In a non-vital pregnancy, something goes wrong in the first fourteen weeks of pregnancy
The combination of two drugs, misoprostol and mifepristone, improves outcomes in treating a non-vital pregnancy and reduces complications. The costs are also going down. This is the conclusion of Lotte Hamel’s PhD research, conducted within a collaboration between Radboudumc and Canisius Wilhelmina Hospital (CWZ). The combination is already in the Dutch guideline, but is not yet reimbursed by health insurers.
In a non-vital 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 does not end in a miscarriage on its own, treatment is needed to empty the uterus again. More than 20 million women worldwide seek medical help for this every year. That number will continue to rise, as women are getting pregnant later and later, and the chance of a non-vital pregnancy increases with age.
The termination of a pregnancy is done with a curettage, emptying the uterus with a suction tube, or with medicines that induce a miscarriage. A curettage is more likely to cause complications, which is why drugs 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 also better in non-vital pregnancies.
Smart combination
‘We used to only use misoprostol, but we now show that pre-treatment 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. That rose to eighty percent with the combination of drugs. In addition, with misoprostol alone, a curettage was still necessary in thirty percent of the women. That dropped to ten percent by both means.’
The combination of drugs not only improves outcomes in the termination of non-vital pregnancies, but also appears to be cost-effective. Although the addition of the second drug mifepristone entails additional costs, Hamel calculated that the combination ultimately saves an average of 135 euros per patient. The addition of mifepristone in many cases prevents further examination with ultrasound and a possible curettage.
Recommended in the guideline
The results of the study were measured after a waiting period of one week between the interview with the patient and the start of treatment. For the time being, a waiting period of five days is mandatory in the Netherlands for an abortion in the event of a vital pregnancy, but not in the case of a non-vital pregnancy. ‘Nevertheless, I argue in favor of the waiting period, even if the pregnancy has stopped developing’, explains Hamel. ‘In half of the cases, a miscarriage still starts spontaneously during the waiting period. The body then regulates the miscarriage itself and medication is not necessary. I think for women this is better for processing.’
In 2020, the combination of the two medicines will be included in the guideline of the Dutch Association for Obstetrics and Gynaecology (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 the Maxima Medical Center. ‘The evidence that the combination works better is therefore very convincing. Unfortunately, the health insurers do not reimburse it yet. Sometimes hospitals pay for it themselves, but that is not possible everywhere. Hopefully the insurers will soon reimburse this care in the basic package.’
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