Miscarriage Care and Facilities in Scotland: Scoping Report NHS Shetland

Management options

In NHS Shetland, the Gilbert Bain Hospital reported that the 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 at present (2022). 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. They disagreed that women are offered only the management options available on site and agreed that women may be referred to another site depending on the management approach they choose.

All treatment options for miscarriage care offered at the Gilbert Bain Hospital are available during the first trimester only. All second trimester losses in NHS Shetland are transferred to a tertiary referral centre (NHS Grampian). In NHS Shetland, there are plans to begin building work which will allow for more treatment options to be delivered on site up to 22 weeks gestation. Gilbert Bain Hospital indicated that once the building work has started staff will receive training to enable them to develop the skills to deliver care for those who experience a loss, up to a gestation of 22 weeks. The options offered at the Gilbert Bain Hospital are listed below in Table 14. It should be noted that these options are currently being reviewed and will be updated accordingly to include management options for second trimester losses up to 22 weeks when the new bereavement suit opens.

Expectant management in NHS Shetland

Expectant Management is offered at the Gilbert Bain Hospital in NHS Shetland. Following a scan to confirm a loss, women are offered choices for their management. Expectant management is offered only to women with a loss under 12 weeks. After this gestation a referral is made to a tertiary referral centre (NHS Grampian). Information is given about expectant management as well as other choices available. This information includes the length of time the process may take, when to contact the hospital and any potential problems such as high temperature or excessive bleeding and pain. A follow up appointment is given for a repeat scan. If necessary further care options are discussed. A letter is sent to the woman's GP informing them of the loss and information is provided about who to contact for advice/support for a subsequent pregnancy, should this be appropriate. Families are also provided with information from the SANDS charity.

Medical management in NHS Shetland

Medical Management with misoprostol is provided at the Gilbert Bain Hospital in the first trimester. Following a scan, women are seen by a gynaecologist and offered choices for management, with medical management available for women with a loss under 12 weeks. After this gestation a referral is made to a tertiary referral centre (NHS Grampian). Women are provided with information about what the process will entail, the length of time the process may take, whether they want to go home or remain in hospital, what the risks are and when to contact the hospital if they return home. The gynaecologist will prescribe medication, pain relief and anti-emetics, which is administered by a midwife. Women are advised to contact the Maternity Unit if there has been no bleeding after 24 hours.

Women receive full written information containing hospital contact numbers. A pregnancy test is also provided with the advice to do this after three weeks. Advice is given about what to do if the test is positive. A letter is also sent to their GP to inform them of the miscarriage and women are given information about SANDS charity.

Surgical management in NHS Shetland

In the Gilbert Bain Hospital surgical management with manual vacuum aspiration (MVA) with local anaesthetic is currently not offered while surgical management under general anaesthetic is offered for women experiencing a loss under 12 weeks gestation. After this gestation a referral is made to a tertiary referral centre (NHS Grampian). As with expectant and medical management, information is provided about all choices available, what the process entails for each option and the length of time the process may take. They are also informed of the risks from general anaesthesia (procedure under local not offered). Written information from the RCOG is also provided.

If surgical management is the preferred option the patient is added to a theatre list and information is provided about fasting requirements. A gynaecologist will decide on whether to use misoprostol prior to the procedure and this will then determine the time of admission. Post operative recovery would take place in the maternity unit on site and the patient would be discharged once fit to do so. However, if the maternity ward is busy, women who have had surgical management are sometimes recovered on a general surgical ward with outreach from maternity prior to discharge. A discharge letter would be sent to their GP and advice given regarding post operative care and what to expect, including the use of analgesia. Women are told to contact maternity services for any problems or concerns and are provided with contact information for SANDS.