“Ugh, another ‘vag’ bleeder in room 10, I guess that’s mine.” His preceding exasperated sigh was not subtle. As a medical student on my emergency medicine rotation, I watched the tired resident slowly will himself out of the chair and shuffle to the room where the patient was waiting on the gyn gurney.
As you read this, do you secretly find your own sentiments toward patients visits for first-trimester vaginal bleeding are similar? Does this anecdote elicit some frustration? Aversion? Or like me, do you wonder why the field of emergency medicine is still avoiding owning first trimester miscarriage?
If you were to ask around, querying your mother perhaps, your sister or friends, and including the partners of women you know, you’d find you’re surrounded by people who’ve lost a pregnancy, or multiple pregnancies. Maybe you don’t have to ask around, your last shift may have provided proof enough (I once had a shift where SIX of my patients presented with vaginal bleeding and all were found to be in various stages of miscarriage). You may have suffered your own miscarriage, or three.
Miscarriage is exceedingly common – one in four women will suffer early pregnancy loss (EPL), or fetal demise in the first trimester at 13 weeks gestation or fewer. And 20% of clinically recognized pregnancies end in miscarriage, which we know is a gross underestimate, as studies show many more women will conceive, and then lose the pregnancy, without ever knowing they had been pregnant.
Half of patients with miscarriage will visit an ER at least once during the process and patients with first trimester symptoms are not commonly sent directly to the labor and delivery floor, rather they stay with us for workup and needed treatment in the ED.
They present to us for a multitude of reasons:
We’re open, and the OBGYN clinic is closed.
The patient has no established outpatient OBGYN provider, so we’re it.
Previously aware or unaware of her pregnancy, the patient is having abnormal vaginal bleeding and/or abdominal pain.
The patient’s OBGYN physician sent her to the ED to be evaluated for an ectopic pregnancy.
We have access to ultrasounds, consultants, treatments, and often a diagnosis.
And many patients think (usually erroneously) that we or medical science has a cure for the inevitable, that we somehow have the power to halt a miscarriage that is already in progress.
First trimester miscarriage care falls squarely within the domain of the practicing emergency physician (after that of the gynecologist). As emergency medicine providers, early pregnancy loss is our jam, so to speak. Or at least I argue that it should be considered so. These patients come to us, and we should own their care. We should understand and be comfortable explaining miscarriage and counseling these patients on the different treatments they may ultimately be offered by our OBGYN consultants, in addition to setting up appropriate follow up. But with respect to providing optimal care for these patients, do you think we’re doing a good job? More importantly, do our patients?
Unfortunately, no. Though there is a paucity of studies examining the care of miscarrying women in ERs, the few studies that have been published show that patients are very unsatisfied with the care they receive while miscarrying, both in the emergency department and the outpatient setting. Reasons include perceived negative attitudes from healthcare providers, providers failing to address the magnitude of the patient’s loss or their emotional well-being, lack of privacy, deficient provision of information on miscarriage, and lack of adequate follow-up care.
Why are we failing to take good care of these patients? One possibility is that we don’t see miscarriage as an emergency and are therefore perhaps less enchanted by a perceived outpatient issue. The American College of Emergency Physicians’ clinical policy on early pregnancy focuses on the diagnosis and treatment of ectopic pregnancy, but does not provide recommendations for addressing miscarriage, justifying the practice of providers who rule out an ectopic pregnancy and consider their work completed. And perhaps emergency physicians with their own miscarriage histories find it painful to delve into the emotional aspects of caring for women who are also losing pregnancies.
But as the average age of maternity in the US continues to increase, we emergency physicians can only expect to care for MORE patients presenting with miscarriage. We’d better get on this.
So what can we do? We can do better. Specifically, emergency physicians, nurses and healthcare providers can take the initiative to work with their OBGYN counterparts to address shortfalls in care in the ED. I volunteer with a specialized group of OBGYN physicians, midwives, social workers and public health workers out of the University of Washington, called TEAMM (Training, Education and Advocacy in Miscarriage Management). TEAMM provides and addresses both the emergency medicine and gynecological perspectives on miscarriage care and why change in the ED is difficult, but possible. This group travels to academic centers and community hospitals for interdepartmental trainings with emergency and OBGYN departments to address barriers to implementing improvements in treating patients with EPL, and to integrate all three forms of early pregnancy loss management – expectant, medication, and manual uterine aspiration – into emergency medicine settings. If you can’t get your two departments together, then enlist a third party.
Own miscarriage, it is emergency medicine.
To learn more, check out TEAMM – Training, Education and Advocacy in Miscarriage Management out of the University of Washington.