Primary care and Emergency Department 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.

  • If definitive results are not available, reassure that not all vaginal bleeding signifies a pregnancy loss, while avoiding guarantees that “everything will be all right.”
  • Keep the patient informed throughout the diagnostic process about your suspicions and next steps, and provide results once EPL is diagnosed, giving the patient time to process.
  • Discuss if the pregnancy is desired to help guide EPL management. Many but not all patients with an undesired pregnancy may feel better knowing the pregnancy is non-viable.
  • Explicitly address feelings of guilt, reassuring that there is no evidence that a patient caused this pregnancy loss (e.g., from coitus, heavy lifting, stress, etc.).
  • Describe that pregnancy loss is common, occurring among 10-20% of clinically recognized pregnancies, and help to normalize the patient’s emotions.
  • Advise patients that no interventions are proven to prevent first trimester loss.
  • Research shows patients have strong preferences for choosing treatment for EPL, 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 be in line with a patient’s preferences for treatment. (See EPL Options Counseling below)
  • 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 through 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 additional counseling resources as needed. Studies show some patients experience depressive symptoms following EPL, while others do not. Evidence is insufficient to demonstrate that counseling is effective post-miscarriage (Murphy 2012 ).
  • 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; this is possibly best saved for follow-up.


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