Rissara Ratchaneesiripap Markhan Jehlee Satit Sataporntanawat Medical Students 5 th year Faculty of medicine Naresuan University Advisor Patcharada Amatyaku MD Sutatip Pongcharoan MD ID: 912765
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Slide1
Comparison of the cost-effectiveness of methods to terminate pregnancy in the indicated patients at Naresuan University Hospital
Rissara Ratchaneesiripap
Markhan Jehlee
Satit Sataporntanawat
Medical Students, 5
th
year
Faculty of medicine Naresuan University
Advisor
Patcharada Amatyaku M.D.
Sutatip Pongcharoan, M.D.
Slide2Introduction
Spontaneous 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
, 254
1
)
Slide3Introduction
Abortion 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 )
Slide4Introduction
About 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)
Slide5Introduction
The 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): 527–533.)
Slide6Introduction
The 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.
Slide7Objective
To 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.
Slide8Material and Methods
(1)
Population
For 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, 2011
Slide9Material and Methods
(2)
Example
abnormal pregnant women in first trimester who need to terminate the pregnancy at Naresuan university hospital
(
n= 53
คน
)
abnormal pregnant women in first trimester who need to terminate the pregnancy by Misoprostol at Naresuan university
hospital
(
n=16
คน
)
abnormal pregnant women in first trimester who need to terminate the pregnancy by Curettage at Naresuan university
hospital
(
n= 30
คน
)
abnormal pregnant women in first trimester who need to terminate the pregnancy by MVA at Naresuan university
hospital
(
n= 7
คน
)
Slide10Material and Methods
(3)
Inclusion Criteria
Abnormal pregnant women who had to terminate their pregnancy in first trimester (14 weeks)
Abnormal pregnancy
Early embryonic death
Death fetus in utero
Blighted ovum
Missed abortion
Elective case
No complication before treatment
Slide11Material and Methods
(4)
Exclusion Criteria
Twin
Maternal health’s problem
Ex
SLE, CHF
Raped
Serious complication before treatment
Molar pregnancy
Slide12Material and Methods
(5)
Setting
Obstetrics and Gynecology department at Naresuan university hospital
The medical records and healthcare services at Naresuan university hospital
Methods
Retrospective cohort study
Slide13Material and Methods
(6)
The variables studied
General data
Age
Gestational age
Gravida
History of previous abortion
Height and BMI
Underlying disease
Medication
Slide14Material and Methods
(7)
The variables studied
Peri-termination the pregnancy
The first method to terminate the pregnancy
Time to terminate the pregnancy
Failure of treatment without complication
Complication
(
Incomplete abortion, Uterine perforation, Hypovolumic shock, Blood transfusion, pelvic infection)
Slide15Material and Methods
(8)
The variables studied
Side effect of
Misoprostol, MVA, Curettage
The secondary method after failure of the first method
Slide16Material and Methods
(9)
The variables studied
Post-termination the pregnancy
Hospital period
Complication after termination the pregnancy
(
Death, Pelvic infection
)
Hospital cost
Slide17Material and Methods
(10)
Data source
Secondary data from Medical record
Analysis
Descriptive statistics
Frequency
Percentage
Average
Slide18Material and Methods
(11)
Statistics analysis
Chi–square test and
Fisher’s exact test (P-value of less than 0.05)
Student-t test
regression analysis
Slide19Definition
Abortion :
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.
Slide20Definition
Criminal 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
Slide21Definition
Blighted ovum :
A fertilized ovum (egg) that did not develop or whose development ceased at an early stage, before 6 or 7 weeks of gestation
Embryonic death :
The death of an embryo before the 8
th
week following conception
(
http://www.medicalnewstoday.com/medicalnews.php?newsid=44486
)
Death fetus in utero :
The death of a fetus, after the 8
th
week until birth.
(
World Health Organization. 1999. Fetal Death. Glossary of Terms. Reproductive health in refugee situations
)
Slide22Results
Slide23Table 1 General characteristics
Characteristics
Misoprostol
MVA
Curettage
P-value
number
%
number
%
number
%
Age (Years)
0.09
average (SD)
27.31 (4.87)
32.86(6.47)
31.4(8.30)
Gravida
0.20
1
10
62.50
4
57.14
11
36.67
2
6
37.50
1
14.29
7
23.33
3
0
0
1
14.29
6
20.00
4
0
0114.29516.675000013.33BMI (n=10)(n=4)(n=18)0.61 < 19.833000633.32 19.8-265504100950 >2622000316.68Had history of abortion before0.04 yes16.52228.571240.00 no 1593.75571.431860.00
Age (Years)
Age (Years)
Slide24Table 2 Comparison between terminating methods with other factors
Characteristics
Misoprostol
MVA
Curettage
number
%
number
%
number
%
P-value
0.21
Early embryonic death
8
50.00
1
14.29
13
43.33
Death fetus in utero
1
6.25
1
14.29
0
0
Blighted ovum
7
43.75
4
57.14
15
50.00
Missed abortion
0
0
1
14.29
2
6.67
Method of first terminating pregnancy
0.00
yes1630.19713.213056.60Total dose (μg) average (SD) 700(357.78)Prime cervix0.00 yes357.141653.33 no442.861446.67yes
Slide25Table 2 Comparison between terminating methods with other factors
Characteristics
Misoprostol
MVA
Curettage
P-value
number
ร้อยละ
number
%
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 pregnancy
0.001
yes
10
62.50
6
85.71
30
100
no
637.50114.2900CostAverage 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)
Slide26Table 3 Procedure failure and complications
Characteristics
Misoprostol
MVA
Curettage
number
%
number
%
number
%
Precedure failure
3
18.75
0
0
0
0
Complication
uterine perforation
0
0
0
0
0
0
pelvic infection
0
0
1
14.29
1
3.33
Blood transfusion
0
0
0
0
1
3.45
bleed
0
0
0013.45 Incomplete abortion531.25114.2900 Death000000Total complication531.25228.5839.99
Slide27Table 4 Comparison between successful of terminating pregnancy with other factors
Variable
RR
95%CI
P-value
Method
0.001
-
Misoprostol
1.00
0.00
-MVA
0.38
0.56 - 2.60
0.33
-Curettage
**100% success (n=0) Predict failure
Gravida
0.694
-Primigravida
-Multigravida
BMI
0.694
< 19.8
19.8-26
>26
Age*
0.2632
ค่าเฉลี่ย
(SD)
-2.61 -
9.37
0.2632
remark number in this table is compare non-successful procedure
*95% Cl mean diff
If p-value less than 0.15 It will bring to Logistic regression
Slide28Table 5 Comparison between complication of terminating of first pregnancy with other factors
*95% Cl mean diff
If p-value less than 0.15 It will bring to Logistic regression
Variable
RR
95%CI RR
P-value
Method
0.052
-
Misoprostol
1.00
0.00
-MVA
0.91
0.23 – 3.63
0.90
-Curettage
0.21
0.05 - 0.98
0.047
Gravida
0.148
-Primigravida
1.00
0.00
-Multigravida
3.125
0.71 – 13.67
0.13
BMI
0.686
< 19.8
19.8-26
>26
Age*
0.67
ค่าเฉลี่ย
(SD)
Slide29Table 6 Comparison of medical fee in first terminating pregnancy with other factors
*95% Cl mean diff
If p-value less than 0.15 It will bring to Logistic regression
Variable
Coef.
95%CI
P-value
Method
0.97
-Misoprostol
5236.64
1.00
0.00
-MVA
5526.72
-2074.35 - 2654.50
0.81
-Curettage
5312.19
-1777.23 - 1928.32
0.93
Gravida
0.80
-Primigravida
5224.65
1.00
0.00
-Multigravida
5420.13
-1392.96 - 1783.91
0.80
BMI
0.11
< 19.8
4664.88
1.00
0.00
19.8-26
3357.67
-1052.34 - 1771.283
0.60
>26
5024.35
-3193.08 - 578.66
0.16Age0.31 ค่าเฉลี่ย (SD)0.31
Slide30Discussion 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.
Slide31Discussion 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.
Slide32Discussion 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.
Slide33Discussion 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.
Slide34Discussion 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.
Slide35Discussion 6
The 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.
Slide36Discussion 7
This study show the retrospective cohort study was considered by gathering secondary data from medical records and delivery room.
Incomplete medical
records
i
nformation
bias.
To decrease bias, the study should be designed as prospective cohort study.
Slide37Conclusion
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.
Slide38Recommendation
Type 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.
Slide39Acknowledgements
Thank you
Supasit
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.
Slide40References
Jana 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=pmcentrez
Kulier 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.com
Cunningham, Leveno, Bloom, Hauth, Rouse, Spong. Williams Obstetrics.
23rd Edition. The McGraw-Hill Companies; 2010
Slide41References
Theera 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
Slide42References
Ian 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=pmcentrez
D 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