Miscarriages and D&CDr. Gerard M. DiLeo
If a miscarriage occurs, it may be merciful and happen very quickly, allowing your doctor to effect closure quickly. Or it may torment you with equivocal blood work and ultrasounds too early to even identify a fetal pole. Eventually a miscarriage will in fact miscarry. By that I mean the pregnancy will die even if the tissue does not pass. If the tissue doesn’t pass (missed AB) or if it passes incompletely (incomplete AB), there is danger of bleeding and infection. The only type of miscarriage that will escape a D&C is a complete miscarriage. Missed and incomplete miscarriages require a little help in the way of a surgical scraping to remove the rest of the products of conception. The D&C (dilation and curettage) involves dilating the cervix for access if it hasn’t already opened (inevitable AB) and scraping the inside of the uterus to dislodge any remaining pregnancy tissue. An anesthetic is required. An epidural or spinal may linger hours longer than the actual procedure, turning an outpatient surgery into an overnight stay, so the more quickly reversible general anesthetic is preferred. The procedure is done under sterile technique, and infection is rare unless it’s there to begin with (septic AB).
Septic ABs are a particularly hazardous matter. They’re rare, occurring with poor technique (“garage” abortions) or when bacteria have had time to colonize the tissue, as in cases in which a patient wanted to wait for an incomplete AB or inevitable AB to follow through spontaneously. It’s also possible that a septic AB isn’t the result of the miscarriage being infected, but a normal pregnancy being infected, actually causing the miscarriage. Treatment is the same. IV antibiotics in combination with a D&C will successfully manage such a complication that in generations past would have killed a woman. It can still be dangerous, though, because a D&C can stir up the infection, possibly seeding the bacteria throughout the bloodstream. I am always a little nervous the night of the D&C, waiting for that temperature spike from the temporary sepsis I created with the D&C. But the D&C is necessary, and the sepsis usually responds well to a full course of antibiotics. This would not be an outpatient procedure, as several days of IV antibiotics are necessary to completely eradicate the infection.
In a straightforward D&C for a miscarriage that isn’t infected, a patient can be at normal activity the next day, although she may feel a little washed out by the anesthetic. Contrary to popular belief, a D&C is not always necessary to finish a miscarriage. There really is such a thing as a complete miscarriage, and an obstetrician-gynecologist would serve her patient well by trying to avoid surgery for her patient if possible. Unfortunately, a D & C is often needed, but it can create for the patient a definitive end to a sad chapter in her life, allowing her to plan for her next pregnancy.
Complications of D&C
Infection: Since a D&C is an invasive procedure, there is always the risk of infection. This is rare. In fact, the most likely complication may be a bladder infection caused by the routine use of a urinary catheter to empty the bladder before the procedure. This will haunt a patient within a week when she begins to complain of pressure or pain associated with urination. Antibiotic pills will treat this common complication.
Synechiae: Thankfully, the more serious complications are infrequent. Synechiae, an infection of the uterus, can cause scarring within the uterine chamber (the intrauterine cavity). This scarring, stringing across from internal uterine wall to internal uterine wall, can interfere with fertility if severe or threaten miscarriage if mild.
Perforation: If your doctor is properly trained, she should know how to use the curette to gently scrape your uterus without pushing the curette through. But surprises can happen if your uterus is thinned out, as in a late first trimester D&C. Also, if there’s an infection already, the tissue can be very mushy and won’t provide a consistency that is normally felt – the accustomed resistance a doctor knows. Even if there’s a perforation, an overnight stay for observation and antibiotics are all that’s necessary. The observation is for bleeding, and that will be obvious quickly — a stable blood count the next morning being plenty of assurance that a patient can go home with her antibiotics.
Psychological: If the clinical aspects of a miscarriage rudely eject you from the fairy-tale land of pregnancy and baby and rest-of-your-life-with-baby, the loss is all the more of a thud into cruel reality because of the unfriendliness of a surgical procedure. True, closure can be the best thing, but a D&C emphasizing what has happened is more than just a closure – it’s a slamming shut of the door. It’s still better to get the whole painful crisis over with, but a D&C, although quick, is not an easy letdown. Then again, nothing would be. It takes about three months to get over such a loss no matter how the miscarriage is addressed.
Other Types of Miscarriage
The loss of a baby for any reason prior to term is a miscarriage. The Medical lexicographers will argue that if it’s past the first trimester, fetal death is no longer called a miscarriage but instead called a fetal demise. These names are useful for a frame of reference, and I use them myself. But from the parents’ point of view, it’s still a miscarriage – a ravaging of their dreams. Intrauterine death, be it a miscarriage or a fetal demise, is no more a miscarriage than other ways in which a pregnancy can go astray. Ectopic pregnancy, molar pregnancies, and absorbed twins will rob a couple of their futures just as terribly as a “conventional” miscarriage.