*Patient name has been changed for privacy
Anna* is a 36-year old new patient on my clinic schedule with a pregnancy loss. She had a positive home pregnancy test last week and reports she started bleeding on Saturday night. She was scared, so she went immediately to the emergency department. There, she waited several hours to be seen, then had an ultrasound showing an 8-week embryo without any signs of cardiac activity. Her exam and labs were all reassuring. She was told she had a miscarriage, and was referred back to her ob/gyn. She is sad about the pregnancy loss, and also frustrated that she spent 9 hours in the emergency department, only to be referred to my clinic without much explanation and no management of her miscarriage.
There are roughly 1 million early pregnancy losses diagnosed annually in the U.S., but the true incidence is even higher, given that we are largely able to report only those miscarriages that come to medical attention. Many pregnant people experiencing miscarriage will call their healthcare provider and, depending on their symptoms, may or may not be told they need to come in for care. Frequently, these patients are directed to an emergency room, either because they need attention outside of regular clinic hours, or because the patient is very concerned about their symptoms, or because the patient doesn't have any other place to easily seek care.
Most of the time, miscarriage is not an emergency -- though it can feel like one to the patient. Healthcare providers, from ob/gyns to providers in the emergency department, can all do a better job of preparing patients for this.
As an ob/gyn, I try to discuss what to do in case of bleeding in early pregnancy at a patient's first prenatal appointment. I tell patients that miscarriages are common, and if they are not bleeding to the point of feeling dizzy or lightheaded, and as long as they are not very concerned about their bleeding or pain, they likely do not need to go to an emergency room and can wait to be seen in clinic. I also tell them, in a compassionate manner, there is unfortunately nothing anyone can do to stop a miscarriage in process. That knowledge can help patients avoid spending unnecessary time in an emergency department, only to be told to follow up with their healthcare provider in clinic. Many ob/gyn providers likely omit the step of talking about the possibility of pregnancy loss with their newly-pregnant patients. As a result, vaginal bleeding is interpreted by too many patients as an emergency. Instead, providers can reassure a patient they have a viable intrauterine pregnancy and discuss the possibility of miscarriage in a constructive way.
Once a patient shows up to the emergency department, the sort of care they get can vary significantly. Because most miscarriage is not an emergency (i.e., most patients are not suffering a life-threatening hemorrhage or infection), these patients are often treated as lower priority -- and they can tell. There are now many studies demonstrating that patients experiencing miscarriage can have depression, anxiety, and post-traumatic stress disorder, sometimes for months after. If we can make them feel that they and their loss are valued, in any medical settings where they seek care, it could greatly decrease the psychosocial impact of miscarriage.
Emergency medicine providers, nurses, and staff are busy and rightly focused primarily on urgent and emergent health concerns. However, there are a few easy ways to positively impact the miscarriage experience once someone is in the emergency department.
- Ask your patient how they feel about their miscarriage. If they see it as a loss or potential loss, treat it as what it is -- a loss.
- If it can be definitively diagnosed at that time, break the news gently, and be sympathetic to however the patient is feeling about the miscarriage. Offer social work services as needed.
- Ask patients how they would want to have this managed. There are three options: expectant, medication, and uterine aspiration. If the situation is not urgent, all three are appropriate options. Ensure you ask the patient what their plans are for the next 1-2 weeks. Will they be traveling or away from medical care? Do they have an ob/gyn provider established who they can easily follow up with? It may not be as convenient or safe for some patients to be discharged without treatment.
- Work with your reproductive health specialists to allow medication and aspiration management in the emergency department for patients who choose that -- either provided by the specialist or the emergency medicine provider, depending on the situation and training.
Not all patients will want, or be candidates for, emergency department or outpatient management of their pregnancy loss, but most are. In a situation in which a patient feels helpless and is experiencing something very scary or undesirable, giving them agency over decisions like management approach and degree of pain management can be really meaningful (i.e., some patients may highly value being completely asleep or unaware during miscarriage management, and waiting to have an aspiration in an operating room may be worth it). Protocols for medication management of miscarriage are available and easy for an emergency medicine provider to implement, as it may take longer to implement uterine aspiration in the emergency department.
Given that 3% of all emergency department visits for reproductive age pregnancy capable people are for care related to early pregnancy loss, it behooves emergency medicine and reproductive health clinicians to collaborate and make this a better experience for the many people suffering from miscarriage.
Sarah Prager, MD, is a professor of obstetrics and gynecology at the University of Washington School of Medicine, and a co-founder of the TEAMM (Training, Education, & Advocacy in Miscarriage Management) project.