Miscarriage Care and Facilities in Scotland: Scoping Report NHS Grampian

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 Health 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 Grampian, a graded approach to treatment of recurrent miscarriage care is provided at Aberdeen Maternity Hospital, where most patients within the Health Board area are referred for all management options.

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 Grampian, after a first miscarriage the information provision and services Aberdeen Maternity Hospital and Dr Gray’s Hospital provide are listed in Table 18 below. Dr. Gray’s Hospital reported that they do not currently offer vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage after a first miscarriage as their current policy is to offer this after a second miscarriage.

No sites in NHS Grampian currently provide screening for mental health issues, Aberdeen Maternity Hospital indicated that this was due to a lack of guidelines and tools available for screening for mental health issues alongside a lack of staff time to do this within current workloads. Regarding referral to necessary services for management and optimisation of chronic maternal medical conditions and development of an individualised care plan, Aberdeen Maternity Hospital stated that they do not currently provide this due to the large number of women seen with a first miscarriage but did indicate that most women are given verbal advice. A formal process it is not viewed as possible within current staff numbers, workload and training (Table 18).

In NHS Grampian the services provided were offered to all women regardless of the gestation when the loss occurred at both Aberdeen Maternity Hospital and Dr. Gray’s Hospital.

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 service provision is at Aberdeen Maternity Hospital.

In NHS Grampian, Aberdeen Maternity Hospital and Dr. Gray’s Hospital signpost patients to most of the services outlined in Table 19. After a first miscarriage, a range of miscarriage association leaflets are provided by Aberdeen Maternity Hospital, along with signposting to MISS local charity support groups.

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 service provision is at Aberdeen Maternity Hospital.

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 almost all of the information provision or services asked about were provided on site at Aberdeen Maternity Hospital, these are listed in Table 20 below. The exception to this is that after a second miscarriage, continuity of carer is not currently provided. Community midwives are advised of women who have had a miscarriage, and women are offered a follow up from a community midwife. After a single second trimester miscarriage a consultant led follow up would be conducted at Aberdeen Maternity Hospital with blood tests arranged. Aberdeen Maternity Hospital offer consultant led antenatal care in any subsequent pregnancy, specifically at the high risk preterm birth clinic. Dr. Gray’s Hospital do not offer appointments at a nurse-led or midwifery-led miscarriage clinic as they refer women to Aberdeen Maternity Hospital for this.

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 service provision is at Aberdeen Maternity Hospital.

After third or 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 the information provision or services provided on each site in NHS Grampian are shown in Table 13 below. At Aberdeen Maternity Hospital after a third of subsequent miscarriage women are offered consultant led antenatal care. Regarding screening and care for mental health issues, NHS Grampian reported that there is no specific pathway for this, however if there are any concerns women are referred back to their GP or can be referred to the relevant mental health team.

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 service provision is at Aberdeen Maternity Hospital.