Missed Miscarriage Clinical Trial
Official title:
A Randomised Placebo-controlled Trial of Mifepristone and Misoprostol Versus Misoprostol Alone in the Medical Management of Missed Miscarriage
Miscarriage is the most common complication of pregnancy. As many as 15-25% of pregnancies
end in miscarriage, and the number of miscarriages in England is estimated to be
approximately 125,000 per year. Miscarriage often brings not only physical pain, bleeding and
risks of infection, but also psychological impacts on women and their families. This study
will focus on women whose pregnancy sac remains inside the womb (known as a missed
miscarriage) and opt for medical management of their miscarriage up to 13+6 weeks of
pregnancy. NICE currently recommends that a drug called misoprostol (a vaginal pessary or
oral tablet that makes the womb contract) should be used in the medical treatment of
miscarriage. However, there is evidence to suggest that combining this drug with mifepristone
(an oral tablet that reduces pregnancy hormones) may be more effective in treating
miscarriage. Therefore, to test this in a clinical trial, participants will be allocated at
random to receive either mifepristone followed by misoprostol, or a dummy drug (placebo)
followed by misoprostol. Neither the participants nor the researchers will know what
allocation is decided, which is necessary to test the treatments fairly. The main outcome of
interest will be whether miscarriage is complete within 7 days of randomisation. If
miscarriage is not complete then further treatment (more tablets or surgery) will be offered.
A number of other key outcomes, such as the need for an operation, will also be assessed. We
will also study the views and experience of the participants regarding the tablet treatment.
We anticipate that 710 women will be required to take part in the study to answer this
question with confidence. We estimate that we would be able to recruit this many women in two
years.
Aim: To investigate the clinical and cost-effectiveness of MifeMiso combination (mifepristone
and misoprostol) versus misoprostol alone in the management of missed miscarriage.
Primary clinical objective: To test the hypothesis that treatment with mifepristone plus
misoprostol is superior to misoprostol alone for the resolution of miscarriage within 7 days
in women diagnosed with missed miscarriage by pelvic ultrasound scan in the first 13+6 weeks
of pregnancy.
Key secondary objective:To test the hypothesis that the addition of mifepristone reduces the
need for surgical intervention to resolve the miscarriage.
Other secondary objectives:
1. To evaluate if the addition of mifepristone reduces the need for further doses of
misoprostol.
2. To evaluate if the addition of mifepristone improves other clinical outcomes including
surgical intervention up to and including 7 days post-randomisation and after 7 days
post-randomisation, duration of bleeding, infection, negative pregnancy test at 21 days
post-randomisation, time from randomisation to discharge from EPU care, side effects and
complications.
3. To evaluate if the addition of mifepristone improves patient satisfaction
4. To assess the cost-effectiveness of the combination of mifepristone and misoprostol in
the medical management of missed miscarriage.
Economic objectives: To assess the cost-effectiveness of the combination of mifepristone and
misoprostol in the medical management of missed miscarriage based on an outcome of additional
cost per additional successfully managed miscarriage and additional cost per additional
quality-adjusted life-year (QALY). Using a model-based economic evaluation we will further
explore the cost-effectiveness of the medical management of missed miscarriage, as explored
in the proposed trial, with alternative management strategies, such as surgical and
expectant, based on available secondary sources.
Mixed-method evaluation objectives: To explore the satisfaction of patients who complete the
trial protocol. The results of the satisfaction survey (CSQ-8) will act as a sampling frame
to conduct semi-structured interviews to further investigate patient experiences and
satisfaction with medical management of missed miscarriage.
;