Mifepristone underutilized in early pregnancy loss

Using both mifepristone and misoprostol for early miscarriage treatment results in fewer uterine aspiration procedures and emergency department visits than using misoprostol alone, according to a UW Medicine study in JAMA Network Open.

 Mifepristone, however, is often not used in early miscarriage treatments, despite its effectiveness and safety, noted lead author and UW Medicine OB-GYN Dr. Lyndsey Benson.

“Despite updated guidance from the American College of Obstetricians and Gynecologists (ACOG) in 2018, mifepristone remains underutilized for patients with early pregnancy loss,” said Benson. “I would say this is largely related to its use in medication abortion and the burden of additional administrative requirements.

“Unfortunately, many emergency departments and other facilities where people receive treatment for early pregnancy loss do not have mifepristone available in their pharmacies for these reasons,” she said.

The researchers found that administering both drugs decreased the chances of needing subsequent procedural management of early pregnancy loss by 29%. The findings were reported last month in JAMA Network Open.

When used during a miscarriage, mifepristone works by blocking the effects of progesterone, which is crucial for pregnancy continuation. Mifepristone prepares the uterus to empty, while misoprostol causes cervical softening and contractions that lead to the expulsion of the pregnancy tissue. Essentially, mifepristone "primes" the uterus for misoprostol and thereby enables the miscarriage to proceed more effectively and efficiently, according to the ACOG.

Researchers analyzed private insurance claims data from 31,977 pregnant individuals ages 15 to 49 years, with a mean age of 33, who received medication management for early pregnancy loss (before 13 weeks gestation) between Oct. 1, 2015, and Dec. 31, 2022.

They found that 3% of the individuals received mifepristone followed by misoprostol, while 97% received only misoprostol. The portion of individuals who received both drugs rose to 8.6% in 2022. Both drugs were more likely to be used when patients were treated in an outpatient setting instead of in an emergency department, the researchers found. 

“The continued underutilization of mifepristone in the setting of early pregnancy loss is multifactorial, with prior studies identifying multiple barriers to its use, including logistical barriers and uncertainty related to the FDA Risk Evaluation and Mitigation Strategy requirements, resistance from institutional leadership and lack of education or prior experience with mifepristone,” Benson and her colleagues wrote.

“Continued efforts are needed to reduce barriers to mifepristone use for medication management of early pregnancy loss,” the researchers wrote. “Increasing access to mifepristone for early pregnancy loss management may decrease healthcare utilization and expenditures.” 

The research was supported in part by Women’s Reproductive Health Research grant K12 HD001264 from the National Institutes of Health Eunice Kennedy Shriver National Institute for Child Health and Human Development.

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