Miscarriage Care and Facilities in Scotland: Scoping Report NHS Lanarkshire

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 Health 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 .

In Scotland, 12 of the 14 Health Board areas said a graded approach to the treatment of recurrent miscarriage is adopted.

In NHS Lanarkshire a graded approach to treatment of recurrent miscarriage care is provided at University Hospital Wishaw, where all patients within the Health Board area are referred for most treatment options and where centralised recurrent miscarriage service are operated from.

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 that state this should be offered for women with early pregnancy bleeding and a history of miscarriage rather than a first miscarriage.

After a first miscarriage all three sites in NHS Lanarkshire provide information about miscarriage on site. The availability of the provision and services varied between sites and are listed in Table 18 below.

None of the three sites in NHS Lanarkshire currently offer screening for mental health issues, however University Hospital Wishaw indicated that there are plans to implement this in the next two years with a mental health pathway being developed for all women who present at the EPU. Currently University Hospital Wishaw listen to women and discuss their care needs with them to devise an individualised care plan which may mean onward referral to different agencies such as psychological/counselling services. University Hospital Wishaw currently do not provide information to optimise health for future pregnancies e.g. smoking cessation, weight loss, folic acid intake, however plans are in place for this to be implemented within two years and leaflets will be developed.

After providing information on miscarriage, University Hospital Monklands does not provide any further provisions and services after a first miscarriage but is able to refer to University Hospital Wishaw.

After a first miscarriage, the three sites in NHS Lanarkshire signpost patients to some of the following services, see Table 19 below. There is a lack of consistency among sites whether signposting is routine for all patients or only provided when deemed appropriate.

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 are not provided at sites in NHS Lanarkshire. University Hospital Wishaw and University Hospital Hairmyres do not offer an appointment at a nurse-led miscarriage clinic. University Hospital Wishaw stated that there are no nurses working within the maternity unit or EPU. University Hospital Hairmyres stated that they previously had a successful nurse-led recurrent miscarriage clinic for women that presented having had more than two miscarriages, but this has changed and now recurrent miscarriage care is centralised and operated from University Hospital Wishaw. Similarly, appointments at midwifery-led miscarriage clinics are not offered after a second miscarriage in NHS Lanarkshire, however discussions are ongoing to implement this provision in the next two years at University Hospital Wishaw. All sites can refer to specialist care if required after a second miscarriage. Both University Hospital Wishaw and University Hospital Hairmyres have access to support and early pregnancy reassurance scans. Of the services University Hospital Wishaw are unable to currently provide, there are plans to implement all in the next two years except for tests for full blood count. However, at University Hospital Wishaw, any women who are over 38 years have investigative bloods taken depending on medical and family history after a second miscarriage.

After third and 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 miscarriage almost all of the information provision or services asked about were provided at University Hospital Wishaw, with University Hospital Monklands and University Hospital Hairmyres able to access them at University Hospital Wishaw. All appointments with a medical consultant are provided at University Hospital Wishaw where recurrent miscarriage services for NHS Lanarkshire are centralised.

Currently, University Hospital Wishaw is unable to provide appropriate screening for mental health issues or vaginal micronized progesterone in women with early pregnancy bleeding and a history of miscarriage but have indicated that there are plans to implement these services in the next two years as they await protocol and consent forms for this. University Hospital Wishaw are in the process of devising a mental health pathway to screen all women who attend the EPU. That said, women can be referred to the Maternity and Neonatal Psychological Intervention Service which is housed in University Hospital Wishaw and is professionally and operationally managed in maternity services. The service consists of a consultant lead, psychologists, a mental health practitioner and admin support. Specialist midwives for mental health and bereavement work in collaboration with the team. University Hospital Wishaw have reported that they are unable to have an investigative pelvic ultrasound scan arranged after a third miscarriage and that there are no future plans to implement this, however both University Hospital Monklands and University Hospital Hairmyres report that they are able to access this service not on site but locally elsewhere in the Health Board.