Miscarriage Care and Facilities in Scotland: Scoping Report NHS Ayrshire and Arran

Graded approach to recurrent miscarriage care

The Lancet series on Miscarriage Matters provided information on the provision of treatment and care after first, second and third or subsequent miscarriage. The Lancet series proposed a graded approach to the treatment of recurrent miscarriage, where after one miscarriage women would have their health needs evaluated and would be provided with information and guidance to support future pregnancies. If a second miscarriage were to occur, they would be offered an appointment at a miscarriage clinic for initial investigations, extra support and early reassurance scans for subsequent pregnancies. After three miscarriages they would be offered a full series of evidence-based investigations and care. RCOG guidelines state that the graded approach should be encouraged as it appears to bridge the gap between sporadic and recurrent miscarriage care, encouraging a systematic graded approach rather than a fragmented one. It also addresses the balance between the need for evidence-based and supportive care, while targeting healthcare resources effectively.

The following sections of this report are based on the Lancet series and will help to ascertain the extent to which the graded approach is currently being delivered in Health Boards across Scotland.

It should be noted that at the time of completion of this questionnaire, RCOG defined recurrent miscarriage as the loss of three or more consecutive pregnancies. RCOG guidelines on the treatment of recurrent miscarriage were updated in June 2023 and this definition now includes non-consecutive miscarriages^[8] .

In Scotland, 12 of the 14 Health Board areas said a graded approach to the treatment of recurrent miscarriage is adopted.

In NHS Ayrshire and Arran, a graded approach to treatment of recurrent miscarriage is adopted at University Hospital Crosshouse, where all patients within the Health Board area are referred.

After first miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 18 below, should be available after a first miscarriage. Vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage is not offered in all 14 Health after a first miscarriage with some sites referring to the NICE Guidelines^[9] that state this should be offered for women with early pregnancy bleeding and a history of miscarriage rather than a first miscarriage.

In NHS Ayrshire and Arran, University Hospital Crosshouse reported that all of the information provision or services recommended in the Lancet series on Miscarriage Matters are provided on site after a first miscarriage and are provided regardless of the gestation when the loss occurred. These are listed in Table 18 below.

Arran War Memorial Hospital reported that they provide women with information about miscarriage and asked women if they had had a previous miscarriage but all other services were provided at Ayrshire Maternity Unit (Crosshouse) where all women would be transferred for treatment. As University Hospital Ayr does not have an EPU, maternity unit, CMU or an obstetrics and gynaecology department they were not asked this question.

Sites in NHS Ayrshire and Arran signpost patients to the following services, however, University Hospital Crosshouse and Arran War Memorial Hospital reported different approaches to this, as outlined in Table 19.

After second miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 20 below, should be available after a second miscarriage.

After a second miscarriage University Hospital Crosshouse reported that almost all of the information provision or services recommended in the Lancet series on Miscarriage Matters are provided on site. These are listed in Table 20 below. The exception to this is that after a second miscarriage, University Hospital Crosshouse reported that care is provided within the obstetrics team rather than within a nurse-led miscarriage clinic, so this would not be offered but the patient would instead be offered a consultant led clinic. Arran War Memorial Hospital reported that women are asked verbally if they have had a previous miscarriage but all other services are provided at University Hospital Crosshouse where women are transferred.

As University Hospital Ayr does not have an EPU, maternity unit, CMU or an obstetrics and gynaecology department they were not asked this question.

After third and subsequent miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 21 below, should be available after a third and subsequent miscarriage.

After a third miscarriage, University Hospital Crosshouse reported that almost all of the information provision or services recommended in the Lancet series on Miscarriage Matters asked about are provided on site. They stated that investigative pelvic ultrasound scan (ideally three dimensional – not a pregnancy scan) are not provided at University Hospital Crosshouse but are planned for implementation in the next two years, with consultants currently awaiting training that has been postponed due to COVID. However, a 3D probe has been acquired. Arran War Memorial Hospital reported that patients would be referred to University Hospital Crosshouse for all of the services and provisions, these are shown in Table 21 below.

As University Hospital Ayr does not have an EPU, maternity unit, CMU or an obstetrics and gynaecology department they were not asked this question.

*Currently, investigative pelvic ultrasound scans are not provided at University Hospital Crosshouse but are planned for implementation in the next two years, with consultants currently awaiting training that has been postponed due to COVID. However, a 3D probe has been acquired. At Arran War Memorial Hospital patients would once again be referred to Crosshouse. For University Hospital Ayr these questions were not asked as service provision would also be at University Hospital Crosshouse.