Revered by many, feared by some, mifepristone is the little pill with a big reputation. By definition, mifepristone is an anti-progesterone. At low doses it blocks the naturally occurring hormone progesterone from binding to its receptor in the body.
This is one of the mechanisms by which it has been used in abortion care, as it blocks the pro-gestation hormone from continuing to support a developing pregnancy. It would be short-sided, erroneous and dangerous to think ill of this medication purely because of one’s personal reaction to the preceding sentence.
About 1 in 3 pregnancies ends in miscarriage. This number is closer to 10-20% once a pregnancy is visible by ultrasound or confirmed by lab work, but the fact remains that everyone knows someone who has mourned the loss of a highly desired pregnancy.
Once I have confirmed this devastating diagnosis beyond a doubt, provided emotional support to my patient and dispelled her deepest fear that she caused this (more than 50% are due to chromosomal abnormalities in the developing embryo), her next question is usually, “What do I do next?” For patients without significant health conditions, three options are available: expectant, medical or surgical management.
Expectant management is waiting for the pregnancy to pass on its own, or miscarry, while maintaining close follow-up with their provider. Surgical management involves removing the pregnancy from the uterus with surgical equipment, either in the office or the operating room while the patient is comfortable.
A large proportion of women choose medical management. This involves taking medication to induce contractions that will cause the failed pregnancy to leave the uterus, mimicking and hastening the natural miscarriage process that would likely have occurred within eight weeks with expectant management. This allows the grieving family to arrange child care, coordinate time off from work, and be able to ensure emotional and physical support with the predictable timing which medical management provides.
Traditionally, medical management is accomplished with misoprostol, a synthetic prostaglandin (a hormonally active lipid, or fat) which causes contractions of the muscle layer of the uterus. Research has shown that with one dose of misoprostol, 71% of women will experience complete miscarriage and with a second dose that percentage increases to 84%. This means that about 1 in 5 women will fail medical management and require surgical management, prolonging emotional distress, loss of pay, and increased out-of-pocket expenses for follow-up visits in clinic, the emergency room and the operating room.
Insert mifepristone. Seven years ago, Dr. Courtney A. Schreiber published her landmark study in the New England Journal of Medicine that the addition of mifepristone before misoprostol increased the success rate of complete miscarriage to 91% and decreased the need for subsequent surgical management from 23.5% to 8.8%. This study has been reproduced multiple times with different variations, but the research has always shown clear benefit of the addition of mifepristone to misoprostol for miscarriage management, with some success rates approaching 100%.
This is a huge win for women desiring medical treatment of their pregnancy loss. And it’s a huge win for providers such as myself who practice evidence-based, patient-centered medicine. Bottom-line, the American College of Obstetricians and Gynecologists (ACOG) recommend the use of mifepristone with misoprostol over misoprostol alone for the management of pregnancy loss.
During Robert F. Kennedy’s nomination hearing in front of the Senate’s Committee on Finance, he stated that President Donald Trump had tasked him with studying the safety of mifepristone. Good thing the Food and Drug Administration, ACOG and hundreds, if not thousands, of researchers have already done that for him. Over and over again. Not only is mifepristone safe, but it is unequivocally safer than acetaminophen, ibuprofen, and (dare I say) sildenafil.
Seeking to eliminate mifepristone would not only hurt the women you know and love who have had to or will someday depend on it to manage a pregnancy loss, but it would increase medical costs in an already burdened system, decrease the GDP with time lost from work and, most importantly, increase the trauma women suffer when mourning the loss of a desired pregnancy.
Kaitlyn Mayer, M.D., FACOG is an obstetrician-gynecologist in Virginia Beach.