Outpatient early pregnancy loss clinics may improve ‘poorly managed’ miscarriage care
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Key takeaways:
- Miscarriage is common with women experiencing various symptoms from bleeding to pelvic pain.
- Care at an outpatient early pregnancy loss center could potentially improve patient satisfaction.
Miscarriage care is often suboptimal for women in Canada experiencing early pregnancy loss and providers should be aware of maternal psychological effects to provide compassionate assessment, management and follow-up, researchers reported.
In a literature review published in CMAJ, researchers noted that for women experiencing a miscarriage that is not a medical emergency, outpatient early pregnancy loss clinics could improve clinical outcomes, reduce repeat assessments in the ED and potentially improve patient satisfaction. However, such services in Canada are lagging, according to Modupe Tunde-Byass, MBBS, FRCOG, FRCS, an obstetrician-gynecologist at the North York General Hospital and associate professor at the University of Toronto.
“The magnitude of early pregnancy loss is huge, yet [it receives] little attention,” Tunde-Byass told Healio. “[Miscarriage] has devastating emotional and psychological effects [and is] poorly managed in Canada, considering my experience from the U.K.”
Tunde-Byass and colleagues conducted a review assessing prevalence, risk factors, presentation, diagnosis, management and follow-up of early pregnancy loss, including clinical practice guidelines, systematic reviews and meta-analyses published through July 2023.
Miscarriage risk factors, diagnosis
According to the researchers, early pregnancy loss impacts 15% to 20% of all clinically recognized pregnancies in Europe and North America, which rose to 31% when pregnant women were followed with serial testing of serum beta-human chorionic gonadotropin (hCG).
Maternal age older than 35 years increases miscarriage risk; women aged 45 years and older have an almost 65% risk for early pregnancy loss, according to the researchers. History of prior early pregnancy loss, infection, older paternal age, higher BMI, smoking, alcohol intake, physical trauma, psychological stress, and air pollution and pesticide exposure are all risk factors for miscarriage. In addition, associations between miscarriage and Black race have also been reported, according to the researchers, and is currently hypothesized to be related to biological, genetic and socioeconomic factors.
Common miscarriage symptoms include:
- bleeding;
- cramping;
- abdominal or pelvic pain;
- passage of tissue; or
- a combination of any of these symptoms.
Despite being a symptom of miscarriage, cramping or pain is common during pregnancy with almost 85% of pregnant women experiencing it during the first 7 weeks. However, previous findings demonstrated that miscarriage risk is five times greater for women with both bleeding and cramping during pregnancy vs. cramping alone (HR = 5.03; 95% CI, 2.07-12.2).
Regarding miscarriage diagnoses, according to the researchers, physicians should obtain detailed patient history and conduct a full physical exam, complete blood count and determination of blood group, Rh factor and hCG levels. If a woman is hemodynamically unstable, she should be referred to the gynecology team and, once stable, undergo transvaginal ultrasonography, the researchers wrote.
According to the researchers, almost 10% of women with miscarriage symptoms during the first trimester have elevated hCG levels without an identified pregnancy location based on ultrasonography. About 15% of pregnant women who undergo transvaginal ultrasonography during the first trimester have pregnancy of unknown location. These women have an 8% to 14% risk for ectopic pregnancy, and for this patient population, empirical medical or surgical interventions are appropriate without further investigation, according to the researchers.
For women who are hemodynamically stable, physicians should obtain a repeat serum hCG level at 48 hours to help stratify ectopic pregnancy risk. Ratios greater than 1.63 suggest intrauterine pregnancies and women should have repeat transvaginal ultrasonography after 7 days while ratios less than 0.5 suggest a failing pregnancy that will resolve naturally without requiring repeated ultrasonography. However, ratios falling between 0.5 and 1.63 suggest an ectopic pregnancy and women require close follow-up, repeat ultrasonography and hCG levels in 48 hours with consultation with a gynecologist, the researchers wrote.
Managing miscarriage
Care for women experiencing miscarriage should be individualized for each patient and decided through shared decision-making and informed consent, researchers wrote. The three methods used for miscarriage are expectant, medical and surgical management.
Expectant management, which occurs in about 50% of women experiencing miscarriage, is safe for women with a known intrauterine pregnancy who are medically stable. If choosing this method, women should be counseled to return for care if they experience excessive bleeding, syncope, severe pain or fever. Women should be informed about the timeline of expectant management and reassured that they can opt for medical or surgical management at any time.
Medical management results in earlier completed miscarriages compared with expectant management. This method should be offered to all hemodynamically stable women with a known intrauterine pregnancy experiencing miscarriage, according to the researchers. Medical management treatments include oral misoprostol alone or combined with oral mifepristone.
Surgical management has the fewest interactions with health care personnel and is the first-line treatment for women with hemodynamic instability, hemoglobin lower than 95 g/dL or a drop in hemoglobin of 20 g/dL. The surgical method is the standard of care for women with suspicion of molar pregnancy or signs of infection.
Most women living in Canada experiencing early pregnancy loss receives care through the ED, Tunde-Byass told Healio, where patients “perceive their care as suboptimal and less compassionate.”
“The psychological impact may include anxiety, depression and PTSD and may last beyond 6 months,” Tunde-Byass said. “For those seeking surgical management, there may be additional wait time on the long emergency list.
“The ED may be the safest place for pregnant individuals undergoing massive hemorrhage, or those with suspected ectopic pregnancy [but] it is not the ideal place to care for those with minimal symptoms,” Tunde-Byass told Healio. “Investing in dedicated clinics to provide a compassionate, streamlined approach to care with reduced wait times and better patient experiences will reduce suffering by bypassing overcrowded EDs.”
Prioritizing miscarriage care
In an accompanying editorial, Catherine Varner, MD, MSc, emergency physician in the department of emergency medicine at Sinai Health, the department of family and community medicine at the University of Toronto and deputy editor for the Canadian Medical Association Journal, wrote that despite expansion of early pregnancy assessment clinics improving care for most women experiencing miscarriage, those for whom medical management failed or those who prefer surgery may continue experiencing delays or barriers to accessing surgical care.
“Given health systems’ current focus on health care innovations that seek to provide the right care, at the right time, by the right provider, in the right location, prioritization of patients experiencing early pregnancy loss would seem deserving of attention, given their risk for enduring physical and psychological effects related to existing models of care,” Varner wrote. “It is time to invest in early pregnancy assessment clinics that are better equipped to provide a more tailored, patient-centered experience and greater understanding of early pregnancy complications and loss than can be found in an overcrowded emergency department.”
For more information:
Modupe Tunde-Byass, MBBS, FRCOG, FRCS, can be reached at modupe.tunde-byass@nygh.on.ca; X (Twitter): @DrMTByass.