A Review of the Management of Loss of Pregnancy in the Emergency Department

Midwives' and registered nurses' role and scope of practice in acute early pregnancy care services: a scoping review

OBJECTIVE

The objective of this scoping review was to investigate and describe what is reported on the role and scope of practice of midwives and registered nurses providing care for women with pregnancy complications under 20 weeks' gestation in acute clinical settings in Australia.

INTRODUCTION

In many high-income countries, women experiencing unexpected complications in early pregnancy attend an acute care service, such as an emergency department, rather than a maternity or obstetric unit. This service structure can impact the care women receive, and determine who provides it. Women and their partners, who are often experiencing emotional distress, have reported difficult experiences when accessing acute services, particularly emergency departments, which are not traditionally staffed by midwives. The role and scope of practice of both midwives and registered nurses providing acute early pregnancy care in most high-income countries, including Australia, is poorly reported. Documenting this area of practice is an important first step in facilitating ongoing research in this important aspect of pregnancy care.

INCLUSION CRITERIA

Published and gray literature that described the role and scope of practice of midwives and/or registered nurses providing care in acute early pregnancy settings in Australia were considered for this review.

METHODS

A scoping review of the literature was conducted following JBI methodological guidance and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist. A 3-step search strategy was conducted to explore evidence from databases and search engines, gray literature sources, and selected reference lists. After screening, data were extracted from records selected for the final review, mapped, and analyzed using content analysis.

RESULTS

The evidence reviewed (n=23) included primary research studies, conference abstracts, and gray literature, such as clinical guidance documents, academic theses, and websites from January 2008 to October 2023. The most common setting for care provision was the emergency department. Midwives' and registered nurses' roles and scope of practice in acute early pregnancy care in Australia can be summarized into 4 areas: physical care, psychosocial support, care co-ordination, and communication. Women's access to midwifery care at this time in pregnancy appears to be limited. Registered nurses, usually employed in emergency departments, have the most prominent role and scope in the provision of care for women with acute early pregnancy complications. Descriptions of midwives' practice focuses more on psychosocial support and follow-up care, particularly in early pregnancy assessment service models.

CONCLUSIONS

This review highlights the inconsistency in midwives' and registered nurses' roles and scope in acute early pregnancy in Australia, a finding which is relevant to other international settings. Both professions could further fulfill role and scope capacity in the provision of supportive, individualized, and timely care for women and families accessing a range of acute early pregnancy services. Emergency departments are the usual practice domain of registered nurses who may be limited in terms of the scope of care they can provide to women with early pregnancy complications. Leaders of the midwifery profession should conduct further research into innovative service models that embed a role for midwives in all settings that provide care for pregnant women, regardless of gestation.

REVIEW REGISTRATION

Open Science Framework osf.io/7zchu.

Spontaneous Miscarriage Management Experience: A Systematic Review

Background: The estimated frequency of spontaneous miscarriage is about a quarter of all clinically identified pregnancies in the United States. Women typically go to the emergency department (ED) or outpatient clinic when they experience symptoms, including but not limited to vaginal bleeding, abdominal pain, and contractions. The care that is provided varies from place to place.

Methods: Researchers searched articles from 2010 to 2021 for reports mentioning treatment for spontaneous abortion. Search terms included "miscarriage aftercare" and "spontaneous abortion care," seeking articles addressing the psychological effects of miscarriage and reporting patient experiences in different clinical settings. Data were independently reviewed, graded for evidence quality, and assessed for risk bias using the AMSTAR checklist.

Results: The search strategy yielded 2,275 articles, six of which met the inclusion criteria. Conservative, medical, and surgical management were provided, with surgical management being more common among women with higher education and socioeconomic status. All qualitative studies reported dissatisfaction with care provided in the emergency department, partially due to a lack of emotional support. Structured bereavement intervention was beneficial for women experiencing early pregnancy loss and led to fewer reports of despair. The quantitative studies referenced interventions that aided patients in coping with pregnancy loss and identified several factors influencing the type of treatment received as well as the patient's ability to cope with feeling depressed following a miscarriage.

Conclusion: Psychological management is not regularly addressed in the emergency department, and protocols including bereavement education for healthcare providers as well as patient involvement in management would improve the overall patient experience with spontaneous miscarriage care.

Exploring the services and management available to women experiencing complications in early pregnancy: a survey of Ontario, Canada hospitals

This investigation surveyed the gynaecologic services and management available to women experiencing early pregnancy complications in the province of Ontario, Canada. The Chiefs of Gynaecology/Obstetrics of 61 Ontario hospitals were invited to complete a 55-item, online questionnaire using modified Dillman methodology. Forty-three hospital site respondents completed the survey (a response rate of 70.5%). It was reported that 18 (41.9%) hospitals had access to an early pregnancy assessment unit (EPAU), and 12 (66.7%) EPAUs had ≤2 days between the referral and the first appointment. Of the 25 (58.1%) hospital respondents without an EPAU, 14 (56.0%) reported previous consideration of creating an EPAU. At these hospitals, patients with early pregnancy complications have access to care through the ED (n = 22, 88.0%), obstetricians/gynaecologists (n = 22, 88.0%), person on-call (n = 16, 64.0%), family physicians (n = 11, 44.0%) or midwives (n = 9, 36.0%). This investigation found great heterogeneity in the care accessible to women experiencing early pregnancy complications in hospitals in Ontario, Canada.Impact statementWhat is already known on this subject? Early pregnancy assessment units (EPAUs) are the standard for evaluating and caring for complications of early pregnancy. It has been well documented that EPAUs result in positive health service outcomes such as more cost-effective care, more timely management, and improved quality of care and patient satisfaction.What do the results of this study add? This investigation found that the province of Ontario, Canada has begun to adopt the EPAU model; however, a great heterogeneity exists in the care accessible to women experiencing early pregnancy complications throughout the province. Nonetheless, where EPAUs are available, they provide a structured referral system for women experiencing complications of early pregnancy that require gynaecologic assessment, such as ectopic pregnancy, providing close follow-up and predictable pathways of care for this patient population.What are the implications of these findings for clinical practice and/or further research? This study highlights the need for hospitals in the province of Ontario to improve their current service delivery models for women experiencing early pregnancy complications. Further research should be undertaken to determine whether the positive health service outcomes of EPAUs are also relevant in the Canadian healthcare system.

A qualitative exploration of women's experiences discovering pregnancies in the emergency department

OBJECTIVES

The few studies examining pregnancy testing in emergency departments (EDs) address pregnancy-related physical risks. Here, we examine experiences of people who discover pregnancies in EDs.

METHODS

Between 2015 and 2017, as part of a larger study, we conducted interviews with 29 women in Southern Louisiana (n = 13) and Baltimore, MD (n = 16), who reported discussing their pregnancy during an ED visit. We analyzed these interviews for content and themes.

RESULTS

Respondents reported diagnosis of pregnancy as a routine and straightforward component of care received in EDs. They reported receiving diagnostic studies and therapeutic interventions to rule out and treat complications of pregnancy and care for what brought them to the ED to begin with, such as treatments for nausea and vomiting; education about physical symptoms and nutrition-related needs during pregnancy; and referrals to prenatal care. However, we find evidence of unmet needs related to patient-centered communication, such as providing emotional care to women discovering pregnancies in EDs and lack of support for transitions to abortion care.

CONCLUSIONS

While diagnosis of pregnancy in the ED may be routine for ED clinicians, it is not necessarily routine or straightforward for people receiving the diagnosis. ED clinicians should not assume that all people who discover their pregnancies in the ED want to continue their pregnancy. People who discover pregnancies in EDs may benefit from patient-centered communication and support for the range of transitions to care people might need in addition to the routinely provided diagnostic and therapeutic interventions.

IMPLICATIONS

ED clinicians may need additional training and support to ensure that they can meet the range of needs of people who discover their pregnancies in the ED.

Patient Experiences With Miscarriage Management in the Emergency and Ambulatory Settings

OBJECTIVE

To quantitatively and qualitatively describe the patient experience for clinically stable patients presenting with miscarriage to the emergency department (ED) or ambulatory clinics.

METHODS

We present a subanalysis of a mixed-methods study from 2016 on factors that influence miscarriage treatment decision-making among clinically stable patients. Fifty-four patients were evaluated based on location of miscarriage care (ED or ambulatory-only), and novel parameters were assessed including timeline (days) from presentation to miscarriage resolution, number of health system interactions, and number of specialty-based provider care teams seen. We explored themes around patient satisfaction through in-depth narrative interviews.

RESULTS

Median time to miscarriage resolution was 11 days (range 5-57) (ED) and 8 days (range 0-47) (ambulatory-only). We recorded a mean of 4.4±1.4 (ED) and 3.0±1.2 (ambulatory-only) separate care teams and a median of 13 (range 8-20) (ED) and 19 (range 8-22) (ambulatory-only) health system interactions. Patients seeking care in the ED were younger (28.3 vs 34.0, odds ratio [OR] 5.8, 95% CI 1.8-18.7), more likely to be of black race (28.3 vs 34.0, OR 3.3, 95% CI 1.1-10.0), uninsured or insured through Medicaid (16 vs 6, OR 6.8, 95% CI 2.1-22.5), and more likely to meet criteria for posttraumatic stress disorder when compared with ambulatory-only patients (10 vs 3, OR 6.0, 95% CI 1.5-23.4). Patients valued diagnostic clarity, timeliness, and individualized care. We found that ED patients reported a lack of clarity surrounding their diagnosis, inefficient care, and a mixed experience with health care provider sensitivity. In contrast, ambulatory-only patients described a streamlined and sensitive care experience.

CONCLUSION

Patients seeking miscarriage care in the ED were more likely to be socioeconomically and psychosocially vulnerable and were less satisfied with their care compared with those seen in the ambulatory setting alone. Expedited evaluation of early pregnancy problems, with attention to clear communication and emotional sensitivity, may optimize the patient experience.

Women's Experiences of Miscarriage in the Emergency Department

INTRODUCTION

Miscarriage is a common event, usually managed in the emergency department. Although studies have examined the impact of miscarriage on women's mental health and the effects of their dissatisfaction with health care received, little is known about the characteristics of the miscarriage experience in the emergency department. The objective of this study was to identify characteristics of care management that may have contributed to the difficulties experienced by women presenting with miscarriage in the emergency department.

METHODS

Forty-eight women treated at 4 emergency departments in different regions of Quebec, Canada, were interviewed for 60 to 90 minutes. A thematic qualitative analysis of these interviews was performed.

RESULTS

Analyses revealed that participants' experiences were characterized particularly by a lack of information at 3 critical junctures of the miscarriage experience: the announcement of the miscarriage, the course of the miscarriage, and the ED discharge. The topics on which the women lacked information were categorized into 7 subthemes within these junctures.

DISCUSSION

Lack of information throughout the care management of miscarriage exacerbated the already-difficult nature of this event for the participants. Training emergency nurses to give adequate and complete information enables the delivery of compassionate care, potentially making a difficult situation less traumatic.

The relationship between support systems and anxiety in couples admitted to the emergency department with vaginal bleeding

INTRODUCTION

First-trimester vaginal bleeding largely occurs due to miscarriage, ectopic pregnancy, gestational trophoblastic diseases. Pregnant women diagnosed with threatened abortion experience and their spouses severe anxiety and stress due to the probability of the pregnancy ending. Couples having difficulty coping with the see motions need support systems. The aim of this study was to examine the relationship between the anxiety levels experienced by couples who present at the emergency department with a complaint of vaginal bleeding and are diagnosed with threatened abortion, as well as their support systems.

METHODS

The study was conducted with 276 participants (138 pregnant women and their spouses) admitted to the obstetrics emergency department of an obstetrics and paediatrics hospital in Turkey between December 2014 and March 2015. Data were collected through a demographic information form developed by the researcher, the State-Trait Anxiety Inventory (STAI), and the Multidimensional Scale of Perceived Social Support (MSPSS).

RESULTS

There were significant negative associations between mean the State-Trait Anxiety Inventory scores and Multidimensional Scale of Perceived Social Support scores of the pregnant women and their spouses (p < 0.05). The couples' anxiety levels did not significantly differ according to whether they received support from each other and from emergency nurses (p > 0.05).

CONCLUSION

It was found that both state and trait anxiety levels of the couples decreased as perceived social support increased. However, it was determined that the support couples received from each other and from emergency nurses was not sufficient in terms of reducing anxiety.

Social work intervention for women experiencing early pregnancy loss in the emergency department

Often referred to as miscarriage, Early Pregnancy Loss (EPL) is the spontaneous death of a fetus experienced within the first 20 weeks of gestation and is the most common complication in pregnancy. Symptoms of an impending EPL are routinely managed in the Emergency Department (ED). EPL can have a substantial impact on women, potentially leading to psychological and emotional health issues and risks to future pregnancies. Despite the high prevalence of EPL, many women suffer in silence due to the common societal belief that EPL are insignificant. Many women experience EPL as an ambiguous loss and are at risk for disenfranchised grief. Compassionate, patient-centred care has been identified by women as an essential and often missing aspect of ED care and can have a profound impact on the overall well-being of women after EPL. Social workers play a critical role in the ED given that they prioritize the psychosocial well-being of patients in a system that is structured to primarily address trauma care. In an effort to reduce the psychological impact and complicated grief reactions of women experiencing EPL, specific recommendations for social work intervention to address the individual needs of women experiencing EPL in the ED are presented. These include acknowledging the loss, providing psychoeducation, honouring the loss, assessing resources, referral and additional information, and building capacity in the ED.