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, 5 th year Faculty of medicine Naresuan University Advisor Patcharada Amatyaku M.D. Sutatip Pongcharoan, M.D.

2. 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)

3. 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 )

4. 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)

5. 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.)

6. 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.

7. 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.

8. 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

9. 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 )

10. 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

11. Material and Methods (4) Exclusion Criteria  Twin  Maternal health’s problem Ex SLE, CHF  Raped  Serious complication before treatment  Molar pregnancy

12. 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

13. Material and Methods (6) The variables studied General data  Age  Gestational age  Gravida  History of previous abortion  Height and BMI  Underlying disease  Medication

14. 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)

15. Material and Methods (8) The variables studied  Side effect of Misoprostol, MVA, Curettage  The secondary method after failure of the first method

16. Material and Methods (9) The variables studied Post-termination the pregnancy  Hospital period  Complication after termination the pregnancy (Death, Pelvic infection)  Hospital cost

17. Material and Methods (10) Data source  Secondary data from Medical record Analysis Descriptive statistics  Frequency  Percentage  Average

18. 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

19. 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.

20. 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

21. 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 8 th week following conception (http://www.medicalnewstoday.com/medicalnews.php?newsid =44486)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)

22. Results

23. Table 1 General characteristics Characteristics MisoprostolMVACurettage P-value numbe r % % % Age (Years) 0.09 average (SD) 27.31 (4.87)32.86(6.47)31.4(8.30) Gravida 0.20 1 1062.50457.141136.67 2 637.50114.29723.33 3 00114.29620.00 4 00114.29516.67 5 000013.33 BMI (n=10)(n=4)(n=18) 0.61 < 19.8 33000633.32 19.8-26 5504100950 >26 22000316.68 Had history of abortion before 0.04 yes 16.52228.571240.00 no 1593.75571.431860.00 Age (Years)

24. Table 2 Comparison between terminating methods with other factors Characteristics Misoprosto l MVACurettage num ber % % % P-value 0.21 Early embryonic death 850.00114.291343.33 Death fetus in utero 16.25114.2900 Blighted ovum 743.75457.141550.00 Missed abortion 00114.2926.67 Method of first terminating pregnancy 0.00 yes 1630.197 13.21 30 56.60 Total dose ( μ g) average (SD) 700(357.78) Prime cervix 0.00 yes 357.141653.33 no 442.861446.67 y es

25. Table 2 Comparison between terminating methods with other factors Characteristics MisoprostolMVACurettage P-value num ber ร้อย ละ numb er % % 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 1062.50685.7130100 no 637.50114.2900 Cost Average medical fee 5236 (n=11) 5526.71 (n=7) 5312.18(n=19)0.96 Average cost in long term complication 0 (n=0)265.5 (n=1)251.5 (n=1)

26. Table 3 Procedure failure and complications Characteristics MisoprostolMVACurettage numb er % % % Precedure failure 318.750000 Complication uterine perforation 000000 pelvic infection 00114.2913.33 Blood transfusion 000013.45 bleed 000013.45 Incomplete abortion 531.25 1 14.2900 Death 000000 Total complication 5 31.25228.5839.99

27. Table 4 Comparison between successful of terminating pregnancy with other factors VariableRR95%CIP-value Method0.001 -Misoprostol1.000.00 -MVA0.380.56 - 2.600.33 -Curettage **100% success (n=0) Predict failure Gravida0.694 -Primigravida -Multigravida BMI0.694 < 19.8 19.8-26 >26 Age*0.2632 ค่าเฉลี่ย (SD) -2.61 - 9.370.2632 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

28. Table 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 VariableRR95%CI RRP-value Method0.052 -Misoprostol1.000.00 -MVA0.910.23 – 3.630.90 -Curettage0.210.05 - 0.980.047 Gravida0.148 -Primigravida1.000.00 -Multigravida3.1250.71 – 13.670.13 BMI0.686 < 19.8 19.8-26 >26 Age*0.67 ค่าเฉลี่ย (SD)

29. Table 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 VariableCoef.95%CIP-value Method0.97 -Misoprostol5236.641.000.00 -MVA5526.72-2074.35 - 2654.50 0.81 -Curettage5312.19-1777.23 - 1928.32 0.93 Gravida0.80 -Primigravida5224.651.000.00 -Multigravida5420.13-1392.96 - 1783.91 0.80 BMI0.11 < 19.8 4664.881.000.00 19.8-26 3357.67-1052.34 - 1771.283 0.60 >265024.35-3193.08 - 578.66 0.16 Age0.31 ค่าเฉลี่ย (SD) 0.31

30. 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.

38. 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.

39. 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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41. References 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

42. References 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