Miscarriage Care and Facilities in Scotland: Scoping Report NHS Lothian

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 Lothian a graded approach to treatment of recurrent miscarriage care is provided at the Royal Infirmary of Edinburgh. A graded approach is currently not provided at St John’s Hospital due to lack of space, staff recruitment, staff training, finance/cost and lack of equipment but there are plans to implement a graded approach within the next two years.

After first miscarriage

The Lancet series on Miscarriage Matters recommended the following 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.

After a first miscarriage almost all of the information provision or services recommended in the Lancet series on miscarriage care asked about were provided on site at Royal Infirmary of Edinburgh and St John’s Hospital or were accessible within the health board area. Neither site currently provide vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage, NHS Lothian attributed lack of specialised nursing staff, lack of physical space, lack of time in a consultation to properly inform and consent a patient to take progesterone and for follow up, finance/cost reasons and staff training as a barrier to providing vaginal micronised progesterone.

St John’s Hospital attributed staff training as a barrier to providing screening for mental health issues and referring to necessary services for management and optimisation of chronic maternal medical conditions. The provisions and services asked about are listed in Table 17 below.

The different treatment and information provisions available for women in NHS Lothian following a first miscarriage are shown in Table 18. NHS Lothian signpost patients to the following services, however both sites approach this differently.

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 many of the information provision or services recommended in the Lancet Series on miscarriage care asked about were not provided at sites in NHS Lothian; these are listed in Table 19 below.

After a second miscarriage, neither site provide appointments at a nurse-led miscarriage clinic or a midwifery-led clinic. Both sites in NHS Lothian attributed lack of physical space, staff recruitment, lack of specialised nursing staff and staff training, finance/cost and lack of equipment as barriers to providing appointments at either a nurse-led or midwifery-led clinic. Royal Infirmary of Edinburgh indicated that they have plans to implement these clinics in the next 3 years while St John’s Hospital reported that they have no plans to implement nurse-led or midwifery-led clinic’s in the future.

Continuity of carer was not provided at either site in NHS Lothian, with staff recruitment and retention thought to have contributed to preventing this provision at Edinburgh Royal Infirmary. While St John’s Hospital stated that continuity of carer does not currently exist in the service due to staff recruitment, lack of specialised nursing staff and staff training.

Tests for full blood count and thyroid function are offered to women after a second miscarriage at Royal Infirmary of Edinburgh. However these tests are not offered at St John’s Hospital at present. St John’s Hospital attributed lack of physical space, staff recruitment, lack of specialised nursing staff, staff training and lack of time in consultations as any barriers to implementation. St John’s Hospital plan to implement these tests in the next 2 years.

Vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage is offered at the Royal Infirmary of Edinburgh after a second miscarriage, this service not offered at St John’s Hospital with finance/cost stated as a barrier to providing vaginal micronised progesterone.

Neither site have access to support and early pregnancy reassurance scans in subsequent pregnancies either on site or in the health board area; Royal Infirmary of Edinburgh attributed lack of space, staff recruitment, staff training, finance/cost and lack of equipment as barriers to providing reassurance scans after a second miscarriage. While St John’s hospital attributed finance/cost as a barrier to providing reassurance scans and further stated there was no scanning resource available to support reassurance scans for a subsequent pregnancy at present.

Both sites refer to specialist care if required after a second miscarriage and have a discussion about lifestyle issues in relation to future pregnancies after a second miscarriage.

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 St John’s Hospital can either provide or are able to access elsewhere in the health board all of the information provision or services asked about and this is offered after a third miscarriage. Regarding appropriate screening for mental health issues, St John’s stated that this provided centrally within the health board so would not be offered specifically on site but can be accessed.

After a third miscarriage the majority of the service provision outlined in table 20 is provided at the Royal Infirmary of Edinburgh. While continuity of carer is not provided, medical continuity is provided. Royal Infirmary of Edinburgh reported that some of the services provided are dependent on the gestation at which losses occur due to lack of staff recruitment and staff training. Royal Infirmary of Edinburgh do not do not offer investigative pelvic ultrasound scans due to lack of space, staff training, finance/cost and lack of equipment.

Services provided after a third miscarriage are shown in Table 20 below.