Miscarriage Care and Facilities in Scotland: Scoping Report NHS Highland

Management options

In NHS Highland 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, while Caithness General Hospital disagreed with this statement. Nairn Town And County Hospital, Campbeltown Hospital, Cowal Community Hospital, Islay Hospital, Lorn & Islands Hospital, Mid Argyll Community Hospital, Mull & Iona Community Hospital and Victoria Hospital all neither agreed nor disagreed that women were free to choose their preferred management option.

All sites in NHS Highland were asked if the management options listed in Table 15 below are either provided on site, accessible locally, or not provided. Raigmore Hospital reported that they provide all management options on site. Dr Mackinnon Memorial Hospital and Caithness General Hospital reported that they provide expectant management on site and refer all women to Raigmore Hospital for all other management options. Belford Hospital refers women to Raigmore Hospital for all management options. Sites within Argyll and Bute reported that all management options are provided outwith the Health Board area via a service level agreement with NHS Greater Glasgow and Clyde. Nairn Town and County Hospital reported that none of the management options listed below are provided on site but did not indicate where women are referred to.

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.

Expectant management in NHS Highland

In NHS Highland women are directed to the Miscarriage Association website and are given leaflets from the Miscarriage Association to read detailing all the management options available. Women then have a scan to confirm miscarriage and a discussion would take place regarding management options. Once expectant management is decided upon as the preferred option, women are advised about expectant management including timescales, risks and benefits. Women are provided with written information and are given a pregnancy test to take home. Women are then advised that they will experience varying levels of pain from mild cramps to severe pain causing nausea and fainting. Women are advised to attend the A&E department if their bleeding is heavy, or they begin to feel unwell. Women are contacted by telephone 7 days later to check progress, if the miscarriage is not complete, they are contacted again over the next 7 days. Women are also informed of signs of infection. Three weeks after the start of management women are contacted to check on their wellbeing and to gather results of the home pregnancy test. Women are also advised to contact their GP if they have if any concerns or experience low mood and are again directed to the Miscarriage Association website for leaflets on what happens next.

Sites within Argyll and Bute reported that all management options are provided outwith the Health Board area via a service level agreement with NHS Greater Glasgow and Clyde. Women who present at any of the sites within Argyll and Bute are offered expectant management after they have been seen by a specialist in NHS Greater Glasgow and Clyde. If expectant management is chosen, women would be cared for by an EPU in NHS Greater Glasgow and Clyde in conjunction with the local maternity unit.

Medical management at NHS Highland

In NHS Highland medical management is provided at Raigmore Hospital only, and women from Belford Hospital, Nairn Town and County Hospital, Caithness General Hospital and Dr MacKinnon Hospital are referred here. Women who present at any of the Argyll and Bute Hospitals are referred to NHS Greater Glasgow and Clyde sites for medical management. Women who are referred from Caithness General Hospital are made aware that they will be required to travel over 200 miles (round trip) for the treatment and that the process may need to be repeated.

At Raigmore Hospital, medical management can be carried out as an inpatient for both first and second trimester losses, or as an outpatient at home for first trimester losses only. Women are advised on what to expect, the time frame is explained along with the likely level of pain, bleeding and risk. Statistics about infection, failure of the treatment option and bleeding are also discussed. Women are also advised that severe pain may require morphine and that they may experience heavy bleeding with large clots which may require surgical management/MVA if bleeding cannot be controlled.

Once diagnosis of miscarriage is confirmed by two sonographers and the patient has made the decision for medical management, treatment is booked for inpatient or outpatient care. Women are given 800 micrograms of misoprostol followed by a further 400 micrograms 3 hours later. If no bleeding is observed after 24 hours, there is a review and discussion about ongoing care. Further treatment would be to either repeat the medical treatment or continue to surgical management depending on the patients choice. Recurrent miscarriage investigation is offered 6 weeks later, if this was the patients second miscarriage. The patient would also be offered or advised about taking progesterone in the future.

If medical management occurs as an inpatient and staff have confirmed that they have visualised products of conception and they appear complete, then there is no further follow up.

If a patient undergoes out-patient medical management and they give a history which is suggestive of complete miscarriage during telephone follow-up, they will be contacted for urine pregnancy test follow-up 3 weeks later. If urine pregnancy test remains positive three weeks post medical management, then the patient would be tested for human chorionic gonadotropin (hCG) again and another ultrasound would be provided, with further management if necessary.

Surgical management at NHS Highland

In NHS Highland surgical management is provided at Raigmore Hospital only, and women from Belford Hospital, Nairn Town and County Hospital, Caithness General Hospital and Dr MacKinnon Hospital are referred here. Women who present at any of the Argyll and Bute Hospitals are referred to NHS Greater Glasgow and Clyde for surgical management. Women who are referred from Caithness General Hospital are made aware that they need to travel over 200 miles (round trip) for the treatment.

At Raigmore Hospital surgical management with manual vacuum aspiration (MVA) with local anaesthetic is offered in the first trimester and surgical management under general anaesthetic is offered in the first trimester also. Raigmore Hospital reported that currently the availability of surgical management with manual vacuum aspiration has been sporadic due to equipment issues.

When surgical management is decided upon, women are advised of the risks of infection, perforation, failure of procedure and heavy bleeding, and are also advised that they will be required to fast before the procedure.

The treatment pathway for surgical management described at Raigmore Hospital involves patients being admitted to the inpatient ward early in the morning of the procedure. Women are given misoprostol two hours before the surgery to allow the cervix to soften. Women are then taken to theatre. Products are sent to pathology and cytogenetics if required. After surgery, Anti D rhesus prophylaxis is given if required, and a referral made to recurrent miscarriage clinic if the patient is within the criteria. Women are taken to the ward to recover and are discharged 3-4 hours later provided pain and bleeding are within an acceptable level. If surgery was straightforward, there is no follow up from surgical management.