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#Grand Rounds

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

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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

METHODS:

  • 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

RESULTS:

  • 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

CONCLUSION:

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

Learn More – Primary Sources:

Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss

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Related ObG Topics:

Managing Early Pregnancy Loss
How Effective are Treatments for Unexplained Recurrent Miscarriage?
Physical Activity and Time-to-Pregnancy in Women with a History of Pregnancy Loss
Conceiving After Pregnancy Loss – Is Waiting Beneficial?  

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