“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.
Thanks Kelly, this is so important for us to recognize how we can do better for these patients. We’re looking forward to the visit to Philadelphia
I so appreciate recognition of this important issue, and that the ED can be a viable location for managing/co-managing pregnancy loss!
Agreed. We can and should do better. As the attending’s attitude is, so usually is the residents’. those of us who have lost a pg should have more compassion than those who have never suffered a loss, but all of us can learn to at least go through the motions of compassion. Always tell the woman it is not her fault, and that (my words) that so many things can go wrong — a million things — between fertilized egg and fetus, and that God wants us to have perfect babies, not those without arms, or head, or metabolic problems,… Read more »
Hi, Dr. Quinley! We found so much value in this article and want to bring this message to our EM interest group at our school. Any interest in speaking to our students via video chat or have any connections in Chicago who may? Thanks so much!
Hi Hannah, Thank you for leading your EM interest group (mine helped me make my decision for a career in EM!), and for taking the time to read this article. I would be delighted to speak to your students. Send me an email to coordinate? Thanks- Kelly
Thanks, Dr. Quinley! That’s so great to hear and thank you for being willing to chat with us. Where can I find an e-mail to contact you at? (tried to find one online but couldn’t, sorry!) Or you can reach out to me at: [email protected]. Thanks!
Thank you for your leadership on this issue and your tireless advocacy, Dr. Quinley. You inspire me to be a better doctor and educator!
I went to the ER bc I was miscarrying at 10 weeks with my first pregnancy. They took my temperature and then had me wait 4 hours before taking me back. I miscarried in the waiting room, which was filled with other people. It was one of the worst experiences of my life. The healthcare system failed me.