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

Management options

In NHS Ayrshire and Arran, all sites strongly agreed that women are free to choose their preferred management approach based on their needs and preferences.

All sites in NHS Ayrshire and Arran were asked if the management options, listed in Table 16 below, were either provided on site, accessible locally or not provided. All management options for miscarriage care were offered only at University Hospital Crosshouse with other sites referring patients to this site for all treatment. All options in Table 16 were offered during first trimester losses. Medical management with mifepristone and misoprostol as an inpatient is offered in the second trimester.

* NHS Ayrshire and Arran reported that since completing this questionnaire medical management with misoprostol only is no longer provided as recent evidence suggests that treatment with mifepristone and misoprostol is more effective than misoprostol alone_.

The EPU at University Hospital Crosshouse cares for all women experiencing miscarriage up to 14 weeks, while all gestations beyond 14 weeks are seen and counselled in EPU but the treatment, which would be medical management, is carried out in a purpose built bereavement room next to Labour Ward.

All sites were asked to fully describe the treatment pathway for expectant management, medical management and surgical management. The descriptions provided have been presented under the relevant subheadings below; these narratives contain only information provided by the sites during this exercise.

In NHS Ayrshire and Arran Before a women chooses their management option, they are assessed at University Hospital Crosshouse, to ensure it is a miscarriage and to exclude ectopic and Pregnancy of Unknown Location (PUL). Scans are performed to confirm intrauterine pregnancy loss. Provision of information leaflets and discussion about management options are undertaken and patients are given time to consider options and make a choice, which may take several days as the patient prefers. Once the choice of management option has been chosen the pathway of care is described below for each option.

Expectant management in NHS Ayrshire and Arran

Once expectant management is decided upon as the preferred option, women are advised about expectant management risks and benefits, provided with written information and are given a pregnancy test to take home. The patient is asked to phone the unit in three weeks’ time to discuss events, blood loss, and results of the pregnancy test. If the test is negative the patient is discharged, if the test is positive or the history is not suggestive of complete miscarriage, the patient is asked to attend the EPU for a scan and medical review. All women are followed up within 2-3 weeks after being seen at University Hospital Crosshouse, with any necessary further reviews referred back to University Hospital Crosshouse.

In Arran when women present with miscarriage, management options are discussed and women are referred to University Hospital Crosshouse on the mainland for treatment even if they chose expectant management. When women from Arran choose expectant management, they will return home after an initial assessment at University Hospital Crosshouse. It was also noted that due to the need to travel back to University Hospital Crosshouse on the mainland if women experience any complications or if treatment is not successful, very few women from Arran chose expectant management as an option for their care. Of those from Arran that chose expectant management the care pathway is the same as those in the rest of NHS Ayrshire and Arran as described above and Arran maternity unit would also be informed that this treatment was being provided. Follow-up would be provided through University Hospital Crosshouse if necessary.

Medical management in NHS Ayrshire and Arran

In NHS Ayrshire and Arran medical management is provided at University Hospital Crosshouse only. Medical management with misoprostol is provided in the first trimester only. Medical Management with mifepristone and misoprostol is offered in the first and second trimester. Medical management is offered as an in-patient service in both the first and second trimester. In regard to outpatient medical management, two sites said this is offered only in the first trimester (University Hospital Crosshouse and University Hospital Ayr) with the service provided at University Hospital Crosshouse only, whereas Arran War Memorial Hospital suggested outpatient medical management is offered in both the first and second trimester but would be provided at University Hospital Crosshouse. University Hospital Crosshouse also noted that for medical management at 9-17 weeks gestation, patients are given mifepristone and misoprostol and stay at the hospital until delivery.

The treatment pathway for medical management described by University Hospital Crosshouse would depend on the gestation and circumstances. If under 9 weeks, medical management with outpatient care is the usual pathway of care. The patient is given Misoprostol in the department and provided with advice on what to expect, with written information. If outpatient treatment is chosen, telephone contacts details for the EPU are provided and analgesia and pregnancy test would are also provided. The patient would be telephoned within 48 hours, to discuss events and how they are feeling/coping. If events are as expected, patients would be telephoned within a further three weeks to discuss the results of a pregnancy test. If the test is negative the patient would be discharged. If the history is not suggestive of complete miscarriage, options would be discussed for further medical or surgical management. If the pregnancy test is positive, the patient would be asked to attend University Hospital Crosshouse for scan and medical review.

As all patients from Arran that were experiencing miscarriage are transferred to University Hospital Crosshouse, few women opt for outpatient medical management due to the need to travel back to University Hospital Crosshouse if further or emergency treatment is required.

Surgical management in NHS Ayrshire and Arran

University Hospital Crosshouse said that surgical management with manual vacuum aspiration (MVA) with local anaesthetic is offered in the first trimester and surgical management under general anaesthetic is also offered in the first trimester. All sites indicated that surgical management options are not offered in the second trimester.

The treatment pathway for surgical management described by University Hospital Crosshouse involves patients attending the EPU the day prior to surgery for COVID testing (when appropriate – linked to COVID guidelines), where information leaflets and a full explanation of the procedure are provided. A pre-operative assessment with full blood count, blood group and blood screening is also carried out. On the day of the procedure women attend at 8am for operation theatre at 8:45am. Misoprostol is given before surgical procedures and patients see surgical, anaesthetic and theatre teams. Recovery after the procedure is with the EPU team.

The treatment pathway for surgical management differed slightly for patients transferred from Arran War Memorial Hospital. Due to the need to travel, most patients opt for surgical management. A pre-operative assessment with full blood count, blood group and blood screening is also carried out and COVID swab is completed (when appropriate – linked to COVID guidelines). Patients are able to stay with family or friends in University Hospital Crosshouse or stay in family rooms within the department. As the procedure is done in the morning, patients are able to take the last ferry home if accompanied by an adult.

Patients are given a pregnancy test to take home and are contacted two to three weeks after the surgery. If the test is negative the patient would be discharged. If the pregnancy test is positive, the patient would be asked to attend University Hospital Crosshouse for scan and medical review.