ABSTRACT
To assess the safety and efficacy of prescribing mifepristone and misoprostol for medical management of abnormal early pregnancy in emergency departments (EDs) compared to outpatient management at a complex family planning office, and to compare post-treatment follow-up. We conducted a retrospective cohort study after implementing mifepristone and misoprostol prescription in three Bronx, NY EDs during the COVID-19 pandemic's first wave. All patients receiving medical management between April 1, 2020 and March 31, 2021 were reviewed. Outcomes were compared by treatment setting. Induced abortion only occurred in the outpatient setting. Treatment success was defined as pregnancy resolution after one dose of mifepristone and misoprostol. Safety outcomes included emergent interventions and blood transfusion. We assessed rates of post-treatment follow-up. Some 167 patients received medical management: 33 (19.8%) in the ED and 134 (80.2%) outpatient. ED patients were older (aged 30.9±6.9 vs. 28.1±5.9, p=0.02) and more likely to have Medicaid insurance (81.8% vs. 51.5%, p=0.003). Treatment success occurred for 23 (69.7%) ED and 119 (88.8%) office patients. A multivariate logistic regression adjusting for age, insurance status, and pregnancy diagnosis showed lower odds of treatment success in the ED vs. outpatient setting, but was not statistically significant (adjusted OR (aOR), 0.60;95% CI, 0.17–2.09;p=0.42). ED safety outcomes included two emergent uterine aspirations, one uterine artery embolization, and two blood transfusions. Outpatient safety outcomes included one admission for intravenous antibiotics. Follow-up was similar: 28 (84%) ED vs 121 (90.3%) outpatients (p=0.36). Medical management of abnormal early pregnancy with mifepristone and misoprostol in the ED is effective. Larger studies are needed to better quantify ED safety outcomes. [ FROM AUTHOR]
ABSTRACT
INTRODUCTION: Compared to misoprostol alone, medical management of early pregnancy loss (EPL) with mifepristone and misoprostol has a 25% higher success rate, reduces subsequent uterine aspiration, and is cost-effective. During the COVID-19 pandemic, we began providing mifepristone and misoprostol for EPL in our urban emergency departments (EDs), aiming to increase access to essential services and to minimize repeated health care visits. We sought to describe the safety and efficacy of this novel practice. METHODS: With institutional review board approval, we retrospectively reviewed the charts of all patients receiving mifepristone and misoprostol for first trimester pregnancy management in our EDs between April 2020 and March 2021 (n=33). Effective treatment was defined as pregnancy resolution after a single treatment with mifepristone and misoprostol. Safety outcomes included need for additional management, emergent surgical interventions, and blood transfusion. Descriptive statistics and univariate analysis were performed. RESULTS: The prevalence of effective treatment was 70% (n=23). Among the 10 subjects (30%) requiring additional management, interventions were: one additional dose of misoprostol (n=4), uterine aspiration (n=4), methotrexate (n=1), and uterine artery embolization (n=1). Three interventions (30%) were emergent, and two of these patients also required transfusion. Demographic characteristics were not associated with effective treatment nor with safety outcomes. Twenty-eight subjects (84%) participated in follow-up, 17 via telemedicine and 11 in person. CONCLUSION: Providing mifepristone and misoprostol for EPL in the ED may be an effective method to increase health care access. Further research is needed to determine whether this population is truly at increased risk for serious complications.