Surgical Options - D & C for Miscarriages

D and C — also known as dilatation (dil-ah-tay'-shun) and curettage (koo-re-tahzh') — is a minor surgical procedure in which the physician first dilates or opens the woman's cervix and then inserts a thin, spoon-shaped instrument and uses it to remove material from the internal lining of the uterus. Dilatation, therefore, stands for opening the cervix; curettage means the scraping of the uterine wall.

This article will explain:

• Why you may need to have a D&C after miscarriage
• How D&C is performed
• What to expect before and after the procedure

This article is not intended to take the place of your surgeon's professional opinion. Rather, the information presented here can help you to begin to understand the basics of this surgical procedure. Read this material carefully. If you have more questions, discuss them openly with your doctor.

Bleeding Associated With Pregnancy

Abnormal bleeding from the uterus (womb) can be due to an abnormal pregnancy or threatened miscarriage. This bleeding is usually pinker and brighter than menstrual bleeding and often starts painlessly. However, if severe cramps follow, a miscarriage is probably on the way. A doctor should be consulted at once. This type of bleeding also occurs as a result of an ectopic pregnancy, a condition in which an egg grows outside the uterus, usually in a fallopian tube. As the egg continues to get larger, severe lower abdominal pain follows. If you experience such pain, particularly in association with bleeding, see your doctor immediately. If not attended to by a health care professional, ectopic pregnancies can result in permanent damage to your reproductive organs, intra-abdominal hemorrhage, and in extreme cases the condition can be fatal.

What Is a Miscarriage?

About one-third of women bleed or have cramping sometime during the first 20 weeks of pregnancy. Of these women, about 15 percent lose their baby - a condition that is called a miscarriage (or spontaneous abortion). In about two-thirds of all miscarriages, the fetus is either absent or is not formed properly. A miscarriage may be a natural rejection of an improperly formed fetus that cannot sustain life. Women who miscarry should go to the doctor for an examination. This examination may involve a D&C.

The Uterus

The uterus is a muscular, pear-shaped organ that has three main functions: (1) to receive an egg that has been fertilized by sperm in the ovary, (2) to nurture and house the fetus (unborn baby) during its development, and (3) to use its muscular walls to push the baby out when it is ready to be born.

Because it is a muscular organ, the uterus has contractions or cramps that occur during the entire monthly cycle, even throughout pregnancy and delivery. The cramps are more intense during your menstrual period, but they also occur throughout the month; you may not even feel them. The pain at menstruation is caused as the cervix opens to release both blood and the lining of the uterus, called the endometrium (en-doh- me-tree'-um).

The uterus of a nonpregnant woman measures about 3 to 4 inches in length and weighs about 3 ounces. During pregnancy, the uterus expands in size to accommodate the growing fetus. At full-term, the uterus weighs about 2 pounds.

Why Do a D&C Following Miscarriage?

There are four types of miscarriages: threatened, inevitable, incomplete and complete. A threatened miscarriage is any bleeding or cramping of the uterus within the first 20 weeks of pregnancy. Inevitable miscarriage is intolerable pain or bleeding that threatens the woman's well-being. If parts of fetal tissue are passed or if the membranes are ruptured, the miscarriage is called incomplete. If the entire fetus is passed, the uterus has reduced in size, and the cervix has closed, the miscarriage is termed complete.

When a woman has a miscarriage, she has cramping pain and bleeds from the vagina. She also may become depressed. She may not feel the need to see a doctor following a miscarriage because she has concluded that the pregnancy is over. But, as in the case of an incomplete miscarriage, she may not expel all the fetal material naturally. A D&C procedure may be performed to remove any remaining material so that she will not develop an infection, inflammation or additional bleeding. Material must be removed from the uterus and cervix to clear the way for the next pregnancy, if one is desired.

D&C is also done in the presence of:

• Abnormal bleeding from the vagina if present without pregnancy.
• Polyps — generally harmless growths that can occur in the cervix or uterus — which become irritated through sexual intercourse or start to bleed. A D&C procedure is usually used to remove polyps.
• Fibroid tumors — generally noncancerous — that can break in the uterus and bleed, occasionally severely. D&C can identify and sometimes remove small tumors, although generally a more extensive operation is required.
• Endometrial hyperplasia — when the uterine lining is too thick. D&C can remedy this condition.

A D&C procedure following miscarriage can be done on an inpatient or outpatient basis in either a hospital or freestanding surgery center. Prior to the operation, you may be given a sedative. An intravenous line (IV) may be started either before or after you enter the operation room. The vaginal area will be washed. Transfusion is rarely needed, but may be employed if severe blood loss has occurred.

There are three steps to a D&C:

1. You will be positioned on your back on a gynecological table; your knees will be bent and your feet will be in stirrups. At this time, the surgeon will pass a series of dilators (narrow instruments of increasing thicknesses) into the vagina and the cervix, gradually opening the strongly contracted muscles of the cervix.
2. When the cervix is sufficiently opened, the surgeon will insert a curette, a sharp-edged loop that is used to scrape the lining of the uterus, into the uterus. Tissue and specimens are removed and examined by the doctor and are sent to a pathology lab for evaluation.
3. A nurse will then put a sanitary napkin in place before you are taken to the recovery room. The operation takes about 10 minutes. You will be in the recovery room for about 30 minutes.

In most cases, you will be discharged from the surgery center or hospital on the same day that a D&C is done. However, you may be kept longer if you have a coexisting problem, such as diabetes or heart disease, or if some complication of the procedure or anesthetic is encountered.

The results of the laboratory evaluation of the removed tissue is usually available within one to two days. At that time, your doctor will recommend treatment for conditions that are identified by the procedure. You will be encouraged to walk to the bathroom and resume normal non-strenuous activity as soon as you are comfortable doing so. Expect slight bleeding and staining for anywhere from five to 14 days following your D&C.

You should refrain from sexual intercourse and the use of tampons for at least seven days or until the bleeding has stopped. Use sanitary napkins during this time. Also, douches should be avoided for two weeks after the operation because the operated area may be exposed to bacteria that can cause infection or inflammation.

Following the D&C, you will be given oral medication for any postoperative pain, such as severe cramps. Most pain disappears within 24 hours. You also may be given an antibiotic to prevent infection.

A D&C procedure that is performed following miscarriage leaves no scar. If your occupation does not involve heavy physical work, you can plan on returning to your job in two to four days. Your doctor will talk to you about when you can again become pregnant if that is what you desire.

Surgery by Surgeons

A fully trained surgeon is a physician who, after medical school, has gone through years of training in an accredited residency program to learn the specialized skills of a surgeon. One good sign of a surgeon's competence is certification by a national surgical board approved by the American Board of Medical Specialties. All board-certified surgeons have satisfactorily completed an approved residency training program and have passed a rigorous specialty examination. The letters F.A.C.S. (Fellow of the American College of Surgeons) after a surgeon's name are a further indication of a surgeon's qualifications. Surgeons who become Fellows of the College have passed a comprehensive evaluation of their surgical training and skills; they also have demonstrated their commitment to high standards of ethical conduct. This evaluation is conducted according to national standards that were established to ensure that patients receive the best possible surgical care.

Reviewed by:

Roger D. Kempers, M.D., F.A.C.S.,
Professor and Vice-Chairman, Department of Obstetrics and Gynecology,
The Mayo Clinic, Rochester, MN

Hugh M. Shingleton, M.D., F.A.C.S.,
J. Marion Sims Professor and Chairman Emeritus, Department of Obstetrics and Gynecology, University of Alabama Hospitals, Birmingham, AL

• Hysteroscopy

• Laparoscopy

• D & C for Uterine Bleeding Problems

• D & C for Miscarriage

• Hysterosalpingography

• Dilation and Curettage