Miscarriage care in Scotland: delivery framework

Diagnosis and Management of Miscarriage

Considerations

Miscarriage diagnosis

Although diagnosis can be achieved by a negative pregnancy test after bleeding, when there has been a positive pregnancy test, often accurate diagnosis of miscarriage relies on high-quality transvaginal ultrasound scanning (TVUS) to identify location and viability of the pregnancy

It is recommended that a second suitably trained practitioner should confirm the diagnosis of miscarriage when the scan is diagnostic of miscarriage, in line with NICE guidelines. Those experiencing miscarriage should be offered a second opinion, including returning on another date to have this second ultrasound opinion where not possible on the same day. Further information on miscarriage diagnosis can be found at Annex D.

Miscarriage management

Women should be given written and verbal information on miscarriage management options, including data on success rates, risks and benefits, and be supported to choose the management approach that suits their needs and preferences. If required, interpretation services, including British Sign Language (BSL) should be available for women, in-person where possible, throughout their assessment and care. These services should be delivered compassionately.

There are three recognised management pathways for miscarriage:

Expectant management (also called natural or conservative management) – this means waiting for the natural passage of pregnancy tissue and allows a miscarriage to happen without medical intervention. This method is often recommended in the early part of the first trimester. Expectant management is an effective approach for women with incomplete miscarriage but is less effective than medical or surgical management for women with missed miscarriage. The NICE guidelines state that expectant management should be the first method considered.

Medical management – this means treatment with medication taken orally and/or vaginal tablets (pessaries) to start or assist the process of a missed or incomplete miscarriage. The medications used for the medical management of miscarriage are mifepristone and misoprostol. Misoprostol is a synthetic prostaglandin E1 analogue that induces cervical softening and uterine contractions. Misoprostol alone can complete an incomplete miscarriage. Mifepristone acts as a competitive progesterone and glucocorticoid receptor antagonist that interferes with the nuclear receptor signalling of progesterone, blocking its actions and sensitising the uterus to the effects of misoprostol to facilitate completion of the miscarriage. Among medical management strategies, a combination of mifepristone and misoprostol is more effective than misoprostol alone in completing a missed miscarriage and NICE recommends a combination of mifepristone and misoprostol for the medical management of missed miscarriages.

Surgical management – this means to remove the pregnancy tissue surgically. Surgical methods involve dilation of the cervix and suction aspiration of pregnancy tissue, with or without the preparation of the cervix with misoprostol to minimise the risk of injury from cervical dilation. Surgical management can be carried out under general anaesthetic or regional anaesthetic (such as spinal block) using electric suction aspiration, although it can be safely performed as manual vacuum aspiration (MVA) under local anaesthetic. The range of anaesthetic options should be made available to women so they can make a choice most acceptable to them. This may include travel to a different site within boards, but wherever possible the range of options should be made possible at all EPU/EPAS.

After miscarriage

Women should be counselled on what to expect following a miscarriage (including expectant management). Advice should be given about potential duration (how long things might take to resolve), extent of pain or bleeding and possible side effects. Some women will require more than one treatment if the initial management fails or if there are worsening symptoms and management needs expediting. Women should be advised when and how to seek help if existing symptoms worsen or new symptoms develop, including giving them a 24‑hour contact telephone number with access to specialist early pregnancy or obstetrics and gynaecology staff. Women should be provided with a take home pack including information on support, signposting to NHS inform pages, pain relief, menstrual pads and a urine pregnancy test to take three weeks after management of miscarriage. It is good practice to keep a log of women who are managing miscarriage at home and provide an individualised patient-centred wellbeing call to support those women. Women should be advised to return for individualised care if the post miscarriage pregnancy test is positive. Anti-D should be provided to women following surgical management of miscarriage.

As well as the practical management of miscarriage there is also the emotional impact of the loss of a pregnancy. The way in which people process this loss varies. Written and verbal information about miscarriage should be provided and the woman offered the ability to recontact the EPU/EPAS. The woman should be signposted to the NHS inform miscarriage pages NHS inform - losing a baby and NHS inform - after losing a baby and the Scottish Government Memorial Book of Pregnancy and Baby Loss Prior to 24 Weeks and The Memorial Book - National Records of Scotland webpages. A list of resources for support is included in Annex E.

Written information about miscarriage should provide information about support for the emotional impact of pregnancy loss. This should include contact numbers to speak to EPU/EPAS staff, and information about support available from the NHS as well as third sector organisations. While it is acknowledged that counselling, bereavement support and psychological support services may be stretched in some areas, there is an unmet need for clear local guidance for EPU/EPAS staff to facilitate onward referral to additional support services, where required.

Key Actions

10. Those experiencing miscarriage at any stage of pregnancy should be seen in a separate private space appropriate for bereavement, as advised in the NBCP Bereavement Care Standards, and if admitted to hospital, where possible be treated in a single room. Generally, this should be located within maternity services away from other pregnant, labouring or postpartum women, or in an EPU/EPAS, or other clinically appropriate environment that has privacy in spaces sensitive to the needs of all individuals. Rooms should ideally have soundproofing. Women/couples who wish to avoid walking through areas where there are other pregnant women should be given the choice of using a different exit, or if that is not possible, they should if they wish, be compassionately accompanied through the shared area rather than being left to walk alone.

11. NHS Boards should ensure that clear local procedures are in place, in line with NICE Guidelines, for the diagnosis of miscarriage using ultrasound scanning by appropriately trained and validated ultrasonography practitioners and conducted in single rooms.

12. NHS Boards should 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.

13. Clear written and verbal information on the miscarriage management options should be given to women and available for other care providers. Women need to be supported to choose the management approach that suits their needs and preferences. If required, interpretation services including British Sign Language (BSL) to be available for women, in-person where possible, throughout their assessment and care, ensuring that this is delivered compassionately.

14. Where medical management is opted for, the use of mifepristone in advance of misoprostol should be standard practice as it increases the chance of success in missed miscarriage.

15. Where surgical management of miscarriage is opted for, women are to be offered a choice of anaesthetic options including manual evacuation under local anaesthetic. Provide clear and realistic information, on each option, including intra and post-surgical pain relief, to support fully informed decisions.

16. Where NHS Boards do not have all anaesthetic options available, the networked approach should be adopted, with clear formal agreements in place to seek care in an adjacent NHS Board to facilitate patient choice.

17. After a miscarriage, women are to be provided with written and verbal information about miscarriage and support available, signposted to the NHS inform miscarriage and pre-conception health pages, and, where appropriate, contraceptive advice should also be provided. The NHS inform information will be accessible to all and made available in translated and audio versions. NHS inform - early pregnancy units and NHS inform - losing a baby and NHS inform - after losing a baby.

18. After miscarriage, women are to be provided with the Scottish Government/National Records of Scotland leaflet on the memorial book of pregnancy and baby loss prior to 24 weeks and directed to the Scottish Government and National Records of Scotland; related webpages: Memorial Book of Pregnancy and Baby Loss Prior to 24 Weeks and The Memorial Book - National Records of Scotland.