The woman arrived in the emergency room late at night with pelvic cramping and vaginal bleeding. An ultrasound showed no embryo, only an empty fluid sac in her uterus.
San Francisco General is a teaching hospital, so I walked down to see the patient with the two OB/GYN residents and a medical student. The senior resident, a skilled doctor and a fluent Spanish speaker, did the talking. “There was nothing you did to cause this,” he/she said. “It just happens in a certain percentage of pregnancies.”
The woman and her husband weren’t satisfied. What could they do to prevent this from happening again?
I have trained scores of OB/GYN residents to give this “You didn’t cause the miscarriage” speech. You didn’t cause the miscarriage because you had sex. You didn’t cause the miscarriage because you took an aspirin, or had a glass of wine. Sometimes there is a problem with the baby’s genes, so the body expels the pregnancy early. Sometimes it just happens for no clear reason. Most likely your next pregnancy will be normal.
But as I listened to my resident counsel the patient, I asked myself if we were leaving out part of the story.
As part of a group studying the relationship between reproductive health and the environment, I have become increasingly aware that some jobs do put women at risk for miscarriage — particularly ones where solvents are used, like housecleaning, or working at a dry cleaners or a nail salon.
As doctors, we are good about asking our pregnant clients about alcohol, drugs and smoking because that is how we were trained. What we don’t ask is what kind of environment a patient lives in, because many of us are still making those connections ourselves. A colleague of mine had a miscarriage in 1990. Something always felt wrong about it to her — as a doctor, she knew that once a baby’s heartbeat has been confirmed on ultrasound, the likelihood of pregnancy loss is less than 2 percent.
But it was years before she realized that the miscarriage happened right after the summer medfly spraying over Los Angeles with malathion. Was there a connection? All she had to compare was the knowledge that in agricultural areas there are greater pregnancy losses with spring and summer conceptions, when spraying is most common.
So I was never trained to look automatically at a patient’s occupation. I’ve only once had a pregnant patient ask me if her job was safe. She worked at a nail salon, and it was so long ago that my memory of what I actually advised her to do is hazy — most likely: “Stop working there. And if you can’t, wash your hands a lot.”
And I’ve only once asked a pregnant patient about where she worked — a woman who came in recently for her first prenatal visit. The nurse’s notes mentioned that she had a history of asthma, and that she worked in a hair salon.
The job might be making her asthma worse, I told her. “Oh, I don’t work there anymore” she responded, in a way that left me wondering if she was telling me the truth. Maybe quitting was not an option and she’d rather not hear repetitive warnings from her doctors. If a lower-income woman is exposed to a potentially harmful substance in her place of work, and that job is the only way to feed herself and her family, the doctor may feel that she is putting the patient between a rock and a hard place by telling her of the possible risk.
I’ve decided to keep on warning, at least for now. But I and a group of other doctors and healthcare workers at UCSF have also decided to keep on asking. Specifically, we decided to conduct a survey of patients at San Francisco General Hospital to find out what they’re likely to be exposed to on the job, and how they want to talk about that job with their doctor or midwife.
We may not be able to find a definitive answer for any individual miscarriage, but the hope is that we’ll be able to start a conversation.