Title : Indications and amount of clinical follow-up after medication or procedural management for miscarriage, actual clinical use study
Abstract:
Background: Early pregnancy loss (EPL) is the most common complication in pregnancy. After diagnosis of EPL, patients have three options: expectant, medical or procedural management. While procedural management is quick and has relatively few complications, medical management is preferred by some patients as the procedure is viewed as invasive and less natural. While there have been several studies looking at the outcomes, particularly with respect to the need for repeat procedures, for medical vs. procedural management, no study has attempted to quantify the patient experience or the degree of need for clinical follow-up after medical or procedural miscarriage management. Therefore, we attempted to understand the clinical course for patients before and after intervention to see how patients respond to treatment and their need for follow-up care in a day-to-day clinical setting.
Methods: EPL patients over 18 years old were retrospectively identified and classified into a medical management group (mifepristone and misoprostol) or procedural management group (uterine aspiration). Patients who received the medications or underwent a uterine aspiration for reasons other than EPL were excluded. Exclusion criteria for surgical management included initial procedures done to remove products of conception, emergency uterine aspiration procedures or complete/partial molar pregnancy. Additionally, patients who initially elected expectant management or patients that were not given all three management options were excluded from both groups. For both subject groups, information about demographics, successful expulsion of pregnancy, gestational information, the need for any additional medical/procedural management, additional prescriptions, number and type of visits, phone calls, my-chart messages, and ultrasounds were collected.
Results: 96 eligible medication patients and 189 eligible surgical patients were identified. 22% of patients undergoing medical management eventually required an additional procedure, in comparison to 8% of those in the procedural group (p=.0008). 5% of patients undergoing medical management required an aspiration for the indication of failure to pass the gestational sac. A greater percentage of patients undergoing medical management utilized post interventional phone calls (41%) and mychart messages (26%) in comparision to the procedural group (27% and 16% respectively). However, there was no significant difference in unplanned visits or ER visits between the two groups. Complications including overnight hospital stay, blood transfusion, and post-procedural infection requiring antibiotics was low for both groups.
Discussion: 22% of patients undergoing medical management of EPL required eventual procedural management. The most common indication for aspiration procedure was retained products of conception, however, around ¼ of those requiring a procedure had retention of the gestational sac. Because patients undergoing medical management had passage of gestational tissue at home, they had a significantly higher incidence of provider communication. This study had a significantly higher failure rate of medical management in comparison to previous RCTs due to the demographic and clinical differences between patients undergoing medical and procedural management, as well as the broader definition of failure in this study.
Audience Take Away:
- Improved counselling in patients with early pregnancy loss (EPL).
- Better understanding of healthcare system utilization in patients with EPL.
- Further research topics including: heterogeneity of EPL follow-up in practice.
