For Teachers & Professionals

Early Pregnancy Loss and Emotional Counselling with a Patient-Centred Perspective

Early pregnancy loss is defined as a nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without fetal heart activity within the first 12 6/7 weeks of gestation. In the first trimester, the terms miscarriage, spontaneous abortion, and early pregnancy loss are used interchangeably. EPL is far more common than one might expect and it is the most common complication in pregnancy. It is crucial to use direct, clear and empathic language when providing the diagnosis of a nonviable pregnancy. Most women, for example, tend to blame themselves. The physician must assure that the woman did not do anything intentional to cause the EPL. Extended delays in diagnosis or treatment over several weeks, lack of continuity of providers, and inadequate communication can further exacerbate the anxiety and trauma associated with EPL.  

Clinical management options for EPL consist of expectant care, medical intervention, or surgical aspiration in the office or operating room: 

1) Expectant management allows for the spontaneous passage of products of conception and allows women to avoid surgical and anaesthesia risks. Expectant management may be perceived as a “more natural” option. Expectant management may be well suited for those who have difficulty accepting the diagnosis of a failed pregnancy and are not able to make a treatment decision. Counselling should address cramping, bleeding and pain management, including contact and follow-up plan for any suspected complications such as excessive bleeding, infection or incomplete expulsion.

2) Medical management can present a more active, patient-controlled, nonsurgical treatment option for women with EPL. The ability to control the timing of the management can relieve some of the emotional burdens that accompany first-trimester pregnancy loss. Usually, misoprostol is used to facilitate the expulsion of pregnancy tissue. It is usually combined with the use of mifepristone (increases uterus contractility). When using mifepristone and misoprostol, the majority of women expel the pregnancy tissue within 72 hours.

3) Surgical management is uterine aspiration with general anaesthesia. This procedure is useful for those women who need a more controlled medical environment and procedure. First-trimester uterine aspiration is generally performed in the outpatient setting and is less costly than procedures done in the operating room. Operating room (OR) aspiration management is another surgical method that offers a faster resolution, but with a higher cost and more time and physical exams than office-based procedures and general anaesthesia.

Despite the last two being safe procedures, the majority of physicians prefer expectant management. A lot of providers express concern about the safety of misoprostol for medical management or office uterine evacuation. Space limitation is another frequently endorsed barrier. Despite this, research in abortion care has demonstrated that women are more satisfied when given the opportunity to choose their treatment plan, and should be offered evidence-based counselling on medical and surgical options. Patient-centred abortion care should be the priority. The choice of management for EPL is often influenced by the woman's socio-economic status, the opinion of those she trusts (including her physician), her experience with the current pregnancy (e.g. acceptance of pregnancy loss), her past pregnancy experiences (or lack thereof) and the timing and control of miscarriage process. Satisfaction lies in the efficiency of care, confidence in the quality of care, sensitive providers and effective two-way communication. 

Decisions regarding the management of EPL often occur in the context of complex emotions that may include shock, disappointment, grief, as well as, relief. Studies have shown that patients express discontent with providers that treated their miscarriage as mundane and lacked sensitivity or urgency towards their condition. There is also a sort of bias leading physicians and the general public to think that women suffer emotionally less with early abortions. It’s not like that. Even in the first trimester, the woman is going through hard times and these women prefer physicians who understand them and guide them step-by-step without judgment, rather than barely and merely provide them with information. Communication should elucidate and explore a patient's values and perspective. Shared decision-making and patient-centred counselling are techniques that incorporate and explore the intersections among scientific evidence for various treatments, patients’ values, family context and social needs.

Practical tips for counselling:

• Consider remaining silent after providing initial results or information, allowing the woman to process and experience her emotions. Follow-up with open-ended questions and active listening.

• Determine if the pregnancy is desired, as this will be important in helping a woman arrive at an emotional resolution and a plan.

• Normalize emotions by making reference to the way others might feel in a similar situation.

• Validate feelings rather than try to change them.

• Avoid opinions about what patients “should” do, being aware of the boundaries between professional responsibilities and personal beliefs.

• Whenever possible, encourage the woman to seek emotional support from others.

• While waiting for the results of an evaluation, provide reassurance that not all bleeding or cramping signifies a miscarriage, while avoiding guarantees that “everything will be all right”.

• Assure that you will be available to her through the process, and answer questions as they arrive.

• Use neutral responses whenever possible, for example:

  • That is a question that a lot of women wonder about;

  • I'm glad you asked that question;

  • That is a difficult question for me to answer;

  • Tell me more about what is concerning you;

  • Is that what you were asking me?;

  • Do you want to ask me more about that?;

  • It is expected that you'll have mixed feelings about this;

  • Some other women I have spoken with have experienced ____;

  • How would that work for you?.

Healthcare providers also have an important role in dissuading feelings of shame and guilt when faced with the diagnosis of EPL and educating patients on optimal prenatal and preconception health behaviours. Due to the many options for the management of EPL, individualized patient counselling is important. Women have strong and diverse preferences and evidence-based, patient-centred counselling improves patient satisfaction. This type of shared clinical decision-making allows for a partnership between providers and patients.

REFERENCES

An enabling environment for comprehensive abortion care (1.3) - Abortion care guideline. (n.d.). Sexual and Reproductive Health and Rights (SRHR). Retrieved September 26, 2022, from https://srhr.org/abortioncare 

Shorter, J. M., Atrio, J. M., & Schreiber, C. A. (2019, March). Management of early pregnancy loss, with a focus on patient centered care. In Seminars in perinatology (Vol. 43, No. 2, pp. 84-94). WB Saunders.