Early Pregnancy Loss Practice Integration for Advanced Practice Providers

Early Pregnancy Loss and the Role of Advanced Practice Providers

Certified nurse-midwives (CNMs), nurse practitioners (NPs), and physician assistants (PAs), collectively referred to as advanced practice providers (APPs), play a vital role in providing health care services in the United States, specifically in emergency, primary, and reproductive health care for millions of women. APPs often practice in medically underserved settings where there are fewer physicians. These services are common, and simple to train on, and integration of the services allows APPs to provide continuity of care for their patients. Additionally, outpatient procedures generally cost less, thus by having more trained APPs employers will likely see cost-savings. 

Early Pregnancy Loss (EPL), also called spontaneous abortion or miscarriage, is defined as a nonviable, intrauterine pregnancy with either an empty gestational sac, or a gestational sac containing an embryo or fetus without cardiac activity before 13 weeks gestation (per ACOG Bulletin). This is a clear distinction from induced abortion, which is the termination of a viable pregnancy that otherwise would have been likely to continue. 

Why is integration of EPL services important? EPL is common; in people with a known pregnancy, it is estimated that 1 in 4 will miscarry before the 12th week. It affects 960,000 people annually, and most EPL occurs before 13 weeks gestation. While many people are able to miscarry at home, it is important for providers to be available to assist when patients prefer to manage their miscarriage with medication or an aspiration procedure. APPs have the skills, follow-up capacity, and can provide improved patient experience from a primary care office or emergency department. By allowing APPs to provide comprehensive EPL services, we expect to see an improvement in patient safety due to early diagnosis and management, an  improvement in patient and clinician satisfaction by integrating EPL care into existing practice, thereby reducing delays and unnecessary referrals.

Clinical Competencies

Protocols, Skills Checklist, and EPL core Competencies

The Skills Checklist and Core Competencies resources below can be used in tandem to reach competence around knowledge, behaviors, and skills that clinicians should be able to demonstrate in order to safely perform MUA. The sample protocol for office MUA can adapted for use at clinical sites. Other types of sample protocols are also available.

Washington Practice Regulations

Knowledge of regulatory structure is important in order to understand scope of practice restrictions. Washington State is a “Full Practice” state, meaning state practice and licensure laws permit all ARNPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing.

Here is a quick summary of what is legal for different types of APPs in Washington State. It is important to note that while this toolkit is focused on utilizing aspiration for EPL, aspiration services are generally discussed in the context of abortion, as it is the same set of skills.

More information about regulatory structure:

• Washington State Board of Nursing // Nursing Commission
  Washington State Professional Licensing Division: (360) 236-4700

• CNM State Resource Center

• American Association of Nurse Practitioners 

Other states

To learn about regulations in states other than Washington, contact the Board of Nursing or professional organization that governs practice in your state.

Barriers & Facilitators to Integration

Implementation of comprehensive miscarriage management services can be challenging for APCs. In the “Tips for Approaching Leadership” document, common barriers and strategies for overcoming them are cited by TEAMM training site participants. The second document includes testimonials from APCs about their experiences being trained in EPL management in Washington State.

Useful Literature

• Grumbach K, et al. Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington.

• Prine LW, et al. Office management of early pregnancy loss. Am Fam Physician. 2011 Jul 1;84(1):75-82.

• ACOG Practice Bulletin: Early Pregnancy Loss - 2018 Interim Update

• Doubilet PM, et al. Diagnostic criteria for nonviable pregnancy early in the first trimester.

There is not a lot of literature that specifically addresses management of EPL by APCs. Here are some articles on using the same medications and MUA procedure in other contexts:

• MUA competency and confidence 

  • Weitz TA et al. Safety of Aspiration Abortion Performed by Nurse Practitioners, Certified Nurse Midwives and Physician Assistants under a California Legal Waiver. March 2013. American Journal of Public Health; 103(3):454-61.

  • Freedman LR Levi A. How Clinicians Develop Confidence in Their Competence in Performing Aspiration Abortion. January 2014. Qualitative Health Research; 24(1):78-89.

• Barriers to APC provision

  • Battistelli M et al . Expanding the Abortion Provider Workforce: A Qualitative Study of Organizations Implementing a New California Policy. February 2018. Perspectives on Sexual and Reproductive Health; 50(1):33-39.

Additional Resources for EPL

• TEAMM Resources
  TEAMM trains healthcare teams to integrate all three forms of early pregnancy loss management – expectant, medication, and manual uterine aspiration – into their office-based and emergency medicine settings. Sample protocols, patient education information, counseling information, administrative tools, teaching tools, and important publications are included in the resources page.

• RHAP Miscarriage Care Initiative
  RHAP mobilizes, trains, and supports clinicians to make reproductive healthcare accessible to everyone, focusing on abortion, contraception, and EPL. 

• Innovating Education in Reproductive Health

  Online courses and resources for abortion and early pregnancy loss. Great jumping off point to learn more about the procedure and answer questions you may have. 

  • Managing Early Pregnancy Loss
    An educational initiative incorporating video-based curriculum with online resources to support an evidence-based and patient-centered approach to miscarriage management. The curriculum provides a comprehensive review of diagnosis and treatment of early pregnancy loss (EPL).

• TEACH Training Program

  Specifically, Chapter 8 on Management of Early Pregnancy Loss and Chapter 5 on uterine aspiration. 

• Nurses for Sexual and Reproductive health (NSRH)

  NSRH is a national grassroots organization dedicated to providing students, nurses and midwives with education and resources to become skilled care providers and social change agents in sexual and reproductive health and justice. They can be a great resource if you are looking for training. Note that their information is targeted to abortion, but the same skills can be used for EPL. 

• UpToDate - Pregnancy Loss (miscarriage)
  UpToDate is a decision support tool that addresses clinical topics in evidence based way, while leaving room for best practices. *Note: UpToDate requires an account for full access to materials.

• Emotional Support Resources for EPL
  TEAMM has created a list of resources patients may find helpful when seeking emotional support for EPL.