The combination of two drugs, misoprostol and mifepristone, improves outcomes in the treatment of a non-viable pregnancy and reduces complications. Costs are also falling. This is the conclusion of Lotte Hamel’s doctoral research, conducted as part of the collaboration between Radboudumc and Canisius Wilhelmina Hospital (CWZ). The combination is already in Dutch guidelines, but has not yet been reimbursed by health insurers.
In a non-viable pregnancy, something goes wrong in the first fourteen weeks of pregnancy: a healthy embryo does not develop, the heart has stopped or has never started beating. If that pregnancy doesn’t end in a miscarriage on its own, treatment is needed to empty the uterus again. More than 20 million women around the world seek medical care for this every year. That number will continue to increase as women become pregnant later and later and the chance of non-viable pregnancy increases with age.
The termination of a pregnancy is done with a curettage, emptying the uterus with a suction tube or with drugs that induce a miscarriage. A curettage is more likely to cause complications, which is why medications are preferred. It was already known for abortion during a vital pregnancy that a combination of two drugs works better than a single drug. Researchers from Radboudumc and CWZ have now shown that the combination is better even in non-viable pregnancies.
Smart combination
“We used to only use misoprostol, but now we show that pretreatment with mifepristone gives much better results,” says Lotte Hamel, who will defend her PhD on the subject on 9 September. “Our clinical study showed that sixty percent of women had a complete miscarriage with misoprostol alone. This rose to eighty percent with the combination of drugs. Also, with misoprostol alone, a curettage in thirty percent of women. That dropped to ten percent by both means. ‘
The combination of drugs not only improves outcomes in terminating non-viable pregnancies, it also appears to be cost-effective. Although adding the second drug mifepristone entails additional costs, Hamel calculated that the combination ultimately saves an average of € 135 per patient. The addition of mifepristone in many cases prevents further ultrasound examination and possible curettage.
Recommended in the guideline
Study results were measured after a one-week waiting period between patient interview and initiation of treatment. For the time being, a five-day waiting period is mandatory in the Netherlands for an abortion in the case of a viable pregnancy, but not in the case of a non-viable pregnancy. “However, I am in favor of the waiting period, even if the pregnancy has stopped developing,” says Hamel. ‘In half of the cases, a miscarriage still starts spontaneously during the waiting period. The body then regulates the abortion itself and medicines are not needed. I think for women it is better for processing. ‘
In 2020, the combination of the two drugs will be included in the guidelines of the Dutch Association of Obstetrics and Gynecology (NVOG). “In addition to our research, studies have also been conducted in the United States and England with comparable results,” says co-supervisor Sjors Coppus of Maxima Medical Center. ‘The evidence that the combination works best is therefore very convincing. Unfortunately, health insurers are not reimbursing it yet. Sometimes hospitals pay for themselves, but it’s not possible everywhere. It is hoped that insurers will soon reimburse these treatments in the basic package. ‘
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