Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial.

OBJECTIVE: To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. DESIGN: Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS). SETTING: Twenty-eight UK NHS early pregnancy units. SAMPLE: A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage. METHODS: Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. MAIN OUTCOME MEASURES: Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). RESULTS: For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. CONCLUSIONS: The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. TWEETABLE ABSTRACT: The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

Comparative study of intravaginal misoprostol with gemeprost as an abortifacient in second trimester missed abortion.

This prospective, randomized study compared the efficacy of intravaginal misoprostol (Cytotec) and gemeprost (Cervagem) as an abortifacient for intrauterine deaths in second trimester pregnancy. Side-effects, complications and the cost-effectiveness associated with each drug were assessed. 21 out of 25 patients (84%) in the misoprostol group aborted whereas only 17 out of 25 patients (68%) in the gemeprost group aborted within 24 hours after the initiation of therapy. In the misoprostol group, the abortion rate was influenced by the gestational age with 100% abortion rate for those > 17 weeks' gestation compared to 67% for those with a gestational age of 13-16 weeks. Side-effects were rare in either group and no major complications were reported in either group. Misoprostol was definitely more cost-effective compared to gemeprost as the mean cost of inducing an abortion using misoprostol was RM 1.08 whereas that of gemeprost was RM 105. We thus concluded that misoprostol was at least as effective as gemeprost as an abortifacient for intrauterine death in second trimester pregnancy. Moreover, it was less costly, with very few side-effects.

PIP: The efficacy of intravaginal misoprostol (Cytotec) and gemeprost (Cervagem) as abortifacients in second-trimester pregnancies was compared in a prospective study of 50 women admitted to Hospital Kuala Lumpur (Malaysia) with an intrauterine death at a gestational age of 13-26 weeks. 25 women were randomly assigned to receive 200 mcg of misoprostol inserted into the posterior fornix of the vagina every 3 hours until abortion occurred; the remaining 25 women received 1 mg of gemeprost every 3 hours until abortion. Within 24 hours of drug administration, 21 women (84%) in the misoprostol group and 17 (68%) in the gemeprost group had aborted. In the misoprostol group, the abortion rate was influenced by gestational age; this rate was 100% in women with pregnancies over 17 weeks' gestation compared with 67% in women in weeks 13-16. No major side effects or complications occurred in either group. The mean cost of abortion induction was RM 1.08 with misoprostol and RM 105 with gemeprost. Misoprostol seems to be the drug of choice for second-trimester pregnancy termination. Not only is intravaginal misoprostol at least as effective as gemeprost, it is less costly, does not require refrigeration for storage, and is associated with few side effects. Additional studies with larger sample sizes are recommended to determine the optimal misoprostol dosage and frequency of administration.