Cases in Cost Conscious Care

Michael Miller, MD
Naval Medical Center San Diego
michael.j.miller57.mil@mail.mil

Clinical Scenario A:
A 27 y.o. G3P0A3, presents for follow-up after undergoing an uncomplicated suction dilation and curettage for an early pregnancy loss at 8 wga. Her first two pregnancies also resulted in early pregnancy loss. Her past medical history is unremarkable. She denies a family history of clotting disorders, diabetes mellitus or thyroid problems. The patient and her husband want to know why they continue to lose pregnancies. A complete physical exam is unremarkable. A workup for anti-phospholipid antibody syndrome (APAS) is completed including lupus anticoagulant, anti-cardiolipin antibody and anti-b2 glycoprotein. Thyroid function is confirmed and maternal and paternal karyotypes completed. A saline infusion sonogram (SIS) is ordered to evaluate the uterine cavity. Karyotype- Maternal $140 Karyotype- Paternal $140 Saline Infusion Sonogram $128.24 DRVVT (Lupus Anticoagulant) $13.81 Anti-cardiolipin IgG/IgM $15.24 Anti-b2 glycoprotein IgG/IgM $23.54 TSH $25.16

Clinical Scenario B:
A 27 y.o. G3P0A3, presents for follow-up after undergoing an uncomplicated suction dilation and curettage at 8 wga. Her first two pregnancies also ended in early pregnancy loss. Her past medical history is unremarkable. She denies a family history of clotting disorders, diabetes mellitus or thyroid problems. The patient and her husband want to know why they continue to lose pregnancies. The patient has read online that inherited clotting disorders can cause recurrent miscarriages and would like to be tested for these disorders. A complete physical exam is unremarkable. A workup for APAS is completed including lupus anticoagulant, anti-cardiolipin antibody and anti-b2 glycoprotein. Thyroid function is confirmed, undiagnosed diabetes mellitus is ruled-out, and maternal and paternal karyotypes are completed. A SIS is ordered to evaluate the uterine cavity. In addition, a workup for inherited thrombophilias is completed including Factor V Leiden mutation, prothrombin G20210A mutation, Protein C, Protein S, and anti-thrombin. Karyotype- Maternal $140 Karyotype- Paternal $140 Saline Infusion Sonogram $128.24 DRVVT (Lupus Anticoagulant) $13.81 Anticardiolipin IgG/IgM $15.24 Anti-b2 glycoprotein IgG/IgM $23.54 TSH $25.16 Free T4 $13.50 Hemoglobin A1c $14.53 Factor V Leiden activity $69.69 Prothrombin G20210A $44.13 Protein C activity $80.80 Protein S activity $21.43 Antithrombin activity $170.00 TOTAL COST $900.07

Discussion Question:
1. What is the incidence of recurrent pregnancy loss (RPL) and the risk of pregnancy loss in the next pregnancy? 2. What tests are indicated in the workup of RPL?

Costs Scenario A:
TOTAL COST $485.99

Costs Scenario B:
TOTAL COST $900.07

Teaching Moment:
RPL is often a distressing diagnosis. Many women are motivated to discover a reason for their loss; however, most cases are idiopathic. Early pregnancy loss is very common, occurring in at least 10-15% of clinically recognized pregnancies. After one lo

References:
Practice Committee of the American Society for Reproductive Medicine. "Evaluation and treatment of recurrent pregnancy loss: a committee opinion." Fertility and Sterility 98.5 (2012): 1103-1111. 

Published: 08/05/16

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