Notes from the Field: Joanna
The Family Medicine Resident:
The first time I met Joanna* was when she and her husband came into the clinic to establish prenatal care. She was 9 weeks pregnant at that time. As soon as I walked into the room, I could tell that they were both so excited, and Joanna expressed to me that she felt lucky to have become pregnant so easily. Joanna’s happiness was contagious; I immediately felt connected to her and imagined how meaningful it would be for me to be the one to deliver her baby in several months’ time. This was Joanna’s first pregnancy, and she was nervous something might go wrong because she was in her late 30s. To add to her stress, she had just found out that she was uninsured and ineligible for Medicaid. I reassured her that we would be able to work together to minimize excessive testing and limit out-of-pocket costs until she would be able to access health insurance through her employer after the new year. As part of our shared decision – making, we decided to hold off on an initial ultrasound until the more formal ultrasound at 16 weeks in order to help keep costs down. Meanwhile, all of Joanna’s other prenatal testing came back normal, and I provided her with my cell phone number to ensure she could easily reach me with any questions or concerns.
A few weeks after our first meeting, Joanna texted me that she had started spotting the night before. While it had initially resolved, she was now at work and the spotting had started up again. I had a sinking feeling and immediately worried that Joanna was having a miscarriage. I called her and we decided it would be best for her to come into clinic right away for an ultrasound. Although I couldn’t be in clinic that afternoon, I scheduled her with Dr. Prine and planned to come to clinic as soon as I could to try to see her before the end of the visit.
The Family Medicine Attending:
When I reviewed Joanna’s chart I was worried. At age 39, there is a high risk of miscarriage. Due to the cost, she hadn’t had an early ultrasound to establish that the pregnancy was what we call “viable” and now she was spotting. I entered the room where Joanna was waiting with trepidation. She looked worried and guarded, and could hardly make eye contact. I explained that I wanted to do an ultrasound to see what was going on. She was so quiet that I couldn’t tell if what I was saying was registering. I left so that she could get changed in private and returned a few minutes later. Sure enough, the ultrasound pictures showed an empty gestational sac, something that might be normal for a 6-week pregnancy, but unfortunately, she was supposed to be 10 weeks at that point. When a patient experiences an early pregnancy loss, I’m reluctant to break the news all at once because it just feels like hitting someone with a hammer. And there are other possibilities: perhaps she got pregnant a month or two later than she thought and perhaps this was just a very early pregnancy that would still develop? I removed the ultrasound probe and told her that I wasn’t seeing a 10-week pregnancy. I mentioned these other possibilities.
Joanna just didn’t respond at all, until a tear trickled down one cheek. “I’m so sorry” I said, starting to choke up myself. “If this is a miscarriage, the one thing I want you to know is that you didn’t cause this, you didn’t do anything to make this happen. Nature just has a way of picking out pregnancies that would not develop normally and making them stop. It’s a normal process and doesn’t mean you can’t get pregnant again and have a successful birth. If it’s a miscarriage, it is not your fault.” She nodded and more tears streamed down her cheeks. I passed the box of tissues. We made a plan for blood tests (hCGs) and another ultrasound, if needed, in a week to be sure of the diagnosis.
In my experience, women tend to blame themselves when they have miscarriages. They think about that bit of rigorous exercise they did, or the wine they drank one night, or the sex they had. But we know, medically, that these things don’t cause miscarriages. As clinicians, it’s so important for us to take away that blame, normalize what they are going through, and give them the space to mourn when they are ready. I gave her my cell number, and she already had her resident’s contact info, so that she could be in touch with us if the spotting turned into bleeding and she needed additional treatment.
The Family Medicine Resident:
I made it to the clinic just as Joanna was leaving. Dr. Prine told me the ultrasound showed a pregnancy that had failed to grow appropriately and it was likely Joanna was having a miscarriage. I ran out to the lobby to find her before she left and gave her a long, tear-filled hug. I’ve felt emotionally invested in many of my patients’ stories before, but this one was particularly difficult. I felt responsible for Joanna’s loss and worried that I could have somehow provided better care to prevent this from happening. Beyond that, though, I was sad to lose the potential relationship we could have built over the next several months of her pregnancy and afterward as I cared for her and her new baby.
Joanna had decided with Dr. Prine that she wanted to do some waiting, to see if the spotting continued. She and I stayed in touch the rest of that week and through the weekend. Then, we confirmed on the following Friday that her hCG level was indeed dropping and the bleeding was continuing; the pregnancy was definitely not viable. Joanna decided to proceed with medical treatment and took misoprostol pills at home to manage her miscarriage. At that point, she wanted to move on and get ready to become pregnant again, but didn’t want a procedure if she didn’t have to have one. Of course, I was happy to support this choice of hers and reviewed what to expect when she used the misoprostol, how to treat the pain of the cramping, and when to call me if anything seemed out of hand. I had Dr. Prine’s phone number as back-up and kept my phone nearby all weekend, as I worried about what she would be going through. When Dr. Prine and I saw her in clinic on Monday, the ultrasound showed the miscarriage was complete and Joanna was starting to ask questions to plan for her next pregnancy. I was so glad to see she was ready to move on, and I was so impressed with her resilience and strength despite her sadness. I was honored when she told me she wanted me to continue to be her physician and to care for her again the next time she becomes pregnant.
Throughout this time, I was so thankful that Joanna was able to reach me so easily and come into our clinic to immediately receive our family medicine patient-centered care, rather than ending up in an emergency room, where, after a long wait, a provider she had never met before would have informed her that her pregnancy was not viable. Too often, people in this setting are given appointments for a “D&C” in the operating room, rather than choices about how to proceed with their care in more non-invasive ways. As family medicine physicians, there are very few things we do that provide such immediate gratification and have significant impact on the lives of our patients as empowering them to make their own reproductive health care choices. Every day that I am able to support a patient to make their own decisions about their bodies, to live the life they imagine for themselves – whether that means preventing, ending, or managing a pregnancy – I feel incredibly privileged to have the job that I have.
*The patient’s name has been changed for privacy.