Establishment of an Early Pregnancy Care Clinic

Abstract

Early pregnancy loss can have a profound impact on the lives of women and their families, but the experience is often underacknowledged, with the diverse and complex needs of these women not always being met. Health care providers are in a unique position to provide support, helping each woman navigate through what is often a significant event in her lifetime.

In response to these gaps, a large academic medical center in the upper Midwest established the Early Pregnancy Care (EPC) Clinic in 2019 as a subclinic of the Department of Obstetrics and Gynecology. The goal of the EPC Clinic is to standardize the management of early pregnancy loss and related concerns to ensure each woman receives timely, holistic, and patient‐centered care that fully encompasses the physical and emotional needs of the patient and her family.

The EPC Clinic is run by a small, dedicated team of certified nurse‐midwives and registered nurses in collaboration with a multidisciplinary team, providing comprehensive care to women with a confirmed early pregnancy loss, first trimester bleeding, pregnancy of unknown location, inconclusive viability, or a history of a prior early pregnancy loss, including ectopic and molar pregnancies. Team members coordinate timely visits and evaluation, offer comprehensive management options, and provide bereavement care and resources. Follow‐up care is arranged to monitor each woman's physical and emotional recovery following a loss, including check‐ins with consistent members of the team to maintain continuity of care.

Anecdotal evidence as well as Press‐Ganey surveys obtained from patients and their families have demonstrated the exceptional value of the EPC Clinic. In this article, we outline our EPC Clinic's components and processes and discuss strategies that may benefit other health care systems aspiring to develop similar programs to improve early pregnancy loss care and the patient experience.

INTRODUCTION

The loss of a pregnancy can be devastating and is, unfortunately, a common reality for many families. Despite its prevalence, early pregnancy losses are often misunderstood by patients and their partners and its significance overlooked by health care providers. ¹

Current literature highlights a universal need for improved health care services following an early pregnancy loss. Essential are comprehensive services that are timely, sensitive, and consistent in supporting families through what is often a profound event in their lives. ² , ³ , ⁴ , ⁵ Globally, an estimated 23 million early pregnancy losses occur each year. ¹ In the United States, 10% of clinically recognized pregnancies end with an early pregnancy loss, ⁶ and evidence has shown as many as one in every 2 women will experience an early pregnancy loss in their lifetime. ⁴ Diagnosing an early pregnancy loss can be straightforward, but in some cases determining viability requires repeated testing, prolonging uncertainty and further amplifying patient distress. ⁶ A lack of care continuity and poor provider‐to‐provider communication can exacerbate stress and anxiety, forcing patients to retell their stories to each new health care provider. ⁷ , ⁸

The psychological impact of early pregnancy loss is often overlooked by health care providers and society as a whole. ⁴ Variations in health care provider opinions regarding management and an emphasis on a purely medicalized view of early pregnancy loss can lead to inadequate psychological support. ¹ , ² Many patients do not receive sufficient follow‐up or bereavement care, and some may feel isolated if they have not shared news of the pregnancy. ¹ Inadequate support following early pregnancy loss can lead to unrecognized and untreated depression or anxiety, impacting quality of life for months to years afterward. ⁹ In turn, heightened anxiety and increased risks for postpartum depression are often seen in subsequent pregnancies. ¹⁰ Although delays in diagnosis and inconsistencies in the plan of care can worsen distress, ⁶ , ¹¹ , ¹² having a supportive, coordinated team has been associated with improved patient satisfaction, regardless of the treatment path chosen. ¹¹

DEVELOPMENT OF AN EARLY PREGNANCY CARE CLINIC

In response to the gaps identified in the literature and current care processes, a large academic medical center in the upper Midwest established the Early Pregnancy Care (EPC) Clinic in 2019 as a subclinic of the Department of Obstetrics and Gynecology. The goal of the EPC Clinic was to standardize management of early pregnancy loss to ensure each patient received timely, holistic, and patient‐centered care that fully encompassed their physical and emotional needs in a sensitive and compassionate manner. The clinic initially launched with one certified nurse‐midwife (CNM) and one registered nurse, but, in response to growing demand, it was expanded to 4 midwives and 3 nurses, with 2 obstetrician‐gynecologists available for consults on complex cases.

QUICK POINTS

• ✦Early pregnancy losses are common, but the diverse and complex needs of the women experiencing them are not always met, validating the need for improved health care services.
• ✦The Early Pregnancy Care (EPC) Clinic standardizes the process of early pregnancy loss care, ensuring each patient receives holistic, timely, sensitive care and receives consistent support throughout the process.
• ✦Connection with a health care team specifically trained and attuned to both the physical and emotional needs of patients experiencing early pregnancy loss can improve the patient experience.
• ✦The value of the EPC Clinic is perhaps most evident in the positive feedback received from women who have used its services.

The EPC Clinic is located within the Department of Obstetrics and Gynecology at an academic medical center and runs in parallel with the hospital‐based prenatal clinic. The EPC midwives and nurses balance both routine perinatal care as well as EPC care. The medical center serves both the local perinatal population as well as referrals from the region for complex or high‐risk pregnancies. The community is relatively well educated and predominantly White but increasingly diverse because of employment opportunities in medical and technology centers. In 2024 there were 2295 births with 26% attended by midwives, 59% attended by obstetric physicians, and 15% attended by family medicine physicians.

Midwifery‐led models of care for early pregnancy and loss support remain relatively uncommon in the United States, where these services are more often embedded within physician‐led care models. A midwifery‐led structure integrates a relationship‐centered philosophy with timely medical evaluation, creating a patient experience that is clinically rigorous but also inclusive of the social and emotional constructs that shape early pregnancy loss.

DAY‐TO‐DAY OPERATIONS

The suspicion of or confirmed diagnosis of an early pregnancy loss can be overwhelming for patients and their families. ¹³ Expediting the evaluation in a location that provides EPC with onsite resources and trained health care providers attuned to both the physical and emotional needs of individuals experiencing early pregnancy loss can improve the patient experience. ¹⁴ Patients evaluated in the EPC Clinic come from a variety of sources, including those calling from home with concerns, referrals from labor and delivery triage, new or returning prenatal care visits, family medicine, the emergency department, and patients seen in outside facilities seeking a second opinion. Other health care providers can refer their patients to the EPC Clinic via phone, page, or the electronic health record (EHR).

Patients who may be eligible for EPC Clinic services include those with known or suspected early pregnancy loss, first trimester bleeding or abnormal pain, prior history of early pregnancy loss, and high risk for an ectopic or molar pregnancy. The referrals and calls are taken by the EPC nurse, and plan of care is established with the EPC midwife. The EPC Clinic can offer same‐day appointments and same‐day ultrasounds as appropriate as well as comprehensive management of a diagnosed early pregnancy loss. The management options include expectant and medical management, ordering of manual vacuum aspiration (MVA), or dilation and curettage (D&C) in our labor and delivery unit. The clinic offers bereavement resources, referrals, and follow‐up care, including return visits, ultrasounds, bloodwork, and early management of subsequent pregnancies if desired. Ideally, each woman who comes through the EPC Clinic is seen and followed by the same midwife and nurse to maintain continuity of care. Please see Figure 1 for an overview of the workflow in the EPC Clinic.

Figure 1.

Patient Progression and Associated Workflow in the Early Pregnancy Care Clinic

The EPC Clinic list, maintained in the EHR, includes the patients currently being followed in the EPC Clinic and is used to enhance communication between team members. Each morning, the EPC midwife and nurse meet to review the EPC Clinic list, which serves as an opportunity to review patient needs and identify tasks for the day, such as follow‐up after procedures or appointments for laboratory testing. Not every patient will have tasks to be completed that day; however, each patient is reviewed to ensure whether any updates or changes in their care plan are needed. This is also an opportunity to remove patients from the list if their care has been completed. Patients with viable pregnancies are left on the list until their first prenatal care visit has been completed.

EPC VISITS

For patients who present with first trimester bleeding or pain, ultrasound findings may be inconclusive regarding both the location and viability of the pregnancy. In cases wherein the ultrasound confirms the viability of an early intrauterine pregnancy, the patient may transition to their preferred provider for routine prenatal care.

When clinical findings are concerning for a nonviable pregnancy but the diagnostic criteria for early pregnancy loss have not yet been met, patients are followed expectantly with repeat ultrasound assessment until a definitive diagnosis can be made. Patients with inconclusive viability or pregnancy of unknown location receive education and counseling at this visit, including information regarding bleeding precautions, signs and symptoms of ectopic pregnancy if appropriate, and the importance of follow‐up care.

If the clinical picture is suspicious for, or diagnostic of, ectopic pregnancy, the obstetric physician team provides coordination for definitive diagnosis and medical versus surgical management as appropriate. Movement between the EPC Clinic and the obstetric physician care teams is fluid, and patients may shift between teams based on evolving clinical needs. Patients who are determined not to have an ectopic pregnancy as well as those who have completed treatment for ectopic pregnancy may transition back to EPC for follow‐up care if they prefer. This flexibility ensures that patients receive the appropriate level of medical care when needed yet can return to the EPC team for the supportive, continuity‐based follow‐up that many patients find most meaningful.

AFTER EARLY PREGNANCY LOSS DIAGNOSIS

Once a loss has been confirmed, patients are offered comprehensive management options, including expectant or medical management and scheduling coordination of procedures. Patients of the EPC Clinic have a follow‐up phone call or portal visit one to 3 days after medication, MVA, or D&C. To further protect their emotional well‐being, patients being seen in the EPC Clinic are never asked to sit in the waiting room alongside those with ongoing pregnancies; they are escorted immediately to a private examination room. A flower card is placed on the examination room door to discreetly alert staff to the loss, reminding the team to be mindful in their words and demeanor. Because the central scheduling area is often crowded with women who are pregnant, follow‐up visits are arranged privately by a scheduler in the examination room, which then allows patients to leave directly without passing through the waiting room.

Providing immediate grief counseling at the time a loss is diagnosed may have limited benefit because patients are often too distressed to absorb the information. Reinforcing this counseling at a later follow‐up visit, when patients are better able to process and engage with the support offered, is important. ⁹ Telephone call check‐ins taking place 2 weeks after an early pregnancy loss have been associated with significantly reduced risk of depression symptoms at 6 weeks and 6 months. ⁹ In the EPC Clinic, the number of “check‐ins” with patients can be individualized to meet their physical and emotional needs, but all patients are offered a 2‐week check‐in after the early pregnancy loss with the EPC midwife who has been participating in their care. This can be done over the phone, virtually, or in person, depending on patient preference. Rapid return to fertility is possible after early pregnancy loss, and individualized reproductive counseling can be offered to patients to help in empowering reproductive autonomy. ⁷ If future pregnancy is desired, preconception counseling is provided, including discussion about the woman feeling physically and emotionally ready to try to conceive. If pregnancy is not desired, counseling on contraception may be offered. If patients have struggled with recurrent early pregnancy loss, referral to a reproductive endocrinology and infertility (REI) specialist can be offered for further evaluation if desired. A genetics referral is part of an REI referral but can also be ordered based on pathology or genetic results as appropriate.

BEREAVEMENT CARE

Bereavement interventions have been recognized as an important component of early pregnancy loss support. ¹⁵ Examples of bereavement interventions can include providing physical mementos and offering referrals to community support groups and art or music therapy. Patients can also be encouraged to keep a journal, write letters, plant a tree or flowers, or create a special remembrance box. Because no single intervention is universally effective, offering grieving patients and their families a wide range of options may help them identify what best supports their unique grieving process.

The EPC Clinic provides bereavement packets for patients who have experienced an early pregnancy loss. These packets contain educational pamphlets on early pregnancy loss and grief, information on local and reputable resources that may assist them in the grieving process, and a small crystal memento as a reminder of the loss that touched their lives and will not be forgotten. It also contains information for an institutionally owned vault located at a local cemetery where remains are held to provide a physical place of remembrance for patients and their families to visit. An annual service of remembrance is held for those who have experienced an early pregnancy loss as another way to acknowledge that their loss and their experience are valid. ¹³

Misconceptions about early pregnancy loss are common and can contribute to significant emotional distress for patients. For example, many patients believe that early pregnancy losses are rare or that they are caused by personal actions, such as strenuous exercise, sexual activity, or prior contraceptive use. Providers can help mitigate these feelings of guilt by offering clear and compassionate reassurance that the patient is not at fault for the early pregnancy loss.

SUBSEQUENT PREGNANCIES

Pregnancies following an early pregnancy loss can cause increased feelings of fear and anxiety for patients. ¹⁰ , ¹⁶ Patients often report difficulty experiencing joy in subsequent pregnancies because of heightened fear of recurrence. ¹³ Patients who have a history of an early pregnancy loss, including a history of ectopic or molar pregnancy, have the option to be managed initially in the EPC Clinic for subsequent pregnancies. The EPC Clinic can provide prompt appointments and early ultrasounds to provide reassurance. This also gives patients an opportunity to maintain continuity of care with health care providers and nurses who may be familiar with their loss history, which many patients find reassuring. ¹³ When patients call with a new pregnancy, they are added to the EPC Clinic list and brought in for a dating and viability ultrasound at 6 weeks’ gestation for history of ectopic pregnancy and at 7 to 8 weeks’ gestation for history of early pregnancy loss.

CHALLENGES AND FUTURE PLANS

The challenges in creating the EPC Clinic were varied, but included the allocation of dedicated nurses for EPC, additional ultrasound availability, same‐day time slots in the schedule of the EPC provider, and mifepristone availability in the clinic. Many multidisciplinary meetings were held to address the obstacles and create protocols, maintaining a patient‐centered focus.

The EPC Clinic continues to evolve in response to patient needs and health care provider feedback. A few years after its creation, the clinic assumed responsibility for the consults and surveillance of molar pregnancies. This transition allowed those patients to remain within the EPC Clinic rather than being referred to another department, ensuring continuity of care with health care providers they already knew and trusted. The overlap between molar pregnancy surveillance and early pregnancy loss has proven to be both practical and patient centered. In addition, the development of dedicated consultation pathways for patients with specific placental pathology, particularly conditions that are increasingly being recognized as contributors to recurrent early pregnancy loss, is also under consideration.

Looking ahead, future goals include increasing the availability of hysteroscopy for the management of retained products of conception, which would reduce delays and further expand the care available to patients already in the EPC setting. At this time, there are no legal restrictions that impact the EPC Clinic because CNMs may independently prescribe prescription drugs, including mifepristone, and can perform MVA.

CONCLUSION

Early pregnancy loss is a devastating and profound experience for many patients and their families. The EPC Clinic was established to meet these diverse and complex needs by providing timely, holistic, and compassionate care. Since its inception, the EPC Clinic has conducted more than 7000 visits, with feedback obtained through institutional channels such as Press‐Ganey surveys and the Office of Patient Experience. The value of the EPC Clinic is perhaps most evident in the words of patients themselves:

Thanks for reaching out and thank you from the bottom of our hearts for the compassion and care you and the team have provided us this last week. The emotional pain is something I certainly wouldn't wish upon anyone, but having the support of the team has been heartwarming, you all are amazing people.

Health care providers who refer their patients to the EPC Clinic also emphasize its role in ensuring prompt, consistent, and sensitive care during a vulnerable time. One referring clinician shared, “A whole team, wrapping around the patient. Scheduling handled, follow‐ups coordinated, thoughtful check‐ins. The team approach delivers what I can't do alone, and my patients feel deeply cared for during a very difficult time.”

Together, these voices highlight the dual impact of the EPC Clinic meeting the profound emotional and physical needs of patients while also supporting the broader health team in providing standardized, patient‐centered care.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.