Miscarriage care in Scotland: delivery framework

The Importance of Miscarriage

Context

Early pregnancy care represents a large, but often unmeasured, volume of clinical activity. For example, in the Royal Infirmary of Edinburgh, which sees approximately 7,000 births each year, around 5,000 women contact the early pregnancy unit annually because of concerns in the first 12 weeks of pregnancy. In Aberdeen Maternity, the early pregnancy unit has over 1,000 calls a month from women under 24 weeks’ gestation. Women who attend may be experiencing bleeding, pain or issues with nausea and vomiting, or have a past history of early pregnancy problems. Early pregnancy services manage all women with potential or actual early pregnancy problems, including suspected or confirmed miscarriage, ectopic pregnancy and molar pregnancy, and all these losses are recognised in the National Bereavement Care Pathway NBCP Scotland. Up to 80% of women attending early pregnancy units have an ongoing pregnancy.

The framework acknowledges all of this but focuses on first trimester miscarriage care.

Definition

Miscarriage is the spontaneous loss of an intrauterine pregnancy up to the end of the 23rd week of pregnancy. Definitions of when the first trimester ends, and the second trimester starts are varied. Herein, we consider that first trimester miscarriages occur in the first 11 weeks and 6 days of pregnancy, while second trimester miscarriages occur between 12 weeks and 23 weeks and 6 days of pregnancy. It is thought that miscarriage affects around one in five pregnancies before 12 weeks gestation, though it is likely that very early miscarriages - sometimes called ‘biochemical pregnancies’ - are even more frequent.

The clinical definition of Recurrent miscarriage varies. For example, The European Society of Human Reproduction and Embryology (ESHRE) defines recurrent miscarriage as two or more pregnancy losses after 6 weeks, excluding ectopic and molar pregnancies. The 2023 Royal College of Obstetricians and Gynaecologists guidance defines recurrent miscarriage as three or more non-consecutive first trimester miscarriages. The American Society for Reproductive Medicine suggests that three or more losses should be used for epidemiological studies while clinical evaluation may proceed following two first-trimester losses.

The Scottish Government supports the graded model of care in the Lancet series, ‘Miscarriage Matters’. This puts in place pathways of care that start after one miscarriage and are linked to the number of previous miscarriages, with initial investigation of causes of miscarriage taking place after two miscarriages.

Type

A Complete miscarriage is where the pregnancy tissue has all been expelled from the uterus and the bleeding has stopped. An ultrasound scan would clearly show no pregnancy tissue in the uterus. It is important to consider an ectopic pregnancy in all cases where an intrauterine pregnancy has not been confirmed and this would involve additional pregnancy hormone testing. This may be referred to as pregnancy of unknown location until hormone tests provide more information.

An Incomplete miscarriage is where some, but not all, pregnancy tissue has passed from the uterus. Women will usually have ongoing pain and bleeding, and pregnancy tissue would be visible in the uterine cavity on an ultrasound scan.

A Missed miscarriage is where the pregnancy tissue remains complete inside the uterus without fetal heart activity or where the pregnancy remains inside the uterus but only a pregnancy sac has developed. The woman may have minimal symptoms, and a missed miscarriage can be discovered at a routine scan appointment.

A Threatened miscarriage is where the pregnancy remains viable (ongoing) or potentially viable with a closed cervix, but the woman experiences early pregnancy bleeding. This is very common: more than 25% of women may experience threatened miscarriage in the first 12 weeks; the majority do not miscarry.

Prevalence

In the UK, an estimated 250,000 miscarriages occur every year, suggesting around 25,000 per year in Scotland. Miscarriage is the commonest complication of pregnancy. The population prevalence of women who have had one miscarriage is 10.8% (10.3–11.4%), two miscarriages is 1.9% (1.8–2.1%), and three or more miscarriages is 0.7% (0.5–0.8%). The prevalence of late miscarriage, defined as being between 12 weeks and 23 weeks and 6 days of pregnancy, is estimated to be 1% of all pregnancies and around 15% of all miscarriages.

However, the exact incidence of miscarriage remains uncertain. Many women do not present to hospital when experiencing a miscarriage and their experiences of miscarriage are not always reported or recorded, with the true impact of miscarriage likely to be underestimated. Miscarriage data have not been published in Scotland since 2016 because data is only collected nationally from inpatient settings, although having a miscarriage will be recorded in a women’s medical records if she presents to services. The Scottish Government recognises that data recording and reporting will facilitate data-informed patient-centred care and has commissioned Public Health Scotland to collect meaningful miscarriage data. A miscarriage (early pregnancy) data set has been agreed and Public Health Scotland is now testing this data set using data extracted from clinical information systems.

Risk of miscarriage

The risk of miscarriage is lowest in women with no history of miscarriage (11%), and increases by about 10% for each additional miscarriage, reaching 42% in women with three or more previous miscarriages. Risk of miscarriage is lowest in women aged 20–29 years at 12%, increasing to 65% in women aged 45 years and older, and likely to be even higher in women with recurrent miscarriage and age-related risk. Black women, additionally, are reported to have a 40% higher miscarriage risk when compared with women of white ethnicity. Male age older than 40 years is also associated with an increased risk of miscarriage.

Female body-mass index (BMI) is associated with miscarriage risk; the BMI associated with the least risk of miscarriage is 18.5–24.9 kg/m². Health-harming products, including tobacco, excessive caffeine and alcohol consumption during pregnancy have been associated with an increased risk of miscarriage, as have persistent stress, exposure to air pollution and exposure to pesticides.

Risks of previous miscarriage

Miscarriage, and especially recurrent miscarriage, is associated with future obstetric complications which can impact on child development. The risk of preterm birth increases stepwise with each previous miscarriage, showing a biological gradient with the highest risk in women with three or more previous miscarriages. The risk of fetal growth restriction, placental abruption, and stillbirth in future pregnancies is also increased. The antenatal care needs of women with recurrent early miscarriage, or late miscarriage in subsequent pregnancies, is largely unknown.

A history of recurrent miscarriage is also a predictor of longer-term health problems and is associated with an increased risk of cardiovascular disease and venous thromboembolism.

There is currently no universally used tool to screen for psychological distress following a pregnancy loss. There is a clear unmet need as women and their partners experiencing recurrent miscarriage are at risk of serious mental health conditions, including depression, anxiety, post-traumatic stress disorder (PTSD) and suicide. The risk of PTSD is 17% at nine months after miscarriage and suicide risk is increased fourfold. Women with these conditions often require specialist psychological support to help manage the significant distress and heartbreak of their losses. For some, access to specialist psychological services in addition to recurrent miscarriage and primary care support will be required. There is a need for improved access to specialist counselling or support services for women and their partners experiencing miscarriage.

Cost

The costs of miscarriage affect individuals, health-care systems, and society. The short-term national economic cost of miscarriage is estimated to be at least £471 million per year in the UK and approximately £47 million in Scotland.

Key Actions

1. Miscarriage can have significant emotional and psychological impacts. At all points of contact, healthcare services should provide compassionate, culturally competent, and high-quality bereavement care, including clear communication and appropriate support.

2. All NHS Boards to fully implement all five National Bereavement Care Pathways (NBCP), including the Miscarriage, Ectopic and Molar Pregnancy Pathway. A link to the NBCP can be found at NBCP Scotland.

We are very pleased to have been part of the Delivery Framework for Miscarriage Care ensuring the lived experience voices were represented in the key actions of the Framework. We hope the new Delivery Framework ensures families across Scotland receive the care they need, and deserve, following loss.

Nicola Welsh, Chief Executive,

Held in Our Hearts

This framework is a vital step in providing evidence-based care and offering women additional support in early pregnancy. We are proud to have contributed to its development and look forward to seeing it bring positive change. This is a crucial milestone in ensuring that miscarriage care is accessible, equitable, and compassionate across Scotland.

Vicki Robinson, Chief Executive,

Miscarriage Association

The Framework is a real milestone on the path to excellent care for women and families in Scotland and Tommy’s has been pleased to work closely with our colleagues in Scottish Government as they have developed the Framework, with compassionate care at its heart. We are looking forward to continuing to support our Scottish colleagues as they oversee the rollout.

Kath Abrahams, Chief Executive,

Tommy’s