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

Management options

In NHS Greater Glasgow and Clyde, all five sites agreed that women are free to choose their preferred management approach based on their needs and preferences. Royal Alexandra Hospital and Queen Elizabeth University Hospital both agreed that women are offered only the management approaches provided on this site while Princess Royal Maternity Hospital, Vale of Leven District General Hospital and Inverclyde Royal Hospital either disagreed or strongly disagreed; Princess Royal Maternity Hospital, Vale of Leven District General Hospital and Inverclyde Royal Hospital all indicated that for some management options women will be transferred to another site.

Almost all management options for miscarriage care, detailed in Table 16 below, were offered at all sites within NHS Greater Glasgow and Clyde. Only Vale of Leven District General Hospital reported that they offer medical management with misoprostol. Inverclyde Royal Hospital reported that they refer all women to Royal Alexandra Hospital for medical management with mifepristone and misoprostol, inpatient medical management and surgical management with manual vacuum aspiration (MVA) with local anaesthetic as they do not have emergency cover on site and also attributed staff training and finance/cost as reasons for not providing these on site. Vale of Leven District General Hospital stated that staff training was a barrier to providing inpatient medical management on site. Regarding surgical management with manual vacuum aspiration (MVA) with local anaesthetic, Vale of Leven District General Hospital reported that they refer all women to Royal Alexandra Hospital for this and attributed lack of space, staff training and lack of equipment as barriers to providing this on site while Princess Royal Maternity Hospital reported that they refer all women to a dedicated ambulatory care hospital, either Stobhill or New Victoria for this due to lack of space. All treatments offered are listed in Table 16 below:

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.

In NHS Greater Glasgow and Clyde assessment of symptoms, scans and management options are discussed in the Early Pregnancy Unit within each site. Patients are followed up within 2-3 weeks after being seen at the EPU. With some management options, patients may need to be transferred to another site within NHS Greater Glasgow and Clyde for treatment.

Expectant management in NHS Greater Glasgow and Clyde

The advice provided to patients about expectant management is similar at all sites within NHS Greater Glasgow and Clyde and includes;

• oral and written information about what to expect throughout the process
• information regarding success rates
• advice on pain relief and where and when to get help in an emergency
• advice regarding signs of infection and when to seek help
• advice regarding staying locally (need to be within 1 hour of services ideally)
• method of sensitive disposal at home or through the hospital
• tests if needed and information leaflets.

Women are also informed of all other options of management as applicable to their gestation and details of expectation and risk associated with each.

Women in NHS Greater Glasgow and Clyde who chose expectant management are provided with written information and consent forms are signed. They are signposted to the relevant ward and out of hours services should they need to access to these for assistance. The patient is scanned and given a pregnancy test to take home and the patient is asked to telephone in three weeks time to provide history of events and results of the pregnancy test. The patient may then be discharged or asked to attend the EPU at their local site for a scan and medical review if the test is positive or the history is not suggestive of complete miscarriage.

Medical management in NHS Greater Glasgow and Clyde

In NHS Greater Glasgow and Clyde medical management with misoprostol is only provided at Vale of Leven District General Hospital and is offered as an out-patient service. Medical management with mifepristone and misoprostol is offered in the other four sites in both the first and second trimester as an in-patient service only. Where patients at Vale of Leven District General Hospital require in-patient treatment, they are transferred to the Royal Alexandra Hospital.

The pathway of care for medical management as an outpatient at Vale of Leven District General Hospital includes an assessment of symptoms to confirm miscarriage, provision of information leaflets and a discussion about management options including the risks associated with the chosen option and other options available. The patient is given misoprostol in the department and provided with advice on what to expect along with written information. All telephone contact details for the EPU, maternity triage and A&E are provided along with analgesia and a pregnancy test. About three hours after the first tablet has been taken women are contacted to ask about pain and progression; they will be advised if any more tablets are required at this stage. If successfully passed, a follow-up telephone call about the pregnancy test is conducted within three weeks. If not successful, further options are discussed (medical or surgical).

The treatment pathway for medical management with mifepristone and misoprostol as an in-patient service depends on the gestation and the woman’s circumstances. All patients initially attend EPU and are given mifepristone orally, following which the patient can go home and then return to the ward 48 hours later where misoprostol (800 micrograms) is administered vaginally as an in-patient. If under 9 weeks and no tissue is passed 4 hours after misoprostol, then a further 400mg of misoprostol is administered vaginally, or orally if bleeding is heavy. If gestation is over 9 weeks and tissue has not passed, 400mg misoprostol is repeated vaginally or orally at 3 hourly intervals to a maximum of three further doses. If pain and bleeding settles the patient would be discharged home with written information and telephone numbers to call if any concerns. The patient then takes a pregnancy test at home after 3 weeks, if this is positive they would be asked to contact the EPU.

Surgical management in NHS Greater Glasgow and Clyde

In NHS Greater Glasgow and Clyde surgical management with manual vacuum aspiration (MVA) with local anaesthetic and surgical management under general anaesthetic are offered in the first trimester.

Surgical management with manual vacuum aspiration (MVA) with local anaesthetic is provided at Royal Alexandra Hospital and Queen Elizabeth University Hospital. Patients from Vale of Leven District General Hospital and Inverclyde Royal Hospital are referred to Royal Alexandra Hospital and women who present at Princess Royal Maternity Hospital are referred to a dedicated ambulatory care hospital, either Stobhill or New Victoria, which offer additional Gynaecology outpatient services in the City of Glasgow.

In NHS Greater Glasgow and Clyde, women who chose surgical management are given information leaflets and are informed of the risks including bleeding, infection, perforation and intra-uterine adhesions. Once a date for surgical management has been confirmed, women are given a pre-op appointment 48 hours before to obtain a full blood count group and to discuss the procedure again to ensure they still wish to proceed. Consent forms and sensitive disposal forms are discussed and signed as per medical management. Women are given advice as per expectant management in case of spontaneous miscarriage while awaiting date. Women are given the EPU number in case of any concerns or further questions in the meantime.

On the morning of the procedure women are given misoprostol to aid softening of the cervix 2-3 hours prior to the procedure. Women who have chosen surgical management with MVA under local anaesthetic are advised to eat breakfast or a light lunch as normal on the day and are given analgesia to be taken 1 hour before the procedure. Women who choose surgical management under general anaesthetic are advised about fasting requirements at their pre-op appointment.

After the procedure women are observed and assessments of pain and bleeding are done. Most women are discharged from hospital the same day. Prior to discharge all women are provided with contact details for EPU and the gynaecology ward. They are offered support and are given contact details for the Miscarriage Association. Staff also have a discussion with the woman about the return of their period and contraception if required. All women are advised to take a home pregnancy test 4 weeks after the procedure and to contact EPU if the test is still positive.