Miscarriage Care and Facilities in Scotland: Scoping Report NHS Lothian

Summary

The overall summary is presented below and is shown in table 25 against the recommendations within the Lancet series on Miscarriage Matters and the Scottish Government Programme for Government commitments.

In NHS Lothian, both the Royal Infirmary of Edinburgh and St John’s Hospital provide care for those that experience miscarriage. Both sites in NHS Lothian said that women are free to choose the management approach that suits their needs.

In NHS Lothian, both sites provide written information about the treatment options for the management of miscarriage and what to expect in terms of miscarriage care and information on what would happen before, during and after any treatment options.

Within NHS Lothian women are also provided with full explanations about what would happen during their chosen method of management, after the chosen method of management and in terms of follow-up.

In NHS Lothian, a graded approach to treatment of recurrent miscarriage is provided at Royal Infirmary of Edinburgh. A graded approach is currently not provided at St John’s Hospital. Most of the elements outlined in the Lancet series on Miscarriage Matters are provided in NHS Lothian except for vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage after a first miscarriage, although this is provided after a second miscarriage at Royal Infirmary Edinburgh and after a third or subsequent miscarriage at both sites. After a second miscarriage NHS Lothian does not provide nurse or midwifery-led miscarriage clinics or access to support and early pregnancy reassurance scans in subsequent pregnancies. While appropriate screening for mental health issues is not provided at Royal Infirmary of Edinburgh or St John’s Hospital these services are provided centrally within NHS Lothian and both sites are able to refer women to this service.

Dedicated facilities are available at both sites in NHS Lothian, where more four to five separate rooms are available away from the labour ward for women that are miscarrying in St John’s Hospital and two rooms are available in Royal Infirmary of Edinburgh.

In NHS Lothian, there are no separate areas to carry out complication/investigative scans separated from women with a continuing pregnancy.

In NHS Lothian data on miscarriage is collected via Trakcare. Data is collected on the number of miscarriages, miscarriages as a proportion of pregnancies, gestation, maternal age, parity, SIMD and ethnicity. Data on miscarriage is presented to clinical nurse managers, medical staff, nursing staff, senior clinical management team and the EPU quality improvement team (QIT) for review.

Table 24: 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
• Service Provision in NHS Greater Glasgow and Clyde - NHS Lothian have dedicated provisions for women experiencing unexpected pregnancy complications at Royal Infirmary of Edinburgh and St John’s Hospital; these facilities were provided in the early pregnancy unit (EPU) and outwith the EPU (up to 12 weeks in Royal Infirmary of Edinburgh) Royal Infirmary of Edinburgh can use two rooms on the gynaecology ward for pregnancy loss and St John’s Hospital has four rooms, one dedicated family room for pregnancy loss within the Women's Services footprint and three single rooms. It is noted that some rooms/areas are not solely used for miscarriage care and may be used for other pregnancy complications or loss.

Source: The Lancet: Miscarriage Matters

• Commitment/Recommendation - A graded approach to the treatment of recurrent miscarriage
• Service Provision in NHS Greater Glasgow and Clyde - Provided at Royal Infirmary of Edinburgh.

After first miscarriage

• After the first miscarriage, women will be guided to information about miscarriage
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• After the first miscarriage, women will be guided to resources to address their physical needs
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• After the first miscarriage, women will be guided to resources to address mental health needs following pregnancy loss
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• After the first miscarriage, women will be guided to ways to optimise their health for future pregnancy
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.

After first miscarriage – this approach could involve:

• Patient support groups
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• Online self-help strategies for mental health
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• Weight management
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• Smoking and recreational drugs cessation services
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• Information on appropriate preconceptual folate and vitamin D supplementation
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• Referral to necessary services for management and optimisation of chronic maternal medical conditions (e.g., diabetes, hypertension, heart disease, and epilepsy)
  • Provided at Royal Infirmary of Edinburgh.
• Screening for mental health issues
  • Sites in NHS Lothian can refer/access this within the Health Board area.

After second miscarriage

• Women will be offered an appointment at a miscarriage clinic nurse or midwifery-led
  • Not provided in NHS Lothian.
• Continuity of Care
  • Not provided in NHS Lothian.
• Tests for full blood count are offered
  • Not provided in NHS Lothian.
• Tests for thyroid function are offered
  • Not provided in NHS Lothian.
• Discussion about lifestyle issues
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• Referral for specialist care will be arranged if tests are abnormal or if there is a chronic medical or mental health problem
  • Provided at Royal Infirmary of Edinburgh.
• Women will have access to support and early pregnancy reassurance scans in subsequent pregnancies
  • Not provided in NHS Lothian.

After third and subsequent miscarriage

• 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
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• Pregnancy tissue from the third and any subsequent miscarriages will be sent for genetic testing
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• Blood tests for antiphospholipid antibodies will be arranged
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• A pelvic ultrasound scan (ideally three dimensional transvaginal) will be arranged
  • Not provided in NHS Lothian.
• 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
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• Appropriate screening for mental health issues
  • Not provided on site at Royal Infirmary of Edinburgh or St John’s Hospital but is provided centrally in NHS Lothian.
• Appropriate care for mental health issues
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.

Overall recommendations

• Appropriate screening and care for future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• 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.
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• Consider giving vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital (provided after second miscarriage at Royal Infirmary of Edinburgh and after third or subsequent miscarriages at both sites).
• 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
  • Both Royal Infirmary of Edinburgh and St John’s Hospital have midwives/nurses with additional specialist training to provide comprehensive miscarriage care. Both Royal Infirmary of Edinburgh and St John’s Hospital have doctors trained to provide comprehensive miscarriage care.
• 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
  • Both Royal Infirmary of Edinburgh and St John’s Hospital conduct scans in the Early Pregnancy Units during opening hours, however scans are conducted in the same area as other expectant mothers. Expectant and medical management with mifepristone and misoprostol are provided at both Royal Infirmary of Edinburgh and St John’s Hospital. Surgical management with manual vacuum aspiration is not currently provided in NHS Lothian.
• 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
  • Data on miscarriage is collected via Trakcare in both sites. Data is collected on the number of miscarriages, miscarriages as a proportion of pregnancies, gestation, maternal age, parity, SIMD and ethnicity. Data on miscarriage is presented to clinical nurse managers, medical staff, nursing staff, senior clinical management team and the EPU quality improvement team (QIT) for review.
• Identifying women at risk of psychological distress following miscarriage
  • Not provided at either Royal Infirmary of Edinburgh or St John’s Hospital but both can access/refer locally.
• Identifying women at risk of psychological distress following miscarriage and the development of optimal treatment strategies have been recognised as research priorities
  • Not assessed
• 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
  • Provided at both Royal Infirmary of Edinburgh and St John’s Hospital.
• Miscarriage Management - women should be presented with the available evidence and be free to choose the management approach that suits their needs and preferences
  • Royal Infirmary of Edinburgh and St John’s Hospital stated that women are free to choose the management approach that suits their needs.
• Consider pathways of care for miscarriage management, treatment of women with a history of miscarriage and care following a miscarriage
  • Not assessed.

The Lancet: Miscarriage Matters - Research Recommendations

• Key epidemiological research priority 1 - Establishing how we can monitor miscarriage rates on a population basis
  • Project underway with Scottish Government and Public Health Scotland
• Key epidemiological research priority 2 - Ascertaining if miscarriage risk and prevalence differ across nations and ethnic groups
  • Project underway with Scottish Government and Public Health Scotland
• 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
  • 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
  • Work to follow from research priorities 1 and 2 above.