Miscarriage Care and Facilities in Scotland: Scoping Report NHS Forth Valley

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 Board areas said a graded approach to the treatment of recurrent miscarriage is adopted.

In NHS Forth Valley, a graded approach to treatment of recurrent miscarriage care is not provided at Forth Valley Royal Hospital due to staff training and financial reasons, with no current plans to implement this approach.

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 Forth Valley, Forth Valley Royal Hospital reported that they provide all women with information about miscarriage and asked women if they had had a previous miscarriage. They also reported that they provided vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage. Screening for mental health issues and the development of an individualised care plan are not currently offered at Forth Valley Royal Hospital, however, no reasons were given as to why these are not offered. Other information provision or services provided after a first miscarriage on site at the Royal Hospital are listed in Table 18 below.

After a first miscarriage, patients are provided with information leaflets regarding all aspects of miscarriage care, although specific strategies are not discussed. NHS Forth Valley provide general advice on maternal optimisation pregnancy such as weight management, pregnancy vitamins, smoking cessation advice and signpost to the Miscarriage Association. The different treatment and information provisions available for women in NHS Forth Valley following a first miscarriage are shown 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 Forth Valley Royal Hospital reported the information provision or services that were provided on site as detailed in Table 20. They reported that appointments at a nurse-led miscarriage clinic, continuity of carer, and test for full blood count are unavailable due to capacity within the current workload. Appointments at a midwifery-led miscarriage clinic are not provided as this service is not run by midwives, however, women over the age of 35 with no living children will be offered a referral to a consultant-led gynaecology clinic after two consecutive miscarriages. Forth Valley Royal Hospital reported that women are asked verbally if they had had a previous miscarriage, that access to support and early pregnancy reassurance scans in subsequent pregancies are provided, and vaginal micronized progesterone offered to women with early pregnancy bleeding and a history of miscarriage is also provided.

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, Forth Valley Royal Hospital reported that almost all of the information provision or services recommended in the Lancet series on Miscarriage Matters asked about are provided on site at Forth Valley Royal Hospital and are shown in Table 21 below. Screening for mental health issues is not available due to lack of staff training. However, women are signposted to other services if felt they are at risk.