Miscarriage Care and Facilities in Scotland: Scoping Report NHS Highland

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 Board areas said a graded approach to the treatment of recurrent miscarriage is adopted.

In NHS Highland a graded approach to treatment of recurrent miscarriage is provided at Raigmore Hospital, where the majority of women are referred. Regarding sites in Argyll and Bute, NHS Greater Glasgow and Clyde provide a graded approach to miscarriage which patients from Argyll and Bute follow.

After first miscarriage

The Lancet series on miscarriage care recommended the services listed in Table 17 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 Highland, Dr MacKinnon Memorial Hospital reported that all of the information provision or services asked about are provided on site. Raigmore Hospital reported that all provision, except screening for mental health issues are provided on site, there are currently no plans to implement this at Raigmore Hospital. Of the remaining sites, all provisions and services are either available on site or are accessible in the Health Board area. However, Belford Hospital currently do not provide vaginal micronised progesterone to women with early pregnancy bleeding and a history of miscarriage and there are no plans to implement this. As Nairn Town and County Hospital does not have an EPU, maternity unit, CMU or an Obstetrics and Gynaecology Department they were not asked this question. In Argyll and Bute, GPs and midwives liaise with consultants in NHS Greater Glasgow and Clyde to provide or access the provisions and services in Table 17. The provisions and services are listed in Table 17 below.

In NHS Highland the services listed above are offered to all women regardless of the gestation when the loss occurred.

In NHS Highland patients are signposted to the following services (Table 18). All sites in NHS Highland reported that they will always signpost women to patient support groups and provide information on appropriate pre-conceptual folate and vitamin D supplementation after a first miscarriage, for the other services sites within the Health Board approach this differently.

As Nairn Town and County Hospital does not have an EPU, maternity unit, CMU or an Obstetrics and Gynaecology Department they were not asked this question.

After second miscarriage

The Lancet series on Miscarriage Matters recommended the following services listed in Table 19 below should be available after a second miscarriage.

After a second miscarriage the information provision or services provided in NHS Highland are listed in Table 19 below. Raigmore Hospital reported that after a second miscarriage an appointment at a midwifery-led clinic is not offered and that there are no plans to implement this as this service is provided by nurses. Raigmore Hospital further explained that their EPU department is nurse-led with continuity of carer provided with nursing staff, within EPU and nurse-led clinics. In Argyll and Bute, GPs and midwives liaise with consultants in NHS Greater Glasgow and Clyde to provide or access the provisions and services in Table 19.

As Nairn Town and County Hospital does not have an EPU, maternity unit, CMU or an Obstetrics and Gynaecology Department they were not asked this question.

After third and subsequent miscarriage

The Lancet series on Miscarriage Matters recommended the following services listed in Table 20 below should be available after a third or subsequent miscarriage.

After a third or subsequent miscarriage, responses from sites in NHS Highland show that all of the information provision or services asked about are either provided or accessible within the Health Board area, Table 20. Raigmore Hospital reported that they do not currently provide investigative pelvic ultrasound scans, however Caithness General Hospital said that they provide this on site with Belford Hospital and Dr MacKinnon Memorial Hospital stating that they are able to access this within the Health Board area. Regarding appropriate screening for mental health issues and appropriate care for mental health issues, Raigmore Hospital reported that they do not provide this on site but can access within the Health Board area. However, Dr MacKinnon Memorial Hospital and sites within Argyll and Bute stated that they provide both of these services on site with Caithness General Hospital and Belford Hospital able to access this within the Health Board area. In Argyll and Bute, GPs and midwives liase with consultants in NHS Greater Glasgow and Clyde to provide or access the provisions and services in Table 20.