRACTED provision of mifepristone and misoprostol for early pregnancy loss during COVID-19 was less effective than outpatient care. There were more serious complications in the ED group due to misdiagnosis and guideline nonadherence.

The Effect of a Simulation-based Intervention on Emergency Medicine Resident Management of Early Pregnancy Loss.

The evaluation of patients with first-trimester vaginal bleeding and concern for early pregnancy loss (EPL) frequently occurs in the emergency department (ED), accounting for approximately 1.6% of all ED visits.1 Unfortunately, these patients consistently report negative experiences with ED care.2-8 In addition to environmental concerns, such as long wait times, patients often describe negative interactions with staff, including a perceived lack of empathy, the use of insensitive language, and inadequate counseling.2,3 These patients and their partners often view EPL as a traumatic loss of life and commonly experience prolonged grief reactions, including anxiety and depression.9-11 Poor satisfaction with care has been associated with worse mental health outcomes.12 These complaints represent an important opportunity for improvement in emergency medicine (EM) training.13 While no published literature to date describes the performance of EM residents in managing patients presenting with EPL, studies suggest that even obstetrics and gynecology (OB/GYN) residents find these interactions challenging.14,15 Simulation- and didactic-based training has been shown to be beneficial in improving OB/GYN resident EPL counseling and has been associated with improved patient outcomes.16 To our knowledge, this has yet to be replicated in EM residency training. We aimed to develop and evaluate a simulation-based educational intervention to improve EM resident management of patients presenting with EPL.

Geographic Access to Early Pregnancy Loss Management.

Early pregnancy loss (EPL) is common, but patients face barriers to the most effective medication (mifepristone followed by misoprostol) and procedural (uterine aspiration) management options. This cross-sectional geospatial analysis evaluated access in New Mexico to mifepristone and misoprostol and uterine aspiration in emergency departments (comprehensive) and to uterine aspiration anywhere in a hospital (aspiration) for EPL. Access was defined as a 60-minute car commute. We collected data from hospital key informants and public databases and performed logistical regression to evaluate associations between access and rurality, area deprivation, race, and ethnicity. Thirty-five of 42 (83.3%) hospitals responded between October 2020 and August 2021. Two hospitals (5.7%) provided comprehensive management; 24 (68.6%) provided aspiration. Rural and higher deprivation areas had statistically significantly lower adjusted odds ratios for comprehensive management (0.03-0.07 and 0.3-0.4, respectively) and aspiration (0.03-0.06 and 0.1-0.3, respectively) access. Mifepristone and uterine aspiration implementation would address disparate access to EPL treatment.

Retrospective cohort study comparing success of medical management of early pregnancy loss in pregnancies conceived with and without medical assistance

To compare the success rates of medical management using a combined mifepristone and misoprostol protocol in cases of early pregnancy loss (EPL) between women who conceived without medical assistance and those who conceived through invitro fertilization (IVF), after fresh or frozen embryo transfer, and evaluate for the predictive factors of success, time to first passage of tissue, and time to complete resolution of pregnancy. Retrospective cohort study. University hospital. Women who presented with EPL below 13 weeks of gestation between June 2013 and July 2021 who were managed medically with mifepristone 200 mg orally and misoprostol 800 mcg vaginally were included in the study. Medical management with mifepristone and misoprostol; conception without medical assistance vs. post-IVF, after fresh or frozen embryo transfer. We evaluated overall success and performed subgroup analysis according to the mode of conception and compared fresh vs. frozen-thawed embryo transfers for IVF pregnancies. In all groups, we also calculated success according to gestational age and compared the time to first passage of tissue. The potential predictive factors of treatment success were analyzed. The side effects and complications of treatment were recorded. A total of 930 women were included in the study, 99 (11%) of whom achieved pregnancy after IVF. The overall success of medical treatment was 89% with no statistically significant difference according to the mode of conception (89% vs. 89%) or type of transfer (fresh 89% vs. frozen 89%). Only lower gestational age by sonography was independently predictive of treatment success, showing a negative regression coefficient of β = -0.333 and an odds ratio of 0.717. The mean time to first passage of tissue was 5.0 ± 2.1 hours. Altogether, 666 women (72%) showed pregnancy resolution on the day of medication administration, an additional 110 women at 1-week follow-up, and a further 74 women after ≥4 weeks on ultrasound. Medical management of EPL with mifepristone and misoprostol is a highly successful treatment option that results in completed abortion in a timely fashion in both pregnancies conceived without medical assistance and those conceived after IVF.

Early pregnancy loss medical management in clinical practice

ObjectivesThis study aimed to review clinical practice outcomes of early pregnancy loss (EPL) medical management using mifepristone and misoprostol outside of a clinical trial setting. Study designIn this retrospective cohort study, we reviewed a deidentified database of patients who received mifepristone-misoprostol for EPL from May 2018 to May 2021 at our academic center–based clinic, which was a study site for a multicenter mifepristone-misoprostol EPL trial completed in March 2018. All patients received mifepristone 200 mg orally and misoprostol 800 mcg vaginally or buccally, with clinic follow-up typically scheduled within 1 week. The primary outcome was successful medical management, defined as management without the need for aspiration, and the secondary outcomes included additional interventions and indications, follow-up ultrasonography findings, and adverse events requiring treatment. ResultsWe treated 90 patients with a median ultrasound-measured gestational size of 49 (range 30–80) days and median time from mifepristone to misoprostol of 24 (range 8–66) hours. Follow-up was completed in clinic by 80 (88.9%), completed remotely by five (5.6%), and not completed by five (5.6%) patients. Overall, 76 (95% CI 82.9%–96.0%) of 85 patients (89.4%) with follow-up were successfully managed without uterine aspiration. Eighty patients had initial follow-up ultrasonography interpreted as gestational sac expulsion; seven (8.8%) of these ultimately underwent aspiration, including one patient who had a previously undiagnosed cesarean scar ectopic pregnancy. Two patients had significant safety outcomes: one pelvic infection and one blood transfusion during aspiration in the patient with a cesarean scar ectopic pregnancy. ConclusionsOutside of a clinical trial setting, medical management of EPL with mifepristone and misoprostol remains effective and safe. ImplicationsMedical management of EPL with mifepristone and misoprostol is effective and safe outside of a clinical trial setting. A standardized protocol based on the best available clinical trial evidence can be used in clinical practice for the medical management of EPL.

Trends in the Use of Mifepristone for Medical Management of Early Pregnancy Loss From 2016 to 2020

This study assesses the use of mifepristone plus misoprostol for miscarriage management among commercially insured adults in the US.

Management of early pregnancy loss among obstetrician-gynecologists in Massachusetts and barriers to mifepristone use

ObjectivesTo 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 designWe 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. Results198 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%). ConclusionsMany 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. ImplicationsHalf 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.

EE410 The Insurance Payer Perspective on Management Options for Early Pregnancy Loss in the United States

Vacuum aspiration is the current standard for surgical management of early pregnancy loss (EPL). Traditionally performed in a hospital, no reductions in efficacy and safety have been reported for lower-acuity settings. We analyzed how shifting the site of service for surgical management of EPL might impact payer budgets.

Evaluation of a decision aid for early pregnancy loss: A pilot randomized controlled trial in Philadelphia, Pennsylvania

ObjectivesTo evaluate the effect of a decision aid on decisional conflict scale in patients choosing management for early pregnancy loss. Study designWe conducted a pilot randomized control trial to assess the effect of the Healthwise patient decision aid on decisional conflict scale in patients with early pregnancy loss as compared with a control website. Patients 18years and older were eligible if they had an early pregnancy loss between 5 and 12 completed weeks of gestation. Participants completed surveys at baseline, poststudy intervention, after consultation, and 1week postconsultation. Surveys assessed participant scores on the decisional conflict scale (scale 0–100), knowledge, assessment of shared decision-making, satisfaction, and decision regret. Our primary outcome was the poststudy-intervention decisional conflict scale score. ResultsFrom July 2020 through March 2021 we randomized 60 participants. After the intervention, the median decisional conflict scale score for the control group was 10 [0–30] and 0 [0–20] for the intervention group (p = 0.17). When assessing the decisional conflict scale subscales postintervention, the informed subscale for the control group was 16.7 [0–33.3] as opposed to 0 [0] for the patient decision aid group (p = 0.003). Knowledge remained significantly higher in the experimental arm from the postintervention to the 1-week follow-up. We found no differences between groups when assessing our other metrics. ConclusionsUse of a validated decision aid did not result in statistically significant differences in the total decisional conflict scale scores as compared with the control. Participants allocated to the intervention were more informed postintervention and had consistently higher knowledge scores. ImplicationsUse of a validated decision aid prior to early pregnancy loss management consultation did not affect overall decisional conflict but resulted in improved knowledge.

The Effect of the COVID-19 Pandemic on the Management and Telehealth Care of Spontaneous Abortions [ID: 1378351

INTRODUCTION: The purpose of this study was to explore the influence of the COVID-19 pandemic on the management of early pregnancy loss. Additionally, we aimed to identify differences in the use of virtual health care for the management of spontaneous abortions (SABs) before and after the COVID-19 pandemic. METHODS: Retrospective cohort study was conducted of patients aged 18–40 receiving obstetric care at Cleveland Clinic hospitals between March 2019 and September 2019 (pre-COVID-19), and between March 2020 and September 2020 (post-COVID-19). SABs were defined as spontaneous pregnancy losses occurring before the 20th week of pregnancy, excluding induced abortions and ectopic pregnancies. Baseline demographic information, medical history, type of SAB management, and use of virtual visits were compared between the pre-COVID-19 and post-COVID-19 groups. RESULTS: Two thousand two hundred eleven patients met inclusion criteria, 1,159 with SAB pre-COVID-19 and 1,052 with SAB post-COVID-19. Demographic factors including race (P=.64) and age (P=.46) did not differ between the two groups. Overall management of SAB differed between the two cohorts, with a higher proportion of post-COVID-19 patients opting for expectant management (49.9%) compared to only 38.1% choosing expectant management in the pre-COVID-19 group (P<.001). Virtual visits for consultation and management of SAB were more prevalent in the post-COVID period with 11.1% of patients choosing to utilize telehealth compared to only 0.09% of patients in the pre-COVID-19 cohort (P<.001). CONCLUSION: The COVID-19 pandemic affected many aspects of the delivery of health care, and women's health is no exception. Our study shows that the pandemic changed the way SABs were managed, with a higher proportion of health care providers and patients opting for expectant management as compared to the pre-pandemic time period. We also saw a change in the way health care was delivered with virtual appointments becoming more popular post-COVID-19, emphasizing the growing role of telehealth in women's health care and in the management of SAB.

Geospatial Analysis of Access to Evidence-Based Early Pregnancy Loss Management in New Mexico [ID: 1377363

INTRODUCTION: Little is known about availability of evidence-based early pregnancy loss (EPL) treatment in emergency departments (EDs), where patients often first seek care. We evaluated geographic access to mifepristone/misoprostol and uterine aspiration in New Mexican hospitals. METHODS: We used an enhanced two-step floating catchment area method to model accessibility from census block groups’ population-weighted centroids to hospitals. Our primary outcome was access to mifepristone/misoprostol and uterine aspiration in EDs; our secondary outcome was access to in-hospital aspiration, both outcomes defined as less than a 60-minute commute. We surveyed all EDs in New Mexico and used public databases to compute census block groups’ demographic, transportation, rurality, and area deprivation data. We used logistic regression to evaluate the associations between access and race and ethnicity, area deprivation, and rural location. The University of New Mexico IRB approved this study. RESULTS: Thirty-five (83%) of 42 hospitals responded. Two (6%) provided in-ED treatment, and 24 (69%) in-hospital aspiration. Half of reproductive-aged women had access to in-ED treatment, and 90% to in-hospital aspiration. Census block groups with higher quartile proportions of American Indian/Native Alaskan reproductive-aged women had higher adjusted odds ratios of accessing in-ED treatment (2.5–7.3, P<.05). Rural areas and higher area deprivation quartiles had lower in-ED access adjusted odds ratios (0.03–0.07 [P<.05] and 0.3–0.4 [P<.05], respectively) compared with urban and lower area deprivation quartiles. In-hospital aspiration results were similar to in-ED treatment results across all categories. CONCLUSION: By prioritizing rural areas and areas with higher socioeconomic deprivation, EPL treatment implementation efforts can improve equitable care access and equity for patients.

Mifepristone and misoprostol in the management of early pregnancy loss

The author presents information on patient-centered care for early pregnancy loss, approaches to management, medication regimens, and patient follow-up.

Study of Oral Versus Vaginal Misoprostol in the Management of Early Pregnancy Loss

Study of Oral Versus Vaginal Misoprostol in the Management of Early Pregnancy Loss

The association between abortion restrictions and patient-centered care for early pregnancy loss at US obstetrics-gynecology residency programs

Early pregnancy loss is a common medical problem, and the recommended treatments overlap with those used for induced abortions. The American College of Obstetricians and Gynecologists recommends the incorporation of clinical and patient factors when applying conservative published imaging guidelines to determine the timing of intervention for early pregnancy loss. However, in places where abortion is heavily regulated, clinicians who manage early pregnancy loss may cautiously rely on the strictest criteria to differentiate between early pregnancy loss and a potentially viable pregnancy. The American College of Obstetricians and Gynecologists also notes that specific treatment modalities that are frequently used to induce abortion, including the use of mifepristone in medical therapy and surgical aspiration in an office setting, are cost-effective and beneficial for patients with early pregnancy loss. This study aimed to determine how US-based obstetrics and gynecology residency training institutions adhere to the American College of Obstetricians and Gynecologists recommendations for early pregnancy loss management, including the timing and types of interventions, and to evaluate the relationship with institutional and state abortion restrictions. From November 2021 to January 2022, we conducted a cross-sectional study of all 296 US-based obstetrics and gynecology residency programs by emailing them and requesting that a faculty member complete a survey about early pregnancy loss practices at their institution. We asked about location of diagnosis, use of imaging guidelines before offering intervention, treatment options available at their institution, and program and personal characteristics. We used chi-square tests and logistic regressions to compare the availability of early pregnancy loss care based on institutional indication-based abortion restrictions and state legislative hostility to abortion care. Of the 149 programs that responded (50.3% response rate), 74 (49.7%) reported that they did not offer any intervention for suspected early pregnancy loss unless rigid imaging criteria were met, whereas the remaining 75 (50.3%) programs reported that they incorporated imaging guidelines with other factors. In an unadjusted analysis, programs were less likely to incorporate other factors with imaging criteria if they were in a state with legislative policies that were hostile toward abortion (33% vs 79%; P<.001) or if the institution restricted abortion by indication (27% vs 88%; P<.001). Mifepristone was used less often in programs located in hostile states (32% vs 75%; P<.001) or in institutions with abortion restrictions (25% vs 86%; P<.001). Similarly, office-based suction aspiration use was lower in hostile states (48% vs 68%; P=.014) and in institutions with restrictions (40% vs 81%; P<.001). After controlling for program characteristics, including state policies and affiliation with family planning training programs or religious entities, institutional abortion restrictions were the only significant predictor of rigid reliance on imaging guidelines (odds ratio, 12.3; 95% confidence interval, 3.2-47.9). In training institutions that restrict access to induced abortion based on indication for care, residency programs are less likely to holistically incorporate clinical evidence and patient priorities in determining when to intervene in early pregnancy loss as recommended by the American College of Obstetricians and Gynecologists. Programs in restrictive institutional and state environments are also less likely to offer the full range of early pregnancy loss treatment options. With state abortion bans proliferating nationwide, evidence-based education and patient-centered care for early pregnancy loss may also be hindered.

Early Pregnancy Loss Management in the Emergency Department vs Outpatient Setting

Early pregnancy loss (EPL), or miscarriage, is the most common complication of early pregnancy, and many patients experiencing EPL present to the emergency department (ED). Little is known about how patients who present to the ED with EPL differ from those who present to outpatient clinics and how their management and outcomes differ. To compare the management and outcomes of patients with EPL who present to the ED vs outpatient clinics. This retrospective cohort study used the IBM MarketScan Research Database, a national insurance claims database. Participants were pregnant people aged 15 to 49 years in the US who presented to either an ED or outpatient clinic for initial diagnosis of EPL from October 2015 through December 2019. Data analysis was performed from May 2021 to March 2022. The primary exposure was location of service (ED vs outpatient clinic). Other exposures of interest included demographic characteristics, current pregnancy history, and comorbidities. The primary outcome was EPL management type (surgical, medication, or expectant management). Complications, including blood transfusion and hospitalization, and characteristics associated with location of service were also evaluated. Bivariable analyses and multivariable logistic regression were used for data analysis. A total of 117 749 patients with EPL diagnoses were identified, with a mean (SD) age of 31.8 (6.1) years. Of these patients, 20 826 (17.7%) initially presented to the ED, and 96 923 (82.3%) presented to outpatient clinics. Compared with the outpatient setting, patients in the ED were less likely to receive surgical (2925 patients [14.0%] vs 23 588 patients [24.3%]) or medication (1116 patients [5.4%] vs 10 878 patients [11.2%]) management. In the adjusted analysis, characteristics associated with decreased odds of active (surgical or medication) vs expectant management included ED (vs outpatient) presentation (adjusted odds ratio [aOR], 0.46; 95% CI, 0.44-0.47), urban location (aOR, 0.87; 95% CI, 0.82-0.91), and being a dependent on an insurance policy (vs primary policy holder) (aOR, 0.71; 95% CI, 0.67-0.74); whereas older age (aOR per 1-year increase 1.01; 95% CI, 1.01-1.01), established prenatal care (aOR, 2.35; 95% CI, 2.29-2.42), and medical comorbidities (aOR, 1.05; 95% CI, 1.02-1.09) were associated with increased odds of receiving active management. Patients in the ED were more likely than those in outpatient clinics to need a blood transfusion (287 patients [1.4%] vs 202 patients [0.2%]) or hospitalization (463 patients [2.2%] vs 472 patients [0.5%]), but complications were low regardless of location of service. In this cohort study of privately insured patients with EPL, differences in management between the ED vs outpatient setting may reflect barriers to accessing comprehensive EPL management options. More research is needed to understand these significant differences in management approaches by practice setting, and to what extent EPL management reflects patient preferences in both outpatient and ED settings.

Emergency physician gender is associated with early pregnancy loss management: a multisite retrospective cohort study

BackgroundPatients experiencing early pregnancy loss often first present to the emergency department (ED) where they can be managed non-operatively through expectant or medical management, or surgically by the obstetrical team....

Comparison of Early Pregnancy Loss Management Between States With Restrictive and Supportive Abortion Policies.

Mifepristone-misoprostol and office uterine aspiration used for abortion care are also evidence-based, cost-effective strategies for early pregnancy loss management. We aimed to compare the provision of mifepristone-misoprostol and office uterine aspiration for early pregnancy loss between states with restrictive and supportive abortion policies. We conducted a cross-sectional, internet-based survey regarding early pregnancy loss management among obstetrician-gynecologists (OBGYNs) at academic medical centers. We assessed management offered along with facilitators and barriers to implementation of mifepristone-misoprostol and office uterine aspiration. We used χ2 and multivariable logistic regression to compare practice patterns. We analyzed responses from 350 physicians, 56% from states with restrictive abortion policies. OBGYNs in states with restrictive abortion policies were less likely than those in states with supportive abortion policies to offer both mifepristone-misoprostol and office uterine aspiration (33.2% vs. 51.3%; p=.001), to report having received induced abortion training (67.3% vs. 89.6%; p<.001), and to report perceived institutional support for abortion care (49.0% vs. 85.0%; p<.001). After adjusting for confounders, restrictive state policy was no longer associated with providing both mifepristone-misoprostol and office uterine aspiration for early pregnancy loss (adjusted odds ratio, 1.19; 95% confidence interval [CI], 0.58-2.45). However both prior induced abortion training and institutional support for abortion care remained significantly associated (adjusted odds ratio, 2.06; 95% CI, 1.07-3.97 and adjusted odds ratio, 3.91; 95% CI, 2.08-7.38, respectively). OBGYNs practicing in states with restrictive abortion policies are less likely than those in states with supportive abortion policies to have received abortion training or perceive institutional support for abortion care, and they are less likely to offer mifepristone-misoprostol and office uterine aspiration for early pregnancy loss.

Mifepristone-misoprostol combination treatment for early pregnancy loss after embryo transfer: a case series

Evidence strongly supports the use of mifepristone-misoprostol combination treatment for early pregnancy loss (EPL) among pregnancies conceived without assisted reproductive technologies. No literature exists, however, regarding the efficacy of this treatment in the medical management of EPL among pregnancies after invitro fertilization and embryo transfer (IVF-ET). These patients differ as some use exogenous hormonal supplementation to provide pregnancy support. Thus, the management for EPL may differ between unassisted conceptions and those after ET. Mifepristone, a progesterone receptor antagonist, may demonstrate an altered treatment effect when used with misoprostol to manage EPL in assisted reproductive technologie-conceived pregnancies. To describe our institution's experience using mifepristone-misoprostol to manage EPL after invitro fertilization with embryo transfer IVF-ET. Retrospective case series. Single academic institution from 2020 to2022. Nine patients with ultrasound confirmed EPL after IVF-ET. All 9 patients underwent invitro fertilization followed by fresh or frozen embryo transfer. All 9 received 200 mg of mifepristone 24 hours before 800 μg of misoprostol. Incomplete abortion, need for surgical management, number of days to negative serum human chorionic gonadotropin (hCG). Of the 9 subjects included, one had a programmed frozen embryo transfer cycle, 6 had modified natural frozen embryo transfer cycles, and 2 underwent fresh ET. Eight subjects had successful expulsion of tissue with one dose of treatment, and one required uterine aspiration. No subjects required additional dosing of misoprostol. The mean number of days elapsed from mifepristone treatment to tissue expulsion was 4.89 ± 11.30 days and the mean days to negative-range serum hCG was 36.89 ± 18.59 days. At the initial ultrasound, all pregnancies had one gestational sac seen; 5/9 had a yolk sac; only 3 had fetal cardiac activity. The mean gestational age at the time of EPL diagnosis was 55.22 ± 8.77 days, with the majority (8/9) having completed 7 weeks gestation. Mifepristone-misoprostol combination treatment appears to be a reasonable option for those with EPL after IVF-ET. Future, larger-scale studies are needed comparing combination treatment with misoprostol only among various ET protocols.

Safety and Efficacy of Misoprostol for the Management of Early Pregnancy Loss: A Non-Randomized Clinical Trial

Background: Management of early pregnancy loss is very crucial for the safety of women.&#x0D; Objective: The purpose of the present study was to see the safety and efficacy of misoprostol for the management of early pregnancy loss.&#x0D; Methodology: This non-randomized clinical trial was conducted in the Department of Obstetrics and Gynaecology in Shaheed Ziaur Rahman Medical College Hospital, Bogra, Bangladesh from January 2007 to December 2007 for a period of 12 months. Women with early pregnancy loss who were fulfilling the selection criteria were selected as the study population during the study period. On admission all women were received a vaginal administration of 800 μg misoprostol by digital insertion into the posterior fornix through a speculum (4 tablets of 200 μg misoprostol). The interval between administration of misoprostol and expulsion of product of conception was recorded. After 7 days (8th day) they were instructed to come to the hospital to see the completeness of expulsion of product of conception by ultrasonography. If sonography shows incomplete expulsion then surgical evacuation was done. Every woman were advised to come for follow-up on 15th day. Results: A total of 200 women with first-trimester pregnancy loss were non-randomly assigned to give treatment with misoprostol. The mean with the SD of the study population was 24.95±4.17 years. In most cases expulsion occurred within 24 hours of application of misoprostol, 142(71.0%) cases completed expulsion within 48 hours, 168(84.0%) cases within 7 days, 170(85.0%) cases out of 200 cases completed expulsion occurred. Complete evacuation after the first dose was in 142(71.0%) cases and remained incomplete was 58(29.0%) cases. After administration of the second dose (85.0%) complete evacuation occurred and 30(15.0%) cases remained complete that needed surgical evacuation. Analysis was reveled statistically significant (P&lt;0.05). Vaginal misoprostol treatment appeared to be well tolerated. Only few percent shows mild side effects. About 190(95.0%) cases required no blood transfusion. Conclusion: In conclusion the efficacy of misoprostol for the management of early pregnancy loss gives a good results with minimum adverse events.&#x0D; Journal of National Institute of Neurosciences Bangladesh, July 2022;8(2):152-156

Mifepristone for miscarriage treatment in Utah: A survey of clinician knowledge and assessment of an educational video on future use.

We aimed to: (a) describe current use of mifepristone for early pregnancy loss (EPL) management in Utah, (b) identify predictors of knowledge pre- and posteducational video, and (c) explore postvideo impacts on the likelihood to use mifepristone. Mifepristone is subject to the Food and Drug Administration's (FDA) Risk Evaluation and Mitigation Strategy (REMS) requirements. Between September 2020 and March 2021 we surveyed Utah clinicians from six specialties caring for people experiencing EPL, recruited through professional organizations and hospital listservs. Participants viewed a 3.5-minute educational video on mifepristone for EPL and completed pre- and postvideo questionnaires. We evaluated predictors of high prevideo and improved postvideo knowledge using random forest regression conditional importance measures and partial dependency plots. We described current mifepristone use and video effects on likelihood to use mifepristone. Of 506 participants, most specialize in emergency medicine (172, 34%) and practice in private settings (253, 51%). Two-thirds had heard of mifepristone (328/471, 70%). Of 176/471 (37%) attempting provision of mifepristone, actual provision occurred for 59% (104/176). Baseline knowledge scores were low (mean 4.81/13 [37%] correct). Predictors of high prevideo knowledge include provision or attempted provision of mifepristone, having heard of mifepristone, providing EPL management expectantly or via medication, and specialty type. Mean postvideo knowledge scores improved by 3.27 points (68% improvement, paired t-test; 95% confidence interval 2.82-3.72, p < 0.0001). Postvideo, 66% (242/364) stated they are much more or somewhat more likely to use mifepristone, with compliance with FDA requirements cited as a barrier to utilization. Among Utah providers, baseline mifepristone knowledge and use for EPL management are low. An educational video improved knowledge and likelihood of use, but FDA REMS requirements continue to be a barrier to including mifepristone in medication management of EPL.