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Comparison of the cost-effectiveness of methods to terminate pregnancy in the indicated patients at Naresuan University HospitalRissara RatchaneesiripapMarkhan JehleeSatit Sataporntanawat

Medical Students, 5th yearFaculty of medicine Naresuan University AdvisorPatcharada Amatyaku M.D.Sutatip Pongcharoan, M.D.1IntroductionSpontaneous abortions can be occur in every pregnant women especially in the first trimester that was found about 25-50% (Jana L Allison, MD, et al, Management of First Trimester Pregnancy Loss Can Be Safely Moved Into the Office, Rev Obstet Gynecol.2011; 4(1): 5-14)

More than 80 % of Spontaneous abortion occur in the first trimester and most of Spontaneous abortions need to terminate of pregnancy such as inevitable abortion, incomplete abortion, missed abortion, and septic abortion (Teera Tongsong, 2541)2IntroductionAbortion has been understood by many as termination of unwanted pregnancy. Article 305 of Thai Penal Code states that abortion is illegal except in cases when it is committed by a medical practitioner and is considered only as necessary if the same endangers the health of the mother or when the pregnancy is due to sexual offences such as rape and incest (Article 305 of Thai Penal Code )

3IntroductionAbout the study, carried out in Thailand in 1999 in 787 government hospitals, examined the magnitude and profile of abortion in Thailand, using data collected prospectively through a review of 45,990 case records (of which 28.5% were classified as induced and 71.5% as spontaneous abortions) and face-to-face interviews with a sub-set of 1854 women patients. Socio-economic reasons accounted for 60.2% of abortions and Medical indications accounted for 30.8%. (Family Planning and Population Division , Department of Health, Ministry of Public Health)4IntroductionThe methodology to termination of pregnancy has a lot of methods for example expectant, medical treatment, and surgical treatment(Jana L Allison, MD, et al, Management of First Trimester Pregnancy Loss Can Be Safely Moved Into the Office, Rev Obstet Gynecol.2011; 4(1): 5-14)The study about the outcome of medication and aspiration for terminating the pregnancy in first trimester , was found both methods was highly successful and low complication (Ian M. Bennett, MD, PhD et al, Early Abortion in Family Medicine: Clinical Outcomes, Ann Fam Med. 2009 November; 7(6): 527533.)

5IntroductionThe study, which compared the cost-effectiveness of MVA, Misoprostol, and Curettege was found MVA is the most effective method with the least complications and cheapest. (D Hu, D Grossman, C Levin, K Blanchard, SJ Goldie , 2009)

This research is to compare the cost-effectiveness of methods for terminating abnormal first trimester pregnancy among indicated patients at Naresuan University.

6ObjectiveTo compare the successful of Misoprostol, Curettage, and Manual Vacuum Aspiration (MVA) in abnormal first trimester pregnancy who need to terminate the pregnancy.To compare the cost of Misoprostol, Curettage, and Manual Vacuum Aspiration (MVA) in abnormal first trimester pregnancy who need to terminate the pregnancy. To compare the complication of Misoprostol, Curettage, and Manual Vacuum Aspiration (MVA) in abnormal first trimester pregnancy who need to terminate the pregnancy.

7Material and Methods(1)PopulationFor this research, they were collected from 53 abnormal pregnant women in first trimester , who need to terminate the pregnancy at Naresuan university hospital since 1 January, 2007- 15 July, 20118Material and Methods (2)Example abnormal pregnant women in first trimester who need to terminate the pregnancy at Naresuan university hospital (n= 53 ) abnormal pregnant women in first trimester who need to terminate the pregnancy by Misoprostol at Naresuan university hospital(n=16 ) abnormal pregnant women in first trimester who need to terminate the pregnancy by Curettage at Naresuan university hospital (n= 30 ) abnormal pregnant women in first trimester who need to terminate the pregnancy by MVA at Naresuan university hospital (n= 7 )9Material and Methods (3)Inclusion CriteriaAbnormal pregnant women who had to terminate their pregnancy in first trimester (14 weeks) Abnormal pregnancyEarly embryonic deathDeath fetus in uteroBlighted ovumMissed abortionElective caseNo complication before treatment

10Material and Methods (4)Exclusion CriteriaTwin Maternal healths problem Ex SLE, CHF RapedSerious complication before treatment Molar pregnancy

11Material and Methods (5)SettingObstetrics and Gynecology department at Naresuan university hospitalThe medical records and healthcare services at Naresuan university hospital

MethodsRetrospective cohort study12Material and Methods (6)The variables studiedGeneral dataAgeGestational ageGravidaHistory of previous abortionHeight and BMIUnderlying diseaseMedication

13Material and Methods (7)The variables studiedPeri-termination the pregnancyThe first method to terminate the pregnancyTime to terminate the pregnancyFailure of treatment without complicationComplication (Incomplete abortion, Uterine perforation, Hypovolumic shock, Blood transfusion, pelvic infection)

1414Material and Methods (8)The variables studiedSide effect of Misoprostol, MVA, CurettageThe secondary method after failure of the first method

1515Material and Methods (9)The variables studiedPost-termination the pregnancyHospital periodComplication after termination the pregnancy (Death, Pelvic infection)Hospital cost

16Material and Methods (10)Data sourceSecondary data from Medical record

AnalysisDescriptive statisticsFrequencyPercentageAverage

17Material and Methods (11)Statistics analysisChisquare test and Fishers exact test (P-value of less than 0.05)Student-t testregression analysis1818DefinitionAbortion:is the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability.

Septic abortion : spontaneous or induced abortion associated with bacterial infection.

19DefinitionCriminal abortion : Article 305 of Thai Penal Code states that abortion is illegal except in cases when it is committed by a medical practitioner and is considered only as necessary if the same endangers the health of the mother or when the pregnancy is due to sexual offences such as rape and incest. Therapeutic abortion : a number of diverse medical and surgical disorders that are indication for termination of pregnancy

20DefinitionBlighted ovum :A fertilized ovum (egg) that did not develop or whose development ceased at an early stage, before 6 or 7 weeks of gestationEmbryonic death :The death of an embryo before the 8th week following conception (http://www.medicalnewstoday.com/medicalnews.php?newsid=44486)Death fetus in utero :The death of a fetus, after the 8th week until birth. (World Health Organization. 1999. Fetal Death. Glossary of Terms. Reproductive health in refugee situations)

21Results22Table 1 General characteristicsCharacteristicsMisoprostolMVACurettageP-valuenumber%number%number%Age (Years)0.09 average (SD)27.31 (4.87)32.86(6.47)31.4(8.30)Gravida0.2011062.50457.141136.672637.50114.29723.33300114.29620.00400114.29516.675000013.33BMI (n=10)(n=4)(n=18)0.61< 19.833000633.3219.8-265504100950>2622000316.68Had history of abortion before0.04 yes16.52228.571240.00 no 1593.75571.431860.00Age (Years)Age (Years)23Table 2 Comparison between terminating methods with other factorsCharacteristicsMisoprostolMVACurettagenumber%number%number%P-value0.21 Early embryonic death850.00114.291343.33 Death fetus in utero16.25114.2900 Blighted ovum743.75457.141550.00 Missed abortion00114.2926.67Method of first terminating pregnancy0.00yes1630.19713.213056.60Total dose (g) average (SD) 700(357.78)Prime cervix0.00yes357.141653.33no442.861446.67yes24Table 2 Comparison between terminating methods with other factorsCharacteristicsMisoprostolMVACurettageP-valuenumbernumber%number%Induction-abortion interval (hr)0.00 average (SD) 14.44(18.74)0.31(0.10)0.36(0.09)EBL(ml)0.15 average (SD) 16.88(13.02)11.43(3.78)110(289.41)Successful of terminating pregnancy0.001yes1062.50685.7130100no637.50114.2900CostAverage medical fee 5236 (n=11)5526.71 (n=7) 5312.18(n=19)0.96Average cost in long term complication 0 (n=0)265.5 (n=1)251.5 (n=1)25Table 3 Procedure failure and complicationsCharacteristicsMisoprostolMVACurettagenumber%number%number%Precedure failure318.750000Complication uterine perforation000000 pelvic infection00114.2913.33 Blood transfusion000013.45 bleed000013.45 Incomplete abortion531.25114.2900 Death000000Total complication531.25228.5839.9926Table 4 Comparison between successful of terminating pregnancy with other factorsVariableRR95%CI P-valueMethod0.001-Misoprostol1.000.00-MVA0.380.56 - 2.600.33-Curettage**100% success (n=0) Predict failureGravida0.694-Primigravida-MultigravidaBMI0.694 < 19.819.8-26 >26Age*0.2632 (SD)-2.61 - 9.370.2632remark number in this table is compare non-successful procedure*95% Cl mean diffIf p-value less than 0.15 It will bring to Logistic regression27Table 5 Comparison between complication of terminating of first pregnancy with other factors*95% Cl mean diffIf p-value less than 0.15 It will bring to Logistic regressionVariableRR95%CI RRP-valueMethod0.052-Misoprostol1.000.00-MVA0.910.23 3.630.90-Curettage0.210.05 - 0.980.047Gravida0.148-Primigravida1.000.00-Multigravida3.1250.71 13.670.13BMI0.686 < 19.8 19.8-26 >26Age*0.67 (SD)28Table 6 Comparison of medical fee in first terminating pregnancy with other factors*95% Cl mean diffIf p-value less than 0.15 It will bring to Logistic regressionVariableCoef.95%CI P-valueMethod0.97-Misoprostol5236.641.000.00-MVA5526.72-2074.35 - 2654.500.81-Curettage5312.19-1777.23 - 1928.320.93Gravida0.80-Primigravida5224.651.000.00-Multigravida5420.13-1392.96 - 1783.910.80BMI0.11 < 19.84664.881.000.00 19.8-263357.67-1052.34 - 1771.2830.60 >265024.35-3193.08 - 578.660.16Age0.31 (SD)0.3129Discussion 1 The results of studying the characteristics of pregnant women who terminated their pregnancy no difference of average age all 3 methods because termination of pregnancy does not depend on age but it depends on the decision of physicians and patients no gold standard to terminate in the first trimester pregnancy.30Discussion 2 The number of pregnant times (gravida) no different results. because the most of pregnant women in these three groups were the first pregnancy. but previous abortion when it was compared with these three methods were found that there were a statistical difference. This might be obviously caused by the more times of abortion in those who were terminated by Curettage than the other methods.31Discussion 3 The results of termination of pregnancy when they were compared to the completion of pregnant termination from these three methods were found that there were a significantly statistic difference. The completion of Curettage was 100%. May be In case of failure in the other methods, the pregnancy will be continued to terminate by Curettage. However, there were no difference between the completion of pregnant termination by Misoprostol and MVA. 32Discussion 4 The results of pregnant termination, when they were compared with the complications after these three pregnant termination methods no statistical difference. However, Misoprostol method had more chances to incomplete abortion than the others. The reasons for no statistical difference of complications after these three pregnant termination methods were the analysis of complications was summation of the number of all complications.

33Discussion 5 The expenses for the termination with these three pregnant termination methods no statistical difference. because the first method, misoprostol, cannot be supposed to be completed. When the first method was failed procedure, there was further procedure; that was curettage, this can increase higher expenses. However, if the first method, misoprostol, was completed, the expenses will be significant different.

34Discussion 6The duration of procedures compared with these three pregnant termination methods statistical difference. It was found that MVA, Curettage, and Misoprostol take the least time, respectively.

35Discussion 7This study show the retrospective cohort study was considered by gathering secondary data from medical records and delivery room. Incomplete medical records information bias. To decrease bias, the study should be designed as prospective cohort study.

36Conclusion The pregnant women in the first trimester of gestation age with abnormal pregnancy who plans to terminate pregnancy should use curettage method because it is the most effective method with the least complications and no highly different expenses when it is compared with the other methods.37RecommendationType of this research is retrospective cohort study. Data is getting from medical records only. If have a chance, we plan to do randomized control trial study, that can determine exactly variables and characteristics, prevent of selection bias and other confounds and study in large population. we need more details in complication and medical fee should be seperated such as procedure cost, medication cost.38AcknowledgementsThank youSupasit Pannarunothai, M.D., Dean of the Faculty of Medicine, Naresuan University.Patcharada Amatyakul, M.D., Department of Obstetrics and Gynecology, Naresuan University Hospital for her consultation.Sutatip Pongcharoan, M.D., Department of Medicine, Naresuan University Hospital for her consultation.Suwit Lertkajornjin, M.D., Department of Community, Family and Occupational Medicine, Naresuan University.Medical record and Health Information Management Department, Naresuan University Hospital.Account and Finance Department, Naresuan University Hospital.

39ReferencesJana L Allison, Rebecca S Sherwood, Danny J Schust. Management of First Trimester Pregnancy Loss Can Be Safely Moved Into the Office. Reviews in Obstetrics & Gynecology [PMCID: PMC3100102]. 2011 [cited 2011 August 3]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100102/?tool=pmcentrezKulier R, Cheng L, Fekih A, Hofmeyr GJ, Campana A. Surgical methods for first trimester termination of pregnancy (Review). The Cochrane Library 2009 [cited 2011 August 3]. Available from: http://www.thecochranelibrary.comCunningham, Leveno, Bloom, Hauth, Rouse, Spong. Williams Obstetrics. 23rd Edition. The McGraw-Hill Companies; 2010

40ReferencesTheera Thongsong, Chanen Wanapirak, Editor. Obstetrics. 4th Edition. Mom and baby section. Department of Obstetrics and Gynecology. Faculty of medicine. Chiangmai university; 2541.Wisut Fongsiripaiboon. Termination of pregnancy within medical council condition: Updated rules Thai physician should known. Forensic and patient. Siriraj medical record 2551;1(2):117.Suwanna Warakame, Nongrak Boonthai. Summarize of survey on terminating pregnancy situation in Thailand 2542. Family planning and population section. Department of Health. Ministry of Public Health [cited 2011 August 3]. Available from: http://www.clinicrak.com/article/disarticle.php?no=91

41ReferencesIan M. Bennett, Margaret Baylson, Karin Kalkstein, Ginger Gillespie, Scarlett L. Bellamy, Joan Fleischman. Early Abortion in Family Medicine: Clinical Outcomes. Annals of Family Medicine [PMCID: PMC2775627]. 2009 November [cited 2011 August 3]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775627/?tool=pmcentrezD Hu, D Grossman, C Levin, K Blanchard, SJ Goldie. Cost-effectiveness analysis of alternative first-trimester pregnancy termination strategies in Mexico City. BJOG An International Journal of Obstetrics and Gynaecology [DOI: 10.1111/j.1471-0528.2009.02142.x]. 2009 Jan [cited 2011 August 3]. Available from: http://www.blackwellpublishing.com/bjog1

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