COUNSELING TIPS FOR EARLY PREGNANCY LOSS
- Primary care and ED clinicians may be the first to evaluate those with vaginal bleeding and abdominal cramping in early pregnancy. As EPL diagnosis often cannot be definitively established during the first visit, counseling presents a unique challenge, requiring heightened sensitivity to emotional needs.
- Acknowledge complex feelings. Not all people have similar pregnancy goals, intentions, sense of reproductive control, and/or supportive environments to safely parent (Borrero 2015, Manze 2020, Arcara 2021), thus the conversation is often not a simple dichotomy (desired vs. undesired, planned vs. unplanned). Explore this nuance with open ended questions like “what does this pregnancy mean to you?”
- While awaiting definitive results for a desired pregnancy, inform patients that not all bleeding signifies EPL. Avoid guarantees that “everything will be alright” and keep people informed with clear and plain language. Provide results once a diagnosis is made, giving them time to process.
- Explore and address any feelings expressed, avoiding assumptions about how a person may be feeling based on desired pregnancy outcome. Respond to specific concerns, informing people that EPL is not caused by common daily activities (e.g., coitus, heavy lifting, stress, exercise, etc.).
- Explain that EPL is common, occurring among 10-20% of clinically recognized pregnancies (with many more unrecognized), and normalize a range of emotions.
- People may have strong preferences for EPL treatment, with greater satisfaction when treated according to their preference and decreased satisfaction when clinicians underestimate the discomfort associated with various management options (Shorter 2018). Since each option is safe and relatively effective in most situations, the choice of management should align with personal preferences.
- Provide assurance that you or a colleague will be available throughout the process, answer questions, and encourage a support person to be at appointments if desired.
- Counsel regarding anniversary phenomena, as well as preparing people to discuss the loss with partner, family and friends (if helpful), acknowledging others may say the wrong thing as they try to support, or may underestimate EPL recovery time. Partners may also experience grief following EPL and may benefit from additional support (Meaney 2017).
- Some people experience depressive symptoms following EPL, while most do not. Provide additional counseling resources as needed, although evidence is insufficient to demonstrate its effectiveness (San Lazaro Campillo 2017).
- When appropriate, inquire and counsel about future fertility goals, providing immediate contraception or preconception care as needed. Inform and counsel about risks of RPL (no increase with first EPL, but increasing thereafter). People can ovulate within weeks of EPL and can attempt to conceive again as soon as they are ready (Schiep 2016).
- Approach people/couples with RPL in a sensitive manner, appreciating their needs, concerns, preferences, cultural differences, religious beliefs/obligations, and wishes around this diagnosis (Pillarisetty 2023).
- Address any treatable risk factors in a non-judgmental way. Consider initiating further work-up for people who have had 2-3 EPLs, or > 35 who have had 2 EPLs (ASRM 2012, ACOG 2018).
- The following resources can guide RPL workup and counseling: