Grand Rounds

Does Adding Mifepristone Prior to Misoprostol Improve Medical Management of Pregnancy Loss?

BACKGROUND AND PURPOSE:

Misoprostol is an alternative to uterine aspiration following miscarriage but often with limited results
Schreiber et al. (NEJM 2018) compared the efficacy and safety of pretreatment with mifepristone versus misoprostol alone for miscarriage management

Randomized Controlled Trial (RCT)
- Comparative Effectiveness of Pregnancy Failure Management Regimens (PreFaiR) trial
Participants
- Healthy women ≥18 years
- Nonviable intrauterine pregnancy at 5-12 weeks (ultrasound confirmed)
Patients randomized to the following
- 200 mg mifepristone followed by 800 µg misoprostol
- 800 µg misoprostol alone
Patients returned for follow-up at 1 to 4 days following misoprostol
Primary outcome
- Gestational sac expulsion with one dose of misoprostol by the first follow-up visit and no additional intervention within 30 days after treatment

148 participants in mifepristone pretreatment group and 149 in the misoprostol alone group were available for analysis
83.8% of mifepristone-pretreatment group and 67.1% of misoprostol alone group experienced complete expulsion
- Relative risk (RR) 1.25; 95% CI, 1.09 to 1.43
Uterine aspiration was performed less frequently in the mifepristone-pretreatment group (8.8%) vs the misoprostol-alone group (23.5%)
- RR 0.37; 95% CI, 0.21 to 0.68
Blood transfusion was not statistically different between the two groups
- 2.0% mifepristone-pretreatment group vs 0.7% in the mifepristone-misoprostol-alone group (P=0.31)
Benefit of mifepristone-pretreatment was also found at ≤9 weeks
- 84.8% (117 of 138 women) in the mifepristone-pretreatment group vs 66.7% (94 of 141 women) in the misoprostol-alone group
There were no significant differences in bleeding intensity and pain

The addition of mifepristone prior to misoprostol improves treatment of early pregnancy loss

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