By Karen Owens
It’s 1730 HOURS on what has been a fairly slow day. You’re pulling a 24-hour shift on the medic unit this cycle and are just getting ready to sit down to dinner when the tones go off: “Medic 6, respond to 123 Main Street for vaginal bleeding.” Additional dispatch information advises your patient is a 26-year-old female who is 14 weeks pregnant and is experiencing vaginal bleeding. On arrival, you enter the house to find your patient on the bathroom floor, visibly upset, with a significant amount of blood saturating her pants. Where do you begin, and how do you best assess and treat this patient?
A healthy pregnancy lasts for 40 weeks from conception to birth; a fetus is considered full term at 37 weeks of gestation. The American Pregnancy Association1 uses the term “spontaneous abortion” (SAB) to describe a loss of pregnancy prior to 20 weeks gestation. The loss of the developing baby anytime after gestational week 20 is referred to as a stillbirth.
Because of negative feelings associated with the term SAB, many individuals, both medical and nonmedical, prefer to refer to these events as miscarriages. Most miscarriages occur in the first 13 weeks of pregnancy, with an overall incidence of between 10 and 25 percent of recognized pregnancies ending in miscarriage. Many factors increase a woman’s chances of experiencing a miscarriage. (1) They include the following:
- Increased maternal age.
- Hormonal/health problems.
- Lifestyle choices.
- Improper implantation of the egg.
- Maternal trauma.
- Previous miscarriages.
A closer look at these risk factors helps providers understand specific impacts on fetal development and loss.
As maternal age increases, the risk of miscarriage also increases significantly. In one study of one million pregnancies with hospital admission, mothers 20 to 30 years of age had a nine to 17 percent risk of experiencing a miscarriage, while mothers age 40 had a 40 percent chance of experiencing a miscarriage.2 A history of previous miscarriages also increases the risk of future miscarriages. Risk of subsequent miscarriage is 20 percent following the first miscarriage, 28 percent after two consecutive miscarriages, and 43 percent for women with three or more consecutive miscarriages. This is in comparison to a five percent chance of miscarriage for women pregnant with their first or with a history of previous successful pregnancies. (2)
When expectant mothers begin experiencing signs and symptoms of a potential miscarriage, their first instinct may be to call 911, involving you in the assessment and treatment process. The signs and symptoms of a potential miscarriage vary from patient to patient and from miscarriage to miscarriage. As a result, the signs and symptoms that your patient presents with may be varied. (1) Women who seek emergency care as a result of a potential miscarriage may present with any or all of the following:
- Abdominal pains/cramping, similar to the pains associated with the first stages of labor.
- Bleedinganywhere from moderate (period-like bleeding) to severe.
- Noticeable discharge of blood and tissue.
Other symptoms that may serve as early warning signs for a miscarriage include the following:
- Mild to severe back pain.
- Weight loss.
- White-pink mucus discharge.
- Brown or bright red bleeding.
- Decrease in the general signs of pregnancy.
An understanding of miscarriages begins with a basic understanding of fetal development. Fetal gestation is measured in weeks, with 40 weeks considered the usual average human gestation. Some women may deliver before or after the 40-week mark, although developing babies are considered “full term” at 37 weeks gestational age. However, a fetus is generally considered viable at 24 weeks gestational age if delivered. By the 13th week of development, when chances for miscarriage significantly decrease, the fetus weighs only about one ounce and measures approximately three inches.3 By 24 weeks gestational age, the age of viability, a fetus weighs approximately 11⁄4 to 11⁄2 pounds and is approximately 121⁄2 inches long.4 Miscarriages that occur early in pregnancy, before 13 weeks, may include the expulsion of little obvious tissue, while later miscarriage may result in the loss of obvious fetal tissue.
There are different types of preterm losses often referred to as miscarriages. In the field and to most lay persons, regardless of the cause, a loss of a pregnancy is referred to as a miscarriage. The medical community recognizes different causes of miscarriages. A missed miscarriage is one in which there is fetal death but no expulsion of tissue. EMS personnel are not likely to see these, as they are rarely accompanied by bleeding or cramping and are normally discovered on ultrasound examination during a regular doctor’s appointment. (1) A threatened miscarriage is one in which a patient experiences bleeding and cramping but, on examination by a physician or midwife, the cervix is closed. (1) Bleeding may be associated with implantation, and many patients will carry to full term after the bleeding subsides. Most patients EMS personnel see are likely experiencing an inevitable or incomplete miscarriage. These patients typically present with back pain and abdominal cramping accompanied by significant bleeding. (1) An important point concerning these patients is that they will continue to bleed if the fetal tissue is not expelled. With this in mind, quick recognition, appropriate treatment, and transport to the proper facility are necessary.
The only way to accurately diagnose a true miscarriage is through relatively invasive clinical assessment and testing not available in the prehospital environment. The responsibility of the EMS provider is to administer the best care possible until the patient can be delivered to the appropriate medical facility.
As you approach your patient, you ask her name and begin the interview. She tells you that she had been experiencing some cramping earlier in the day but had thought it was because of dehydration. When she stood up to use the bathroom, she felt a gush of fluid and realized it was blood. She yelled for her husband to call 911, and this is how you found her. She tells you she is 14 weeks pregnant and that this is her first pregnancy.
Although a potential miscarriage may be emotionally difficult for the patient, family members, and even the crew, it is important to focus on the physical treatment. As with any assessment, the first step is to ensure scene safety and appropriate levels of personal protective equipment (PPE) because of the presence (or potential presence) of bodily fluids.
Basic patient care for a potential miscarriage is similar to any other medical scenario. After an initial check of airway, breathing, and circulation, obtain baseline vitals to provide a clear picture of the patient’s physical status. If your patient is experiencing significant bleeding, control the bleeding. Treat vaginal bleeding by placing a sanitary napkin to absorb the blood. During transport, replace any blood-soaked pads. However, you should hand over to the hospital for further examination anything you use to treat the patient. Hospital staff can examine expelled fetal tissue to help determine what caused the miscarriage and count blood-soaked pads to help calculate blood loss.
Along with controlling any bleeding, you, as the provider, should also prepare to treat your patient for any signs and symptoms of shock. At the basic life support (BLS) level, this includes applying high-flow oxygen via nonrebreather mask.5 In cases of hypotension, position the patient slightly tipped to the left side to improve perfusion to the fetus and possibly to help increase the mother’s blood pressure. Left-sided positioning moves the fetus away from the mother’s vena cava, alleviating compression that may decrease perfusion. When available, inflate the leg compartments of a pneumatic antishock garment (PASG), which may help increase blood pressure.
Advanced life support (ALS) treatment may also include a large-bore IV of normal saline or ringers lactate. The IV will be most beneficial to patients who have experienced significant fluid loss or are exhibiting signs and symptoms of shock. Not every patient will require IV fluids. ALS providers may also place the patient on a cardiac monitor to verify that there is no disturbance in the heart rhythm as a result of the miscarriage. Beyond these additional advanced interventions, there is minimal additional treatment necessary. The important focus for any EMS provider (BLS or ALS) is to treat the signs and symptoms that are present and to be prepared for the unexpected.
THE TRANSPORT DECISION
After you provide on-scene treatment, it is obvious that your patient needs to be transported. You now need to determine the most appropriate facility for your patient. When you realize her hospital of choice is not the closest, your first instinct is to advise her to go to the nearest hospital.
When a patient presents with a significant medical emergency, it is standard protocol to transport to the nearest facility. You should take patients in shock to a trauma center. With miscarriages, consider transporting to the nearest appropriate facility. A miscarriage patient may require transport to a facility capable of supporting her unique specialty diagnostic and emergency obstetrical needs. For miscarriages occurring prior to viability of the fetus, there may be a need for the patient to undergo a dilation and curettage (D & C), because of retention of fetal tissue. A D & C is a surgical procedure that removes retained tissue to stop bleeding and prevent subsequent infection. If your patient is experiencing signs and symptoms of a miscarriage later in the pregnancy (22 to 24 weeks), consider transport to a hospital with a high-level Neonatal Intensive Care Unit. Ensuring the appropriate medical intervention for an infant born around 22 to 24 weeks of gestation increases the chances of survival. Transport to appropriate obstetrical and neonatal destinations significantly impacts survival of both mother and infant.
In all cases involving destination and patient care decision making, the number one priority must be the welfare of the mother. Proper resuscitation of the mother is the only means of ensuring fetus survival.
After placing your patient on the stretcher and in the back of the truck, you continue to monitor her vitals and place her on oxygen. Although her blood pressure and pulse are within normal limits, her respiratory effort is increased because of her current emotional state. You realize that treatment of her physical symptoms is adequate, and you now need to focus on her emotional needs.
As with any call, treatment of emotional signs and symptoms is just as important as, if not more important than, treatment of physical signs and symptoms. It is also important to remember that each patient may be experiencing different ranges of emotions as a result of the miscarriage. Most patients will probably be experiencing a miscarriage for which they were unprepared. These women are more likely to experience shock and denial in dealing with the event. They may try to rationalize that the bleeding is not related to the pregnancy and that they are not experiencing a miscarriage.6 Some women experiencing a miscarriage may have been told by their prenatal care practitioner that it was inevitable. These miscarriages may have been noticed on an ultrasound and could be the result of numerous issues, including health problems, improper implantation, blighted ovum, and so on. These women may have had time to work through the denial and shock and may be exhibiting signs of depression, guilt, or even acceptance of what they knew was going to happen. (6) While they knew a miscarriage was a significant possibility, the actual event may have led them to call 911 for medical assistance. These women need just as much emotional support as those experiencing an unexpected miscarriage.
Remember, when focusing on these patients’ emotional needs, be careful what you say to them. It may seem natural to offer some reassurance, but make sure that you aren’t offering false reassurance. Avoid making statements such as “I’m sure the baby is fine” or “This is probably nothing.” Such statements are not based on facts and may result in additional emotional distress for the patient. It may be best to simply allow the patient to talk and verbalize her thoughts while transporting her to the hospital.
You wheel your patient into the ER and complete your patient transfer. After finishing the paperwork, you and your partner head back to the truck to finish cleaning up, but you can’t help looking in on your patient one last time before you leave.
As EMS providers, we treat physical and emotional suffering daily. A patient experiencing a miscarriage will need treatment for the physical and emotional effects of the event. It is your job to stay focused on the appropriate treatments and comfort measures for each patient. Making smart decisions on where to transport your patient can help ensure the patient receives the best care possible from 911 call to hospital discharge.
1. American Pregnancy Association (2008), Miscarriage, American Pregnancy Association, http://www.americanpregnancy.org/pregnancycomplications/
miscarriage.html (accessed December 3, 2008).
2. T. Tolandi and H.M. Al-Fozan, “Spontaneous abortion: risk factors, etiology, clinical manifestations, and diagnostic evaluation,” in: UpToDate, eds D. Levine and R.L. Barbieri, Waltham, MA, 2008.
3. American Pregnancy Association (2009), Fetal development: First trimester. American Pregnancy Association, http://www.americanpregnancy.org/duringpregnancy/
fetaldevelopment1.htm (accessed January 7, 2009).
4. American Pregnancy Association (2009), 24th week of pregnancy, American Pregnancy Association, http://www.americanpregnancy.org/weekbyweek/week24.htm (accessed January 10, 2009).
5. D. Limmer et al., Emergency Care: 10th Ed. (New Jersey: Brady/Prentice Hall, 2007).
6. American Pregnancy Association (2008), After a miscarriage: Surviving emotionally. American Pregnancy Association, http://www.americanpregnancy.org/pregnancyloss/
mcsurvivingemotionally.html/ (accessed December 3, 2008).
KAREN OWENS is the emergency operations assistant manager for the Virginia Office of EMS, where she has been employed since 2001. Her duties include oversight of the emergency operations training programs including MCI management, terrorism awareness, and vehicle rescue. She has a BA in psychology and an MA in public safety leadership. She is a Virginia certified firefighter and has been a Virginia EMT-B instructor since 2002.