Case Study: Suspected Incomplete Miscarriage Complicated by Barriers to Care in a Restrictive Healthcare Environment

Case at a Glance

A 28-year-old female presented with symptoms suggestive of an incomplete miscarriage, including prolonged bleeding, persistent uterine cramping, and systemic symptoms concerning for infection. Her ability to seek timely care was significantly hampered by a recent move, a temporary lack of health insurance, and the complex legal and healthcare landscape in her new state regarding pregnancy-related procedures.

Patient's Story

The patient is a 28-year-old female with no significant past medical history, not taking any medications. Her symptoms began approximately two weeks prior to presentation, starting with abnormal vaginal bleeding that occurred one week after her expected menstrual period had ended. Confused by the bleeding, she took a home pregnancy test, which returned a strong positive result. The bleeding continued for two weeks, during which she passed small amounts of tissue. While the bleeding eventually tapered to light spotting, she began to experience new symptoms over the subsequent 12 hours, including nausea, diarrhea, and a subjective low-grade fever. She also reported mild but persistent uterine cramping, which she noted was more pronounced than during the period of active bleeding. A repeat home pregnancy test remained strongly positive, with minimal fading compared to the test taken two weeks prior. The patient's primary concerns were retained products of conception (RPOC) and the potential for a uterine infection.

Initial Assessment

The patient's situation was complicated by significant non-medical barriers. Having recently relocated to a new state and started a new job, she was in a waiting period for her health insurance to become active. This lack of coverage made her hesitant to visit an Emergency Department (ED) due to the anticipated high cost. Her attempts to find alternative care were unsuccessful; OB/GYN offices had months-long waiting lists for new patients, urgent care centers declined to see her as they were not equipped for obstetric ultrasounds, and local women's health clinics were unable to provide care due to her active bleeding and lack of an on-staff physician. The patient expressed significant distress and felt the ED was her only remaining option. This was further compounded by her location in a state with restrictive laws surrounding abortion, leading to her fear that necessary medical procedures for miscarriage management, such as a dilation and curettage (D&C), might not be readily available.

The Diagnostic Journey

After numerous phone calls, the patient successfully found a private gynecology clinic that agreed to see her for a same-day appointment. By the time of her visit, the subjective fever had resolved, though the uterine cramping continued. The gynecologist performed a transvaginal ultrasound. The physician noted that the ultrasound machine had limited resolution but reported a largely empty-appearing uterine cavity, with the exception of a small, unidentifiable piece of tissue. To further evaluate the situation, blood was drawn for a quantitative serum hCG level. The working diagnosis was a suspected incomplete miscarriage, with ectopic pregnancy remaining a key differential to be ruled out.

Final Diagnosis

The initial diagnosis is Suspected Incomplete Miscarriage. Differential diagnoses include completed miscarriage, ectopic pregnancy, and endometritis, given her transient systemic symptoms.

Treatment Plan

The management plan was contingent on the forthcoming hCG results.

1. If hCG levels are low and declining appropriately: This would be consistent with a resolving miscarriage. The plan would be expectant management, or medical management with misoprostol to ensure complete expulsion of any remaining uterine contents.
2. If hCG levels are unexpectedly high or fail to decline: This would increase suspicion for either significant retained products of conception or an ectopic pregnancy. A follow-up visit with a repeat ultrasound in several days would be required to definitively rule out an ectopic pregnancy. If RPOC were confirmed, a D&C procedure or medical management would be offered.

The patient was counseled to return to the ED immediately if she developed high fever, severe abdominal pain, or heavy vaginal bleeding.

Outcome and Follow-up

The patient successfully accessed initial specialist care, avoiding an ED visit and receiving a preliminary diagnosis and management plan. However, she still anticipates a significant out-of-pocket medical bill. She is currently awaiting her hCG lab results, which will guide the next steps in her treatment. This case highlights the profound impact of socioeconomic and systemic factors on patient care, demonstrating how lack of insurance and a complex legal environment can create significant delays and psychological distress for individuals needing essential reproductive healthcare.