Miscarriage Care and Facilities in Scotland: Scoping Report NHS Grampian

Summary

The overall summary 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 Grampian, Aberdeen Maternity Hospital and Dr Gray’s Hospital are the main sites that provide care for women that experience miscarriage. Sites in NHS Grampian said that women are free to choose the management approach that suits their needs and preferences.

In NHS Grampian, Aberdeen Maternity Hospital and Dr Gray’s Hospital provide written information about the treatment options for the management of miscarriage and Dr Gray’s Hospital provide written information on what to expect in terms of miscarriage care. Both Aberdeen Maternity Hospital and Dr Gray’s Hospital provide written information on what would happen before, during and after any treatment options.

Within NHS Grampian women are 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 Grampian a graded approach to treatment of recurrent miscarriage is provided at Aberdeen Maternity Hospital. Most of the elements outlined in the Lancet series on Miscarriage Matters are provided in NHS Grampian with the exception of appropriate screening and care for mental health issues and recognition of women being at an increased risk of obstetric complications including pre-term birth although women are offered consultant-led antenatal care after a second miscarriage.

Dedicated facilities are available at both Aberdeen Maternity Hospital and Dr Gray’s Hospital in NHS Grampian, where seven separate rooms are available away from the labour ward for women who are miscarrying in Aberdeen Maternity Hospital and two rooms are available in Dr Gray’s Hospital.

In NHS Grampian, Aberdeen Maternity Hospital has a separate area to carry out complication/investigative scans separated from women with a continuing pregnancy.

In NHS Grampian data on miscarriage is collected via BadgerNet, Trakcare, and the local Health Intelligence team. Currently, all sites in NHS Grampian noted that they do not routinely collect any data on characteristics of women who experience a miscarriage.

Table 25: 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 Grampian: Dr Gray’s Hospital indicated that they currently provide dedicated facilities for women experiencing unexpected pregnancy complications at any gestation both within and outwith the EPU. Aberdeen Maternity Hospital indicated that they currently provide dedicated facilities for women experiencing unexpected pregnancy complications within the EPU with no plans to implement this provision outwith the EPU. At Aberdeen Maternity Hospital there are seven separate rooms available away from the labour ward for women that are miscarrying, and two rooms are available in Dr Gray’s Hospital.

Source: The Lancet: Miscarriage Matters

Commitment/Recommendation:A graded approach to the treatment of recurrent miscarriage

Service provision in NHS Grampian: In NHS Grampian a graded approach to treatment of recurrent miscarriage is provided at Aberdeen Maternity Hospital.

After first miscarriage

Source: After the first miscarriage, women will be guided to information about miscarriage

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital where all women in NHS Grampian experiencing miscarriage are referred.

Source: After the first miscarriage, women will be guided to resources to address their physical needs

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: After the first miscarriage, women will be guided to resources to address mental health needs following pregnancy loss

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: After the first miscarriage, women will be guided to ways to optimise their health for future pregnancy

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital.

After first miscarriage – this approach could involve:

Source: Patient support groups

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: Online self-help strategies for mental health

Service provision in NHS Grampian: Provided at Dr Gray’s Hospital.

Source: Weight management

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: Smoking and recreational drugs cessation services

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: Information on appropriate preconceptual folate and vitamin D supplementation

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: Referral to necessary services for management and optimisation of chronic maternal medical conditions (e.g., diabetes, hypertension, heart disease, and epilepsy)

Service provision in NHS Grampian: Not provided in NHS Grampian.

Source: Screening for mental health issues.

Service provision in NHS Grampian: Not provided in NHS Grampian.

After second miscarriage

Source: Women will be offered an appointment at a miscarriage clinic nurse or midwifery-led

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital (Dr Gray’s Hospital can access/refer locally).

Source: Continuity of Carer

Service provision in NHS Grampian: Provided at Dr Gray’s Hospital.

Source: Tests for full blood count are offered

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: Tests for thyroid function are offered

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital (Dr Gray’s Hospital can access/refer locally).

Source: Discussion about lifestyle issues

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital (Dr Gray’s Hospital can access/refer locally).

Source: Referral for specialist care will be arranged if tests are abnormal or if there is a chronic medical or mental health problem.

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: Women will have access to support and early pregnancy reassurance scans in subsequent pregnancies.

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

After third and subsequent miscarriage

Source: 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.

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital (Dr Gray’s Hospital can access/refer locally).

Source: Pregnancy tissue from the third and any subsequent miscarriages will be sent for genetic testing.

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: Blood tests for antiphospholipid antibodies will be arranged.

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: A pelvic ultrasound scan (ideally three dimensional transvaginal) will be arranged

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital (Dr Gray’s Hospital can refer to Aberdeen Maternity Hospital).

Source: 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

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: Appropriate screening for mental health issues

Service provision in NHS Grampian: Aberdeen Maternity Hospital and Dr Gray’s Hospital can refer locally to the GP or Mental Health Team.

Source: Appropriate care for mental health issues

Service provision in NHS Grampian: Aberdeen Maternity Hospital and Dr Gray’s Hospital can refer locally to the GP or Mental Health Team.

Overall recommendations

Source: Appropriate screening and care for future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth.

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: 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.

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: Consider giving vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital provide after first, second and third or subsequent losses. (Dr Gray’s Hospital can refer to Aberdeen Maternity Hospital).

Source: 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.

Service provision in NHS Grampian: Aberdeen Maternity Hospital and Dr Gray’s Hospital have midwives/nurses with additional specialist training to provide comprehensive miscarriage care. Aberdeen Maternity Hospital and Dr Gray’s Hospital have doctors trained to provide comprehensive miscarriage care.

Source: 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

Service provision in NHS Grampian: Aberdeen Maternity Hospital and Dr Gray’s Hospital conduct scans in the Early Pregnancy Units during opening hours, however at Dr Gray’s Hospital scans are conducted in the same area as other expectant women.

Expectant and medical management with mifepristone and misoprostol are provided at both Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Surgical management with manual vacuum aspiration is provided at Aberdeen Maternity Hospital.

Source: 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.

Service provision in NHS Grampian: Data on miscarriage is collected via BadgerNet at all sites in NHS Grampian. Trakcare is also used in Dr Gray’s Hospital, Fraserburgh Hospital and Jubilee Hospital.

The local Health Intelligence team also collect data on miscarriage. All sites in NHS Grampian noted that they do not collect any data on characteristics of women who experience a miscarriage.

Source: Identifying women at risk of psychological distress following miscarriage

Service provision in NHS Grampian: Provided at Aberdeen Maternity Hospital and Dr Gray’s Hospital.

Source: Identifying women at risk of psychological distress following miscarriage and the development of optimal treatment strategies have been recognised as research priorities.

Service provision in NHS Grampian: Not assessed

Source: 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.

Service provision in NHS Grampian: Provided at Dr Gray’s Hospital. Plans to implement in next two years at Aberdeen Maternity Hospital.

Source: Miscarriage Management - women should be presented with the available evidence and be free to choose the management approach that suits their needs and preferences

Service provision in NHS Grampian: Sites in NHS Grampian said that women are free to choose the management approach that suits their needs. Aberdeen Maternity Hospital and Dr Gray’s Hospital provide written information about the treatment options for the management of miscarriage and Dr Gray’s Hospital provide written information on what to expect in terms of miscarriage care. Both Aberdeen Maternity Hospital and Dr Gray’s Hospital provide written information on what would happen before, during and after any treatment options.

Source: Consider pathways of care for miscarriage management, treatment of women with a history of miscarriage and care following a miscarriage.

Service provision in NHS Grampian: Not assessed

Source: The Lancet: Miscarriage Matters

Research Recommendations

• Key epidemiological research priority 1 - Establishing how we can monitor miscarriage rates on a population basis.

Service provision in NHS Grampian: Project underway with Scottish Government, Public Health Scotland and Maternity and Children Quality Improvement Collaborative (MCQIC).

• Key epidemiological research priority 2 - Ascertaining if miscarriage risk and prevalence differ across nations and ethnic groups.

Service provision in NHS Grampian: Project underway with Scottish Government, Public Health Scotland and Maternity and Children Quality Improvement Collaborative (MCQIC).

• 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.

Service provision in NHS Grampian: 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.

Service provision in NHS Grampian: Work to follow from research priorities 1 and 2 above.