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GENERAL GYNECOLOGY

Mifepristone and misoprostol for early
pregnancy failure: a cohort analysis
Kathleen M. Kollitz, BS; Leslie A. Meyn, MS; Patricia A. Lohr, MD, MPH; Mitchell D. Creinin, MD
OBJECTIVE: We sought to examine outcomes of mifepristone and mi-
soprostol for early pregnancy failure (EPF) treatment in a nonresearch
setting.
STUDY DESIGN: A protocol was developed for physicians to use mife-
pristone 200 mg orally and misoprostol 800 ␮g vaginally for EPF. Suc-
cess rates were analyzed and an adjusted multivariable regression was
used to identify factors predictive of success.
RESULTS: Treatment success occurred in 99 (80%; 95% confidence
interval, 72–87%) of 123 patients after mifepristone and a single dose
of misoprostol and 102 (83%; 95% confidence interval, 75–89%) pa-
tients overall. The odds of successful medical treatment were increased
in women with a diagnosis of intrauterine embryonic/fetal demise (odds
ratio, 3.80) and decreased in women who made additional emergency
department visits (odds ratio, 0.12).
CONCLUSION: Patients and clinicians may be more likely to intervene
surgically with an EPF when a strict study protocol is not being followed.
Key words: early pregnancy failure, mifepristone, misoprostol
Cite this article as: Kollitz KM, Meyn LA, Lohr PA, et al. Mifepristone and misoprostol for early pregnancy failure: a cohort analysis. Am J Obstet Gynecol
2011;204:386.e1-6.
E
arly pregnancy failure (EPF) is a
common complication, occurring
in approximately 15-20% of pregnan-
cies.
1,2
One in 4 women will experience a
pregnancy loss over the course of her
life.
2
EPF can be further defined by the
subtypes of pregnancy abnormality in-
cluding intrauterine embryonic/fetal de-
mise, anembryonic pregnancy, inevita-
ble abortion, and incomplete abortion
diagnosed at Ͻ12 weeks’ gestation.
3
Use of medical management with mi-
soprostol, a prostaglandin E
1
analog, has
become increasingly popular since the
mid-1990s. Studies of misoprostol for
treatment of EPFare difficult tocompare
because of the different criteria used to
identify pregnancy failure, varying drug
doses, delivery methods, criteria for suc-
cess, and time interval between medica-
tion and outcome assessment. Accord-
ingly, success rates using misoprostol
vary significantly.
4
The results of the first
large, multicenter, randomized trial
comparing surgical management to
medical management with misoprostol
were published by Zhang et al
5
in 2005,
reporting successful uterine evacuation
using 1 or 2 doses of misoprostol 800 ␮g
vaginally in 86% of women.
However, studies of elective medical
abortion using a combination of mife-
pristone, a progesterone antagonist, with
misoprostol demonstrate a higher suc-
cess rate than misoprostol alone, exceed-
ing 95% in women up to 9 weeks’ gesta-
tion.
6
Additionally, multiple studies
have shown efficacy of Ն90%Ͼ9 weeks’
gestation.
7
Oddly, when used for EPF,
the reported overall success rates with
mifepristone and misoprostol are much
lower, with wide discrepancies because
of varying dosing regimens and differing
criteria for success, ranging primarily
from 67-84%.
8-13
Only 2 studies have
shown efficacy at Ն90%. Schreiber et
al
12
reported a 90% first-dose success
rate in a small pilot study using 200 mg
mifepristone and 800 ␮g misoprostol
per vagina, which increased to 93% after
a second dose of misoprostol. Kushwah
and Singh
13
reported 92%efficacy of 200
mg mifepristone followed by 600 ␮g mi-
soprostol sublingually; however, medi-
cations were administered on an inpa-
tient basis and up to 3 additional doses of
misoprostol were given.
Importantly, all of the trials in the lit-
erature examine outcomes basedonpro-
spective researchprotocols. Withthe un-
derstanding that study protocols create
situations that likely overestimate real-
life outcomes, we sought to examine the
results of such treatment by nonresearch
providers in standard patient care set-
tings. Unlike study protocols that re-
quire strict timing of study follow-up
and treatment, real-life treatment could
potentially include women having more
input into howto proceed if initial treat-
ment is unsuccessful and permit provid-
ers to recommend surgical intervention
without needing to meet specified study
criteria. We used an existing database
created for a quality assurance investiga-
Fromthe Department of Obstetrics,
Gynecology, and Reproductive Sciences,
University of Pittsburgh Medical Center (Ms
Kollitz, Ms Meyn, and Dr Creinin); the
University of Pittsburgh School of Medicine,
the Center for Family Planning Research,
and Magee-Womens Research Institute (Ms
Meyn and Dr Creinin); and the University of
Pittsburgh Graduate School of Public Health
(Dr Creinin), Pittsburgh, PA, and bPAS,
Stratford-on-Avon, England, UK(Dr Lohr).
Received Aug. 13, 2010; revised Oct. 15,
2010; accepted Dec. 10, 2010.
Reprints: Mitchell D. Creinin, MD, University of
Pittsburgh School of Medicine, Department of
Obstetrics, Gynecology, and Reproductive
Sciences, Magee-Womens Hospital, 300
Halket St., Pittsburgh, PA 15213-3180.
mcreinin@upmc.edu.
Disclosure: Dr Creinin has received honoraria
fromDanco Laboratory.
0002-9378/$36.00
© 2011 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2010.12.026
Research www.AJOG.org
386.e1 American Journal of Obstetrics &Gynecology MAY 2011
tion of clinical use of mifepristone and
misoprostol for medical treatment of
EPF to examine outcomes.
MATERIALS AND METHODS
We reviewed a deidentified database
created for quality assurance of an inno-
vative treatment programusing mifepri-
stone and misoprostol for EPF at Magee-
Womens Hospital of the University of
Pittsburgh Medical Center. The institu-
tional review board (IRB) at the Univer-
sity of Pittsburgh granted exempt ap-
proval for this analysis. The database
included 28 women from an IRB-ap-
proved clinical trial, conducted from
May 2006 through August 2007, and 128
women treated under the innovative
treatment program from October 2007
through September 2009. The clinical
trial was prospectively investigating out-
comes with this treatment in a clinical
setting. The 2 protocols were identical
except that consent during the clinical
trial had to be obtained by a study inves-
tigator whereas, for the innovative treat-
ment program, the program-specific
consent form could be provided by any
clinician initiating treatment.
Anonviable pregnancy was defined by
one of the following ultrasound criteria:
(1) an embryonic pole Ն5 mm without
cardiac activity
14
; (2) a gestational sac
with mean sac diameter Ͼ16 mmand no
embryonic pole
15
; (3) no documented
growth on ultrasound examination of a
confirmed pregnancy defined as growth
in mean sac diameter of Ͻ3 mm over 5
days or Ͻ4 mm over 7 days
16
; or (4) an
increase in serum ␤-human chorionic
gonadotropinϽ15%over a 2-day period
with a yolk sac present.
Mifepristone and misoprostol could
be prescribed by any obstetrician/gyne-
cologist affiliated with Magee-Womens
Hospital for women who met one of the
following criteria: (1) a nonviable preg-
nancy with an embryonic pole with a
crown-rump length of Յ40 mm; (2) a
nonviable pregnancy without an embry-
onic pole and with a mean sac diameter
Յ45 mm; (3) an incomplete abortion
with expulsion of some products of con-
ception with or without active bleeding
from the cervical os and an endometrial
lining Ͼ30 mmand the uterine size Ͻ13
weeks by pelvic examination; or (4) an
inevitable abortion: an intrauterine ges-
tational sac on ultrasound examination
and an open cervical os on digital exam-
ination with active vaginal bleeding with
a mean sac diameter between 16-45 mm.
In addition, patients needed to be hemo-
dynamically stable, willing and able to
signthe informed consent, and willing to
comply with the treatment protocol and
visit schedule.
Patients were ineligible for medical
management if they had any of the fol-
lowing: (1) orthostatic hypotension; (2)
contraindication to mifepristone such as
chronic corticosteroid administration or
adrenal disease; (3) contraindication to
misoprostol such as glaucoma, mitral
stenosis, sickle cell anemia, poorly con-
trolled seizure disorder, or known al-
lergy to prostaglandin; (4) clinical indi-
cationrequiring karyotyping of products
of conception; (5) prior surgical or med-
ical attempted uterine evacuation, either
self-imposed or physician provided; (6)
known or suspected extrauterine preg-
nancy; (7) evidence of ovarian hyper-
stimulation syndrome; (8) known or
suspected pelvic infection; (9) hemoglo-
bin Ͻ9.5 g/dL; (10) known clotting de-
fect or receiving anticoagulants; (11)
cardiovascular disease; (12) current
breast-feeding; (13) pregnancy with an
intrauterine device in situ; (14) current
use of any experimental drug; or (15)
suspected or confirmed endometrial ar-
teriovenous malformation.
After consent, measurements of he-
moglobin, height, weight, blood pres-
sure, and pulse were performed. Blood
type was assessed and Rh-immune glob-
ulin administered to Rh-negative pa-
tients. A physician in the office or clinic
setting or in the emergency department
(ED) could initiate treatment; an obstet-
rics and gynecology faculty or resident
provided all treatment in the ED. A pre-
scription for 200 mg of mifepristone and
800 ␮g of misoprostol was completed by
the physician and faxed to the hospital
pharmacy. The physician provided all
counseling and prescription for pain
medication, and arranged follow-up. In
addition, the physician provided stan-
dardized written information that re-
viewed how to properly take the med-
ications, expectations for pain and
bleeding, instructions for recognizing
and managing problems, and telephone
numbers for the treating physician and
the hospital ED.
The patient was to swallow the mife-
pristone immediately after it was dis-
pensed by the pharmacist and to use the
misoprostol vaginally 24 hours later.
A follow-up transvaginal ultrasound
examination was to be performed 1 week
later either inthe physician’s office or the
hospital ultrasound department, and to
discuss further management if needed.
Physicians were instructed per the pro-
tocol that presence of a gestational sac or
an endometrial thickness of Ͼ30 mmin-
dicated further management was neces-
sary. Options could include suction
aspiration, a second dose of vaginal mi-
soprostol, or expectant management.
Those women who chose additional mi-
soprostol or expectant management
were to be followed up with weekly en-
dovaginal ultrasound examinations un-
til the gestational sac had expelled.
Success was determined by a diagnosis
of complete abortion made at a fol-
low-up visit by the treating physician,
who was to use ultrasound criteria of ab-
sence of a gestational sac and an endo-
metrial lining Ͻ30 mm. Failure was
automatically assigned to any woman
having a surgical intervention. Records
for all University of Pittsburgh Medical
Center hospitals were searched at the
conclusion of data collection to deter-
mine whether any unknown surgery
related to the pregnancy had been
performed.
Data analysis was performed on the
modified intent-to-treat (MITT) popu-
lation, which consisted of all women
who started the medical treatment and
had at least 1 follow-up interaction (Fig-
ure). Physicians were defined in groups
as gynecologic specialties faculty (aca-
demic gynecology faculty), general ob-
stetrics and gynecology faculty (includ-
ing all academic faculty and private
faculty who were not members of the gy-
necologic specialties faculty), and resi-
dents. The resident cases were all super-
vised by gynecologic specialties faculty.
Statistical analysis was performed using
www.AJOG.org General Gynecology Research
MAY 2011 American Journal of Obstetrics &Gynecology 386.e2
statistical software (SPSS, version 17.0;
SPSS Inc, Chicago, IL). Associations of
demographic, medical, and clinical fac-
tors with treatment success were evalu-
ated using Student t test, ␹
2
analysis, and
Fisher’s exact test, where appropriate.
Multivariable logistic regression was
performed to identify factors that were
independently associated with treatment
success. Variables with a univariate
P value Ͻ .2 were considered for inclu-
sion in the regression analysis. The final
multivariable model was adjusted for
treating physician and enrollment loca-
tion. Adjusted P values were calculated
based on the Wald ␹
2
test.
RESULTS
FromMay 2006 through September 2009,
156 women were treated and 123 patients
wereincludedintheMITTgroup(Figure).
Of these 123 women, 25 (20%) were
treatedinthe original IRB-approvedstudy
protocol. Subjects inthe MITTpopulation
had a mean age of 28.5 years (median, 28;
range 16.7–42.5). Other demographic in-
formationis presentedinTable1. Of the32
women who had experienced prior spon-
taneous abortion, 14 (44%; 95% confi-
dence interval [CI], 26–62%) had experi-
enced Ն2.
The overall treatment success rate
was 102/123 (83%; 95% CI, 75–89%).
Ninety-nine (80%; 95% CI, 72–87%)
women expelled the products of concep-
tionwithuse of mifepristone anda single
dose of misoprostol. Only 4 of the 24
(17%; 95% CI, 2–32%) women who did
not expel the pregnancy with the first
dose of misoprostol received an addi-
tional dose; 3 expelled the pregnancy
successfully and 1 had a suction aspira-
tion 9 weeks after her original treatment.
No patients received a third dose. The
success rates were similar between
womeninthe IRB-approvedclinical trial
(84%; 95% CI, 64–95%) and the inno-
vative treatment program(83%; 95%CI,
74–90%; P ϭ1.0).
The 21 failures (women who had sur-
gical intervention) included 3 with a per-
sistent gestational sac, 3 with an endo-
metrial lining Ͼ30 mm, 2 with persistent
bleeding, and 3 for nonspecified reasons.
The 10 other women all had an endome-
trial lining Ͻ30 mm but had interven-
tion related to comments on the ultra-
sound report. All of these ultrasound
examinations were performed by ultra-
sound faculty and not by the physicians
in their office. Eight women had a report
that stated retained products and 2
women had repeat ultrasound examina-
tion with an increase or no change in the
lining. Surgical treatment occurred in
the operating room for 10 (48%) pa-
tients and office setting for 11 (52%) pa-
tients. The 3 women who had surgical
interventionwhowere treatedby general
obstetrics and gynecology faculty all had
their procedures in the operating room
whereas 11 of the 18 procedures in pa-
tients treated by the gynecologic special-
ties faculty or residents were performed
in an office setting.
Twenty (14%; 95% CI, 9–21%) pa-
tients initiated treatment and then failed
to return for assessment of outcome.
FIGURE
Treatment outcomes
Women treated
N = 156
Charts reviewed
n = 151
Missing charts
n = 5
Failure with 1 dose
of misoprostol
n = 24
20% (95% CI, 13–28%)
Overall success
n = 102
83% (95% CI, 75–89%)
Second dose misoprostol
n = 4
17% (95% CI, 5–37%)
Success after second dose
of misoprostol
n = 3
75% (95% CI, 19–99%)
Success with 1 dose
of misoprostol
n = 99
80% (95% CI, 72–87%)
Suction aspiration
n = 20
83% (95% CI, 63–95%)
Suction aspiration
n = 1
25% (95% CI, 0–81%)
Modified intent to
treat population
n = 123
Lost to follow-up
n = 20
Did not take medications
n = 8
CI, confidence interval.
Kollitz. Mifepristone and misoprostol for EPF. AmJ Obstet Gynecol 2011.
Research General Gynecology www.AJOG.org
386.e3 American Journal of Obstetrics &Gynecology MAY 2011
Lost-to-follow-up rates did not differ by
type of treating physician, with an odds
ratio (OR) of 1.7 (95% CI, 0.6–4.4) for
residents as compared to faculty or pri-
vate gynecologists. Women who re-
ceived treatment in the ED were more
likely to be lost to follow-up (OR, 2.7;
95% CI, 1.0–7.0) compared to an office
setting (resident clinic and physician’s
office). If the patients lost to follow-up
were considered a treatment success,
success rates would increase to 122/143
(85%; 95% CI, 78–91%) with a first mi-
soprostol dose success rate of 83% (95%
CI, 76–89%). However, if these women
were considered failures, the overall suc-
cess rate would decrease to 102/143
(72%, 95% CI, 63–79%).
Success rates did not differ by type of
treating physician or location of initia-
tion of study treatment (Table 2). The
only variables associated with treatment
outcome were type of EPF and follow-up
visit to the ED. In multivariable analysis,
both of these predictors remained signif-
icant. Women with an embryonic or fe-
tal demise were 3.8 times more likely to
experience a treatment success com-
pared to women with an anembryonic
gestation. Women who presented to the
ED at some time after initial treatment
had a nearly 8-fold increased risk of
treatment failure comparedtothose who
did not present to the ED (OR of success
ϭ 0.12). Of note, patients who initiated
treatment in the ED were significantly
more likely to return to the ED for addi-
tional care (P Ͻ.001) (Table 3).
Two (2%; 95% CI, 0–6%) women
were diagnosed with endometritis and
both treated as outpatients. No other se-
rious adverse outcomes were noted.
COMMENT
This evaluation was intended to assess
outcomes for patients experiencing EPF
in a true-to-life clinical setting, and
therefore reflects the diversity of treating
physician, type of pregnancy failure, and
clinical milieu found at Magee-Womens
Hospital. The overall success in expul-
sion of products of conception for this
study was 80% with 1 dose of misopros-
tol and 83% overall.
Only 17% of women who did not ex-
pel the pregnancy with a single dose of
misoprostol opted for another dose. Be-
cause suction aspiration can often be
easily performed in an office setting and
quickly resolve any bothersome symp-
toms, it is highly likely that both patients
and clinicians are more likely to opt for
surgery for any persistent symptoms or
TABLE 1
Demographics, modified
intent-to-treat group
Demographic n %
Race/ethnicity, n
..................................................................................................
White 77 63
..................................................................................................
African American 36 29
..................................................................................................
Asian 4 3
..................................................................................................
Undocumented 6 5
...........................................................................................................
Marital status, n
..................................................................................................
Married 52 42
..................................................................................................
Single 69 56
..................................................................................................
Other 2 2
...........................................................................................................
Gravidity, n
..................................................................................................
1 34 28
..................................................................................................
2 32 26
..................................................................................................
3 25 20
..................................................................................................
Ն4 32 26
...........................................................................................................
Parity, n
..................................................................................................
0 60 49
..................................................................................................
1 33 27
..................................................................................................
2 18 15
..................................................................................................
Ն3 12 10
...........................................................................................................
Prior spontaneous
abortion, n
..................................................................................................
No 73 59
..................................................................................................
Yes 32 26
..................................................................................................
Unknown 18 15
...........................................................................................................
Prior elective
abortion, n
..................................................................................................
No 79 64
..................................................................................................
Yes 26 21
..................................................................................................
Unknown 18 15
...........................................................................................................
Kollitz. Mifepristone and misoprostol for EPF. AmJ
Obstet Gynecol 2011.
TABLE 2
Association of physician, location, and type
of pregnancy failure with treatment success
Variable n
No.
success
Percent
(95% CI)
Adjusted
a
OR
(95% CI) P value
b
Treating physician
.....................................................................................................................................................................................................................................
General faculty
c
28 25 89 (72–98) Referent
.....................................................................................................................................................................................................................................
Specialty faculty
d
37 31 84 (68–94) 0.79 (0.13–4.96) .80
.....................................................................................................................................................................................................................................
Resident
e
58 46 79 (67–89) 0.89 (0.10–7.88) .92
..............................................................................................................................................................................................................................................
Enrollment location
.....................................................................................................................................................................................................................................
Resident clinic 51 41 80 (67–90) Referent
.....................................................................................................................................................................................................................................
Faculty office 43 38 88 (75–96) 1.03 (0.15–6.82) .98
.....................................................................................................................................................................................................................................
Emergency department 29 23 79 (60–92) 1.14 (0.29–4.45) .86
..............................................................................................................................................................................................................................................
Pregnancy type
f
.....................................................................................................................................................................................................................................
Anembryonic 35 24 69 (51–83) Referent
.....................................................................................................................................................................................................................................
IUED/IUFD 84 74 88 (79–94) 3.80 (1.21–11.88) .022
..............................................................................................................................................................................................................................................
Follow-up visit to emergency
department
.....................................................................................................................................................................................................................................
No 96 87 91 (83–96) Referent
.....................................................................................................................................................................................................................................
Yes 27 15 56 (35–75) 0.12 (0.04–0.42) .001
..............................................................................................................................................................................................................................................
CI, confidence interval; IUED/IUFD, intrauterine embryonic/fetal demise; OR, odds ratio.
a
Adjusted for all factors shown;
b
FromWald ␹
2
test;
c
General obstetrics and gynecologic faculty (all academic faculty and private
faculty who were not members of gynecologic specialties faculty);
d
Academic gynecology faculty;
e
All supervised by gynecologic
specialties faculty;
f
Incomplete/inevitable abortion not included because of small sample (n ϭ4).
Kollitz. Mifepristone and misoprostol for EPF. AmJ Obstet Gynecol 2011.
www.AJOG.org General Gynecology Research
MAY 2011 American Journal of Obstetrics &Gynecology 386.e4
concerns. Whereas study protocols typi-
cally limit when surgical intervention
can occur, women are treated outside of
a study protocol appear to be interested
indeclining additional misoprostol if the
first treatment did not work.
The first-dose success rates in our
study are also lower than that found in
clinical trials using mifepristone and mi-
soprostol for EPF. Schreiber et al
12
re-
ported a first-dose success rate of 90%
Ͼ24 hours and an overall success rate of
93%using mifepristone andmisoprostol
in combination for EPF. Although our
cohort was given the same dosing sched-
ule and more time to expel products of
conception, it appears that treatment
outside of a research setting resulted in
lower first-dose success rates. Our first-
dose success rate of 80% is higher than
the reported 71% for misoprostol.
5
Given that women are likely to only take
1 dose of misoprostol ina clinical setting,
it appears that the addition of mifepris-
tone does offer additional benefit over
misoprostol alone.
The finding that women are less likely
to use a second dose in clinical practice
also limits the interpretation of cost-ef-
fectiveness analyses that have been pub-
lished evaluating medical treatment of
EPF.
17,18
Such analyses typically depend
on the outcomes outlined in clinical tri-
als, which are likely different than clini-
cal practice. Accordingly, new analyses
are needed before we can make cost-
based conclusions.
Previously, Creinin et al
19
found that
lower abdominal pain, vaginal bleeding,
Rh-negative blood type, and nulliparity
were associated with increased chances
of successful treatment with misopros-
tol. We found that follow-up visits in the
ED were negatively associated with suc-
cess while a diagnosis of intrauterine em-
bryonic/fetal demise raised the chances
of successful treatment with mifepris-
tone and misoprostol. These different
findings may reflect the outcomes seen
in real-life practice as opposed to what is
seen with treatment under a strict study
protocol.
We initially believed that making the
treatment available in the ED would be a
benefit, allowing women to receive im-
mediate treatment after diagnosis if they
desired. However, the high rate of return
care in the EDdemonstrates that women
who are treated in the ED will return,
perhaps because they do not identify a
clinic or office as their place of care. Ac-
cordingly, we found that lost-to-fol-
low-up rates were highest in the ED-
treated population. Although women
who had an ED follow-up were more
likely to have surgical intervention, it is
unclear if these women were just more
likely to need an emergent suction pro-
cedure or if womenwhoreturntothe ED
may more easily opt out of the process
and have surgical intervention. Based on
these findings, improving both the lost-
to-follow-up rates and utilization of re-
sources may be achieved by deferring
medical treatment to an office setting.
There were a few important differ-
ences in this analysis compared with
medical abortion in a clinical setting.
Our loss-to-follow-up rate of 14% is
much higher than rates reported for
medical abortion. Creinin et al
20
studied
medical abortion in a nonresearch set-
ting andusedthe same medications, dos-
ing, and follow-up schedule examined
here. They reported only 2% of patients
as lost to follow-up. It is likely that pa-
tients view treatment for medical abor-
tion differently than EPF. These differ-
ences merit further investigation. In
addition, Creinin et al
20
observed a 95%
first-dose success rate withmedical abor-
tion, which is much higher than the rate
of 80% found in this analysis. It remains
unclear why medical management of
EPF is not as effective as with medical
abortion, and this difference also merits
study.
These findings are limited by the ret-
rospective nature of data collection. The
innovative treatment program did not
include standard documentation forms
so the data that was collected came di-
rectly from patient charts, which may
not have contained every interesting de-
tail about the patient’s care. Although
the treatment protocol was standard-
ized, clinicians used their own clinical
judgment to decide on intervention. It is
exactly for this reason that this informa-
tionis important tothe medical commu-
nity. These findings suggest that women
treated with mifepristone and misopros-
tol for EPF are different than women
who receive the same treatment for med-
ical abortion. Womenandphysicians are
potentially more willing to do a suction
aspiration procedure if the bleeding
seems a little heavy or the patient just
wants to resolve her symptoms–both
circumstances where a suction aspira-
tion would not be indicated under a re-
search protocol. These factors may have
been exemplified by the availability
of office aspiration, although our num-
bers were too small to evaluate that
hypothesis.
It is likely that improved education of
clinicians and counseling of patients could
help to reduce surgery rates, especially in
regardtounderstanding that ultrasoundis
only meant to determine if the gestational
sac has expelled and that incomplete abor-
tion is a clinical diagnosis. The difference
in success rates in clinical practice as com-
pared to research trials may center on this
misinterpretation of the follow-up ultra-
sound evaluation. The most important in-
formation demonstrated by this study is
that in real life, success rates are variable.
Physicians may misinterpret study testing
TABLE 3
Patients with at least 1 follow-up visit in emergency
department based on site of initial treatment
Place of initial
treatment n
Follow-up in
emergency department
Percent
(95% CI)
Resident clinic 51 12 24 (13–37)
..............................................................................................................................................................................................................................................
Faculty office 43 2 5 (1–16)
..............................................................................................................................................................................................................................................
Emergency department 29 13 45 (26–64)
..............................................................................................................................................................................................................................................
Total 123 27 22 (15–30)
..............................................................................................................................................................................................................................................
CI, confidence interval.
Kollitz. Mifepristone and misoprostol for EPF. AmJ Obstet Gynecol 2011.
Research General Gynecology www.AJOG.org
386.e5 American Journal of Obstetrics &Gynecology MAY 2011
and womenare likely to decline additional
misoprostol if the first medical interven-
tion fails. f
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