Miscarriage Care and Facilities in Scotland: Scoping Report NHS Lanarkshire

Management options

In NHS Lanarkshire, all treatment options for miscarriage care, detailed below, are offered only at University Hospital Wishaw with other sites referring patients to this site for all treatment. The exception to this is expectant management which is provided at both University Hospital Hairmyres and University Hospital Wishaw. University Hospital Hairmyres is able to provide expectant management for first trimester losses and refers women to University Hospital Wishaw for all other options. The treatments offered are listed in Table 16 below:

The consultation asked about the advice given to women about expectant management of miscarriage. Advice was provided by all sites in Scotland. Within NHS Lanarkshire, University Hospital Monklands indicated that all aspects of miscarriage management options are delivered at University Hospital Wishaw as part of their maternity services.

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 Lanarkshire

The advice provided to patients was similar at University Hospital Hairmyres and University Hospital Wishaw about expectant management 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
• method of sensitive disposal at home or through the hospital
• tests if needed and information leaflets

Information leaflets for miscarriage support and miscarriage association leaflets are also provided. Women are informed of all other options of management as applicable to their gestation and details of expectation and risk with each.

The patient is provided with a scan and are advised to monitor their symptoms and contact the EPU if they have any concerns. Women are given a pregnancy test to take home. Two weeks after the initial diagnosis of miscarriage in the EPU the patient is rescanned to ensure the miscarriage is complete and the patient is asked about the history of events. The patient is also advised that they can have a reassurance scan at 8 weeks in their next pregnancy.

Medical management in NHS Lanarkshire

In NHS Lanarkshire all options of medical management are only provided at University Hospital Wishaw and this is offered as an in-patient or out-patient service for first trimester losses and as an in-patient service for the second trimester losses.

The pathway of care for medical management at University Hospital Wishaw includes an assessment of symptoms to confirm miscarriage. Women are provided with information leaflets and there is a discussion about management options including the risks associated and success rates for their chosen approach. The patient is given misoprostol in the department and provided with written information and advice on what to expect. All telephone contact details for EPU, maternity triage and A&E are provided along with analgesia, sanitary pads and further misoprostol to be taken at home. The patient is advised to stay at home and that they should have a responsible person with them for the next 48 hours. If there is no bleeding after 2 hours the patient is advised to take another 400mcg misoprostol; if still no bleeding after 48 hours they are advised to contact the EPU. Inpatient treatment is currently provided in University Hospital Wishaw. After being provided with information leaflets and having a discussion about their management options, women are given mifepristone then go home and return to the ward for misoprostol administration as an inpatient as per NICE guidelines.

If successfully passed, the patient is advised to take a home pregnancy test in three weeks time. If the pregnancy test still positive after three weeks they must call the EPU to arrange a scan and if it is found that the miscarriage is incomplete they will be offered an alternative management option.

Surgical management in NHS Lanarkshire

In NHS Lanarkshire all options for surgical management are provided only at University Hospital Wishaw and are offered only in the first trimester.

The advice for surgical management for University Hospital Wishaw comprises a discussion of all management options (surgical, medical and expectant) and information leaflets are provided. Patients are advised of treatment success rates, time scales, risks and advantages including risk of infection, perforation of uterus and excessive bleeding. Patients are given time to consider all options and, if required, given several days to allow them to make a choice.

The treatment pathway for surgical management involves patients being provided with information leaflets comprising a full explanation of the procedure, full blood count, blood group and blood screening is also carried out. For MVA treatment, misoprostol is administered two hours prior to being taken to theatre. Staff are present to support the patient throughout the procedure and the patient should expect to be in hospital for six hours.

For surgical management with general anaesthetic, the patient arrives as above but the procedure takes place in theatre with either general anaesthetic or deep sedation. However during the COVID-19 pandemic, all women wishing surgical evacuation of the uterus were offered MVA rather than surgery under general anorthic as first line as long as no contraindications exist and criteria are fulfilled to reduce covid risk through use of aerosol generating procedures (AGP).

In all cases patients are given a pregnancy test to take home and are contacted or required to contact the site two to three weeks after the surgery. If the pregnancy test is still positive then patients would return for further management and are advised to contact the EPU in subsequent pregnancies to arrange a reassurance scan.