Caring for women and their partners experiencing pregnancy loss*: GPs

* miscarriage, ectopic or molar pregnancy

A note of caution: this film includes scenes and conversations that viewers might find upsetting, especially if they have been through pregnancy loss themselves.  You may prefer just to use the good practice guides alone.

GP couldn't change

 

Our good practice guide

From a medical perspective, miscarriage is a common and generally minor complication of pregnancy but for patients and their partners it can be distressing, frightening and lonely.

This may be even more so for ectopic and molar pregnancy, which are much less common and can carry additional complications.

GP was fabulousPatients may present with symptoms or worries during pregnancy, or they may come after a loss, or during a subsequent pregnancy. Some may present with other problems, such as anxiety or depression, and it becomes clear that these are related to pregnancy loss.

In all of these situations, your approach can make a positive difference to their experience.

We spoke to women and GPs about what helps and what makes things harder. Here’s a summary of what they told us.

 

Listen to the women (and her partner, if present)

Taking a good history includes listening to additional information that she (and perhaps her partner) gives, as well as reading her notes. Not only can it aid diagnosis, but good listening can also make her feel respected and cared for at what might be a vulnerable time.

always check for ectopic

 

Consider how she (or they) might be feeling

Everyone reacts individually to pregnancy loss. Some women may accept it and some might feel relieved. But many women (and partners) patient talkingfeel:

  • very anxious if they have worrying symptoms (or lack of) in pregnancy
  • shocked, distressed, grieving and possibly self-blaming after a loss
  • anxious about trying again and/or about future fertility
  • very anxious in the next pregnancy

After ectopic pregnancy, women may also feel shocked by the speed of events in diagnosis and treatment, especially after emergency surgery.

Everything happened so quicklyAfter molar pregnancy, women may also feel very frightened by the association with cancer and what it might mean for their future and upset by having to delay trying again during follow-up

 

 

Show understanding and empathy

doctor listeningYou might not be able to meet all her expectations but understanding, kindness and acknowledging her feelings can help.

  • Acknowledge the woman’s emotional response, whatever it is.
  • Say (and show) you are sorry for her/their loss, if appropriate, but
  • … be aware that it might make some women feel worse.
  • Recognise that uncertainty is difficult to cope with and acknowledge how hard it is to wait – for a scan, or a specialist appointment, or test results.
  • Acknowledge the impact of additional factors: loss after fertility problems or treatment; recurHaving someone to listen helpsrent miscarriage.
  • Don’t assume that the shorter the gestation, the less the sense of loss.
  • She might need time off work. Ask her if it would help.
  • Giving statistics might help, but it also might not.

 

Think about your language

more than bad luckWhen it comes to pregnancy loss, women and their partners are often acutely sensitive to the words you use or that they hear in hospital. They also might not understand some medical terminology.

  • Most (but not all) women think of their pregnancy as a baby. Most (but not all) prefer you to refer to it that way.
  • If you’re not sure what term to use, mirror what the patient uses (baby, fetus, pregnancy) or ask her what she’d prefer.
  • Terms like ‘spontaneous abortion’ or ‘products of conception’ are upsetting to most women.
  • Try not to minimise the loss. Referring to it as a ‘just a heavy period’, ‘back luck’ or saying ‘at least you know you can conceive’ can actually increase distress.
  • You many need to explain medical terminology that she has heard or read elsewhere.

 

 

Give clear information about what is happening now…

  • Ask what information she/he wants and be guided by the responses.
  • If you can’t give clear answers, explain why not and refer on to other services and/or specialists as appropriate.
  • Provide or refer to written information where that might help.

 

… and about next steps

leaflet coverMany women will seek information and advice.

Causes and treatment

  • Was it something they did/didn’t do? That’s very unlikely. See our leaflet Why Me?
  • Referral to a specialist clinic*.

Management options for miscarriage

  • Advice on which option to choose.

Pregnancy remains

  • Information about testing: histology vs karyotyping.
  • Histology aims to identify distinguish between normal pregnancy tissue, molar tissue or only maternal tissue (i.e. possible ectopic).
  • Fetal karyotyping is usually offered only as part of investigations into recurrent miscarriage.

Options for disposal:

  • Hospitals will have their own policies & procedures for disposal, which may include disposal as clinical waste. It is worth finding out what your local provider offers.

     

    *The RCOG recommends referral for investigations following three or more first-trimester miscarriages or one or more second trimester miscarriages.

    Many women find these criteria hard to accept, especially if they are older or have problems conceiving. They are searching for an explanation for their losses and treatment to reduce the risk of recurrence and may be especially vulnerable to treatments which are not evidence-based.

    Clear information and support can help. See our leaflet on recurrent miscarriage.

     

    Give her information about additional support available

    Women told us that they often underestimated the impact of pregnancy loss on their mental health. You can help by providing additional information and follow up.

    • After a miscarriage (or ectopic or molar pregnancy), try to ensurefollow up call thanks that information is passed to other services so women are not contacted by midwives or other services after their loss.
    • Suggest a follow-up appointment.
    • Consider discussing a plan for the next pregnancy (possibly including an early scan).
    • Provide information about local/national support services. The Miscarriage Association provides support and information via our website, phone, email and online groups.
    • Refer to/provide information about professional counselling services where appropriate.

     

    Got more time?

    These additional resources might be helpful.

    Lecture photoOnline lecture ‘Talking about Miscarriage’ available free of charge (20 mins).

    Our additional information for GPs  based on past training documents.

    The BMJ Miscarriage: Management in Primary Care podcast (requires subscription)

    The e-learning module Sensitive communication and breaking bad news produced by the Association of Early Pregnancy Units in association with the Miscarriage Association (available with AEPU membership) and/or

    The Royal College of Obstetricians and Gynaecologists has produced a course called Early pregnancy loss: Breaking bad news (requires subscription)

    Take a look at the Miscarriage Association’s leaflet Your feelings after miscarriage

    In this short teaching video for GPs and junior doctors, Professor Tom Bourne discusses both the medical and emotional aspects of ectopic pregnancy.

    Additional information for GPs 

    View other films in this series.

     

    Consider your needs too

    consultations can be hardCaring for patients with pregnancy loss can be stressful. They are likely to be anxious, distressed, grieving or even angry. They may express wants and needs that you just can’t meet.

    What’s more, you are their central port of call, even if they also have hospital care. However good that care is, it is brief. It’s the GP who is going to be looking after them after their loss and in the longer term.

    Considering your needs may seem like a pipedream, given the increasing demands of general practice, but we hope the following suggestions might help.

    Identify the stressors

    These can include:

    • dealing with patients’ anxiety and uncertainty
      • about this pregnancy, future pregnancies, future fertility
    • dealing with distress, grief and loss, especially:
      • if you have been through something similar or
      • if you feel it is out of proportion compared with other issues or patients
    • limited consultation time
    • being a bridge between patients and other services, especially regarding:
      • referral criteria
      • waiting lists/times
      • budget constraints
    • fatigue – physical and emotional

    Identify your sources of support…

    Your most likely source of support will be your peers:

    • colleague/s in your practice:
      • informally and/or individually
      • in practice meetings and/or training sessions
    • colleagues working in other practices:
      • you may find it easier to unload, de-brief etc outside your own practice

    But you might also consider:

    • your partner, if you have one, or a trusted friend
    • mentoring or coaching, via the CCG or elsewhere
    • talking to us at the Miscarriage Association in strict confidence.

     

    … and make use of them

    It’s one thing to know where you can find support. It’s another thing to do something about it. It’s worth considering that your peers may have similar concerns and might also benefit from talking about these issues together.

    The comments below, from a GP who had herself been through miscarriage, may be the best example of this.

    Long quote from GP

     

     

    And finally

    Miscarriage is never easy – for the woman or couple involved or for the staff who are tasked with looking after them. You may not get it right for everyone, but patients will always remember your care, kindness and compassion.

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