Emergency physicians are prepared to care for any affliction that rolls through the ER doors. Or at least we try to be. But if you are reading this and you are an emergency provider, I want to challenge the notion that you are well prepared to deal with miscarriage.
My guess is that for the countless hours you spent training for your career in emergency medicine, miscarriage care was touched upon lightly, or perhaps skipped entirely after the charge to learn how to ‘rule out’ an ectopic was fulfilled for your patients with vaginal bleeding in the first trimester. You may not feel completely comfortable counseling a patient with miscarriage on the treatment options an OBGYN provider may offer her. And most emergency physicians lack familiarity with manual uterine aspiration, a procedure that is safe, simple and can stop uterine hemorrhage from miscarriage in an unstable patient, which can be an essential skill to have if you work in a hospital without in-house OBGYN providers on call.
Miscarriage is exceedingly common, and we care for women and families experiencing pregnancy loss on an almost daily basis. Approximately 25% of all women will have at least one miscarriage, and 20% of all pregnancies will end in miscarriage. And as the age of maternity increases in the US, we should only expect to care for more patients with miscarriage.
Whether or not you think their care is best managed in a clinical setting other than the emergency department, women with vaginal bleeding in the first trimester come to the ED. They present at all hours of the day. They come concerned, looking for answers, and hoping that we may have the power to stop the inevitable and halt a miscarriage in progress. In many emergency departments, patients with first trimester miscarriage don’t move to the Labor and Delivery floor, rather the entire trajectory of their care takes place in the ED independent of whether they receive an OBGYN consult. We administer medications, we prepare patients for procedures, and we are responsible for determining when they are safe for discharge or perhaps need admission.
But not everyone in emergency medicine is convinced that miscarriage care is the responsibility of the emergency medicine provider, and comprehensive miscarriage care has not been well integrated into the training curriculum of the emergency medicine resident. The American College of Emergency Physicians’s clinical policy on bleeding in first trimester pregnancy is limited to evaluating for and treating ectopic pregnancy only, but does not provide guidance or recommendations for addressing miscarriage, which is a much more common cause of bleeding in early pregnancy.
For many women, miscarriage is devastating, and studies show our patients are often frustrated by perceived negative attitudes from emergency providers, they believe that emergency medicine providers are not attuned to the magnitude of their loss, and they often feel they receive insufficient information about miscarriage.
In a field such as emergency medicine, where doctors have jumped at the opportunity not only to improve patient care, but specifically to learn procedural skills previously ‘owned’ by other specialties (such as ultrasound, peripheral nerve blocks, even REBOA!), it is surprising that we as emergency providers continue to hesitate to take more ownership of our patients with miscarriage. We’re on the front lines, these are our patients, and we can provide them with better care.
Emergency providers frequently diagnose patients with miscarriage, and we should educate ourselves to be able to begin to counsel women on their options for treatment – expectant management (do nothing, let the products of conception pass at home), medical management (taking uterotonic medications to facilitate uterine expulsion of products of conception) or surgical management (manual uterine aspiration at the bedside in the ED or in the operating room).
But we should not stop at superb counseling for our patients with first trimester miscarriage. We should also work with our OBGYN colleagues to facilitate manual uterine aspiration in our ED setting for the right patients. The availability of this simple, efficacious and safe bedside procedure is becoming the standard of care for patients with early pregnancy loss in EDs across the country. Facilitating MUAs in the ED for appropriate patients (i.e. those who are bleeding too briskly to safely be discharged home with a plan for expectant or medical management) can prevent admissions, the unnecessary risk of general anesthesia, can save patients and hospitals costs, and can even decrease patient length of stay in the ED. Most of these procedures are performed by OBGYN consultants, but if you work in a rural or resource-limited setting where the nearest OBGYN on call is hours away, an emergency physician who knows how to perform MUA could stabilize a hemorrhaging patient with miscarriage in minutes, so you should consider adding this skill to your toolkit.
Miscarriage forms part of emergency medicine, and if we participate in a culture change around early pregnancy loss in the ED, we can provide better patient-centered care for our patients.
Watch the FIX19 talk below!