Transcript ภาพนิ่ง 1

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, 5th year
Faculty of medicine Naresuan University
Advisor
Patcharada Amatyaku M.D.
Sutatip Pongcharoan, M.D.
Introduction
• 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, 2541)
Introduction
• 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 )
Introduction
• 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)
Introduction
• 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.)
Introduction
• 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.
Objective
• 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.
Material 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
Material 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)
Material 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
Material and Methods (4)
• Exclusion Criteria
 Twin
 Maternal health’s problem Ex SLE, CHF
 Raped
 Serious complication before treatment
 Molar pregnancy
Material 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
Material and Methods (6)
• The variables studied
• General data
 Age
 Gestational age
 Gravida
 History of previous abortion
 Height and BMI
 Underlying disease
 Medication
Material 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)
Material and Methods (8)
• The variables studied
 Side effect of Misoprostol, MVA, Curettage
 The secondary method after failure of the first method
Material and Methods (9)
• The variables studied
• Post-termination the pregnancy
 Hospital period
 Complication after termination the pregnancy (Death,
Pelvic infection)
 Hospital cost
Material and Methods (10)
• Data source
 Secondary data from Medical record
• Analysis
Descriptive statistics
 Frequency
 Percentage
 Average
Material 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
Definition
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.
Definition
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
Definition
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 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)
Results
Table 1 General characteristics
Misoprostol
Characteristics
number
MVA
number
%
P-value
Curettage
number
%
%
Age (Years)
0.09
27.31 (4.87)
average (SD)
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 (Years)14.29
Age
6
20.00
4
0
0
1
14.29
5
16.67
5
0
0
0
0
1
3.33
BMI
(n=10)
(n=4)
(n=18)
< 19.8
3
30
0
0
6
33.32
19.8-26
5
50
4
100
9
50
>26
2
20
0
0
3
16.68
Had history of abortion before
0.61
0.04
yes 1
no 15
6.52
2
28.57
12
40.00
93.75
5
71.43
18
60.00
Table 2 Comparison between terminating methods with
other factors
Characteristics
Misoprostol
number
%
MVA
number
%
Curettage
number
%
P-value
0.21
Early embryonic
8
50.00
1
14.29
13
43.33
Death fetus in utero
Blighted ovum
Missed abortion
Method of first terminating
pregnancy
1
7
0
6.25
43.75
0
1
4
1
14.29
57.14
14.29
yes
0
15
2
0
50.00
6.67
yes
16
death
0.00
30.19
7
13.21
30
56.60
Total dose (μg)
average (SD)
700(357.78)
Prime cervix
yes
no
0.00
3
4
57.14
42.86
16
14
53.33
46.67
Table 2 Comparison between terminating methods with other
factors
Characteristics
Induction-abortion
interval (hr)
average (SD)
Misoprostol
MVA
number ร้อยละ number
%
Curettage
number
%
0.00
14.44(18.74)
0.31(0.10)
0.36(0.09)
EBL(ml)
average (SD)
Successful of
terminating pregnancy
yes
no
Cost
Average medical fee
Average cost in long term
complication
P-value
0.15
16.88(13.02)
11.43(3.78)
110(289.41)
0.001
10
6
62.50
37.50
5236 (n=11)
0 (n=0)
6
1
85.71
14.29
30
0
100
0
5526.71 (n=7)
5312.18(n=19)
265.5 (n=1)
251.5 (n=1)
0.96
Table 3 Procedure failure and complications
Characteristics
Misoprostol
MVA
Curettage
number
%
number
%
number
%
3
18.75
0
0
0
0
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
0
0
1
3.45
Incomplete abortion
5
31.25
1
14.29
0
0
Death
0
0
0
0
0
0
5
31.25
2
28.58
3
9.99
Precedure failure
Complication
Total complication
Table 4 Comparison between successful of terminating
pregnancy with other factors
Variable
RR
95%CI
Method
-Misoprostol
-MVA
-Curettage
0.38
1.00
0.56 - 2.60
**100% success (n=0)
Predict failure
Gravida
P-value
0.001
0.00
0.33
0.694
-Primigravida
-Multigravida
BMI
0.694
< 19.8
19.8-26
>26
Age*
ค่าเฉลีย่ (SD)
-2.61 - 9.37
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
0.2632
0.2632
Table 5 Comparison between complication of terminating of first pregnancy with
other factors
Variable
RR
95%CI RR
Method
-Misoprostol
-MVA
-Curettage
0.91
0.21
1.00
0.23 – 3.63
0.05 - 0.98
3.125
1.00
0.71 – 13.67
Gravida
-Primigravida
-Multigravida
BMI
P-value
0.052
0.00
0.90
0.047
0.148
0.00
0.13
0.686
< 19.8
19.8-26
>26
Age*
0.67
ค่าเฉลีย่ (SD)
*95% Cl mean diff
If p-value less than 0.15 It will bring to Logistic regression
Table 6 Comparison of medical fee in first terminating pregnancy
with other factors
Variable
Coef.
95%CI
Method
-Misoprostol
-MVA
-Curettage
5236.64
5526.72
5312.19
1.00
-2074.35 - 2654.50
-1777.23 - 1928.32
-Primigravida
-Multigravida
5224.65
5420.13
1.00
-1392.96 - 1783.91
< 19.8
4664.88
3357.67
1.00
-1052.34 - 1771.283
5024.35
-3193.08 - 578.66
Gravida
BMI
19.8-26
>26
Age
ค่าเฉลีย่ (SD)
*95% Cl mean diff
If p-value less than 0.15 It will bring to Logistic regression
P-value
0.97
0.00
0.81
0.93
0.80
0.00
0.80
0.11
0.00
0.60
0.16
0.31
0.31
Discussion 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.
Discussion 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.
Discussion 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.
Discussion 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.
Discussion 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.
Discussion 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.
Discussion 7
This 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.
Conclusion
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.
Recommendation
•
•
•
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.
Acknowledgements
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.
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•
•
•
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