Miscarriage care in Scotland: delivery framework

The Graded Model of Miscarriage Care

Considerations

First miscarriage

After a first miscarriage, information about the effects of body mass index (BMI), diet, micronutrients (Vitamin D and folic acid), and health-harming products (excessive caffeine, alcohol, tobacco smoking) and medical co-morbidities should be highlighted to women/couples at an appropriate time, with the opportunity for appropriate additional contact and referral. An important concern is the psychological effects of miscarriage: women should be given information about how to seek support for psychological distress after miscarriage. This includes signposting to bereavement care, high-quality information, third sector support groups, and self-help websites, as well as their primary care team. Miscarriage can highlight some future obstetric risks and as well as preconception health optimisation there are tools available for risk assessment for preterm birth, fetal growth restriction and stillbirth to personalise antenatal care. Further information about counselling can be found in Annex E. Further information on BMI, diet and nutrients, and health-harming products can be found at Annex F .

Progesterone use

To facilitate the use of micronised progesterone treatment, as set out in professional guidance, for those with a previous miscarriage who are experiencing bleeding in early pregnancy, NHS Boards must follow the NHS Scotland National Guidance on the Use of Progesterone in the Management of Threatened Miscarriage and Recurrent Miscarriage. Further information on the use of micronised progesterone can be found at Annex F.

Two previous miscarriages

In addition to the information and support offered after one miscarriage, the graded model of care in the Lancet series, ‘Miscarriage Matters’, recommends additional follow-up care, including offering an appointment at a nurse-led or midwife-led please miscarriage clinic for full blood count and thyroid function testing. In line with other guidance, screening for acquired thrombophilia with anticardiolipin and lupus anticoagulant testing is also appropriate at this stage. A reassurance scan should also be offered at 7 to 8 weeks of a subsequent pregnancy, or at a gestation prior to 12 weeks that is preferred by the woman; for example, someone who has always miscarried at 9 or 10 weeks may prefer a slightly later ultrasound scan. Further information on anaemia, thyroid function and acquired thrombophilia can be found at Annex F .

Three previous miscarriages

After a third miscarriage, women will be offered an appointment at a specialist recurrent miscarriage clinic where additional tests and a full range of treatments can be offered. The consultant/appropriate medical staff should have specialist interest in recurrent miscarriage and be up to date with latest national, international guidance and latest research findings. Each clinic should have dedicated nursing and clerical support. Pregnancy tissue from the third and any subsequent miscarriages will be sent for genetic testing.

A comprehensive medical history should be taken for both partners, where appropriate. A history proforma can be implemented, which collates the details regarding previous miscarriages. The Royal College of Obstetricians and Gynaecologists has produced evidence-based guidelines for the delivery of high-quality recurrent miscarriage care. For some people who experience recurrent miscarriage, a potential cause is an underlying medical problem that may or may not already be identified. Such problems include thyroid disease, anaemia, poorly controlled diabetes and anti-phospholipid syndrome. Women with these conditions often require joint-specialist antenatal surveillance throughout pregnancy and ongoing primary care follow up. Referral pathways to access appropriate specialist clinics (such as clinical genetics, haematology, endocrinology, infertility and obstetric pre-pregnancy) should be in place.

Unexplained recurrent miscarriage itself is associated with adverse antenatal and perinatal outcomes. In addition, co-morbidities associated with recurrent miscarriage, and further information obtained during investigation of miscarriage, can worsen antenatal and perinatal outcomes. That means that clear pathways of communication with the multidisciplinary antenatal team are essential. Support, with health optimisation and clear information, before, during and after pregnancy is also vital.

After three previous miscarriages, women should be offered assessment for congenital uterine abnormalities, ideally with a 3D ultrasound and an early pregnancy reassurance scan in subsequent pregnancies. After four previous miscarriages, the addition of vaginal micronised progesterone (such as uterogestan 400mg BD) from positive urine pregnancy test to 12 weeks of gestation should be offered. This guidance, with regards to when to start and duration for treatment, is based on the PROMISE study and differs from the guidance for threatened miscarriage in those with previous miscarriage(s), which is based on the PRISM study and NICE guidelines. To ensure intrauterine gestation, an ultrasound scan should be offered at 6 weeks’ gestation for those women treated with progesterone. After five or more miscarriages it is appropriate to perform parental karyotype assessment if no genetic information is available. Follow-up may be with the consultant, specialised nurse/midwife, or the bereavement care team.

Further information on medical management of those with experience of three or more miscarriages can be found at Annex G.

Delivering the Graded Model of Care

It is recommended that caregivers neither normalise nor over-medicalise recurrent miscarriage care but individualise care according to women’s, and their partners’, needs and preferences. The Lancet series ‘Miscarriage Matters’ defines the minimum set of investigations and treatments that should be offered to women/couples who have had repeated miscarriages (Figure 3). Services for couples who have had recurrent miscarriages should not only have their physical support needs at the centre of their care, but also their psychological support needs. Staff working within the EPU/EPAS setting may need additional training to sensitively deliver the graded model of miscarriage care.

Current evidence indicates that treatment of tobacco dependency and stress management should be prioritised to improve general health and reduce the risk of miscarriage. Alcohol should be avoided throughout pregnancy, fruit and vegetables should be thoroughly washed to avoid the risk of ingesting pesticides, and the possibility of reducing night shifts should be explored. Further information on BMI, diet and nutrients, reduction in the use of health-harming products (e.g. tobacco, alcohol), and the use of progesterone after a first miscarriage where the patient is currently bleeding can be found at Annex F.

Figure 3. Graded model of miscarriage care

1st Miscarriage

Provide information and guidance to optimise preconceptual health

Patient assessment and self-assessment for access to additional support

Referral to improve diet and reduce use of health-harming products and address medical co-morbidities as required

2nd Miscarriage

Additionally:

Offer discussion with early pregnancy health care professional

Assessment of preconception health with advice and intervention as required

Investigation of full blood count and thyroid function and screening for acquired thrombophilia

Offer early reassurance scan in subsequent pregnancy

3rd Miscarriage

Additionally:

Offer support at a recurrent miscarriage clinic

Assessment of pre-pregnant uterus using ultrasound

Offer tissue karyotyping in subsequent pregnancy

Appropriate referral for assessment and health optimisation where indicated

4th Miscarriage

Additionally:

Recommend vaginal micronised progesterone from positive pregnancy test to 12 weeks

5th Miscarriage

Additionally:

Parental karyotyping

Key Actions

19. All NHS Boards to provide a graded model of miscarriage care as recommended in the Lancet series, Miscarriage Matters published in 2021.

20. After a first miscarriage, women should be given and/or signposted to high-quality information to allow them to self-assess modifiable risks at a time appropriate to their individual circumstances.

21. After a first miscarriage, women/couples should be able to speak to a nurse/midwife with expertise in early pregnancy complications and care if they have additional questions and require additional support after accessing the above information, and self-assessing.

22. After a second miscarriage, women should be offered an appointment with an early pregnancy nurse/midwife where personalised care and initial investigations can take place or be organised. Where abnormal investigation results are found, a local pathway should be developed to manage these results including, where appropriate, a referral to an appropriate primary or secondary care doctor.

23. After two miscarriages, women should be offered full blood count, thyroid function testing and screening for obstetric antiphospholipid syndrome (APS) using anticardiolipin antibodies and lupus anticoagulant tests.

24. After two or more previous miscarriages, an early ultrasound scan in a subsequent pregnancy should be offered, at a time most sensitive to the couple’s needs, but not before 7 weeks’ gestation if asymptomatic (no pain or bleeding).

25. After three miscarriages, women/couples should be offered the opportunity to attend a specialist recurrent miscarriage clinic. All NHS Boards should provide specialist consultant or equivalent medical staffing within these clinics and ensure dedicated time is allocated, or develop a formal agreement where women can be referred to their preferred NHS Board that can provide such a recurrent miscarriage clinic.

26. After three miscarriages, women should be offered uterine imaging for congenital and acquired uterine abnormalities using 3D ultrasound. 3D ultrasound has been shown to improve detection of uterine anomalies therefore NHS Boards should develop access to this service where it is not available.

27. Where 3D ultrasound is not available, 2D ultrasound should be offered after a third miscarriage. Where any abnormality is suspected, further imaging with 3D ultrasound, at a different site or with an agreement with another NHS Board, or MRI should be offered.

28. Cytogenetic analysis should be offered on pregnancy tissue of the third and subsequent miscarriage(s). This may require a maternal blood sample to check that the fetal genotype has been tested.

29. Asymptomatic women with four previous miscarriages should be offered vaginal micronised progesterone from a positive urine pregnancy test until 12 weeks of gestation, where clinically appropriate. They should be provided with written information on available evidence and potential benefits/risks. An ultrasound scan should be provided at 6 weeks’ gestation, for these women treated with progesterone, in order to confirm intrauterine gestation.

30. Couples with five or more previous miscarriages should be offered parental karyotyping where no results of genetic testing of pregnancy tissue are available (including previous maternal cell contamination, or where no pregnancy tissue is available for testing). National discussions are ongoing to support this deliverable.

31. All NHS Boards should have a nurse-led or midwife-led team with specialist training and expertise in recurrent miscarriage and time allocated commensurate with local service needs to provide support to couples with recurrent miscarriage and work alongside the specialist medical clinic.