Treatment of Early Pregnancy Loss With Mifepristone and Misoprostol Compared With Misoprostol Only

I read with great interest the study by Friedman et al1 in the February 2025 issue, which highlights the advantages of mifepristone–misoprostol combination therapy over misoprostol monotherapy for the medical management of missed miscarriage and anembryonic gestation. Although the findings are clinically relevant, I would like to address three critical points that warrant further discussion. First, although the study appropriately critiques earlier research for having short follow-up durations and underscores the necessity of the current study, the authors did not provide any information regarding the follow-up period in their own cohort. The absence of even a median follow-up time makes it challenging to fully contextualize the observed rates of outcome measures. Because follow-up duration can have a significant effect on rates of surgical interventions, including this information would be valuable for a more accurate interpretation of the results. Second, although the authors adjusted for baseline differences between groups, the analysis could be strengthened by incorporating additional potential confounders that have been reported repeatedly in the literature and also are extractable from medical records. For example, body mass index (BMI) and vaginal bleeding within the previous 24 hours are factors that have been linked to treatment outcomes in early pregnancy loss, yet these were not included in the analysis.2,3 Additionally, it is not clear how the authors selected the factors for inclusion in the multivariable analysis or the criteria they used. For instance, a factor such as parity, with a bivariate P-value of .526 between the two groups, was not included, whereas prior vaginal deliveries, with a P-value of 1, was included, despite both having clinical relevance. Lastly, the article title uses the term “early pregnancy loss,” which encompasses a broad spectrum of conditions, including missed miscarriage, incomplete and complete miscarriage, and others. However, the study specifically excluded cases such as incomplete or septic miscarriages, focusing solely on missed miscarriage and anembryonic gestation. To better reflect the cohort and avoid misinterpretation, I suggest using a term such as, “missed miscarriage and anembryonic gestation” in the title, which more accurately describes the population studied.