By the time she completed her residency in emergency medicine, Dr. Andreia Alexander had seen all manner of injuries and complications — everything from kidney stones and broken bones to stab wounds and seizures. She was prepared, as an ER saying goes, for "anyone, anything, anytime."
But until recently, neither Alexander nor any of her colleagues in the emergency department at Indiana University School of Medicine in Indianapolis had ever performed one of the most common procedures for women of reproductive age — a uterine aspiration (also commonly known as a D&C) or the removal of tissue from the uterus via suction.
The procedure is a standard method for treatment of miscarriage and can be a life-saving intervention if a woman is hemorrhaging. But uterine aspiration is also routinely used to perform early abortions, and that's one reason many emergency departments have historically resisted efforts to make the option available to patients who come in for miscarriage-related care.
That care already accounts for more than 900,000 emergency room visits every year, according to the most recent estimates. Now, as states move to restrict access to abortion in the wake of the Supreme Court's decision in June to overturn Roe v. Wade, experts say that number is likely to surge even higher.
"Fewer abortions will mean more pregnancies, and more pregnancies will mean more miscarriages," said Dr. Sarah Prager, a professor of obstetrics and gynecology at the University of Washington and a co-author of the guidelines on miscarriage management for the American College of Obstetricians and Gynecologists.
Around 15% of known pregnancies end in miscarriage, and the first medical professional many of those patients see will be in an emergency room. Yet, by and large, she says, "emergency medicine physicians aren't trained in managing miscarriage and don't see it as something they should own."
A mission to train
For more than a decade, Prager has been trying to change that through her work with the TEAMM Project, the nonprofit she co-founded on the premise that "many people experience miscarriage before they're established with an OB-GYN." Short for Training, Education and Advocacy in Miscarriage Management, TEAMM has conducted in-person workshops for clinicians at more than 100 sites in 19 states on all aspects of miscarriage care — everything from the use of ultrasound to diagnose fetal death to the three treatment options miscarrying patients should be offered when they come in for care.
A uterine aspiration is recommended when patients are bleeding heavily, are anemic, or are medically fragile, and many patients prefer the procedure because it can resolve a miscarriage most quickly. Another option is medication — usually mifepristone followed by misoprostol — which can help the body expel pregnancy tissue in a matter of hours. And the third is "expectant management": waiting for the tissue to pass on its own. The latter can take several weeks and is unsuccessful for about 20% of patients, who remain at risk for hemorrhage and have to return to the hospital for surgery or medication.
In many emergency departments, expectant management has long been the only option made available. But now, amid the legal uncertainty unleashed by the fall of Roe, Prager and colleagues say they've been inundated with inquiries from emergency departments across the country. Doctors in states that have since criminalized abortion face stiff penalties, including felony charges, prison time, and the loss of their medical license and livelihoods.
"I think they're scared," says Prager. "They want to be able to know, with 100% certainty, that a pregnancy is no longer viable."
Many also want to be able to offer patients the option of having a procedure right then and there. "We effectively decide for patients, without having a conversation with them, that they go home and wait," said Dr. Kelly Quinley, an emergency medicine physician in California who volunteers as a TEAMM trainer. "But what if home is three hours away? What if they're traveling the next day? What if they can't get into their OB-GYN? When we send patients home, they're going to bleed in a time frame nobody can predict, and when it happens it might be inconvenient or it might be dangerous."
Those patients bleeding too heavily to be sent home are typically referred to the OB-GYN on call — or transferred to another facility — for a surgical evacuation in the operating room. But that can involve lengthy delays in care — long waits in transit or for an operating room to become available — which raise the risk of complications.
A tool underused in the U.S.
As a TEAMM trainer, Quinley has helped emergency departments across the country change the way they operate, namely by advocating for and teaching health providers to use a tool long underused by American hospitals—what's known as the manual vacuum aspiration (MVA) kit.
A plastic hand-held syringe attached to a flexible tube, the MVA kit made it possible to move uterine aspiration out of the operating room to almost anywhere else in the hospital. Simple, portable, and easy-to-operate, the device was originally developed for use in poor, rural parts of the world — places with little or no electricity, clinical infrastructure or skilled care. But it also promised to expand access to uterine aspiration in the United States at a time when the incidence of miscarriage had begun to go up sharply.
"It's the quickest, most effective way to treat a first-trimester miscarriage," says Quinley, adding that she uses papayas as uterine models to demonstrate how the device works. That alone doesn't prepare a provider for the real thing, she says, "but it's exposure; it demystifies a procedure that, I think, to many in our field — to many in medicine — is still unfamiliar and daunting."
Indeed, though the MVA kit had been widely adopted by clinicians in low-income countries, doctors in the U.S. were for many years reluctant to follow suit. Specialists trained in uterine aspiration had been accustomed to using a machine, the electric vacuum aspirator, which was usually housed in the operating room and typically required the use of general anesthesia.
"Although the technology for [manual vacuum aspiration curettage] has been available for 20 years, its use has never become popular in the U.S.," wrote the authors of a 1994 study of the MVA kit at Johns Hopkins Bayview Medical Center in Baltimore. That study, the first to compare the treatment of miscarriage in the operating room to use of the MVA kit in a U.S. hospital, found that the latter reduced the costs of care by 41% and patient wait times by more than half.
"My boss at the time felt we should really try to spread the word about this," recalls Dr. Paul Blumenthal, the lead author of the study and now an emeritus professor of obstetrics and gynecology at Stanford University. But when they presented the findings to hospital leadership "in hopes that they would take this up," he says, the response was: "Nope. That's not the way we do it at Johns Hopkins Hospital."
Over the nearly three decades since, numerous studies have shown that manual vacuum aspiration is as safe and effective as electric vacuum aspiration. Still, resistance remains, and researchers say one of the biggest hurdles has been the fact that the device and the procedure are the same as those used to terminate an early pregnancy.
"We encountered a ton of resistance by nurses and other staff who felt that their religious beliefs precluded them from doing that," said Dr. Mira Mamtani, an associate professor of emergency medicine at Penn Medicine, who led a 2012 study that looked at the use of MVA for miscarriage in the emergency department. "They were concerned about MVA being used in live pregnancies because they had never been educated about what is actually being performed—they didn't understand that this is for cases of fetal demise, and that in the absence of this care, a patient could hemorrhage and die."
Blumenthal, who helped design the current version of the MVA kit made by Ipas, the nonprofit founded in 1973 to manufacture and distribute the device, concurs. "It's been a chronic problem," he says. "We can do MVAs in the emergency department at Stanford — we can provide medical abortion pills too — but it has, and sometimes still does, require a lot of advocacy on our part."
Prager and colleagues say they've frequently faced similar challenges over the years, but now the stakes are even higher. On top of the fact that many people can't get abortions, the average age of maternity is increasing, says Quinley, "and the older you are the greater your chances of having a miscarriage." Moreover, research suggests abortion restrictions may prompt greater numbers of people to self-manage their abortion with pills, which can result in bleeding that is clinically indistinguishable from a miscarriage and treated the same.
'Really sick, really fast'
All of which points to more patients in the emergency room — "either because they don't have an OB-GYN or because their OB-GYN is too busy with other patients," said Alexander, the emergency physician in Indiana, which passed new legislation to ban abortion with limited exceptions in August.
In 2019, Alexander invited TEAMM to do a training for her emergency department at the IU School of Medicine to help remedy what she felt was "subpar care for patients with miscarriage." If the patient is bleeding heavily, "she can get really sick, really fast." That's when an MVA becomes a time-sensitive, life-saving procedure, she said, "and something I think we all should know how to do."
Quinley acknowledges that not everyone in emergency medicine is convinced that miscarriage care should be the responsibility of the emergency provider. "But emergency medicine has been in flux since its inception," she says. "We have continuously expanded our skill set and added to our toolkit. I think it's time we consider offering our patients more options for miscarriage care."
Patrick Adams is a freelance journalist based in Atlanta. Find him on Twitter @jpatadams
