Miscarriage Care and Facilities in Scotland: Scoping Report NHS Borders

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 NHS 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^[7].

In Scotland 12 of the 14 health Boards said a graded approach to the treatment of recurrent miscarriage is adopted on their site.

In NHS Borders a graded approach to treatment of recurrent miscarriage care is provided at Borders General Hospital, where all patients within the Health Board area are referred for all management options.

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^[8] that state this should be offered for women with early pregnancy bleeding and a history of miscarriage rather than a first miscarriage.

In NHS Borders, Borders General Hospital reported that almost all of the information provision or services recommended in the Lancet series on Miscarriage Matters is provided on site after a first miscarriage and are provided regardless of the gestation when the loss occurred (Table 18). Borders General Hospital stated they do not provide vaginal micronised progesterone to women with early pregnancy bleeding and a history of miscarriage and there are no plans to implement this routinely in the future, however, if a woman requests this after a first miscarriage they will be given it.

NHS Borders signpost patients to the following services 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, Borders General Hospital reported that not all of the information provision or services asked about were provided on site, as shown in Table 20 below. After a second miscarriage, care is provided within the obstetrics team rather than within a nurse-led or midwifery-led miscarriage clinics, so this would not be offered but the patient would instead be offered a consultant-led clinic. Borders General Hospital also do not test thyroid function after a second miscarriage. Borders General Hospital do test for full blood count but this is not specific to second miscarriages; this test is routinely offered to all women after a first miscarriage.

After third or subsequent miscarriage

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

After a third or subsequent miscarriage, Borders General Hospital reported that all of the information provision or services asked about were provided on site, as shown in Table 21 below.