Referral to Special Clinics Urged for Miscarriage in Canada

Miscarriage, or early pregnancy loss, can have “devastating” psychological effects that can be relieved by empathetic communication and supportive follow-up, ideally in an outpatient early pregnancy assessment clinic (EPAC), Canadian researchers suggest in a new guidance.
Miscarriage is “common, distressing, and frequently poorly managed in Canada,” wrote Modupe Tunde-Byass, MBBS, an obstetrician/gynecologist at North York General Hospital and associate professor at the University of Toronto in Toronto, Ontario, Canada, and colleagues.
Their article is needed “to assist primary care providers with the diagnosis and management of early pregnancy complications and loss (EPCL) and to emphasize the importance of compassion and sensitivity in the care” of affected patients, Tunde-Byass told Medscape Medical News.
Data suggest that 15%-20% of all confirmed pregnancies result in miscarriage, with about half caused by chromosomal abnormalities, a risk that increases with age.
“Healthcare providers should not only focus on the medical aspect of EPCL, but also acknowledge the psychological and emotional aspects,” said Tunde-Byass. “Patients undergoing EPCL should be offered management options and be given time for shared decision making based on their values, preferences, and time commitment.”
The guidance was published on October 15 in the Canadian Medical Association Journal (CMAJ).
EPACs Improve Outcomes
The authors conducted a targeted search of the literature published through July 2023 using relevant terminology. They then summarized the best available evidence on miscarriage to guide physicians on how to diagnose and manage the condition.
Miscarriage, or early pregnancy loss, was defined as “an empty gestational sac or a gestational sac with embryo without fetal cardiac activity before 13 weeks’ gestation.”
According to the guidance, common symptoms include bleeding, cramping, abdominal or pelvic pain, and passage of tissue. Symptoms of ectopic pregnancy, which should be ruled out, include worsening abdominal pain, dizziness, bleeding, or shoulder-tip pain.
A diagnosis requires an assessment of serum beta human chorionic gonadotropin levels and pelvic ultrasonography, preferably transvaginal, to investigate pregnancy viability and distinguish early pregnancy loss from an ectopic pregnancy. Findings from the pelvic ultrasonography and a physical exam can also be used to categorize miscarriage as incomplete, complete, or missed.
Management options include expectant, medical, and surgical. Expectant management is considered safe for patients with a known intrauterine pregnancy experiencing early pregnancy loss who are medically stable, without active pelvic infections, severe anemia or bleeding disorders, or active uterine hemorrhage. Patients who choose expectant management must be counseled to return to care if excessive bleeding, syncope, severe pain, or fever occur.
Medical management results in completed miscarriages earlier than expectant management and should be offered to all hemodynamically stable patients with a known intrauterine pregnancy experiencing early pregnancy loss, according to the guidance. Treatment consists of oral misoprostol alone or in combination with pretreatment with oral mifepristone.
Surgical management is the first-line treatment for patients with hemodynamic instability, low hemoglobin (< 95 g/dL), or a drop in hemoglobin of 20 g/dL. It is also the standard of care when there is suspicion of a molar pregnancy, an intrauterine device that cannot be removed, or a sign of infection. Suction dilation and curettage has better outcomes than sharp curettage.
“Early pregnancy loss can have serious emotional and psychological effects and may invoke grief, guilt, depression, anxiety, or other responses for patients and their families,” the authors wrote. “Symptoms have been found to persist a year after pregnancy loss and during subsequent pregnancies. Grief can be exacerbated by poor social support. Partners who experience similar reactions may be disregarded. People who identify as 2SLGBTQ+ often experience stigma and discrimination after pregnancy loss and may feel an amplified sense of shame.”
‘Dedicated Outpatient Clinics’
The guidance supports referral to an EPAC to ameliorate emotional and psychological effects and improve outcomes. Togas Tulandi, MD, MHCM, chair of the department of obstetrics and gynecology at McGill University in Montreal, Quebec, Canada, agreed, noting that McGill University Health has an EPAC. “Here, the patients are seen by a nurse, a physician, and an ultrasonographer on site.” Tulandi did not participate in drafting the guidance. 
“In view of the psychological impact, our staff is sensitive and well trained,” he told Medscape Medical News. “However, we have a reproductive psychiatrist who could be consulted if needed.”
Regarding the recommendations, Tulandi said, “The authors stated that ‘endometrial scarring has been associated with sharp curettage, although it is rare.’ As a reproductive surgeon, I have seen many patients with intrauterine adhesions. The adhesions could interfere with fertility, and most are due to curettage, especially repeated curettage. Repeated curettage should be avoided.”
In the absence of severe bleeding and abdominal pain, he said, “early pregnant patients with uterine bleeding should be evaluated at an EPAC.”
Dustin Costescu, MD, a family planning specialist and associate professor at McMaster University in Hamilton, Ontario, told Medscape Medical News, “Unfortunately, EPACs are largely relegated to large urban centers, and even then, many of these clinics cannot meet the demand for timely care.” Costescu did not contribute to the document. 
“Furthermore, hospital constraints limit the ability of providers and patients to access urgent operating time when surgical management is requested or indicated,” he noted. “Until there are resources provided to establish and integrate EPACs within the broader system, there will continue to be different levels of care across different jurisdictions.”
Where an EPAC is available, said Costescu, “it should be properly resourced to ensure that the community need can be met, and clinicians must have the appropriate information to facilitate referrals.”
Abortion clinics in or outside the hospital are not mentioned in the paper, but they do provide “a lot” of early pregnancy care, he continued. “Abortion providers are frequently presented with early pregnancy loss, pregnancies of unknown viability or location, or requests for timely care in the setting of miscarriage. With the advent of medication abortion, many clinics have additional capacity for surgical management with much shorter wait times than hospitals.”
“Miscarriage management is challenging for clinicians because of the need for diagnostic certainty, a complex referral process, resource constraints in operating rooms, a shortage of gynecologists, and a near-complete lack of resources for psychosocial care,” he concluded. “Clinicians should take steps to acquaint themselves with the resources available to them locally, building relationships as needed, to help reduce delays in care for patients experiencing early pregnancy loss.”
In a related editorial, Catherine Varner, MD, an emergency medicine physician and deputy editor of CMAJ wrote that patients have reported “appalling experiences” when seeking care for miscarriage symptoms in the Canadian health system.
“Health policymakers should seize the current momentum in healthcare innovations to champion a patient population with an ambulatory-sensitive condition that has well-defined standards of care and a proven, cost-effective alternative environment to overcrowded emergency departments.”
Tunde-Byass, Tulandi, and Costescu reported having no relevant financial relationships. For Varner’s conflicts of interest, see www.cmaj.ca/staff.
Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, the Lancet (where she was a contributing editor), and Reuters Health.
 
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