An Economic Perspective on Early Pregnancy Failure

An Economic Perspective on Early Pregnancy Failure February 18, 2010 Neel Shah, MD, MPP

Case ID: 37 yo G3P1011 @ 9 wk GA HPI: + pregnancy test PObHx: SVD x 1 (term), TAB x 1 (12wk) PGynHx: irreg menses, nml PAP, no STI PMH: unremarkable PSH: none Meds: PNV All: NKDA SH/FH: noncontributory

Case PEx: AVSS abd soft/NT/ND pelvic slightly enlarged freely mobile uterus, no mass speculum os visualized and closed, no blood, physiologic discharge Labs: HCG 13863 HCT 42 PLT 241

First Trimester SAB Surgical Expectant Medical Septic Hemorrhage Threatened Complete Inevitable Missed Incomplete

Decision-Making Paradigm Safety Efficacy Cost

Decision-Making Paradigm Safety

MIScarriage Treatment (MIST) Trial Trinder J, et al. BMJ 2006;332:1235-1240 ,[object Object],[object Object],[object Object],[object Object],[object Object]

Management Evidence: Safety Trinder J, et al. BMJ 2006;332:1235-1240

Management Evidence: Safety Smith LF, Ewings PD, Quinlan C. BMJ. 2009 Oct 8;339:b3827

Decision-Making Paradigm Safety Efficacy

Management Evidence: Efficacy Study Type of SAB Treatment Arm Outcomes Blohm et al (2005) “ signs of miscarriage” (n = 126) ,[object Object],[object Object],54% complete at 7d 81% complete at 7d

Management Evidence: Efficacy Study Type of SAB Treatment Arm Outcomes Blohm et al (2005) “ signs of miscarriage” (n = 126) ,[object Object],[object Object],54% complete at 7d 81% complete at 7d Zhang et al (2005) “ pregnancy failure” (n = 652) ,[object Object],[object Object],84% complete at 8d 97% successful

Management Evidence: Efficacy ,[object Object],[object Object],[object Object],[object Object],Study Type of SAB Treatment Arm Outcomes Blohm et al (2005) “ signs of miscarriage” (n = 126) ,[object Object],[object Object],54% complete at 7d 81% complete at 7d Zhang et al (2005) “ pregnancy failure” (n = 652) ,[object Object],[object Object],84% complete at 8d 97% successful Trinder et al (2006) Incomplete or missed (n = 1200) ,[object Object],[object Object],[object Object],50% curettage 38% curettage 5% repeat

Cost-effectiveness: MIST trial ,[object Object],Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89 C medical - C surgical E medical - E surgical C = hospital resources, cost to woman, lost production E = gynecological infection avoided

Cost-effectiveness: MIST Trial Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89

Cost-effectiveness: MIST Trial Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89 C medical - C surgical E medical - E surgical C = hospital resources, cost to woman, lost production E = gynecological infection avoided

Cost-effectiveness: MIST trial ,[object Object],[object Object],Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89 nonparametric bootstrap estimation (95% CI) simultaneously summarizes uncertainty in costs and effects uses alternative willingness to pay thresholds for preventing gyn infection C medical - C surgical E medical - E surgical C = hospital resources, cost to woman, lost production E = gynecological infection avoided

Cost-effectiveness Medical vs. Surgical

Cost-effectiveness Medical vs. Surgical Expectant vs. Surgical Expectant vs. Medical

Cost-effectiveness expectant medical surgical 98% 2%

Manual Vacuum Aspiration Rocconi RP et al. J Reprod Med. 2005 Jul;50(7):486-90 X 500K women = $779M savings

Summary ,[object Object],[object Object],[object Object]

An Economic Perspective on Early Pregnancy Failure

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