Miscarriage Care and Facilities in Scotland: Scoping Report NHS Tayside

Summary

A summary of findings is presented below and shown in Table 25 against the recommendations within the Lancet series on Miscarriage Matters and the Scottish Government Programme for Government commitments.

In NHS Tayside, Ninewells Hospital is the core site that provides care for those that experience miscarriage. In NHS Tayside Ninewells Hospital and Perth Royal Infirmary both agreed that women are free to choose their preferred management approach based on their needs and preferences, while Arbroath Infirmary neither agreed nor disagreed.

In NHS Tayside, Arbroath Infirmary does not provide any written information about the treatment options for the management of miscarriage and what to expect in terms of miscarriage care or information on what would happen before, during and after any treatment options as all women are transferred to Ninewells Hospital where they are provided with this information.

In NHS Tayside, at Ninewells Hospital women are provided with full explanations about what would happen during their chosen method of management, after the chosen method of management and in terms of follow-up. Women are free to choose their preferred management approach based on their needs and preferences.

In NHS Tayside a graded approach to treatment of recurrent miscarriage is provided at Ninewells Hospital, where all patients within the Health Board area are referred. Almost all elements outlined in the Lancet series on Miscarriage Matters are provided in NHS Tayside. Regarding mental health care, Ninewells Hospital stated that emotional counselling is offered to women but there is currently no scope for mental health management on site and that women are advised to seek GP support for this.

Dedicated facilities are available at Ninewells Hospital, where more than five separate rooms are available away from the labour ward for women that are miscarrying.

In NHS Tayside, Ninewells Hospital has a separate area to carry out complication/investigative scans separated from women with a continuing pregnancy.

In NHS Tayside data on miscarriage is collected via BadgerNet and Trakcare. Currently only Perth Royal Infirmary collect data including; the number of miscarriages, miscarriages as a proportion of pregnancies, gestation, maternal age, parity, ethnicity and SIMD. Ninewells Hospital reported that they have not started collecting data due to change in booking services firstly to Trakcare and then to BadgerNet, there is a plan to have a database and dashboard in the near future. However, some of the data above can be filtered out from the current system used at Ninewells Hospital.

Table 25: Scottish Government Programme for Government (PfG) Commitments and the Lancet Miscarriage Matters Recommendations

Source: PfG

Commitment/Recommendation: Ensure women’s services in Health Boards have dedicated facilities for women who are experiencing unexpected pregnancy complications.

Service provision in NHS Tayside: NHS Tayside have dedicated provision for women experiencing unexpected pregnancy complications at Ninewells Hospital; these facilities are provided in the early pregnancy unit (EPU) and outwith the EPU, in the gynaecology ward and in the maternity assessment area. Ninewells Hospital has more than five single rooms available. It is noted that some rooms/areas are not solely used for miscarriage care and may be used for other pregnancy complications or loss.

Source: The Lancet: Miscarriage Matters

Commitment/Recommendation: A graded approach to the treatment of recurrent miscarriage

Service provision in NHS Tayside: Provided at Ninewells Hospital.

After first miscarriage Source: After the first miscarriage, women will be guided to information about miscarriage

Service provision in NHS Tayside: Provided at Ninewells Hospital.

Source: After the first miscarriage, women will be guided to resources to address their physical needs

Service provision in NHS Tayside: Provided at Ninewells Hospital.

Source: After the first miscarriage, women will be guided to resources to address mental health needs following pregnancy loss

Service provision in NHS Tayside: Provided at Ninewells Hospital.

Source: After the first miscarriage, women will be guided to ways to optimise their health for future pregnancy

Service provision in NHS Tayside: Provided at Ninewells Hospital.

After First Miscarriage - this approach could involve: Source: Patient support groups

Service provision in NHS Tayside: Provided at Ninewells Hospital, Perth Royal Infirmary and Arbroath Infirmary.

Source: Online self-help strategies for mental health

Service provision in NHS Tayside: Provided at Ninewells Hospital, Perth Royal Infirmary and Arbroath Infirmary.

Source: Weight management

Service provision in NHS Tayside: Provided at Ninewells Hospital, Perth Royal Infirmary and Arbroath Infirmary.

Source: Smoking and recreational drugs cessation services

Service provision in NHS Tayside: Provided at Ninewells Hospital, Perth Royal Infirmary and Arbroath Infirmary.

Source: Information on appropriate preconceptual folate and vitamin D supplementation

Service provision in NHS Tayside: Provided at Ninewells Hospital, Perth Royal Infirmary and Arbroath Infirmary.

Source: Referral to necessary services for management and optimisation of chronic maternal medical conditions (e.g., diabetes, hypertension, heart disease, and epilepsy)

Service provision in NHS Tayside: Provided within NHS Tayside. Mostly seen by GP.

Source: Screening for mental health issues.

Service provision in NHS Tayside: Provided at Ninewells Hospital.

After second miscarriage Source: Women will be offered an appointment at a miscarriage clinic nurse or midwifery-led

Service provision in NHS Tayside: Provided at Ninewells Hospital (Nurse-led or consultant-led clinic).

Source: Continuity of Carer

Service provision in NHS Tayside: Provided at Ninewells Hospital and Perth Royal Infirmary.

Source: Tests for full blood count are offered

Service provision in NHS Tayside: Provided at Ninewells Hospital (if clinically indicated) and Perth Royal Infirmary.

Source: Tests for thyroid function are offered

Service provision in NHS Tayside: Provided at Perth Royal Infirmary.

Source: Discussion about lifestyle issues

Service provision in NHS Tayside: Provided at Ninewells Hospital and Perth Royal Infirmary.

Source: Referral for specialist care will be arranged if tests are abnormal or if there is a chronic medical or mental health problem.

Service provision in NHS Tayside: Provided at Perth Royal Infirmary. Provided at Ninewells Hospital if aged over 35 years, women are offered direct referral to the dedicated recurrent miscarriage clinic, referred to obstetric care in pregnancy if risk assessment relevant

Source: Women will have access to support and early pregnancy reassurance scans in subsequent pregnancies.

Service provision in NHS Tayside: Provided at Ninewells Hospital and Perth Royal Infirmary.

After third and subsequent miscarriage Source: 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.

Service provision in NHS Tayside: Provided at Ninewells Hospital and Perth Royal Infirmary.

Source: Pregnancy tissue from the third and any subsequent miscarriages will be sent for genetic testing.

Service provision in NHS Tayside: Provided at Ninewells Hospital.

Source: Blood tests for antiphospholipid antibodies will be arranged.

Service provision in NHS Tayside: Provided at Ninewells Hospital (after review at recurrent miscarriage clinic) and Perth Royal Infirmary.

Source: A pelvic ultrasound scan (ideally three dimensional transvaginal) will be arranged

Service provision in NHS Tayside: Provided at Ninewells Hospital as assessed at recurrent miscarriage clinic and if no previous successful pregnancy.

Source: 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

Service provision in NHS Tayside: Provided at Ninewells Hospital

Source: Appropriate screening for mental health issues

Service provision in NHS Tayside: Ninewells Hospital stated that emotional counselling is offered to women but there is currently no scope for mental health management on site and that women are advised to seek GP support for this. Perth Royal Infirmary can refer/access within Health Board area.

Source: Appropriate care for mental health issues

Service provision in NHS Tayside: Provided on site at Arbroath Infirmary. Ninewells Hospital stated that emotional counselling is offered to women but there is currently no scope for mental health management on site and that women are advised to seek GP support for this. Perth Royal Infirmary can refer/access within Health Board area.

Overall recommendations Source: Appropriate screening and care for future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth.

Service provision in NHS Tayside: Provided at Ninewells Hospital, Perth Royal Infirmary and Arbroath Infirmary.

Source: 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.

Service provision in NHS Tayside: Provided at Ninewells Hospital, Perth Royal Infirmary and Arbroath Infirmary.

Source: Consider giving vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage

Service provision in NHS Tayside: Provided at Ninewells after second and third miscarriage.

Source: 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.

Service provision in NHS Tayside: There are staff with additional specialist training to deal with all baby losses including miscarriage at Ninewells Hospital, Perth Royal Infirmary plan to implement this in the next two years. At Ninewells Hospital, doctors are trained to provide comprehensive miscarriage care.

Source: 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

Service provision in NHS Tayside: Ninewells Hospital reported that scans are conducted in the Early Pregnancy Unit during opening hours. All management options are available at Ninewells Hospital.

Source: 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.

Service provision in NHS Tayside: Data on miscarriage is collected via BadgerNet at all three sites and via Trakcare at Perth Royal Infirmary and Ninewells Hospital. Currently only Perth Royal Infirmary collect data including; the number of miscarriages, miscarriages as a proportion of pregnancies, gestation, maternal age, parity, ethnicity and SIMD. Ninewells Hospital reported that they have not started collecting data due to change in booking services firstly to Trakcare and then to BadgerNet, there is a plan to have a database and dashboard in the near future. However, some of the data above can be filtered out from the current system used by Ninewells Hospital.

Source: Identifying women at risk of psychological distress following miscarriage

Service provision in NHS Tayside: Not provided at Ninewells Hospital, Perth Royal Infirmary and Arbroath Infirmary but can refer/access locally.

Source: Identifying women at risk of psychological distress following miscarriage and the development of optimal treatment strategies have been recognised as research priorities.

Service provision in NHS Tayside: Not assessed

Source: 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.

Service provision in NHS Tayside: Provided at Ninewells Hospital, Perth Royal Infirmary and Arbroath Infirmary.

Source: Miscarriage Management - women should be presented with the available evidence and be free to choose the management approach that suits their needs and preferences

Service provision in NHS Tayside: Ninewells hospital and Perth Royal Infirmary stated women are free to choose their preferred management approach based on their needs and preferences.

Source: Consider pathways of care for miscarriage management, treatment of women with a history of miscarriage and care following a miscarriage.

Service provision in NHS Tayside: Not assessed

Source: The Lancet: Miscarriage Matters Research Recommendations

• Key epidemiological research priority 1 - Establishing how we can monitor miscarriage rates on a population basis.

Service provision in NHS Tayside: 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.

Service provision in NHS Tayside: 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.

Service provision in NHS Tayside: 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

Service provision in NHS Tayside: Work to follow from research priorities 1 and 2 above.