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

Management options

In NHS Western Isles all three sites strongly agreed that women are free to choose their preferred management approach based on their needs and preferences. Uist and Barra Hospital and Barra Community Hospital disagreed that women are offered only the management approaches provided on site as they refer women to Western Isles Hospital for most management options. All three sites strongly agreed that women may be referred to another site depending on the management approach they choose.

All treatment options for miscarriage care, detailed below, are offered at Western Isles Hospital with other sites referring patients to this site for all treatment. All options were offered during first trimester losses and medical management is offered during second trimester losses. These include:

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.

Expectant management in NHS Western Isles

All women who are treated for miscarriage at Western Isles Hospital are provided with a one-to-one discussion with a consultant about appropriate care, geographical location is also considered in line with the woman's preference. Women will have ongoing monitoring of their situation during weekly consultations either by telephone or via a midwife where women's wishes will be discussed. Expectant management is offered to women under 10 weeks' gestation.

At Uist and Barra Hospital, women in their first trimester who chose expectant management can remain at home and be advised that it could take a few days or weeks for tissue to pass. They are informed that they may experience extreme pain and heavy bleeding and are advised to take regular analgesia for comfort. They will be advised to take a home pregnancy test after 3 weeks. If the pain and bleeding have not started within 7 to 14 days, or it is continuing or getting worse, they will be offered a scan. Support is given by the community midwife and contact information for the miscarriage association is also given.

At Barra Community Hospital women who chose expectant management are given contact details for NHS24 and have daily communication with midwives. Women will also be provided with a local hospital number for advice.

Medical management in NHS Western Isles

Medical management is carried out at Western Isles Hospital, with patients from Barra and Uist Hospital and Barra Community Hospital being referred to Western Isles Hospital. Women and their partners (if applicable) are advised of the process and are asked to attend the hospital for assessment where treatment with a tablet or pessary is administered to start the process. Women are given leaflets to discuss the differences between medical and expectant management and any potential need for surgical intervention. They are also advised that they can call the unit at any time if needed.

Medical management as an outpatient is offered for first trimester losses at Western Isles Hospital. Inpatient medical management is offered for first and second trimester losses. Both outpatient and inpatient medical management involves women taking mifepristone, followed by misoprostol a minimum of 12 hours apart, and preferably at least 24 hours after mifepristone. This is repeated at hourly intervals to a maximum of four doses. If the first course is unsuccessful there should be a break of 12 hours after the last dose of misoprostol; mifepristone would be repeated and a consultant informed.

Treatment is followed up with a pregnancy test after a few weeks and support is offered by midwifery staff. Women are also offered the opportunity to attend the Gynaecology clinic if they have any concerns. Relevant blood tests are taken. Community midwifes and the patients GP are informed prior to the patient leaving the site, with a follow-up appointment arranged with the patient's consultant in 4-6 weeks.

Surgical management in NHS Western Isles

All women receiving surgical management for miscarriage are seen at Western Isles Hospital where the procedure is explained as well as risks regarding uterus trauma and future pregnancy.

The treatment pathway for surgical management described by Western Isles Hospital involves a dilation and curettage procedure. Depending on the situation the treatment pathway would be considered routine, gynaecology-led or emergency-led.

The follow-up is similar to medical management, investigations should be discussed such as relevant blood tests and testing pregnancy tissue if necessary. Follow-up appointments would be made with the patient's consultant within 4-6 weeks, the community midwife and the patient's GP would also be informed. Bereavement counselling and support is provided as well as discussion about future fertility and contraception.