Examining the Evidence
Are ObGyns offering the range of treatment options for early pregnancy failure?
NO The findings of this survey of 976 ObGyns, midwives, and family medicine practitioners suggest that modern approaches to early pregnancy failure (EPF) are much underutilized.
Although misoprostol administration and office evacuation of uterine contents have each been demonstrated to be safe, effective, and economical, 52.7% of ObGyn respondents reported that they had not used misoprostol for EPF during the 6 months preceding the survey, and only 16.2% had performed office uterine evacuation. Rather, most respondents continue to rely on expectant management or perform uterine evacuation under general anesthesia in the operating room.
Dalton VK, Harris LH, Gold KJ, et al. Provider knowledge, attitudes, and treatment preferences for early pregnancy failure. Am J Obstet Gynecol. 2010;202(6):531.e1–e8.
One in every four women experiences EPF. Although office uterine evacuation and misoprostol administration are less invasive and less expensive alternatives to traditional OR evacuation, it is not clear how extensively clinicians employ these options in the United States.1,2
In 2008, Dalton and colleagues surveyed ObGyns, certified nurse midwives (CNMs), and family physicians (FPs) in the United States who had evaluated or treated, or both, a woman for EPF in the preceding 6 months. They achieved response rates of 51.0%, 70.9%, and 53.5%, respectively. Evaluable respondents had a mean age of 49 to 50 years and included 309 ObGyns (46.9% of whom were female), 368 CNMs (97.8% female), and 299 FPs (43.6% female).
Overall, approximately one third of respondents believe that office evacuation is riskier than OR evacuation. In addition, 65.7% of ObGyns believe that most patients prefer OR evacuation, compared with 46.2% and 43.1% of CNMs and FPs, respectively (P < .001). Among ObGyns, an adjusted analysis estimated the likelihood of providing office evacuation to be five times higher among those who have undergone training in induced abortion (P < .05). As for misoprostol for EPF, about two thirds of respondents overall believe that it is safe.
Dalton and associates posit that providers “perceive that their personal treatment preferences are different than their patients’. Whether this discordance results in women undergoing operating room uterine evacuation more often than is necessary or preferred could not be assessed by this study.” However, the authors also assert that, “given that providers affect treatment choice greatly, it is plausible that provider treatment preferences are an important influence on current treatment patterns.”
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Certainly, women have diverse preferences for how EPF is managed, but many do find office evacuation and misoprostol to be acceptable methods. Accordingly, we should offer all options to them. As the investigators in this study suggest, we may need to focus on correcting inaccurate beliefs about these modalities among providers to increase their willingness to offer them.
The findings of this survey also underscore the fact that training programs that do not teach induced abortion—or that allow trainees to opt out of such training—can compromise the care provided to women who have EPF.—ANDREW M. KAUNITZ, MD
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1. Zhang J, Gilles JM, Barnhart K, et al. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med. 2005;353(8):761-769.
2. Harris LH, Dalton VK, Johnson TR. Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care. Am J Obstet Gynecol. 2007;196(5):445.e1–e5.-