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

Summary

A summary of findings is presented below and is shown in Table 25 against the recommendations within the Lancet series on Miscarriage Matters and the Scottish Government Programme for Government commitments.

In NHS Dumfries and Galloway, both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital provide care for those that experience miscarriage, with most women referred to Dumfries and Galloway Royal Infirmary. Both sites in NHS Dumfries and Galloway said that women are free to choose the management approach that suits their needs.

In NHS Dumfries and Galloway, both sites provide written information about the treatment options for the management of miscarriage and what to expect in terms of miscarriage care and information on what would happen before, during and after any treatment options.

Within NHS Dumfries and Galloway women are also 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.

In NHS Dumfries and Galloway a graded approach to treatment of recurrent miscarriage care is provided at Dumfries and Galloway Royal Infirmary and Galloway Community Hospital. Most of the elements outlined in the Lancet series on Miscarriage Matters are provided in NHS Dumfries and Galloway. Appointments at nurse-led or midwifery-led miscarriage clinics are not offered in NHS Dumfries and Galloway due to the small number of women using Early Pregnancy Services. Although appropriate screening for mental health issues is not provided at Royal Infirmary or Galloway Community Hospital, these services can be referred to within the health board area through GP, primary care or third sector.

Dedicated facilities are available at Dumfries and Galloway Royal Infirmary, where there is one separate room available away from the labour ward for women that are miscarrying.

In NHS Dumfries and Galloway, Dumfries and Galloway Royal Infirmary has a separate area to carry out complication/investigative scans separated from women with a continuing pregnancy.

In NHS Dumfries and Galloway data on miscarriage is collected via Badgernet Maternity and Clinical Portal. Data on miscarriages is collected for local purposes for Early Pregnancy Services follow up but not for formal purposes. No data is routinely collected on proportion of pregnancies, gestation, maternal age, parity, SIMD or ethnicity but data could be analysed if required.

Table 24: Scottish Government Programme for Government (PfG) Commitments and the Lancet Miscarriage Matters Recommendations

Source: PfG

• Commitment/Recommendation - Ensure women’s services in Health Boards have dedicated facilities for women who are experiencing unexpected pregnancy complications
• Service Provision in NHS Greater Glasgow and Clyde - NHS Dumfries and Galloway have dedicated provisions for women experiencing unexpected pregnancy complications at Dumfries and Galloway Royal Infirmary. Dumfries and Galloway Royal Infirmary can use one room on the gynaecology ward for pregnancy loss. 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 Matters

• Commitment/Recommendation - A graded approach to the treatment of recurrent miscarriage
• Service Provision in NHS Greater Glasgow and Clyde - Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital.

After first miscarriage

• After the first miscarriage, women will be guided to information about miscarriage
  • Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital.
• After the first miscarriage, women will be guided to resources to address their physical needs
  • Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital.
• After the first miscarriage, women will be guided to resources to address mental health needs following pregnancy loss
  • Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital.
• After the first miscarriage, women will be guided to ways to optimise their health for future pregnancy
  • Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital.

After first miscarriage – this approach could involve:

• Patient support groups
  • Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital.
• Online self-help strategies for mental health
  • Provided at Galloway Community Hospital.
• Weight management
  • Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital.
• Smoking and recreational drugs cessation services
  • Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital.
• Information on appropriate preconceptual folate and vitamin D supplementation
  • Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital.
• Referral to necessary services for management and optimisation of chronic maternal medical conditions (e.g., diabetes, hypertension, heart disease, and epilepsy)
  • Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital.
• Screening for mental health issues
  • Not provided at Galloway Community Hospital or Dumfries and Galloway Royal Infirmary. Screening for mental health issues would usually be referred via GP, primary care or third sector.

After second miscarriage

• Women will be offered an appointment at a miscarriage clinic nurse or midwifery-led
  • Not provided in NHS Dumfries and Galloway.
• Continuity of Care
  • Not provided in NHS Dumfries and Galloway.
• Tests for full blood count are offered
  • Provided at Dumfries and Galloway Royal Infirmary.
• Tests for thyroid function are offered
  • Provided at Dumfries and Galloway Royal Infirmary.
• Discussion about lifestyle issues
  • Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital.
• Referral for specialist care will be arranged if tests are abnormal or if there is a chronic medical or mental health problem
  • Provided at Galloway Community Hospital.
• Women will have access to support and early pregnancy reassurance scans in subsequent pregnancies
  • Not provided in NHS Dumfries and Galloway.

After third and subsequent miscarriage

• 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
  • Provided at Dumfries and Galloway Royal Infirmary.
• Pregnancy tissue from the third and any subsequent miscarriages will be sent for genetic testing
  • Provided at Dumfries and Galloway Royal Infirmary.
• Blood tests for antiphospholipid antibodies will be arranged
  • Provided at Dumfries and Galloway Royal Infirmary.
• A pelvic ultrasound scan (ideally three dimensional transvaginal) will be arranged
  • Currently not in the guidance to provide in NHS Dumfries and Galloway but can be arranged at Dumfries and Galloway Royal Infirmary on request.
• 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
  • Provided at Dumfries and Galloway Royal Infirmary.
• Appropriate screening for mental health issues
  • Screening for mental health issues would usually be referred via GP, primary care or third sector.
• Appropriate care for mental health issues
  • Care for mental health issues would usually be referred via GP, primary care or third sector.

Overall recommendations

• Appropriate screening and care for future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth
  • Not provided in NHS Dumfries and Galloway. Although women are individually assessed at Dumfries and Galloway Royal Infirmary and recurrent miscarriage is documented as a risk at Galloway Community Hospital.
• 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.
  • Provided at Dumfries and Galloway Royal Infirmary. Galloway Community Hospital women are referred to a consultant if additional information provided.
• Consider giving vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage
  • Provided at both Dumfries and Galloway Royal Infirmary and Galloway Community Hospital (provided after second and third or subsequent miscarriage at both sites).
• 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
  • There are staff with additional specialist training to deal with all baby losses including miscarriage and stillbirth at Dumfries and Galloway Royal Infirmary.
• 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
  • Dumfries and Galloway Royal Infirmary carries out scans in the Maternity Unit within the same area as other expectant mothers and within the Obstetrics and Gynaecology department separated from other expectant mothers. Galloway Community Hospital has scanning facilities available 09:00-17:00 on Tuesdays and Wednesdays, where scans are carried out in the same area as other expectant mothers. Both sites offer expectant management and medical management with mifepristone and misoprostol, however, Galloway Community Hospital cannot offer this as an inpatient. Surgical management with manual vacuum aspiration is not currently offered in NHS Dumfries and Galloway as the service is still being developed, but this can be requested.
• 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
  • In NHS Dumfries and Galloway data on miscarriage is collected via Badgernet Maternity and Clinical Portal. Data on miscarriages is collected for local purposes for Early Pregnancy Services follow up but not for formal purposes. No data is routinely collected on proportion of pregnancies, gestation, maternal age, parity, SIMD or ethnicity but data could be analysed if required.
• Identifying women at risk of psychological distress following miscarriage
  • Provided at Dumfries and Galloway Royal Infirmary.
• Identifying women at risk of psychological distress following miscarriage and the development of optimal treatment strategies have been recognised as research priorities
  • Not assessed
• 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
  • Dumfries and Galloway Royal Infirmary and Galloway Community Hospital stated women are assessed individually.
• Miscarriage Management - women should be presented with the available evidence and be free to choose the management approach that suits their needs and preferences
  • Dumfries and Galloway Royal Infirmary and Galloway Community Hospital stated that women are free to choose the management approach that suits their needs.
• Consider pathways of care for miscarriage management, treatment of women with a history of miscarriage and care following a miscarriage
  • Not assessed.

The Lancet: Miscarriage Matters - Research Recommendations

• Key epidemiological research priority 1 - Establishing how we can monitor miscarriage rates on a population basis
  • 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
  • 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
  • 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
  • Work to follow from research priorities 1 and 2 above.