Early Pregnancy Complications and Loss

Care for Adults in All Settings

Resources The Quality Standard In Brief Advisory Committee About

Summary

This quality standard addresses care for people experiencing complications, such as pain and vaginal bleeding, and/or the loss of their pregnancy in the first 13 weeks. It applies to all health care settings and includes diagnosis, follow-up, and management of physical and emotional aspects of care for early pregnancy complications or loss.

This standard includes pregnancy of unknown location (where a person has a positive pregnancy test but no pregnancy is visible in an ultrasound), tubal ectopic pregnancy (a potentially dangerous condition in which the embryo implants in a fallopian tube), and intrauterine pregnancy loss (missed, complete, or incomplete miscarriage).

Scope of This Quality Standard

This quality standard addresses care for people experiencing early pregnancy complications (such as pain and vaginal bleeding) and/or loss in the first trimester of pregnancy. This standard applies to all settings and includes diagnosis, follow-up, management, and psychosocial aspects of care for early pregnancy complications and loss up to 13 completed weeks of pregnancy. The standard includes:

Pregnancy of unknown location (a temporary diagnosis meaning a person has a positive pregnancy test but no pregnancy is visible on ultrasound)
Tubal ectopic pregnancy (a pregnancy in which the embryo implants in a fallopian tube)
Intrauterine pregnancy loss (missed, complete, or incomplete miscarriage)

This standard does not address other types of ectopic pregnancy, termination of pregnancy (therapeutic abortion), or molar pregnancy (gestational trophoblastic disease, a rare pregnancy-related condition in which the cells that form the placenta develop abnormally).

A Note on Terminology

Language used to talk about early pregnancy complications and loss should be led by the person and family. Health care professionals should avoid using terms such as “missed abortion” and should ask people what terminology they prefer when referring to the pregnancy (e.g., whether they prefer “baby” or “fetus”).

Why This Quality Standard Is Needed

Early pregnancy complications and loss affect many people in Ontario. It is estimated that approximately 20% of pregnancies end in miscarriage, and nearly 80% of miscarriages occur in the first trimester.

The emotional and psychological impacts of early pregnancy loss can be serious. For some people, the emotional distress can result in clinical depression, post-traumatic stress disorder, and/or anxiety. Ontario families experiencing early pregnancy loss have reported a lack of kindness and respect from health care professionals, that they felt less supported, and that they experienced more stigma at the time of their loss, compared with people whose loss occurred later in the pregnancy. They were also less likely to be offered a follow-up appointment and get the support they needed, highlighting the need for significant system improvement.

There were an estimated 47,776 emergency department (ED) visits for early pregnancy complications or loss in Ontario in 2017/18 (IntelliHealth Ontario). An estimated 6% to 13% of patients presenting to the ED with vaginal bleeding or abdominal pain in early pregnancy have an ectopic pregnancy. Ectopic pregnancy is a potentially life-threatening event, and there is a need to standardize care for pregnant people and their families, as well as to ensure people are offered their choice of management options. Currently, early pregnancy clinics offering assessment, diagnosis, and management of early pregnancy complications and loss outside of the ED setting are available in some communities in Ontario, but the services offered and hours of operation vary. In a 2017 survey of Ontario EDs with an annual census of more than 30,000 ED visits, 34 of the 63 EDs reported that they did not have access to early pregnancy clinic services for people who presented to the ED with early pregnancy complications and were safe to discharge home. Over half of EDs without access to an early pregnancy clinic agreed that patients returned to the ED frequently because there was no adequate follow-up available.

Principles Underpinning This Quality Standard

This quality standard is underpinned by the principles of respect and equity.

People experiencing early pregnancy complications and/or loss should receive services that are respectful of their rights and dignity and that promote shared decision-making. High-quality care for early pregnancy complications and loss is family centred. Family or friends who can offer support should be encouraged to attend and be welcomed at all related appointments.

People experiencing early pregnancy complications and/or loss should be provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, linguistic, ethnic, and religious backgrounds), and disability. Equitable access to the health system also includes access to culturally safe care.

Language, a basic tool for communication, is an essential part of safe care and needs to be considered throughout a person’s health care journey. For example, in predominantly English-speaking settings, services should be actively offered in French and other languages.

Health care professionals should acknowledge and work toward addressing the historical and present-day impacts of colonization in the context of the lives of Indigenous Peoples throughout Canada. This work involves being sensitive to the impacts of intergenerational and present-day traumas and the physical, mental, emotional, and social harms experienced by Indigenous people, families, and communities. This quality standard uses existing clinical practice guideline sources developed by groups that may not include culturally relevant care or acknowledge traditional Indigenous beliefs, practices, and models of care.

A high-quality health system is one that provides good access, experience, and outcomes for everyone in Ontario, no matter where they live, what they have, or who they are.

Patient Guide

The patient guide on early pregnancy complications and loss can help patients and families have conversations with their health care provider. Inside you will find questions you may want to ask as you work together to make a plan for your care.

Clinicians and health services planners can make patient guides available in all settings where people receive care.

How Success Can Be Measured

The Early Pregnancy Complications and Loss Quality Standard Advisory Committee identified a small number of overarching goals for this quality standard. These have been mapped to indicators that providers may want to monitor to assess quality of care provincially and locally.

How Success Can Be Measured Provincially

In this section, we list indicators that can be used to monitor the overall success of the standard provincially, given currently available data:

Number of emergency department visits by people with early pregnancy complications and/or loss
Percentage of people with early pregnancy complications and/or loss who have repeat emergency department visits within 30 days of the initial visit for early pregnancy complications or loss
Percentage of people with a tubal ectopic pregnancy that ruptures within 30 days after an emergency department visit for tubal ectopic pregnancy
Percentage of people with early pregnancy complications and/or loss who receive a blood transfusion

If additional data sources are developed, other indicators could be added.

How Success Can Be Measured Locally

Providers may want to monitor their own quality improvement efforts and assess the quality of care they provide to people experiencing early pregnancy complications or loss. It may be possible to do this using their own clinical records, or they might need to collect additional data. We recommend the following indicators to measure the overall success of the standard and the quality of care patients are receiving; these indicators cannot be measured provincially using currently available data sources:

Average time that people with early intrauterine pregnancy loss who need a dilatation and curettage (D&C) procedure wait for a D&C
Average wait time from first presentation to a health care professional of early pregnancy complications or loss, to a diagnosis via transvaginal ultrasound of early pregnancy complications or loss
Percentage of people with early pregnancy complications or loss who are satisfied with the care they receive

In addition to the overall measures of success, each quality statement within the standard is accompanied by one or more indicators. These statement-specific indicators are intended to guide the measurement of quality improvement efforts related to the implementation of the statement.

To assess the equitable delivery of care, the statement-specific indicators and the overall indicators can be stratified by patient socioeconomic and demographic characteristics, such as income, education, language, and age.

What Does It Mean for Patients and Caregivers?

An estimated 1 in five pregnancies end in a loss, and 80% of those are in the first trimester. I had two early pregnancy losses, one at 12 weeks and one at 10 weeks. They were both awful. Even if our doctors can’t change the outcome, we all need and deserve compassionate care. Miscarriage is an often-silent, unexpected and heart-wrenching experience for many.

For health care professionals, a quality standard offers guidance on the diagnosis, follow-up, and management of the physical and emotional aspects of care for patients experiencing early pregnancy complications or loss. Whether you seek care at a large, teaching hospital on University Avenue or a small, rural hospital in Northern Ontario, you should expect how you are treated to be similar. The patient conversation guide is also a key resource, that can help patients ask informed questions of their health care providers.

– Amanda Ross-White, Lived Experience Advisor, Early Pregnancy Complications and Loss Quality Standard Advisory Committee

What Does It Mean for Providers?

Early pregnancy loss is unfortunately a very common occurrence affecting approximately one in every four pregnancies in Ontario. Currently, the physical and emotional care provided to families is not consistent between care providers or facilities. By having clearly defined standards and requirements we can better meet the care needs and improve quality.

– Early Pregnancy Complications and Loss Quality Standard Advisory Committee Member

Timeline for This Quality Standard

This quality standard was completed in July 2019.

Evidence to Improve Care