Miscarriage Care and Facilities in Scotland: Scoping Report NHS Fife

Management options

In NHS Fife, Victoria Hospital strongly agreed that women are free to choose their preferred management approach based on their needs and preferences.

In NHS Fife Victoria Hospital was asked if the management options listed in Table 16 below were either provided on site, accessible locally or not provided. Currently in NHS Fife medical management with mifepristone and misoprostol is not provided, instead multiple doses of misoprostol are given. NHS Fife stated that this is based on evidence which shows that multiple doses of misoprostol give similar results to that of combination of mifepristone and misoprostol (when compared with single dose of misoprostol).

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 Fife

In NHS Fife the advice given to women on expectant management includes verbal and written information. Women are advised of current success rates for the treatment option and are made aware of risk of infection and that, in an emergency, there may be need for an emergency admission. All women are provided with information on what to expect, are given contact numbers in case of emergency and are made aware of where to attend if they need to be seen by a medical professional. Provision of information leaflets, contact numbers 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 expectant management is decided upon as the preferred option, women are advised about expectant management risks and benefits and are provided with written information. Women are followed closely to provide support and often they receive a telephone call the next day to determine how they are managing and to offer support. Background history will be checked to assess risk of heavy bleeding, underlying medical issues as well as social circumstances and support at home. Women receive a follow up appointment after two weeks to ensure they have passed all the pregnancy tissue, an ultrasound scan is done to assess this. Based on blood loss and their general condition, haemoglobin is also sometimes checked this stage. If there is evidence of retained products, further intervention is discussed and followed.

Women are given information about the hospital chaplain and memorial service and information leaflets about third party counselling services. It is recognised that some women may require further psychological support and a referral can be made. All women are put in touch with a bereavement midwife and their GP is informed of the episode. Advice is given regarding when to expect a period and how that may present. If the women and their partner are planning to conceive, they are given advice on when to try again - usually after two to three cycles to allow time for recovery.

Medical management in NHS Fife

Medical management with misoprostol is provided in NHS Fife while medical management with mifepristone and misoprostol is not offered. Medical management with misoprostol is provided in the first and second trimester. Medical management is offered as an in-patient service in both the first and second trimester. Outpatient medical management is only offered in the first trimester.

The treatment pathway for medical management described by Victoria Hospital would depend on the gestation and circumstances. Those who are in first trimester and those who do not have significant medical conditions are deemed suitable for outpatient management at home. Management is through multiple doses of misoprostol (800 mg followed by 400 mg twice at 4-6 hourly intervals). Bleeding can take a few hours to start after the patient returns home. If there is no bleeding for 24 hours or if the bleeding is heavy, patients are asked to come into the hospital. In these situations, further intervention, sometimes surgical intervention may be required. A follow up is conducted after 2-3 weeks to ensure the process is complete and no further intervention is required. At the follow up appointment, assessment of physical and psychological wellbeing is carried out at to determine if the patient requires further appropriate referral. Contact details of bereavement midwife are provided along with information leaflets and details of third party counselling services. Advice on what to expect regarding periods and when to try for next pregnancy discussed (if relevant). If there is a history of recurrent miscarriages, appropriate referrals are made.

Surgical management in NHS Fife

Surgical management with manual vacuum aspiration (MVA) with local anaesthetic is not provided in NHS Fife, while management under general anaesthetic is provided in the first trimester only.

The advice for surgical management in NHS Fife comprised of an assessment of symptoms of miscarriage. All management options were discussed (surgical, medical, expectant) and information leaflets provided. The procedure is fully explained to the patient, including risks of the surgery including injury to the uterus/cervix, bleeding, infection, retained products and anaesthetic risks.

The treatment pathway for surgical management provided by NHS Fife detailed patients being provided with information leaflets and consent provided by the patient. Once consent is given the patient is placed on the next day list for theatre. On the morning of the procedure, patient details are provided to theatre staff by the gynaecology nurse. A dialogue takes place between these areas to ensure safety of the area and decision made to bring the patient in for the procedure. Pre-operative misoprostol is administered for cervical softening and to reduce uterine injury as well as bleeding. Once the procedure is carried out by the emergency gynaecology team the patient is transferred to the emergency gynaecology ward where a period of rest and recovery is observed by the gynaecology nursing staff and, if required, anti D is administered. Necessary counselling is offered and the relevant information and contact details of the bereavement midwife are provided.

Where further medical input is required, the patient is referred to the early pregnancy service and also for counselling, if required. If required a referral to the recurrent miscarriage clinic is made. The patient is also provided with information regarding progesterone in future pregnancies where she may present with bleeding in early pregnancy. If further support is required, the patient is asked to contact the early pregnancy unit.