Miscarriage Care and Facilities in Scotland: Scoping Report NHS Orkney

Introduction

The Scottish Government's 2021-22 Programme for Government: A Fairer, Greener Scotland^[1] includes a commitment to 'establish a dignified and compassionate miscarriage service'. The aim of this commitment is to support the development of individualised care plans following a woman's first miscarriage, take forward specific recommendations made in the Lancet series on Miscarriage Matters published on 26 April 2021^[2], and ensure women's services in Health Boards have dedicated facilities for women who are experiencing unexpected pregnancy complications.

Miscarriage is the loss of intrauterine pregnancy before viability, at 23 weeks and 6 days or less. First trimester miscarriages occur in the first 11 weeks and 6 days of pregnancy, while second trimester miscarriages occur between 12 weeks and 23 weeks and 6 days of pregnancy.

The Lancet series on Miscarriage Matters found that the risk of miscarriage in the UK was 15.3% of all recognised pregnancies and that the risk of miscarriage was lowest in women with no history of miscarriage (11%)^[3].

It is thought that miscarriage affects around one in five pregnancies before 12 weeks. It is estimated that 1–2% of second-trimester pregnancies miscarry before 23 weeks and 6 days of gestation. After 24 weeks gestation the death of a baby in utero is regarded as a stillbirth.

Treatment of miscarriage is dependent on gestation. Patients in early first trimester may choose to go home and miscarry with support; those in late first trimester or second trimester will usually be advised to be admitted to hospital.

There are three recognised management pathways for miscarriage available for women:

Expectant (also called natural or conservative) management – this allows a miscarriage to happen without medical intervention and is often recommended in the early first trimester. National Institute for Health and Care Excellence (NICE) guidelines state that expectant management should be the first method of consideration.

Medical management – treatment with medication taken orally and/or vaginal tablets (pessaries) to start or assist the process of a missed or incomplete miscarriage.

Surgical management – to remove the pregnancy tissue surgically. This is usually carried out under general anaesthetic although it can be done under local anaesthetic.

As well as the physical treatment of miscarriage there is also the emotional consideration of the loss of a pregnancy and the way in which people process this loss varies.

Recurrent miscarriage is defined by the Royal College of Obstetrics and Gynaecology (RCOG) as three or more first trimester miscarriages and is thought to affect one in every hundred women. Previously, the RCOG defined recurrent miscarriage as the loss of three or more consecutive pregnancies, however, this was redefined in June 2023 to include non-consecutive miscarriages^[4]. The risk of recurrent miscarriage increases after each successive pregnancy loss, reaching approximately 40% after three consecutive pregnancy losses. Miscarriage, and especially recurrent miscarriage, is associated with future obstetric complications. The chance of preterm birth increases stepwise with each previous miscarriage, showing a biological gradient with the highest chance in women with three or more previous miscarriages. The chance of fetal growth restriction, placental abruption, and stillbirth in future pregnancies is also increased.

The prognosis worsens with increasing maternal age. Previous live birth does not preclude a woman developing recurrent miscarriage.

The chances of finding a treatable cause for recurrent miscarriage are better than in a single miscarriage but a cause will not be identified in many women, despite undergoing investigation.