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

Management options

Both sites in NHS Dumfries and Galloway agreed that women are free to choose their preferred management approach based on their needs and preferences. Galloway Community Hospital noted that women may be referred to another site depending on the management approach they choose.

All management options for miscarriage care, detailed below, are offered at Dumfries and Galloway Royal Infirmary with the exception of surgical management with manual vacuum aspiration (MVA) with local anaesthetic which is only available on request through Dumfries and Galloway Royal Infirmary as the service is still being developed. The available options include:

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.

Expectant management in NHS Dumfries and Galloway

At Dumfries and Galloway Royal Infirmary expectant management is offered to women when gestation is no greater than 10 weeks. Women are provided with written leaflets about management options, as well as contact numbers for 24/7 support and to enable escalating concerns for welfare or symptoms. Women are able to change their mind and request medical or surgical alternatives at any time. Women will be discharged with written and verbal advice, with a follow up call arranged. Women will receive a follow up pregnancy test and recommendations for analgesia during and following miscarriage and for contraception following miscarriage should this be required.

At Galloway Community Hospital women are also given advice about the timescale of expectant management and analgesia recommendations are offered. Weekly contact is maintained with Early Pregnancy Services via telephone. As with Dumfries and Galloway Royal Infirmary, women can request medical or surgical intervention at any time if expectant management is not progressing. All options for management are discussed, with information and arrangements made for options requested.

Women in NHS Dumfries and Galloway who chose expectant management, are followed up weekly with a telephone call and a well-being call three to four weeks after their loss for emotional support, health and lifestyle advice, and contraception or folic acid recommendations. If there is no evidence of pregnancy loss, they are individually assessed for physical follow up. If a miscarriage occurs spontaneously, there is more frequent contact as preferred by individuals. Women are also recommended to repeat a pregnancy test three weeks post miscarriage.

Medical management in NHS Dumfries and Galloway

In NHS Dumfries and Galloway written and verbal information is provided about the side effects of medication used for medical management and about outpatient and inpatient options. Medical management of miscarriage with Misoprostol alone and also with a combination of Mifepristone and Misoprostol may be offered up to 12 weeks gestation (depending on clinical presentation) at Dumfries and Galloway Royal Infirmary and Galloway Community Hospital. However, at gestations over 10 weeks, women are advised to have inpatient care which is available at Dumfries and Galloway Royal Infirmary (women living in the region covered by Galloway Community Hospital would be treated at Dumfries and Galloway Royal Infirmary if they chose medical management as an inpatient if more than 10 weeks gestation).

Women are advised that the timeframe is different for everyone but it is usual to have some response to medication within a few hours and passage of pregnancy within a few days. Options for inpatient or at home management are discussed, recommendations for analgesia and support of another adult if at home, and follow up by the Early Pregnancy Service are also discussed.

When a loss is confirmed, women are advised of the options available, either with a discussion in hospital (if an inpatient) or a return appointment that is arranged. Misoprostol and mifepristone options are also discussed. For inpatient treatment misoprostol may be administered and/or a clinical assessment undertaken followed by misoprostol 36-48 hours later. If there is no response to initial dose, women will be reviewed by medical staff prior to further repeat doses. If miscarriage does not occur after a full course of treatment women will be advised to rest overnight and consider further medical management or surgical options.

If an outpatient, similarly mifepristone and misoprostol will be taken and if there is no response within 72 hours, women will be advised to contact Early Pregnancy Services for further discussion of management options. Prescriptions can be self administered for outpatients, with disposal of tissue advice provided and, when appropriate, sent for pathology. Women are recommended to take a home pregnancy test after three weeks and a follow up is arranged by Early Pregnancy Services 3-4 weeks after miscarriage for well-being, support and advice.

Surgical management in NHS Dumfries and Galloway

In NHS Dumfries and Galloway women undergoing surgical management receive information leaflets and advice on the length of time, risk and benefits, including those associated with anaesthesia and surgery recovery time. They also receive advice on fasting information and telephone numbers for advice once they are discharged. The timeframe for this procedure is more exact and would be planned as a day case under general anaesthetic. Women are advised of post surgery analgesia, bleeding and the need for support by another adult for 24 hours post surgery.

If surgical management option is chosen, a pre-assessment questionnaire is completed, including recommendations for full blood count and blood group antibody check. Women are given a pre-assessment and then admitted for surgical procedure via the day surgery if the procedure is planned. Emergency admissions are done via gynaecology admissions in the surgical ward in Dumfries and Galloway Royal Infirmary. Misoprostol would be recommended approximately 1-2 hours prior to surgery. Women are given a miscarriage leaflet containing 24/7 contact numbers in the event they need advice after surgery. Women would be informed of the post operative recovery routine and would be discharged home with advice and a follow up with a well-being call arranged for 2-3 days following the procedure. A further well-being call would also be arranged 3-4 weeks later.