Miscarriage Care and Facilities in Scotland: Scoping Report NHS Dumfries and Galloway

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^[7].

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

In NHS Dumfries and Galloway a graded approach to treatment of recurrent miscarriage care is provided at both the Royal Infirmary and Galloway Community Hospital.

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 Dumfries and Galloway, after a first miscarriage some of the information provision or services asked about were provided on site at both the Royal Infirmary and Galloway Community Hospital and are listed in Table 18 below. Screening for mental health issues would usually be referred via GP, primary care or third sector.

In NHS Dumfries and Galloway these services are offered to all women regardless of the gestation when the loss occurred. While vaginal micronised progesterone is not provided to women with early pregnancy bleeding after a first miscarriage it is provided after a second and third or subsequent miscarriage.

After the first miscarriage sites in NHS Dumfries and Galloway signpost patients to some of the following services, however, Dumfries and Galloway Royal Infirmary and Galloway Community 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 the information provision or services provided on site at Dumfries and Galloway Royal Infirmary and Galloway Community Hospital are shown in Table 20 below. Both sites in NHS Dumfries and Galloway reported that they do not currently provide appointments at a nurse-led or midwifery-led miscarriage clinic with no plans to implement. Both sites reported that this is due to the low numbers of women accessing services. Access to support and early pregnancy reassurance scans in subsequent pregnancies is currently not provided at either site. Dumfries and Galloway Royal Infirmary reported that this is due to a lack of space, staff recruitment, staff training and lack of equipment.

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 or subsequent miscarriage.

After a third miscarriage some of the information provision or services asked about are provided on site at Dumfries and Galloway Royal Infirmary and Galloway Community Hospital are listed below in Table 21. Currently, arranging an investigative pelvic ultrasound scan is not provided in NHS Dumfries and Galloway as it is not in current guidance. However, Dumfries and Galloway Royal Infirmary reported that this can be accommodated on site if required. Regarding screening and care for mental health concerns, both sites reported that this is not offered on site. However, although there is no formal screening, if mental health is a concern they would refer women accordingly to psychology teams within the Health Board region and Community Mental Health Teams. Regarding recognising women as being at an increased risk of obstetric complications including pre-term birth, this is not provided as such in NHS Dumfries and Galloway, however, women are all individually assessed throughout their pregnancy for any risks.