Miscarriage Care and Facilities in Scotland: Scoping Report NHS Highland

Summary

The overall summary is presented below and is shown in Table 23 against the recommendations within the Lancet series on Miscarriage Matters and the Scottish Government Programme for Government commitments.

In NHS Highland, Raigmore Hospital is the core site that provides the majority of care for those that experience miscarriage. Raigmore Hospital and Dr Mackinnon Memorial Hospital both agreed that women are free to choose their preferred management approach based on their needs and preferences. Caithness General Hospital disagreed that women are free to choose their preferred management approach based on their needs and preferences and all other sites in NHS Highland neither agreed nor disagreed. The geography in NHS Highland has implications for women in terms of how they can access their chosen approach, with some women having to travel over 200 miles (round trip) to access management options. Although sites in Argyll and Bute are part of NHS Highland, the services for miscarriage care and pregnancy complications are provided via a service level agreement by NHS Greater Glasgow and Clyde, this also presents a need for women to travel to access management options.

In NHS Highland, Raigmore Hospital, Dr MacKinnon Memorial Hospital and Caithness General Hospital all responded that written information about treatment options and what to expect is provided at their sites. Sites within Argyll and Bute reported that they provide information on treatment options for the management of miscarriage but do not provide information in what to expect next in terms of miscarriage care as all women are referred to sites within NHS Greater Glasgow and Clyde for treatment where this information would be provided.

Within NHS Highland Raigmore Hospital, Dr MacKinnon Memorial Hospital, Caithness General Hospital and Nairn Town and County Hospital all either agreed or strongly agreed that what will happen during and after the chosen method of management of miscarriage and what happens in terms of follow-up after the management of miscarriage is fully explained to women. Sites within Argyll and Bute neither agreed or disagreed with these statements as this is provided once the pathway of care for the Health Board had been followed and the patient is at the site that offers treatment for miscarriage, which in this case is delivered by NHS Greater Glasgow and Clyde.

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

All elements of care outlined in the Lancet series on Miscarriage Matters are provided within NHS Highland, however, not all elements are provided in all sites.

Dedicated facilities for women experiencing unexpected pregnancy complications at any gestation are provided within the EPU at Raigmore Hospital. Raigmore Hospital is also able to provide a separate room area/ward/unit with dedicated services to admit women who are miscarrying both within and outwith the EPU away from the labour ward.

In NHS Highland, there currently are no separate areas to carry out complication / investigative scans separated from areas for women with a continuing pregnancy, however, sites in the Argyll and Bute area reported that they can access this outwith the Health Board area in NHS Greater Glasgow and Clyde.

In NHS Highland data on miscarriage is collected via BadgerNet in all sites. Raigmore Hospital and Belford Hospital also reported using Trakcare. Data is collected on the number of miscarriages, miscarriages as a proportion of pregnancies, gestation, maternal age, SIMD, parity, and ethnicity. However, the data collected differs depending on the site.

Table 23: Scottish Government Programme for Government (PfG) Commitments and the Lancet Miscarriage Matters Recommendations

Source: PfG

Commitment/Recommendation: Ensure women’s services in Health Boards have dedicated facilities for women who are experiencing unexpected pregnancy complications.

Progress in NHS Highland: Dedicated facilities for women experiencing unexpected pregnancy complications are located within the EPU in Raigmore Hospital. Raigmore Hospital provide a separate room, area, ward, or unit with dedicated services to admit women who are miscarrying both within and outwith the EPU on site. There are two ensuite rooms available for women in the EPU. It is noted that some rooms/areas are not solely used for miscarriage care and may be used for other pregnancy complications or loss. For sites in Argyll and Bute women would be transferred to NHS Greater Glasgow and Clyde for management of miscarriage where there are dedicated facilities for women experiencing unexpected pregnancy complications at the five sites included in this study.

Source: The Lancet: Miscarriage Matters

Commitment/Recommendation: A graded approach to the treatment of recurrent miscarriage.

Progress in NHS Highland: A graded approach to treatment of recurrent miscarriage is provided at Raigmore Hospital where the majority of women are referred. For sites in Argyll and Bute women would be transferred to NHS Greater Glasgow and Clyde for management of miscarriage where a graded approach is provided in 4 of the 5 sites.

After first miscarriage

Source: After the first miscarriage, women will be guided to information about miscarriage

Progress in NHS Highland: Provided at Raigmore Hospital, Dr. MacKinnon Memorial Hospital, Caithness General Hospital, Belford Hospital and all sites within Argyll and Bute.

Source: After the first miscarriage, women will be guided to resources to address their physical needs

Progress in NHS Highland: Provided at Raigmore Hospital, Dr. MacKinnon Memorial Hospital, Caithness General Hospital, Belford Hospital and all sites within Argyll and Bute.

Source: After the first miscarriage, women will be guided to resources to address mental health needs following pregnancy loss

Progress in NHS Highland: Provided at Raigmore Hospital, Dr. MacKinnon Memorial Hospital, Caithness General Hospital and all sites within Argyll and Bute (Belford Hospital can refer/access locally).

Source: After the first miscarriage, women will be guided to ways to optimise their health for future pregnancy

Progress in NHS Highland: Provided at Raigmore Hospital, Dr. MacKinnon Memorial Hospital, Belford Hospital, Caithness General Hospital can refer/access within Health Board area and Argyll and Bute sites can refer/access outwith NHS Highland.

After first miscarriage - this approach could involve:

Source: Patient support groups

Progress in NHS Highland: Provided at all sites in NHS Highland except Nairn Town and County Hospital. Provided at sites in the Argyll and Bute area.

Source: Online self-help strategies for mental health

Progress in NHS Highland: Provided at Dr. MacKinnon Memorial Hospital, Caithness General Hospital, Belford Hospital and sites in the Argyll and Bute area.

Source: Weight management

Progress in NHS Highland: Provided at all sites in NHS Highland except Nairn Town and County Hospital. Provided at sites in the Argyll and Bute area.

Source: Smoking and recreational drugs cessation services

Progress in NHS Highland: Provided at all sites in NHS Highland except Nairn Town and County Hospital. Provided at sites in the Argyll and Bute area.

Source: Information on appropriate preconceptual folate and vitamin D supplementation

Progress in NHS Highland: Provided at all sites in NHS Highland except Nairn Town and County Hospital. Provided at sites in the Argyll and Bute area.

Source: Referral to necessary services for management and optimisation of chronic maternal medical conditions (e.g., diabetes, hypertension, heart disease, and epilepsy)

Progress in NHS Highland: Provided at Raigmore Hospital, Dr. McKinnon Hospital and Belford Hospital. Sites in Argyll and Bute and also Caithness Hospital can access locally.

Source: Screening for mental health issues.

Progress in NHS Highland: Provided at Dr. MacKinnon Memorial Hospital. Sites in the Argyll and Bute area can refer/access in NHS Greater Glasgow and Clyde.

After second miscarriage

Source: Women will be offered an appointment at a miscarriage clinic nurse or midwifery-led

Progress in NHS Highland: Appointment at a nurse-led miscarriage clinic provided at Raigmore Hospital. Sites in the Argyll and Bute area can refer/access in NHS Greater Glasgow and Clyde.

Source: Continuity of care

Progress in NHS Highland: Provided at all sites in NHS Highland (Belford Hospital can access within the Health Board area). Provided at sites in the Argyll and Bute area.

Source: Tests for full blood count are offered

Progress in NHS Highland: Provided at Raigmore Hospital, Dr. MacKinnon Memorial Hospital, Belford Hospital and all sites in the Argyll and Bute area (Caithness General Hospital can refer/access locally within the Health Board area).

Source: Tests for thyroid function are offered

Progress in NHS Highland: Provided at Raigmore Hospital, Dr. MacKinnon Memorial Hospital, Belford Hospital and all sites in the Argyll and Bute area (Caithness General Hospital can refer/access locally within the Health Board area).

Source: Discussion about lifestyle issues

Progress in NHS Highland: Provided at all sites in NHS Highland except Nairn Town and County Hospital. Provided at sites in the Argyll and Bute area.

Source: Referral for specialist care will be arranged if tests are abnormal or if there is a chronic medical or mental health problem.

Progress in NHS Highland: Provided at Raigmore Hospital, Dr. MacKinnon Memorial Hospital, Belford Hospital and Caithness General Hospital. Sites in the Argyll and Bute area can refer/access in NHS Greater Glasgow and Clyde.

Source: Women will have access to support and early pregnancy reassurance scans in subsequent pregnancies.

Progress in NHS Highland: Provided at all sites in NHS Highland except Nairn Town and County Hospital. Sites in the Argyll and Bute area can refer/access in NHS Greater Glasgow and Clyde.

After third and subsequent miscarriage

Source: Women will be offered an appointment at a medical consultant-led clinic, in which additional tests and a full range of treatments can be offered.

Progress in NHS Highland: Provided at Raigmore Hospital and Dr. MacKinnon Memorial Hospital. Sites in the Argyll and Bute area can refer/access in NHS Greater Glasgow and Clyde.

Source: Pregnancy tissue from the third and any subsequent miscarriages will be sent for genetic testing.

Progress in NHS Highland: Provided at Raigmore Hospital. Sites in the Argyll and Bute area can refer/access in NHS Greater Glasgow and Clyde.

Source: Blood tests for antiphospholipid antibodies will be arranged.

Progress in NHS Highland: Provided at Raigmore Hospital and Dr MacKinnon Memorial Hospital. Provided at sites in the Argyll and Bute area.

Source: A pelvic ultrasound scan (ideally three dimensional transvaginal) will be arranged

Progress in NHS Highland: Provided at Caithness General Hospital. Sites in the Argyll and Bute area can refer/access in NHS Greater Glasgow and Clyde.

Source: If necessary, parental karyotyping will be offered depending on the clinical history and the results of the genetic analysis of pregnancy tissue from previous losses

Progress in NHS Highland: Provided at Raigmore Hospital and Dr. MacKinnon Memorial Hospital. Sites in the Argyll and Bute area can refer/access in NHS Greater Glasgow and Clyde.

Source: Appropriate screening for mental health issues

Progress in NHS Highland: Provided at Dr. MacKinnon Memorial Hospital. Provided at sites in the Argyll and Bute area.

Source: Appropriate care for mental health issues

Progress in NHS Highland: Provided at Dr. MacKinnon Memorial Hospital. Provided at sites in the Argyll and Bute area.

Overall recommendations

Source: Appropriate screening and care for future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth.

Progress in NHS Highland: Provided at all sites in NHS Highland except Nairn Town and County Hospital. Provided at sites in the Argyll and Bute area.

Source: Appropriate screening and care for future obstetric risks and mental health issues will need to be incorporated into the care pathway for couples with a history of recurrent miscarriage.

Progress in NHS Highland: Provided at all sites in NHS Highland except Nairn Town and County Hospital. Provided at sites in the Argyll and Bute area.

Source: Consider giving vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage.

Progress in NHS Highland: Provided at Raigmore Hospital, Dr. MacKinnon Memorial Hospital and Caithness General Hospital (after first, second and third or subsequent miscarriage) Sites in the Argyll and Bute area can refer/access locally within the Health Board.

Source: We urge health-care funders and providers to invest in early pregnancy care, with specific focus on training for clinical nurse specialists and doctors to provide comprehensive miscarriage care within the setting of dedicated early pregnancy units.

Progress in NHS Highland: Raigmore Hospital and Caithness General Hospital have midwives/nurses with additional specialist training to provide comprehensive miscarriage care. Raigmore Hospital has doctors trained to provide comprehensive miscarriage care. Sites in the Argyll and Bute area can refer/access in NHS Greater Glasgow and Clyde.

Source: Early pregnancy services need to focus on providing an effective ultrasound service, as it is central to the diagnosis of miscarriage, and be able to provide expectant management of miscarriage, medical management with mifepristone and misoprostol, and surgical management with manual vacuum aspiration

Progress in NHS Highland: Raigmore Hospital is able to carry out scans in the EPU. All management options are available at Raigmore Hospital. Sites in the Argyll and Bute area can provide expectant management on site and can refer/access in NHS Greater Glasgow and Clyde for surgical management with manual vacuum aspiration.

Source: Recommend that miscarriage data are gathered and reported to facilitate comparison of rates among countries, to accelerate research, and to improve patient care and policy development. We recommend that every country reports annual aggregate miscarriage data, similarly to the reporting of stillbirth.

Progress in NHS Highland: Data on miscarriage is collected at all sites via BadgerNet. Raigmore Hospital and Belford Hospital reported that they also use Trakcare. Data is collected on the number of miscarriages at Dr Mackinnon Memorial Hospital, Caithness General Hospital and Belford Hospital, miscarriages as a proportion of pregnancies, gestation, maternal age, SIMD parity and ethnicity are collected at Belford Hospital only. While Raigmore Hospital stated data on miscarriages is collected it is unclear what data is collected.

Source: Identifying women at risk of psychological distress following miscarriage

Progress in NHS Highland: Provided at Raigmore Hospital and Dr MacKinnon Memorial Hospital. Sites in the Argyll and Bute area can refer/access in NHS Greater Glasgow and Clyde.

Source: Identifying women at risk of psychological distress following miscarriage and the development of optimal treatment strategies have been recognised as research priorities.

Progress in NHS Highland: Not assessed.

Source: Women with a history of miscarriage, particularly those with three or more miscarriages, are at an increased risk of obstetric complications including preterm birth. Therefore, these women should be treated as patients at high risk during antenatal and intrapartum care.

Progress in NHS Highland: Provided at all sites in NHS Highland except Belford Hospital and Nairn Town and County Hospital. Provided at sites in the Argyll and Bute area.

Source: Miscarriage Management - women should be presented with the available evidence and be free to choose the management approach that suits their needs and preferences.

Progress in NHS Highland: Caithness General Hospital disagreed that women are free to choose their preferred management approach based on their needs and preferences, while Raigmore Hospital and Dr Mackinnon Memorial Hospital agreed. All other sites including those in Argyll and Bute neither agreed nor disagreed.

Source: Consider pathways of care for miscarriage management, treatment of women with a history of miscarriage and care following a miscarriage.

Progress in NHS Highland: Not assessed.

Source: The Lancet: Miscarriage Matters

Research Recommendations

• Key epidemiological research priority 1 - Establishing how we can monitor miscarriage rates on a population basis.

Progress in NHS Highland: Project underway with Scottish Government, Public Health Scotland and Maternity and Children Quality Improvement Collaborative (MCQIC).

• Key epidemiological research priority 2 - Ascertaining if miscarriage risk and prevalence differ across nations and ethnic groups.

Progress in NHS Highland: Project underway with Scottish Government, Public Health Scotland and Maternity and Children Quality Improvement Collaborative (MCQIC).

• Key epidemiological research priority 3 - Whether miscarriage rate is increasing, and if so why; what the key outcomes are from women’s point of view.

Progress in NHS Highland: Work to follow from research priorities 1 and 2 above.

• Key epidemiological research priority 4 - Which risk factors for miscarriage are potentially causative and modifiable; and the effect of modification of the risk factor on clinical outcomes.

Progress in NHS Highland: Work to follow from research priorities 1 and 2 above.