Medical management of early pregnancy loss with mifepristone and misoprostol in Emergency Departments compared to a Complex Family Planning office: implementation of a COVID-19 institutional policy change.

OBJECTIVES: To evaluate the implementation of mifepristone and misoprostol for medical management of early pregnancy loss (EPL) in emergency departments (EDs) by comparing efficacy, complication, and follow-up rates for patients treated in EDs to those in the Complex Family Planning (CFP) outpatient office.

STUDY DESIGN: In COVID-19's first wave, we expanded medication management of EPL to our EDs. This retrospective study evaluated 72 patients receiving mifepristone and misoprostol for EPL from 4/1/2020-3/31/2021, comparing treatment success, safety outcomes, and follow-up rates by location. We did not perform a power calculation.

RESULTS: Thirty-three (46%) patients received care in the ED and 39 (54%) at CFP. Treatment success was lower in the ED (23, 70%) compared to CFP (34, 87.2%), but after adjusting for insurance status and type of pregnancy (miscarriage, uncertain viability, unknown location) this was not significant: aOR 0.48 (95%CI 0.13-1.81), p=0.28. More ED patients underwent emergent interventions (3 vs 0). Complications in the ED cohort included two emergent uterine aspirations, one uterine artery embolization, and two blood transfusions. Among these, two cases were attributed to misdiagnosis (a cesarean scar and a cervical ectopic pregnancy interpreted as incomplete miscarriages) and one to guideline nonadherence (anticoagulated patient). No complications occurred in the CFP group. Follow-up rates were over 80% in both groups. More ED patients engaged in telehealth follow-up (67% vs 18.0%, p≤0.0001).

CONCLUSIONS: In this small sample, we observed a trend toward lower rates of treatment success following medication management of EPL in the ED, compared to the CFP office. This analysis highlights that both correctly making uncommon diagnoses and adhering to new guidelines presented challenges during our implementation process.

IMPLICATIONS: Implementing mifepristone and misoprostol for EPL in our EDs achieved lower rates of pregnancy resolution compared to outpatient management. Complex uncommon diagnoses and implementing new care pathways in EDs may have contributed to complications and highlight opportunities for improvement. Additional studies are needed to further quantify safety outcomes for EPL management in EDs.

TWEETABLE ABSTRACT: ED provision of mifepristone and misoprostol for early pregnancy loss during COVID-19 was less effective than outpatient care. There were more serious complications in the ED group due to misdiagnosis and guideline nonadherence.