Primary care and ED providers may be the first to evaluate patients with vaginal bleeding and abdominal cramping in early pregnancy. As the diagnosis often cannot be made definitively during the first visit, counseling presents a unique challenge, requiring heightened sensitivity to a patient’s emotional needs.

  • Have a conversation that acknowledges complex feelings. Not all people have similar pregnancy goals, intentions, sense of reproductive control, or supportive environments to safely parent (Borrero 2015), thus the conversation is often not a simple dichotomy (desired vs. undesired, planned vs. unplanned). Explore this with open ended questions like “what does this pregnancy mean to you?”
  • While awaiting definitive results for a desired pregnancy, reassure that not all vaginal bleeding signifies pregnancy loss. Avoid guarantees that “everything will be alright.”
  • Keep a patient informed throughout the diagnostic process regarding impressions and next steps. Provide results once a diagnosis is made, giving the patient time to process.
  • Explore and address feelings of guilt or responsibility expressed regardless of the patient’s desired pregnancy outcome. Respond to specific concerns, reassuring that nearly all cases of early pregnancy loss have no identifiable cause, and cannot be caused by common daily activities (e.g., from coitus, heavy lifting, stress, etc.).
  • Describe that early pregnancy loss is common, occurring among 10-20% of clinically recognized pregnancies, and help to normalize the patient’s emotions. Advise that no interventions are proven to prevent first trimester loss.
  • Patients have strong preferences for choice of EPL treatment, and have greater satisfaction when treated according to their preference (Wallace 2010, Dalton 2006). Since each option is safe and relatively effective in most clinical situations, the choice of management should align with a patient’s treatment preferences.
  • Underestimating the discomfort associated with any management option has been negatively associated with satisfaction (Dalton 2006).
  • Assure that you or a colleague will be available throughout the process, answer questions as they arise, and encourage a support person to be at the visit.
  • Counsel patients who are particularly bereaved regarding anniversary phenomena, as well as preparing themselves to discuss the loss with family and friends. Provide resources for counseling or phone support if desired by the patient.
  • Prepare patients that well-meaning friends, family, and even partners may say the wrong thing as they try to support them, or may underestimate how long the emotional recovery time can be after an early pregnancy loss.
  • Studies show some patients 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 a patient is ready, inquire and counsel about future fertility, providing immediate contraception or preconception care as needed. Inform and counsel about recurrent miscarriage risks (approximately baseline risk after one; 30% risk after two and increasing thereafter). Address any treatable risk factors, as appropriate, in a non-judgmental way. Consider initiating further work-up for patients who have had 3 EPLs, or for patients > 35 who have had 2 EPLs.



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