Miscarriage Care and Facilities in Scotland: Scoping Report NHS Tayside

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^[7].

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

In NHS Tayside a graded approach to treatment of recurrent miscarriage care is provided at Ninewells Hospital, where all patients within the Health Board area are referred for all management options.

After first miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 18 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^[8] that state this should be offered for women with early pregnancy bleeding and a history of miscarriage rather than a first miscarriage.

In NHS Tayside, Ninewells Hospital reported that almost all of the information provision or services recommended in the Lancet series on miscarriage care are provided on site after a first miscarriage for all gestations. Regarding the provision of vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage, Ninewells Hospital has recently started implementing this and Perth Royal Infirmary are able to refer women to Ninewells Hospital for this treatment. Ninewells Hospital does not currently refer women to necessary services for management and optimisation of chronic maternal medical conditions as patients are mostly already being seen by their GP in these circumstances. All of the provisions offered after a first miscarriage are listed in Table 18 below.

After the first miscarriage, sites in Scotland signpost patients the following services listed in Table 19 below. There was a lack of consistency among sites both within and between Health Board areas on whether signposting was routine for all patients or only provided when deemed appropriate.

At Ninewells Hospital, emotional support is always provided through a dedicated pregnancy loss counsellor for all losses (first, second, third or subsequent loss) should the patient require this. Also, if significant issues are identified such as obesity, then optimising circumstances by weight loss endeavours is advised.

However, Ninewells Hospital do not routinely screen for all medical factors after first pregnancy loss. The different information provisions available for women in NHS Tayside following a first miscarriage are shown in Table 19.

After second miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 20 below, should be available after a second miscarriage.

In NHS Tayside, after a second miscarriage almost all of the information provision or services recommended in the Lancet series on miscarriage care asked about were provided at both Ninewells Hospital and Perth Royal Infirmary; these are listed in Table 20 below. The exception to this was that after a second miscarriage at Ninewells Hospital, care is provided within the obstetrics team or a nurse-led miscarriage clinic rather than a midwifery-led miscarriage clinic, so a midwifery-led clinic would not be offered but the patient would instead be offered a consultant or nurse-led clinic. Perth Royal Infirmary reported that they are unable to provide nurse-led or midwifery-led miscarriage clinics due to not having staff trained for this.

At Ninewells Hospital, women who are over 35 years and have had two miscarriages are made aware of the recurrent pregnancy loss (dedicated) clinic, which has a short waiting time. If they wish to be referred to this service, there is an internal referral pathway, with the referral being forwarded directly to the consultant leading the service. This cuts back the waiting time for women as they bypass the need for a referral from their GP. During the COVID pandemic this clinic converted to a telephone appointment which has continued. This will likely revert back to a face-to-face clinic in the near future, as COVID policies are relaxed (data from summer 2022).

After third and subsequent miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 21 below, should be available after a third or subsequent miscarriage.

In NHS Tayside, after a third or subsequent miscarriage almost all of the information provision or services recommended in the Lancet series on miscarriage care asked about were provided on all three sites or were available elsewhere in the Health Board. Currently, all services except appropriate screening and care for mental health issues are available at Ninewells Hospital. 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.