Miscarriage Care and Facilities in Scotland: Scoping Report NHS Tayside

Management options

All treatment options for miscarriage care, detailed in Table 16 below, are offered only at Ninewells Hospital with other sites referring patients to this site for treatment. Ninewells Hospital only offers medical management with mifepristone and misoprostol for second trimester losses, all other options are offered in first trimester losses.

All sites were asked to fully describe the treatment pathway for expectant management, medical management and surgical management. The descriptions provided have been presented under the relevant subheadings below; these narratives contain only information provided by the sites during this exercise.

In NHS Tayside before a woman chooses their management option, they are assessed at Ninewells Hospital. Scans are performed to confirm intrauterine pregnancy loss. Provision of information leaflets and discussion about management options are undertaken and patients are given time to consider their options and make a choice, which may take several days as the patient prefers. Once the choice of management option has been chosen the pathway of care is described below for each option.

Expectant management in NHS Tayside

The consultation asked about the advice given to women about expectant management of miscarriage. Advice is provided only at Ninewells Hospital; Arbroath Infirmary and Perth Royal Infirmary transfer patients to Ninewells Hospital who then provide any advice.

The advice provided to patients at Ninewells Hospital about expectant management included; the time period of expectant management, expectations at home, symptoms to be aware of in terms of sepsis cautions, bleeding or feeling unwell, contact numbers to call during the day and out of hours, method of sensitive disposal at home or through the hospital, tests if needed to be done and information leaflets. Women are also informed of all other options of management as applicable to their gestation and details of expectation and risk with each.

Women in NHS Tayside who choose expectant management are provided with written information and sign consent forms. They are then provided with the contact details for the ward and out of hours services. Information is provided in a communication suitable to the patient, including a language line, face to face interpreters or sign language if required. The patient is given a pregnancy test to take home and the patient is asked to telephone in three weeks’ time to provide history of events and results of the pregnancy test. The patient is asked to telephone the EPU if history is not suggestive of complete miscarriage.

Medical management in NHS Tayside

In NHS Tayside medical management with misoprostol is provided in the first trimester only and medical management with mifepristone and misoprostol is offered in the second trimester only. Medical management is offered as an in-patient service in both first and second trimester. Regarding outpatient medical management, all sites said this is offered only in the first trimester and all cases are reviewed in Ninewells Hospital and a plan of care developed.

The pathway of care for medical management at Ninewells Hospital includes an assessment of symptoms to confirm miscarriage and all patients are screened for contraindication to medical management. Patients are provided with information leaflets and management options including the risks associated with the management option and other options available are discussed. Patients are informed of how to take the medication, possible side effects and expectations of the timeframe. They are also given information on how to report significant bleeding and to bring products for testing if this is a third loss. Patients are given time to consider options and make a choice, which may take several days depending on the patient’s preferences, as long as there are no clinical concerns for health.

The treatment pathway described by Ninewells Hospital depends on the gestation and circumstances. If under nine weeks and six days, medical management with outpatient care is the usual medical management option, if chosen by the patient. The patient is given misoprostol in the department and provided with advice on what to expect, with written information. If outpatient treatment is chosen, telephone contacts details for the EPU is provided and analgesia and a pregnancy test are also provided. When at home, early pregnancy unit staff telephone the patient around three hours after the first tablet has been taken to enquire about pain and progression; they will advise if any more tablets are required at this stage. The patient is then telephoned after 48 hours, to check progress and to check how the patient is feeling/coping. If successfully passed, a follow-up telephone call about the pregnancy test is conducted within three weeks. If not successfully passed further medical or surgical options are discussed.

Surgical management in NHS Tayside

In NHS Tayside surgical management with manual vacuum aspiration (MVA) with local anaesthetic is offered in the first trimester (below nine weeks and six days gestation) and surgical management under general anaesthetic is offered in the first trimester.

All treatment using surgical management for patients is conducted at Ninewells Hospital. The advice for patients opting for surgical management at Ninewells Hospital comprised an assessment of symptoms to ensure miscarriage and exclude ectopic and Pregnancy of Unknown Location (PUL). Scans are carried out to confirm intrauterine pregnancy loss. All management options are discussed (surgical, medical, expectant) and information leaflets provided. Patients are given time to consider all options and given several days if required to allow them to make a choice.

The treatment pathway for surgical management provided by Ninewells Hospital involves patients being provided with information leaflets with a full explanation of procedure, full blood count, blood group and blood screening is also carried out. For MVA outpatient treatment with misoprostol is administered and the procedure is performed by middle grade specialty trainee or by consultants. Staff are present to support the patient throughout the procedure. A scan is conducted to ensure the procedure is complete and a period of rest and recovery is observed by the EPU team before the patient is discharged home.

For surgical management with general anaesthetic, the patient arrives as above but the procedure takes place in the theatre with either general anaesthetic or deep sedation. However, during the COVID-19 pandemic all women wishing surgical evacuation of the uterus were offered MVA first as long as no contraindications existed as there was a need to reduce aerosol generating procedures (AGP) and unnecessary hospital appointments.

All inpatients are given a pregnancy test to take home and are contacted or will contact the site two to three weeks after the surgery. If the pregnancy test is still positive, then patients would return for further management.

Referrals and assessment following a loss

All sites were asked if they provide or can access referrals and assessments for support services following a loss.

In NHS Tayside, all three sites were asked if they are able to provide the assessments and referrals listed below in Table 17. All women experiencing miscarriage are referred to Ninewells Hospital. However, all three sites are able to make referrals to other NHS services and can access referrals to third party services locally.

When assessing women for risk of psychological distress following miscarriage and referring women to NHS or third-party services for mental health support following a loss, Ninewells Hospital offer emotional counselling if it is related to current loss. If the patient displays more significant distress the woman’s GP is informed to offer further support which is outwith the remit of the EPU.