Miscarriage Care and Facilities in Scotland: Scoping Report NHS Shetland
This report details the findings of a scoping exercise to better understand miscarriage care in Scotland within this Health Board. The individual Health Board reports and the national report seek to aid policy makers and Health Boards in making decisions about improvements to Miscarriage Care
Summary
The overall summary is presented below and is shown in Table 22 against the recommendations within the Lancet series on Miscarriage Matters and the Scottish Government Programme for Government commitments.
In NHS Shetland, the Gilbert Bain Hospital provides care for those that experience miscarriage in the first trimester; second trimester losses are transferred out of the Health Board area to a tertiary centre (NHS Grampian). The Gilbert Bain Hospital reported that this site is limited to what it can provide and that referral to the tertiary centre (NHS Grampian) is offered, particularly for women over 12 weeks gestation. Due to this the Gilbert Bain Hospital neither agreed nor disagreed that women are free to choose their preferred management approach based on their needs and preferences.
In NHS Shetland, the Gilbert Bain Hospital provides written information on the treatment options for the management of miscarriage and what to expect next in terms of miscarriage care. The Gilbert Bain Hospital agreed that what will happen during the chosen method of management option is explained fully to women. They neither agreed nor disagreed that what will happen after the chosen method of management or what will happen in terms of follow up.
In NHS Shetland a graded approach to miscarriage is not provided within the Health Board but is accessible in another Health Board area (NHS Grampian). Most of the elements outlined in the Lancet series on Miscarriage Matters are provided in NHS Shetland after a first miscarriage with the exception of information provided to optimise health for future pregnancies and referrals to necessary services for management and optimisation of chronic medical conditions. However, a pre-conception 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.
Dedicated facilities are available for those up to 12 weeks gestation at the Gilbert Bain Hospital in NHS Shetland. A new bereavement suite will be open from August 2023 which will enable NHS Shetland to provide miscarriage care up to 22 weeks gestation.
In NHS Shetland, there is no separate area to carry out complication/investigative scans separated from women with a continuing pregnancy.
In NHS Shetland data is collected via BadgerNet. Data is collected on the number of miscarriages and gestation. There is currently no data collected on miscarriages as a proportion of pregnancies, maternal age, parity, SIMD or ethnicity. This data is then presented to the Scottish Heads of Midwifery for review. The board records a miscarriage from any women who have accessed the service.
Source |
Commitment/Recommendation |
Service provision in NHS Shetland |
|---|---|---|
PfG |
Ensure women's services in Health Boards have dedicated facilities for women who are experiencing unexpected pregnancy complications. |
Dedicated facilities are available for those up to 12 weeks gestation at the Gilbert Bain Hospital in NHS Shetland, however a new bereavement suite which will be open from August 2023 will enable NHS Shetland to provide miscarriage care up to 22 weeks gestation. |
The Lancet: Miscarriage Matters |
A graded approach to the treatment of recurrent miscarriage |
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 |
||
After the first miscarriage, women will be guided to information about miscarriage |
Provided at the Gilbert Bain Hospital. |
|
After the first miscarriage, women will be guided to resources to address their physical needs |
Provided at the Gilbert Bain Hospital. |
|
After the first miscarriage, women will be guided to resources to address mental health needs following pregnancy loss |
Provided at the Gilbert Bain Hospital. |
|
After the first miscarriage, women will be guided to ways to optimise their health for future pregnancy |
Not currently provided in NHS Shetland |
|
After First Miscarriage – this approach could involve: |
||
Patient support groups |
Provided at the Gilbert Bain Hospital. |
|
Online self-help strategies for mental health |
Provided at the Gilbert Bain Hospital. |
|
Weight management |
Provided at the Gilbert Bain Hospital. |
|
Smoking and recreational drugs cessation services |
Provided at the Gilbert Bain Hospital. |
|
Information on appropriate preconceptual folate and vitamin D supplementation |
Provided at the Gilbert Bain Hospital. |
|
Referral to necessary services for management and optimisation of chronic maternal medical conditions (e.g., diabetes, hypertension, heart disease, and epilepsy) |
Not currently provided in NHS Shetland |
|
Screening for mental health issues. |
Provided at the Gilbert Bain Hospital. |
|
After Second Miscarriage |
||
Women will be offered an appointment at a miscarriage clinic nurse or midwifery-led |
Not provided within NHS Shetland but is accessible in another Health Board area (NHS Grampian). |
|
Continuity of Carer |
Not provided within NHS Shetland but is accessible in another Health Board area (NHS Grampian). |
|
Tests for full blood count are offered |
Not provided within NHS Shetland |
|
Tests for thyroid function are offered |
Not provided within NHS Shetland |
|
Discussion about lifestyle issues |
Provided at the Gilbert Bain Hospital. |
|
Referral for specialist care will be arranged if tests are abnormal or if there is a chronic medical or mental health problem. |
Not provided within NHS Shetland but is accessible in another Health Board area (NHS Grampian). |
|
Women will have access to support and early pregnancy reassurance scans in subsequent pregnancies. |
Provided at the Gilbert Bain Hospital. |
|
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. |
Not provided within NHS Shetland but is accessible in another Health Board area (NHS Grampian). |
|
Pregnancy tissue from the third and any subsequent miscarriages will be sent for genetic testing. |
Not provided within NHS Shetland but is accessible in another Health Board area (NHS Grampian). |
|
Blood tests for antiphospholipid antibodies will be arranged. |
Not provided within NHS Shetland but is accessible in another Health Board area (NHS Grampian). |
|
A pelvic ultrasound scan (ideally three dimensional transvaginal) will be arranged. |
Not provided within NHS Shetland but is accessible in another Health Board area (NHS Grampian). |
|
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. |
Not provided within NHS Shetland but is accessible in another Health Board area (NHS Grampian). |
|
Appropriate screening for mental health issues. |
Provided at the Gilbert Bain Hospital. |
|
Appropriate care for mental health issues. |
Provided at the Gilbert Bain Hospital. |
|
Overall Recommendations |
||
Appropriate screening and care for future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth. |
Provided at the Gilbert Bain 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 the Gilbert Bain Hospital. |
|
Consider giving vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage. |
Provided at the Gilbert Bain Hospital. |
|
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. |
There are staff with additional specialist training to deal with all baby losses from early pregnancy to stillbirth at the Gilbert Bain Hospital. There are no midwifes/nurses or doctors who are trained to provide comprehensive miscarriage care in NHS Shetland. |
|
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. |
In NHS Shetland, scans are provided in the Maternity Unit by the midwife sonographers, with consultants available for scans out of hours. These scans are carried out in the same area as women with a continuing pregnancy. Expectant management is provided at the Gilbert Bain Hospital in the first trimester. Medical management with mifepristone and misoprostol is not currently provided but there are plans to implement this in the next two years. Surgical management with manual vacuum aspiration is not provided in NHS Shetland. |
|
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. |
In NHS Shetland data is collected via BadgerNet. Data is collected on the number of miscarriages and gestation. There is currently no data collected on miscarriages as a proportion of pregnancies, maternal age, parity, SIMD or ethnicity. This data is then presented to the Scottish Heads of Midwifery for review. The board records a miscarriage from any women who have accessed the service. |
|
Identifying women at risk of psychological distress following miscarriage. |
Provided within Health Board area for first trimester losses. Accessed in NHS Grampian for second trimester losses. |
|
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 the Gilbert Bain 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. |
The Gilbert Bain Hospital reported that they provide written information on the treatment options for the management of miscarriage and what to expect next in terms of miscarriage care on site. The Gilbert Bain Hospital agreed that what will happen during the chosen method of management option is explained fully to women. They neither agreed nor disagreed that what will happen after the chosen method of management or what will happen in terms of follow up. The Gilbert Bain Hospital reported that this site is limited to what it can provide and that referral to a tertiary centre (NHS Grampian) is offered, particularly for women over 12 weeks gestation. Due to this the Gilbert Bain Hospital neither agreed nor disagreed that women are free to choose their preferred management approach based on their needs and preferences. |
|
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. |
|
Contact
Email: socialresearch@gov.scot
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