Miscarriage Care and Facilities in Scotland: Scoping Report NHS Western Isles

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 Western Isles a graded approach to treatment of recurrent miscarriage care is provided at both Western Isles Hospital and Uist and Barra Hospital.

After first miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 15 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.

After a first miscarriage almost all of the information provision or services asked about were provided on site at Uist and Barra Hospital and Western Isles Hospital (Table 15). Both sites provided information about miscarriage, physical health needs, mental health needs, previous miscarriages and optimising health for future pregnancies. Western Isles Hospital does not currently provide development of an individualised health plan, although this service is currently being developed. Regarding vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage, this is offered at Western Isles Hospital. However, circumstances dictate the use of this – although recommended for recurrent miscarriage, it may be considered for women who request this or if they are of advancing age.

As Barra Community Hospital does not have an EPU, Maternity Unit, CMU or an Obstetrics and Gynaecology Department they were not asked this question.

In NHS Western Isles the services offered are provided to all women regardless of the gestation when the loss occurred.

Sites in NHS Western Isles signpost patients to the following services, however, Western Isles Hospital and Uist and Barra Hospital reported different approaches to this, as outlined in Table 16.

As Barra Community Hospital does not have an EPU, Maternity Unit, CMU or an Obstetrics and Gynaecology Department they were not asked this question.

After second miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 17 below, should be available after a second miscarriage.

After a second miscarriage, the majority of the information provision or services asked about are provided on site at Western Isles Hospital, these are listed in Table 17 below. The exceptions to this are appointments at nurse-led and midwifery-led miscarriage clinics and continuity of carer, both due to a lack of need due to small numbers of patients.

As Barra Community Hospital does not have an EPU, Maternity Unit, CMU or an Obstetrics and Gynaecology Department they were not asked this question.

After third and subsequent miscarriage

The Lancet series on Miscarriage Matters recommended the following services, listed in Table 18 below, should be available after a third or subsequent miscarriage.

After a third or subsequent miscarriage the information provision or services asked about that were provided at Western Isles Hospital and Uist and Barra Hospital sites are shown in Table 18 below.

Western Isles Hospital reported that they do not offer sending pregnancy tissue for testing, blood tests for antiphospholipid antibodies or parental karyotyping due to lack of equipment, however, these services can be accessed in another Health Board area.

As Barra Community Hospital does not have an EPU, Maternity Unit, CMU or an Obstetrics and Gynaecology Department they were not asked this question.