September 14, 2017
The spontaneous loss of a fetus, called a miscarriage, is one of the most common complications of pregnancy, and while a miscarriage can cause tremendous personal grief, it is a loss that often goes unnoticed.
Studies reveal that anywhere from 10 to 25 percent of all clinically recognized pregnancies will end in miscarriage. A pregnancy lost shortly after implantation may account for 50 to 75 percent of all miscarriages, and when this occurs, most women may not realize that they had conceived.1
Spontaneous miscarriage is typically defined as a clinically recognized (i.e., by blood test, urine test, or ultrasonography) pregnancy loss before 20 weeks' gestation, although ranges are undergoing modification due to the advanced care available to infants born prematurely. This includes ranges in Medical Priority Dispatch System™ (MPDS®) version 13.0.
Spontaneous miscarriages are categorized as:2
- Complete abortion: All of the products (tissue) of conception leave the body.
- Incomplete abortion: Only some of the products of conception leave the body.
- Inevitable abortion: Symptoms cannot be stopped and a miscarriage will happen.
- Infected (septic) abortion: The lining of the womb (uterus) and any remaining products of conception become infected.
- Missed abortion: The pregnancy is lost and the products of conception do not leave the body.
After 20 weeks, losing a pregnancy is called stillbirth. Stillbirth is less common than miscarriage, with causes that include problems with the placenta, genetic problems in the fetus, poor fetal growth, and infections. Almost half of the time the reason for stillbirth is not known.
The pathophysiology of a spontaneous miscarriage may be suggested by its timing.5
Chromosomal abnormalities account for 80 to 90 percent of first trimester miscarriages, especially those that occur during 4 to 8 weeks' gestation.
Insufficient or excessive hormonal levels can result in spontaneous miscarriage before 10 weeks' gestation. Infectious, immunologic, and environmental factors are also seen in first-trimester pregnancy loss. Anatomic factors, such as cervical incompetence, are usually associated with second-trimester loss.
Age and the number of times a female has carried pregnancies to a viable gestational age (parity) affect a woman's risk of miscarriage. In women younger than 20 years, miscarriage occurs in an estimated 12 percent of pregnancies. In women older than 20 years, miscarriage occurs in an estimated 26 percent of pregnancies.
In some cases, light spotting or bleeding during the first 12 weeks of pregnancy is normal, but the spotting or bleeding can also be a sign of a possible loss of the pregnancy. This is called a threatened miscarriage.
Miscarriage is accompanied by symptoms of tissue or clot-like material that passes from the vagina; low back pain or abdominal pain that is dull, sharp, or cramping; and vaginal bleeding, with or without abdominal cramps.
Treatment of a patient who has had a complete miscarriage varies depending on the degree of certainty of the diagnosis.
Protocol 24: Pregnancy/Childbirth/Miscarriage
MPDS v13.0 introduced significant revisions to the rules, definitions, and axioms relating to miscarriage.
A new rule was added to Protocol 1: Abdominal Pain/Problems, directing the EMD to the correct Chief Complaint if a pregnant patient reports abdominal pain. This Rule is also found on Protocol 24: Pregnancy/Childbirth/Miscarriage.
Notable changes to Protocol 24 include:
- redefining the range of months/weeks for the 2nd TRIMESTER, 3rd TRIMESTER, and MISCARRIAGE definitions, as well as the Premature birth range in the HIGH RISK Complications definition
- adding Protocol G: Miscarriage
- modifying instructions on Protocol F: Childbirth – Delivery throughout to improve patient care
The defined ranges within the protocol were adjusted based on the likelihood of fetal survival outside the womb in the prehospital setting. Accordingly, the MISCARRIAGE definition was changed from “prior to 5 months or 20 weeks of gestation” to “prior to 6 months or 24 weeks of gestation” as reflected in:
- The Pre Question Qualifier (PQQ) on Key Questions 2 and 3
- The clarifier on 24-D-3
- The clarifier on 24-B-1
- The range for “Premature birth” was changed from “(20–36 weeks)” to “(24–36 weeks).”
- The range for “Multiple birth” was changed from “(≥ 20 weeks)” to “(≥ 24 weeks).”
Additions and modifications to definitions err on the side of caution and emphasize that the EMD should consider a description of abdominal pain or cramping to be contractions anytime during pregnancy, including for a woman who is not in her 3rd TRIMESTER (less than 6 months/24 weeks along).
Key Question 4 was added: “(< 6 months/24 weeks) Does she have abdominal pain?” The remaining Key Questions have been renumbered accordingly.
Determinant Code 24-C-3 was added: “Abdominal pain/cramping (< 6 months/24 weeks and no fetus or tissue).” The remaining CHARLIE-level code and the corresponding director “Baby born (no complications)” following Key Question 2 were renumbered accordingly.
Former Axiom 3 was moved to Rule 2 and slightly modified to include the words “cramping” and “anytime”: “Abdominal pain/cramping anytime during pregnancy should be considered contractions until proven otherwise.” The remaining Rules and Axioms were renumbered accordingly.
Former Rule 3 was moved to Axiom 2: “Presentation of the cord, hands, feet, or buttocks first (BREECH) is a dire prehospital emergency. Often the only chance for survival of the baby is at the hospital. (See also PAI Childbirth – Delivery sequence ‘Evaluate BREECH’ F-20.) The remaining Rules and Axioms have been renumbered accordingly. This information provides important background knowledge and is better expressed as an Axiom because it does not direct the EMD to take a specific action.
POSTPARTUM hemorrhage was defined for clarification (“Vaginal bleeding
The condition “cervical cerclage (stitch)” is handled on Protocol F using the BREECH Positioning pathway (DLS Link to Panel F-25). This condition is considered HIGH RISK (new Rule 5) and must be handled by medical professionals, as indicated. The condition was added to the HIGH RISK Complications definition list.
New Rule 6 provides an exception to obstetric council recommendations for allowing additional time (three minutes) after delivery prior to tying the cord. According to the Rule, the umbilical cord should be tied immediately if the mother or baby develops complications after delivery.
“Placenta abruption” and “placenta previa” are now Academy-recommended HIGH RISK Complications that can be defined and authorized by local Medical Control. Axioms 4 and 5 provide EMDs with an understanding of these conditions.
The added description of “pushing or straining” expands the IMMINENT Delivery definition.
Protocol G: Miscarriage
The former DLS Link to X-1 “Other situations (MISCARRIAGE)” was removed and replaced by a new DLS Link to Panel G-1: “MISCARRIAGE.”
The new protocol was added in conjunction with Protocol F: Childbirth – Delivery to handle MISCARRIAGE situations. (This Protocol appears as a pullout behind Protocol 24 in the cardset.) These instructions are considered essential for safely and empathetically addressing the needs of a miscarriage patient and include instructions for “Evaluate MISCARRIAGE,” “Wrap Fetus (and Afterbirth),” “Suprapubic Pressure,” “Fundal Massage,” and “Wait and Monitor.”
Protocol F: Childbirth – Delivery
While revisions to Protocol F do not affect instructions involving miscarriage, they do merit mentioning, in brief, in context to childbirth and delivery.
The instructions on Panels F-5 and F-8 in the cardset version only were separated to suggest a natural break. On Panel F-8, green “Confirm” symbols were added after each instruction to direct the calltaker to pause after each instruction to allow the caller to carry out each instruction and confirm its completion before moving ahead.
On Panel F-6, instructions were combined to improve fluency and better connect the requested action with the reason: “Remember, the baby will be slippery, so don’t drop it.”
Because of the recommended three-minute wait period before tying off the umbilical cord in the absence of complications after delivery, instructions on Panel F-8 were revised to “put the baby down between the mother’s legs, level with her bottom.” The Academy finds the instruction necessary to prevent gravitational blood flow from baby to mother immediately after birth.
Wording to tie the cord was slightly modified in Panel F-9 to immediately warn the caller not to cut the umbilical cord in keeping with the prevention of gravitational blood flow: “Without pulling on the cord, tie a string (shoelace) tightly around the umbilical cord, about 6 inches (15 cm) from the baby, but do not cut it. Tie it now and tell me when it’s done.”
Blankets and towel instructions were revised as a matter of good sense. On Panel F-8, the word “another” was added in the instruction to “Dry the baby off with a clean towel (cloth), then wrap the baby in another clean, dry towel.” On Panel F-13, the instruction “Use a blanket to keep the mother warm” was changed to “Use a blanket to keep the mother and baby warm.”
On Panel F-37, instructions were added for placing towels under the bleeding mother to allow for a more accurate assessment of the bleeding by first responders and hospital personnel: “Now place some towels under her bottom so we can monitor the bleeding.”
On Panel F-14, new instructions replace former instructions to briskly rub the baby’s back: “Gently wipe the baby’s mouth and nose, then vigorously dry the baby with a clean, dry towel (cloth) for 30 seconds. Then tell me if the baby is crying or breathing.”
On Panel F-23, instructions were added to prevent a potential loss of body heat when any part of the baby is exposed after birth: “If any part of the baby’s body delivers, keep it warm with a towel or soft cloth. Remember to gently support the baby’s body, but do not pull on the baby or cord.”
1 “Miscarriage: Signs, Symptoms, Treatment, and Prevention.” American Pregnancy Association. 2017; May 2. http://americanpregnancy.org/pregnancy-complications/miscarriage/ (accessed July 5, 2017).
2 Gaufberg S, Taylor Pritchard J. “Early Pregnancy Loss in Emergency Medicine.” Medscape. 2017; Jan. 3. http://emedicine.medscape.com/article/795085-overview (accessed June 29, 2017).
3 Chen X, Chen M, Xu B, et al. “Parental phenols exposure and spontaneous abortion in Chinese population residing in the middle and lower reaches of the Yangtze River.” Chemosphere. 2013; September. http://reference.medscape.com/medline/abstract/23714150 (accessed June 29, 2017).
4 Koonin LM, MacKay AP, Berg CJ, Atrash HK, Smith JC. “Pregnancy-related mortality surveillance—United States, 1987–1990.” MMWR CDC Surveill Summ. 1997; Aug. 8. http://reference.medscape.com/medline/abstract/9259215 (accessed June 29, 2017).
5 See note 4.