Miscarriage Care and Facilities in Scotland: Scoping Report NHS Shetland

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^[8] .

In Scotland, 12 of the 14 Health Board areas said a graded approach to the treatment of recurrent miscarriage is adopted.

Currently in NHS Shetland a graded approach is not provided within the Health Board but is accessible in another Health Board area (NHS Grampian).

After first miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 15 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^[9] that state this should be offered for women with early pregnancy bleeding and a history of miscarriage rather than a first miscarriage.

In NHS Shetland, the information provision or services asked about that were provided on site at the Gilbert Bain Hospital are listed in Table 15 below. Information provided to optimise health for future pregnancies and referrals to necessary services for management and optimisation of chronic medical conditions are not currently provided, with plans to implement these within in the next two years. However, a preconceptual care clinic has recently been commissioned to optimise health and well-being for those planning a pregnancy. It will include weight management, lifestyle, smoking cessation and referral to a gynaecologist (if necessary) to support pre-pregnancy planning. In NHS Shetland these services are offered to all women regardless of the gestation when the loss occurred.

NHS Shetland signpost patients to the following services outlined in Table 16.

After second miscarriage

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

After a second miscarriage the information provision or services asked about that were provided on site at the Gilbert Bain Hospital are listed in Table 17 below. After two consecutive miscarriages (with the same partner) women are referred to the Midwife with specialist interest in fertility. Where services listed below are not available within NHS Shetland, the Board can refer women to a tertiary referral clinic in NHS Grampian.

After third and subsequent miscarriage

The Lancet series on Miscarriage Matters recommended the following services listed in Table 18 below should be available after a third or subsequent miscarriage.

After a third or subsequent miscarriage the information provision or services asked about provided on site at the Gilbert Bain Hospital are shown in Table 18 below. Where services listed below are not available within NHS Shetland, the Board can refer women to a tertiary referral clinic in NHS Grampian.

In NHS Shetland the board has recently employed substantive consultants and the pathway for miscarriage management is currently under review pending a restructure to allow for a bereavement suite. Specialist support and genetic testing are provided at a tertiary centre (NHS Grampian) with management of subsequent pregnancy plans also being provided from that centre.