Miscarriage Care and Facilities in Scotland: Scoping Report NHS Orkney

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 Health 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 Orkney a graded approach to treatment of recurrent miscarriage is provided at Balfour Hospital.

After first miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 14 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 in NHS Orkney, the information provision or services asked about and provided on site at Balfour Hospital are listed in Table 14 below. Balfour Hospital reported that due to the smaller size of maternity services in NHS Orkney, screening for mental health issues and referral to services for management and optimisation of chronic maternal medical conditions are not provided on site, however these are referred to appropriate teams within the Health Board area.

In NHS Orkney these services were offered to all women regardless of the gestation when the loss occurred.

In NHS Orkney, Balfour Hospital signposts patients to the following services as outlined in Table 15.

After second miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 16 below, should be available after a second miscarriage.

After a second miscarriage the information provision or services recommended in the Lancet Series on miscarriage care that Balfour Hospital reported to provide are listed in Table 16 below. Midwifery-led and nurse-led miscarriage clinic appointments are not currently provided, with no plans to implement these, this is because the clinic is run with joint support from obstetrics and gynaecology staff after a second miscarriage. Referrals to specialist care is also not provided at Balfour Hospital due to service size, with referrals provided to the appropriate team within the Health Board area.

After third and subsequent miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 17 below, should be available after a third or subsequent miscarriage

After a third miscarriage almost all of the information provision or services asked about were provided on site at Balfour Hospital, these are shown in Table 17 below. The exceptions to this are appropriate screening and care for mental health issues, where women would be referred to an appropriate team locally within the Health Board.