Miscarriage Care and Facilities in Scotland: Scoping Report NHS Ayrshire and Arran
This report details the findings of a scoping exercise to better understand miscarriage care in Scotland within this Health Board. The individual Health Board reports and the national report seek to aid policy makers and Health Boards in making decisions about improvements to Miscarriage Care
Summary
A summary of findings is presented below and is shown in Table 25 alongside the recommendations within the Lancet series on Miscarriage Matters and the Scottish Government Programme for Government commitments.
In NHS Ayrshire and Arran, University Hospital Crosshouse is the core site that provides care for those that experience miscarriage. Although all sites in NHS Ayrshire and Arran said that women are free to choose the management approach that suits their needs, the geography in Ayrshire and Arran has implications for women in terms of how they can access their chosen approach. Arran War Memorial Hospital suggested that very few women opt for expectant management or out-patient medical management, which are both provided at University Hospital Crosshouse, due to the need to travel between the mainland and Arran potentially more than once if they experience any complications or if the management option is not successful.
In NHS Ayrshire and Arran, University Hospital Ayr Hospital does not provide any written information about the treatment options for the management of miscarriage and what to expect in terms of miscarriage care or information on what would happen before, during and after any treatment options as all women are transferred to University Hospital Crosshouse where they are provided with this information.
Within NHS Ayrshire and Arran women are provided with full explanations about what would happen during their chosen method of management, after the chosen method of management and in terms of follow-up. Women are free to choose their preferred management approach based on their needs and preferences.
In NHS Ayrshire and Arran a graded approach to treatment of recurrent miscarriage is provided at University Hospital Crosshouse, where all patients within the Health Board area are referred. All elements outlined in the Lancet series on Miscarriage Matters are provided in NHS Ayrshire and Arran at Crosshouse with the exception of a pelvic ultrasound scan (ideally three dimensional transvaginal), however there are plans to implement this within the next two years and equipment has already been procured to provide this service.
Dedicated facilities are available at University Hospital Crosshouse, where more than five separate rooms are available away from the labour ward for women that are miscarrying.
In NHS Ayrshire and Arran, University Hospital Crosshouse has a separate area to carry out complication/investigative scans separated from women with a continuing pregnancy.
In NHS Ayrshire and Arran data on miscarriage is collected via BadgerNet, Symphony (University Hospital Ayr) and through patient and paper records. Data is collected on the number of miscarriages, miscarriages as a proportion of pregnancies, gestation, maternal age, parity and ethnicity. There is currently no data collected on SIMD. Data on miscarriage is presented to senior medical and maternity staff for review.
Table 25: Scottish Government Programme for Government (PfG) Commitments and the Lancet Miscarriage Matters Recommendations
Source: PfGCommitment/Recommendation: Ensure women’s services in Health Boards have dedicated facilities for women who are experiencing unexpected pregnancy complications.
Service provision in NHS Ayrshire and Arran: NHS Ayrshire and Arran have dedicated provision for women experiencing unexpected pregnancy complications at University Hospital Crosshouse; these facilities were provided in the early pregnancy unit (EPU) and out with the EPU, in the gynaecology ward and in maternity assessment. University Hospital Crosshouse has more than 5 rooms which are single rooms within maternity assessment and the gynaecology ward. It is noted that some rooms/areas are not solely used for miscarriage care and may be used for other pregnancy complications or loss.
Source: The Lancet: Miscarriage MattersCommitment/Recommendation: A graded approach to the treatment of recurrent miscarriage
Service provision in NHS Ayrshire and Arran: A graded approach to treatment of recurrent miscarriage is provided at University Hospital Crosshouse
After first miscarriage
Source: After the first miscarriage, women will be guided to information about miscarriage
Service provision in NHS Ayrshire and Arran: Provided at both University Hospital Crosshouse and Arran War Memorial Hospital
Source: After the first miscarriage, women will be guided to resources to address their physical needsService provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: After the first miscarriage, women will be guided to resources to address mental health needs following pregnancy loss
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: After the first miscarriage, women will be guided to ways to optimise their health for future pregnancy
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
After first miscarriage - this approach could involve:
Source: Patient support groups
Service provision in NHS Ayrshire and Arran: Provided at both University Hospital Crosshouse and Arran War Memorial Hospital
Source: Online self-help strategies for mental health
Service provision in NHS Ayrshire and Arran: Provided at both University Hospital Crosshouse and Arran War Memorial Hospital
Source: Weight management
Service provision in NHS Ayrshire and Arran: Provided at both University Hospital Crosshouse and Arran War Memorial Hospital
Source: Smoking and recreational drugs cessation services
Service provision in NHS Ayrshire and Arran: Provided at both University Hospital Crosshouse and Arran War Memorial Hospital
Source: Information on appropriate preconceptual folate and vitamin D supplementation
Service provision in NHS Ayrshire and Arran: Provided at both University Hospital Crosshouse and Arran War Memorial Hospital
Source: Referral to necessary services for management and optimisation of chronic maternal medical conditions (e.g., diabetes, hypertension, heart disease, and epilepsy)
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Screening for mental health issues.
Service provision in NHS Ayrshire and Arran: Provided at both University Hospital Crosshouse and Arran War Memorial Hospital
After second miscarriage
Source: Women will be offered an appointment at a miscarriage clinic nurse or midwifery-led
Service provision in NHS Ayrshire and Arran: Appointment at midwifery-led or consultant led clinic provided at University Hospital Crosshouse
Source: Continuity of Care
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Tests for full blood count are offered
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Tests for thyroid function are offered
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Discussion about lifestyle issues
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Referral for specialist care will be arranged if tests are abnormal or if there is a chronic medical or mental health problem.
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Women will have access to support and early pregnancy reassurance scans in subsequent pregnancies.
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
After third and subsequent miscarriage
Source: Women will be offered an appointment at a medical consultant-led clinic, in which additional tests and a full range of treatments can be offered.
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Pregnancy tissue from the third and any subsequent miscarriages will be sent for genetic testing.
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Blood tests for antiphospholipid antibodies will be arranged.
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: A pelvic ultrasound scan (ideally three dimensional transvaginal) will be arranged
Service provision in NHS Ayrshire and Arran: Not provided in NHS Ayrshire and Arran
Source: If necessary, parental karyotyping will be offered depending on the clinical history and the results of the genetic analysis of pregnancy tissue from previous losses
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Appropriate screening for mental health issues
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Appropriate care for mental health issues
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Overall recommendations
Source: Appropriate screening and care for future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth.
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Appropriate screening and care for future obstetric risks and mental health issues will need to be incorporated into the care pathway for couples with a history of recurrent miscarriage.
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Consider giving vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: We urge health-care funders and providers to invest in early pregnancy care, with specific focus on training for clinical nurse specialists and doctors to provide comprehensive miscarriage care within the setting of dedicated early pregnancy units.
Service provision in NHS Ayrshire and Arran: University Hospital Crosshouse has midwives/nurses with additional specialist training to provide comprehensive miscarriage care. University Hospital Crosshouse has doctors trained to provide comprehensive miscarriage care.
Source: Early pregnancy services need to focus on providing an effective ultrasound service, as it is central to the diagnosis of miscarriage, and be able to provide expectant management of miscarriage, medical management with mifepristone and misoprostol, and surgical management with manual vacuum aspiration
Service provision in NHS Ayrshire and Arran: University Hospital Crosshouse can carry out scans in the EPU. All management options are available at University Hospital Crosshouse.
Source: Recommend that miscarriage data are gathered and reported to facilitate comparison of rates among countries, to accelerate research, and to improve patient care and policy development. We recommend that every country reports annual aggregate miscarriage data, similarly to the reporting of stillbirth.
Service provision in NHS Ayrshire and Arran: Data on miscarriage is collected via BadgerNet (University Hospital Crosshouse/Arran War Memorial Hospital / University Hospital Ayr), Symphony (University Hospital Ayr) and through patients and paper records. Data is collected on the number of miscarriages, miscarriages as a proportion of pregnancies, gestation (at University Hospital Crosshouse/Arran War Memorial Hospital only), maternal age, parity and ethnicity. There is currently no data collected on SIMD. Data on miscarriage is presented to senior medical and maternity staff for review.
Source: Identifying women at risk of psychological distress following miscarriage
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Identifying women at risk of psychological distress following miscarriage and the development of optimal treatment strategies have been recognised as research priorities.
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Women with a history of miscarriage, particularly those with three or more miscarriages, are at an increased risk of obstetric complications including preterm birth. Therefore, these women should be treated as patients at high risk during antenatal and intrapartum care.
Service provision in NHS Ayrshire and Arran: Provided at University Hospital Crosshouse
Source: Miscarriage Management - women should be presented with the available evidence and be free to choose the management approach that suits their needs and preferences
Service provision in NHS Ayrshire and Arran: All sites said that women are free to choose the management approach that suits their needs, however the geography in NHS Ayrshire and Arran has implications for women in terms of how they can access their chosen approach. Arran War Memorial Hospital suggested that very few women opt for expectant management or out-patient medical management due to the need to travel between the mainland and Arran.
Source: Consider pathways of care for miscarriage management, treatment of women with a history of miscarriage and care following a miscarriage.
Service provision in NHS Ayrshire and Arran: Not assessed
Source: The Lancet: Miscarriage Matters Research Recommendations
- Key epidemiological research priority 1 - Establishing how we can monitor miscarriage rates on a population basis.
Service provision in NHS Ayrshire and Arran: Project underway with Scottish Government and Public Health Scotland
- Key epidemiological research priority 2 - Ascertaining if miscarriage risk and prevalence differ across nations and ethnic groups.
Service provision in NHS Ayrshire and Arran: Project underway with Scottish Government and Public Health Scotland
- Key epidemiological research priority 3 - Whether miscarriage rate is increasing, and if so why; what the key outcomes are from women’s point of view.
Service provision in NHS Ayrshire and Arran: Work to follow from research priorities 1 and 2 above.
- Key epidemiological research priority 4 - Which risk factors for miscarriage are potentially causative and modifiable; and the effect of modification of the risk factor on clinical outcomes
Service provision in NHS Ayrshire and Arran: Work to follow from research priorities 1 and 2 above.
Contact
Email: socialresearch@gov.scot
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