Miscarriage Care and Facilities in Scotland: Scoping Report NHS Lothian

Management options

Within NHS Lothian both sites agreed that women are free to choose their preferred management approach based on their needs and preferences. Both sites also agreed that women are offered only the management approaches provided on site and both disagreed that women may be referred to another site depending on the management approach they choose. St John’s Hospital stated that they provide all options on this site and that options are not restricted as all options excluding surgical management with manual vacuum aspiration are available.

Almost all treatment options for miscarriage care, detailed below, are offered at both Royal Infirmary of Edinburgh and St. John’s Hospital, except surgical management with manual vacuum aspiration (MVA) with local anaesthetic. Surgical management with manual vacuum aspiration (MVA) with local anaesthetic is not offered at either site in NHS Lothian due to lack of physical space and staff training. The management options offered in NHS Lothian are shown in table 15 below.

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 Lothian

The advice provided to patients about expectant management is similar at both sites within NHS Lothian and includes; oral and written information about what to expect throughout the process, advice on pain relief and where and when to get help in an emergency, advice regarding signs of infection and when to seek help. NHS Lothian stated that patients are also made aware that expectant management is not advised past 9 weeks gestation, although it can be offered up to 12 weeks if women request this and are aware of the risks. Both sites in NHS Lothian indicated that this option is not offered in the second trimester. If expectant management is chosen, discussions are held with the patient about how to access reassurance scans in future pregnancies and women are signposted to the miscarriage association. Women are also informed of all other options of management as applicable to their gestation and details of expectation and risk with each.

Women in NHS Lothian who chose expectant management are provided with written information and consent forms are signed, they are then signposted to the ward and out of hours services. The patient is given a pregnancy test to take home and is asked to telephone in three weeks time to provide history of events and results of the pregnancy test. The patient may then be discharged or asked to attend the EPU at their local site for a scan and medical review if the test is positive or the history is not suggestive of complete miscarriage.

Medical management in NHS Lothian

In NHS Lothian medical management with misoprostol is provided at both sites in the first trimester only up to 9 weeks gestation; medical management with mifepristone and misoprostol is offered at in both the first and second trimester. NHS Lothian indicated that medical management as an outpatient is only offered for gestations up to 9 weeks+6 days, patients over 10 weeks are treated as an in-patient.

The pathway of care for medical management in NHS Lothian includes an assessment of symptoms to confirm miscarriage, provision of information leaflets and a discussion about management options including the associated risks and other options available. Women are also signposted to the miscarriage association.

For outpatient medical management the patient is given misoprostol in the department and provided with advice on what to expect with written information. All telephone contact details in case of emergency or advice are supplied along with analgesia and a pregnancy test. The patient is advised that an adult will need to be with them throughout the process. About 4 hours after the first tablet has been administered the patient is advised to take two more tablets. Nursing staff will routinely telephone the patient later the same day and the following day to ask about bleeding, pain and symptoms. If successfully passed, a follow-up telephone call about the pregnancy test would be conducted within three weeks. If not successfully passed further options are discussed. If there is no evidence of miscarriage following treatment, treatment may be repeated after a minimum of 24 hours. A third dose is rare and only with medical staff involvement. The patient’s GP is also notified.

Inpatient medical management will be offered to those over 10 weeks gestation, it may also be offered to those under 10 weeks gestation where an underlying medical condition is present, the woman’s condition is unstable, they are very young or where English is not their first language. The process is similar to outpatient management but will take place in a ward.

Surgical management in NHS Lothian

Surgical management with manual vacuum aspiration (MVA) with local anaesthetic is not provided in NHS Lothian due to lack of physical space and staff training.

Surgical management under general anaesthetic is provided at both sites in NHS Lothian in the first trimester only. The advice for surgical management in NHS Lothian is similar at both sites and comprises an assessment of symptoms to ensure miscarriage and scans carried out to confirm intrauterine pregnancy loss. All management options are discussed (surgical, medical, expectant) and information leaflets are provided. Discussions are held with the patient about how to access reassurance scans in future pregnancies and women are signposted to the miscarriage association. Patients are given time to consider all options and given several days if required to allow them to make a choice.

The treatment pathway for surgical management offered by NHS Lothian involves patients being provided with information leaflets with a full explanation of the procedure. Blood count, blood group and blood screening are also carried out. Patients arrive at the hospital on the day of surgery and undergo pre-operative assessment and further blood tests at the EPU, before being given general anaesthetic.

Staff are present to support the patient throughout the procedure. Once the procedure is complete a period of rest and recovery is observed by the EPU team before the patient is transferred home. All patients are given a pregnancy test to take home and are contacted or will contact the site two to three weeks after the surgery. If the test is remains positive then patients are advised to contact the EPU for further management.