Miscarriage Care and Facilities in Scotland: Scoping Report NHS Grampian

Management options

Within NHS Grampian women are free to choose their preferred management approach based on their needs and preferences. All treatment options for miscarriage care, detailed below in Table 16, are offered at Aberdeen Maternity Hospital. The majority of options are provided at Dr Gray’s Hospital also.

In addition to the treatments asked about, Aberdeen Maternity Hospital also offered surgical management under spinal anaesthetic for first trimester losses. Aberdeen Maternity Hospital stated that surgical management under spinal anaesthetic is generally offered under 13 weeks gestation, but can be performed in second trimester if required clinically or preferred by patient although it is uncommon to have surgical management procedure in the second trimester at this unit. NHS Grampian reported that second trimester miscarriage is usually recommended to be treated with medical management.

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 Grampian

All women undergoing expectant management of miscarriage at Dr. Gray’s Hospital or Aberdeen Maternity Hospital are advised on what to expect during expectant management including risk of infection, retained tissue, haemorrhage and analgesia. Women are also advised that expectant management may not always be successful and are given contact information for a 24 hour telephone advice line. If a women has chosen expectant management they can change their mind and opt for medical or surgical management at any time.

At Aberdeen Maternity Hospital all women would be asked to return to for a follow-up ultra-sound scan after 1-2 weeks of expectant management to ascertain if miscarriage is complete or not. Women would be re-offered management options if miscarriage is not complete at that time, with a repeat scan arranged if necessary. All women are also offered a telephone follow up two weeks after complete miscarriage with an EPU midwife or nurse. Follow up from a community midwife is also offered.

At Dr. Gray’s Hospital, if an urine pregnancy test is negative no follow up care is routinely offered. If a pregnancy test remains positive, a follow up scan is offered to check for retained pregnancy tissue.

Medical management in NHS Grampian

Women who are treated for medical management at Aberdeen Maternity Hospital and Dr. Gray’s Hospital are able to choose outpatient or inpatient treatment in their first trimester. Women are advised to have inpatient treatment if in their second trimester and would be diagnosed by an ultrasound scan, with all women referred to the EPU. If medical management is chosen, they would be advised of risks of bleeding, infection, retained tissue, failed treatment and haemorrhage. They would also be advised that a pregnancy test may remain positive for two weeks even after successful treatment.

In both sites, emergency or elective medical management treatment can be arranged 24 hours a day. A single dose of misoprostol is given sublingually or vaginally, with follow up examinations after 6-8 hours. Speculum examination is conducted 12 hours following medication if there is uncertainty whether entire pregnancy has been passed.

Following medical management in both sites, women are provided with a pregnancy test to be done two weeks following treatment and told to monitor their pain and bleeding at home. All women are offered a telephone follow up with an EPU midwife or nurse two weeks after a completed miscarriage. A follow up with a community midwife is also offered. Women are also offered a follow up telephone call at two weeks by bereavement midwife.

Surgical management in NHS Grampian

All women who choose surgical management are advised of options for manual vacuum aspiration (MVA) with local anaesthetic or surgical management under general or spinal anaesthetic. At Dr. Gray’s Hospital surgical management is only offered under general anaesthetic. Woman are fully advised of the risks and complete a detailed consent form including all risks on the Royal College for Obstetrics and Gynaecology consent advice including adhesions. They are advised of the risk of retained tissues, infection, uterine rupture, bladder or organ trauma or the need for repeat procedures.

Women are diagnosed by ultrasound in the EPU or clinically. They are offered an elective or emergency procedure depending on their clinical presentation. If undergoing an elective procedure they will attend at 7:30am for surgical management in theatre, where they are given misoprostol priming with the procedure scheduled for two hours later. For MVA procedures, women arrive at 11:00 and receive misoprostol priming with the procedure usually scheduled at 13:00. Post operative observations occur after MVA (2 hours), after general anaesthetic (4 hours) and spinal anaesthetic (6 hours). The majority of all surgical management of miscarriage cases are day cases. Women are kept on the ward for monitoring following the procedure to ensure they are tolerating diet and fluid, voiding urine and that they feel comfortable going home.

Women are asked to monitor their pain and bleeding at home and to repeat urine pregnancy test two weeks following the procedure. As with other management options, all women are offered telephone follow up two weeks after complete miscarriage with an EPU midwife or nurse, as well as a community midwife follow up. They are also offered a phone call from a bereavement midwife two weeks after the procedure. Referrals and assessment following a loss

All sites were asked if they provide or can access referrals and assessment for support services following a loss.

The majority of referrals and assessments are provided from Aberdeen Maternity Hospital or Dr Gray’s Hospital. However, Aberdeen Maternity Hospital noted that no NHS counselling services or third party counselling services are available locally that women can be directly referred to from the EPU. Women are advised to see their GP who can refer them to services. Dr. Gray’s Hospital does not currently refer women to NHS services for mental health support or counselling following a loss, although these services are in the process of being established (Table 17).

Women that present at Peterhead Community Hospital and Inverurie Health & Care Hub are referred to Aberdeen Maternity Hospital for miscarriage management.

Fraserburgh Hospital and Jubilee Hospital were not asked these questions as women are referred to Aberdeen Maternity Hospital for miscarriage care.