Helping your patient navigate a pregnancy loss

Pregnancy loss is often unexpected and sudden, and it is crucial that clinicians communicate information to patients during this vulnerable time in a validating and empathetic manner.

Definitions vary widely, but at the heart of it, pregnancy loss is the death of an unborn baby. In Australia, a spontaneous loss prior to 20 weeks of gestation is referred to as a miscarriage or early pregnancy loss. Internationally, these definitions vary by gestational age and birthweight, making the global burden difficult to quantify.

In Australia, there is no national data collected on the number of pregnancy losses. Estimates based on the Australian longitudinal study on women’s health and the Australian Bureau of Statistics indicate an overall miscarriage rate of 25 per 100 live births.

Although definitions and parameters are necessary for comparable statistics, the way clinicians communicate this information to patients during this vulnerable period is important. Pregnancy loss is often unexpected and sudden. Loss should always be conveyed with validation and empathy.  

First steps in a suspected pregnancy loss

Before the diagnosis of a pregnancy loss, assessment should include the following three key steps.

1. Determine if the patient is haemodynamically stable;
2. Confirm the location of the pregnancy via a transvaginal ultrasound scan (TVS);
3. Assess viability and gestational age of the pregnancy.

Confirming a pregnancy loss

Miscarriage occurs most commonly (80%) in the first trimester when patients may not have shared news of their pregnancy and consequently their loss. Health professionals should acknowledge the loss suffered no matter how early. Sensitive communication of results is important especially when there is uncertainty in the outcome.

Non-viable intrauterine pregnancy (IUP)

A non-viable pregnancy can be diagnosed on TVS by a:

• Mean sac diameter (gestational sac) ≥ 25 mm and no fetal pole
• Fetus with crown rump length ≥ 7 mm but no fetal heart movements
• Lack of gestational sac/fetal development over at least 7 days including:

  • Absence of embryo with heartbeat ≥ 2 weeks after a scan that showed a gestational sac without a yolk sac;
  • Absence of embryo with heartbeat ≥ 11 days after a scan that showed a gestational sac with a yolk sac

• Absence of embryo with heartbeat ≥ 7 days after a scan showed a fetal pole < 7 mm with no fetal heartbeat

  • Absence of heartbeat seen on an earlier scan
  • If viability is uncertain, repeat a TVS in 7–10 days and consider another beta-human chorionic gonadotropin (hCG) test. To avoid repeated inconclusive scans, normal mean sac diameter growth rate is 1 mm per day. Consider referring to your local early pregnancy assessment service if appropriate.

Pregnancy of unknown location

• Serial hCG measurements – at least two serum beta-hCG measurements 48–72 hours apart

  • Fall of ≥ 50% indicates likely non-viable pregnancy
  • Rise of ≥ 66 % indicates an IUP is more likely (although an ectopic is not excluded)
  • If serial serum beta-hCG levels fall by ≤ 50% or rise by ≤ 66% and no IUP on TVS, then suspect an ectopic pregnancy

Ectopic pregnancy or gestational trophoblastic disease is suspected or confirmed

• Refer to specialist services.

Termination for medical reasons

It is important to include and acknowledge the heart-wrenching decision and grief associated with terminating a pregnancy for a medical condition. It is one of the most frequent reasons for referral to Red Nose.

Rhesus D negative patients

Ensure patients who are Rhesus D (Rh D) negative receive an appropriate dose of prophylactic Rh D immunoglobulin as outlined in guidelines from the National Blood Authority.

Communicating pregnancy loss

The language used around early pregnancy loss matters. Mirroring the preference of patients, medical literature has moved away from terms like “spontaneous abortion” or “failed pregnancy”, which can attribute blame or stigma. Language used should be compassionate and remove shame or guilt. Phrases like “at least you know you can fall pregnant” or “everything happens for a reason” minimise the parent’s grief. It’s also crucial to ensure there is a private waiting area for patients experiencing pregnancy loss, which is separate from pregnant patients.

The personal impact of pregnancy loss

Miscarriage is generally unexpected and often happens when women have not yet shared news of their pregnancy with others. The lack of rituals like funerals or commemorations also contribute to the isolation experienced by women. Although chromosomal factors are known to contribute to 50% of miscarriages, the majority of women will not have a confirmed cause. The inability to attribute the loss to a known or modifiable factor, can increase the self-blame and psychological distress suffered by women.

A recent study in the United Kingdom, highlighted the psychological impact of early pregnancy loss with 29% women suffering symptoms consistent with post-traumatic stress disorder (PTSD), 24% women had anxiety and 11% had depression. This was compared to a baseline in healthy pregnancies of no PTSD, 13% anxiety and 2% depression.

Research highlights that partners grieve too and require care. One Australian study found “men may face double-disenfranchised grief in relation to the pregnancy/neonatal loss experience”.

Support and resources

Providing education and advice to patients around the frequency and potential causes of miscarriage is important and may reduce feelings of failure and guilt. Clinicians should counsel women that loss and grief can significantly impact their mental health and provide them and their partners with close monitoring and information on community resources. Organisations like the Pink Elephants Support Network and SANDS provide suggestions on how a woman and their partner can be supported. The Pink Elephants Support Network provides options of group therapy, phone and online support, access to an online community, and a range of digital resources including information on grief and loss, coping strategies and workplace support.

As of May 2024, funding specifically for miscarriage was announced in the federal budget. This will cover three key areas: funding for frontline bereavement support services such as Pink Elephants, funding to deliver an audit of EPAS (Early pregnancy assessment services) and funding for the AIHW (Australian Institute of Health & Welfare) to look at data captured around miscarriage in Australia.

Miscarriage and pregnancy loss is a common but hidden issue within our community. Clinicians have a key role in diagnosing pregnancy loss, guiding management and supporting families to navigate this distressing experience. Clinicians need to ensure conversations are validating, empathetic and offer a referral to support services.

Dr Ka-Kiu Cheung is a senior medical officer (paediatrics and obstetrics) at Gold Coast Hospital Health Service, board director of the Gold Coast Primary Health Network, shared care diplomate representative of RANZCOG, and chair of the RACGP Specific Interest Group Antenatal Postnatal Care.

Samantha Payne is co-founder and CEO of the Pink Elephants Support Network.

Support services

The Pink Elephants Network: Support for miscarriage and early pregnancy loss

Red Nose: Grief and loss support

Bears of Hope: Pregnancy and infant loss support

Penthos: Couple therapy for grieving parents

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.  

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