Miscarriage Treatment-Related Morbidities and Adverse Events in Hospitals, Ambulatory Surgery Centers, and Office-Based Settings

Preimplantation genetic testing for aneuploidy in unexplained recurrent pregnancy loss: a systematic review and meta-analysis

IMPORTANCE

Preimplantation genetic testing for aneuploidy (PGT-A) to deselect aneuploid embryos in assisted reproductive technology (ART) treatment cycles may hold promise by augmenting pregnancy rates per transfer and reducing pregnancy loss rates for patients with unexplained recurrent pregnancy loss (RPL).

OBJECTIVE

To explore effectiveness of PGT-A in managing unexplained RPL by evaluating several key aspects: the likelihood of live birth in a subsequent spontaneous pregnancy, whether women with unexplained RPL have a higher rate of aneuploidy, whether euploid blastocysts offer comparable live birth rate (LBR) in patients with unexplained RPL, whether the endometrium is less selective in unexplained RPL loss, and whether PGT-A increases the LBR or reduces pregnancy losses until delivery.

DATA SOURCES

PubMed and Cochrane Library databases were searched from inception until June 2024.

STUDY SELECTION AND SYNTHESIS

Studies involving patients with ≥2 unexplained RPL who underwent ART with or without PGT-A or expectant management were included.

MAIN OUTCOME MEASURES

The primary outcome measure was the LBR. Secondary outcome measures were aneuploidy rate, clinical pregnancy rate, and clinical pregnancy loss rate.

RESULTS

Whether couples with unexplained RPL have higher embryo aneuploidy rates remains equivocal. Euploid blastocyst transfers yielded comparable clinical pregnancy loss rate (odds ratio [OR], 1.10; 95% confidence interval [CI], 0.57-2.13) and LBR (OR, 1.04; 95% CI, 0.74-1.44) in patients with and without unexplained RPL. Comprehensive chromosome analysis of products of conception shows similar aneuploidy rates between patients with and without RPL and does not support the less selective endometrium hypothesis. Preimplantation genetic testing for aneuploidy decreased clinical pregnancy loss rate (OR, 0.42; 95% CI, 0.27-0.67) and enhanced LBR per transfer (OR, 2.17; 95% CI, 1.77-2.65) and LBR per patient (OR, 1.85; 95% CI, 1.18-2.91) in patients with unexplained RPL.

CONCLUSION AND RELEVANCE

Current low-quality evidence suggests that PGT-A enhances LBR per transfer and per patient in unexplained RPL. Well-designed randomized controlled trials comparing ART with PGT-A vs. expectant management for unexplained RPL are warranted.

REGISTRATION NUMBER

CRD42021291546.

Deception by obfuscation: Studnicki et al.'s retracted longitudinal cohort study of emergency room utilization following abortion

OBJECTIVES

In November 2022, the anti-abortion advocacy group Alliance for Hippocratic Medicine filed a lawsuit against the U.S. Food and Drug Administration challenging the initial 2000 approval of mifepristone and its subsequent approvals, which removed unnecessary restrictions on its use, by disputing the medication's safety record. Such challenges relied on a study examining the incidence of emergency room visits following medication abortion with mifepristone and procedural abortion using Medicaid claims data from 1999-2015. In February 2024 that study was retracted by its publisher. In this paper, we analyzed the methods and presentations of the data used in the study.

STUDY DESIGN

We drew upon commonly accepted principles in responsible epidemiologic and scientific research to evaluate the methods and presentations of the data and organized our findings into themes.

RESULTS

We found multiple instances of methodological flaws, mischaracterizations, and obfuscations of data in this study, including use of a misleading research question and framing, analytic flaws, inappropriate use of an unvalidated proxy measure for outcomes of interest, and inappropriate and deceptive visualizations of data. In each instance, the resulting effect obfuscated and misrepresented the safety of medication abortion with mifepristone.

CONCLUSIONS

The misrepresentation and exaggeration of data promoted and exacerbated misinterpretations about the study's findings, resulting in substantial harm before it was retracted. Recognizing that ongoing judicial proceedings threaten access to conventional reproductive health care in the United States, public health policies must be informed by scientific and medical literature that is comprehensive, methodologically sound, and absent any obfuscations or misrepresentations.

IMPLICATIONS

Studnicki et al.'s study of emergency room visits after abortion misrepresented the safety of mifepristone with multiple instances of methodological flaws and obfuscations of data. While the study has now been retracted, it led to irrevocable harm, threatening access to medication abortion, which has an established safety record.

What organisational and regional factors influence the outpatient provision of curettages in Germany? A longitudinal secondary data analysis using hospital quality reports data from 2013 to 2019

OBJECTIVES

The rate of outpatient therapeutic curettage is lower in Germany than in other countries, although there are no differences in patient safety between outpatient and inpatient management. In this context, outpatient surgery is economically advantageous and efficient. This study aims to identify organisational and regional factors that determine the rate of outpatient curettage in German hospitals.

METHODS

We analysed the hospital quality reports for 2013-2019, which include data from all German hospitals with gynaecology departments (n=709). These organisational data (teaching status, size, ownership, department type and hospital group) are enhanced by contextual data (degree of urbanisation, market concentration and population income). We calculated a zero-one inflated beta regression model to identify factors that influence the rate of outpatient curettages in 2019.

RESULTS

Increasing numbers of curettages are provided on an outpatient basis; accordingly, the number of inpatient curettages declined during the analysis period. In 2019, 69.6% of in-hospital curettages were performed as outpatient surgery. Hospital size is significantly negative and outpatient physician department type is significantly positively associated with outpatient curettage rates. We found no effects of hospital ownership type, degree of urbanisation or market concentration. A high income in the surgical district's population is also associated with a higher rate of outpatient curettages.

CONCLUSIONS

The analyses demonstrate that organisational factors are associated with the outpatient curettage rate. This indicates that external elements, such as reimbursements and regulations, influence outpatient surgical events in Germany, and current regulations do not incentivise hospitals to significantly increase their rate of outpatient curettages.

Early Pregnancy Loss Management in the Emergency Department vs Outpatient Setting

Importance

Early pregnancy loss (EPL), or miscarriage, is the most common complication of early pregnancy, and many patients experiencing EPL present to the emergency department (ED). Little is known about how patients who present to the ED with EPL differ from those who present to outpatient clinics and how their management and outcomes differ.

Objective

To compare the management and outcomes of patients with EPL who present to the ED vs outpatient clinics.

Design, Setting, and Participants

This retrospective cohort study used the IBM MarketScan Research Database, a national insurance claims database. Participants were pregnant people aged 15 to 49 years in the US who presented to either an ED or outpatient clinic for initial diagnosis of EPL from October 2015 through December 2019. Data analysis was performed from May 2021 to March 2022.

Exposures

The primary exposure was location of service (ED vs outpatient clinic). Other exposures of interest included demographic characteristics, current pregnancy history, and comorbidities.

Main Outcomes and Measures

The primary outcome was EPL management type (surgical, medication, or expectant management). Complications, including blood transfusion and hospitalization, and characteristics associated with location of service were also evaluated. Bivariable analyses and multivariable logistic regression were used for data analysis.

Results

A total of 117 749 patients with EPL diagnoses were identified, with a mean (SD) age of 31.8 (6.1) years. Of these patients, 20 826 (17.7%) initially presented to the ED, and 96 923 (82.3%) presented to outpatient clinics. Compared with the outpatient setting, patients in the ED were less likely to receive surgical (2925 patients [14.0%] vs 23 588 patients [24.3%]) or medication (1116 patients [5.4%] vs 10 878 patients [11.2%]) management. In the adjusted analysis, characteristics associated with decreased odds of active (surgical or medication) vs expectant management included ED (vs outpatient) presentation (adjusted odds ratio [aOR], 0.46; 95% CI, 0.44-0.47), urban location (aOR, 0.87; 95% CI, 0.82-0.91), and being a dependent on an insurance policy (vs primary policy holder) (aOR, 0.71; 95% CI, 0.67-0.74); whereas older age (aOR per 1-year increase 1.01; 95% CI, 1.01-1.01), established prenatal care (aOR, 2.35; 95% CI, 2.29-2.42), and medical comorbidities (aOR, 1.05; 95% CI, 1.02-1.09) were associated with increased odds of receiving active management. Patients in the ED were more likely than those in outpatient clinics to need a blood transfusion (287 patients [1.4%] vs 202 patients [0.2%]) or hospitalization (463 patients [2.2%] vs 472 patients [0.5%]), but complications were low regardless of location of service.

Conclusions and Relevance

In this cohort study of privately insured patients with EPL, differences in management between the ED vs outpatient setting may reflect barriers to accessing comprehensive EPL management options. More research is needed to understand these significant differences in management approaches by practice setting, and to what extent EPL management reflects patient preferences in both outpatient and ED settings.

Disseminating Evidence on Abortion Facilities to Health Departments: A Randomized Study of E-mail Strategies

Given the politicization of abortion, professionals working in U.S. health departments (HDs) may not be receptive to communications about abortion, despite often regulating abortion facilities. This paper reports results of a randomized, prospective, observational study to test the effects of e-mail language when disseminating evidence on abortion to HD professionals. Our sample was 302 HD employees who oversee healthcare facilities inspection/regulation in all 50 U.S. state HDs, clustered by HD and randomized into two study groups. In November-December 2019, we sent biweekly e-mails containing links to a website summarizing evidence on abortion facility regulation. E-mails/headers sent to one group emphasized public health values and did not include the word abortion; e-mails/headers to the other group used the word abortion. Primary outcome measures were e-mail open rates and click-through rates. Among 221 participants to whom e-mails were deliverable, the overall open rate was 36%. Open rate was 25% for PH values and 46% for abortion groups (p < .05). Effects were moderated by state abortion policy environment: in both supportive and restrictive environments, participants in the abortion messaging group were statistically more likely to open e-mails than those in the PH values group. There was no difference between groups in states with middle-ground abortion policy environments. Among participants opening at least one e-mail, 19% clicked through to the website, with no significant difference by group. This study demonstrates that repeated targeted e-mail campaigns can reach HD professionals with research summaries. Concerns that communications to HDs should avoid the word abortion are unsupported.

Effect of a family planning program on documented emotional support and reproductive goals counseling after previable pregnancy loss

OBJECTIVES

To evaluate the effect of the Ryan Program for family planning training on patient counseling surrounding previable pregnancy loss.

METHODS

We conducted a retrospective cohort study of patients with first- and second-trimester miscarriages, therapeutic abortions, ectopic and molar pregnancies, from years before and after establishing a Ryan Program. We compared documentation of coping and future reproductive goals by patient factors, using chi square testing and logistic regression.

RESULTS

We included 285 pregnancies: 138 pre-Ryan, 147 post-Ryan. Documentation of coping and future goals was greater post-Ryan than pre-Ryan (57.8% vs. 26.8% for coping, 72.8% vs. 50.7% for goals; both p < 0.001). Coping was less likely to be documented for adolescents (aOR 0.02), patients of Asian race (aOR 0.08), those diagnosed in the emergency department (aOR 0.22), and those with ectopic or molar pregnancy (aOR 0.14) (all p < 0.005). Coping documentation increased with second-trimester loss (aOR 6.19) and outpatient follow-up (aOR 3.41) (all p < 0.005).

CONCLUSIONS

Establishment of a Ryan Program was associated with greater attention to patient coping and goals after previable pregnancy loss. Patients experiencing medically-dangerous pregnancy losses receive less attention to their coping.

PRACTICE IMPLICATIONS

Comprehensive family planning training and outpatient access may improve patient-centeredness of care for previable pregnancy loss.

Healthcare costs for abortions performed in ambulatory surgery centers vs office-based settings

BACKGROUND

Several states require that abortions be provided in ambulatory surgery centers. Supporters of such laws argue that they make abortions safer, yet previous studies have found no differences in abortion-related morbidities or adverse events for abortions performed in ambulatory surgery centers versus office-based settings. However, little is known about how costs of abortions provided in ambulatory surgery centers differ from those provided in office-based settings.

OBJECTIVE

To compare healthcare expenditures for abortions performed in ambulatory surgery centers versus office-based settings using a large national private insurance claims database.

MATERIALS AND METHODS

A retrospective cohort study compared expenditures for abortions performed in ambulatory surgery centers versus office-based settings. Data on women who had abortions in an ambulatory surgery center or office-based setting between January 1, 2011, and December 31, 2014 were obtained from the MarketScan Commercial Claims and Encounters database. The sample was limited to women who were continuously enrolled in their insurance plans for at least 1 year before and at least 6 weeks after the abortion. Healthcare expenditures were assessed separately for the index abortion and the 6-week period after the abortion. Costs were measured from the perspective of the healthcare system and included all payments to the provider, including insurance company payments and any patient out-of-pocket payments.

RESULTS

Overall, 49,287 beneficiaries who had 50,311 abortions met inclusion criteria. Of the included abortions, 47% were first-trimester aspiration, 27% first-trimester medication, and 26% second-trimester or later abortions. Most abortions (89%) were provided in office-based settings, with 11% provided in ambulatory surgery centers. Unadjusted mean index abortion costs were higher in ambulatory surgery centers than in office-based settings ($1704 versus $810; P < .001). After adjusting for patient clinical and demographic characteristics, costs of index abortions were $772 higher (95% confidence interval, $746-$797), total follow-up costs for abortions that had any follow-up care were $1099 higher (95% confidence interval, $1004-$1,195), and total follow-up costs for abortions that had an abortion-related morbidity or adverse event were not significantly different in ambulatory surgery centers compared to office-based settings. There were also no significant differences in the likelihood of having any follow-up care or abortion-related event follow-up care.

CONCLUSION

Abortions performed at ambulatory surgery centers are significantly more costly than those performed in office-based settings, with no difference in the likelihood of receiving follow-up care. Laws requiring that abortions be provided in ambulatory surgery centers may only result in increased costs for abortions, with no effect on abortion safety.