Miscarriage Care and Facilities in Scotland: Scoping Report NHS Greater Glasgow and Clyde

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 Boards said a graded approach to the treatment of recurrent miscarriage is adopted on their site.

In NHS Greater Glasgow and Clyde, a graded approach to treatment of recurrent miscarriage care is provided at four sites, Vale of Leven District General Hospital reported that they do not provide a graded approach on site.

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 Greater Glasgow and Clyde, four sites responded that all of the information provision or services recommended in the Lancet series on miscarriage care that are provided on site after a first miscarriage and are provided regardless of the gestation when the loss occurred these are listed in Table 18 below.

After a first miscarriage all of the information provision or services asked about were provided on site at both Princess Royal Maternity Hospital and Inverclyde Royal Hospital. Royal Alexandra Hospital reported that they are currently awaiting agreed guidance on vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage so are unable to provide this while awaiting the guidance.

Royal Alexandra Hospital cited staff training and finance/cost as reasons for not currently providing referrals to necessary services for management and optimisation of chronic maternal medical conditions and development of an individualised care plan. Regarding information about physical health needs following pregnancy loss, screening for mental health issues and information to optimise health for future pregnancies, Royal Alexandra Hospital cited staff training, finance, cost and lack of equipment as reasons for not currently providing these but have stated that they would like resources to support this development. Royal Alexandra Hospital also attributed staff retention as a barrier to providing information about physical health needs following pregnancy loss, while Vale of Leven District General Hospital attributed staff training as a barrier to providing screening for mental health issues.

The availability of these provisions and services among the other sites varied; these are listed in Table 18 below.

NHS Greater Glasgow and Clyde signpost patients to the following services, however sites reported different approaches to this as outlined 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 almost all of the information provision or services asked about were not provided at sites in NHS Greater Glasgow and Clyde (Table 20).

After a second miscarriage, all sites except Royal Alexandra Hospital have access to support and early pregnancy reassurance scans in subsequent pregnancies and would have discussions about lifestyle issues in relation to future pregnancies. Royal Alexandra Hospital stated a lack of space was a barrier to providing these services.

Royal Alexandra Hospital, Inverclyde Royal Hospital and Queen Elizabeth University Hospital cited lack of space, staff retention, staff training and finance/cost as reasons for not providing appointments at a nurse-led or midwifery-led clinic. In addition, Royal Alexandra Hospital also cited staff recruitment and lack of equipment as additional reasons for lack of provision of these services. Regarding offering tests for full blood count and thyroid function, Queen Elizabeth University Hospital and Royal Alexandra Hospital attributed finance/cost as barriers to providing these.

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 or subsequent miscarriage, all of the information provision or services asked about are provided at Inverclyde Royal Hospital and Princess Royal Maternity Hospital. Queen Elizabeth University Hospital and Vale of Leven District General Hospital do not provide any of this provision on site, although they are able to access/refer within the health board area.

Royal Alexandra Hospital cited finance/cost as a reason for not providing appointments at a medical consultant led clinic or continuity of carer after a third miscarriage. Regarding appropriate screening and care for mental health issues, Royal Alexandra Hospital attributed staff training and cost/finance as barriers to providing these services on site. Vale of Leven District General Hospital attributed staff training as a barrier to providing appointments at a medical consultant led clinic, investigative pelvic ultrasound scans and appropriate care for mental health issues after a third or subsequent miscarriage. Availability of all services provided after a third or subsequent miscarriage are shown in Table 21 below.