I just wanted to say, before getting into the details of D&C or D&E, I am sorry for your loss and that you even need to be reading this area. I have miscarried three different ways (detailed further in the text), so I hope my experiences can help you to make a decision on how you handle yours.
There is no right or wrong way to manage your miscarriage, as long as it is not life-threatening to you. Sometimes you do not have an option in how you manage your miscarriage--it just begins without warning and you miscarry naturally. Other times, you have choices and time to make those decisions, and your choices should be made based on your own personal wants and needs to honor the baby to whom you are saying goodbye.
Why You Would Opt For a D&C or a D&E?
As background, D&C (which stands for Dilation and Curettage) is a procedure done in the uterus by scraping of the lining of the uterus (the endometrium). Another, less invasive, version of a D&C is the D&E (which stands for Dilation and Evacuation). In a D&E, instead of scraping, the lining of the uterus is suctioned out.
The following are the main health reasons a woman may have a D&C or a D&E done:
- for a woman who knows she is going to miscarry and opts not to have a natural miscarriage at home;
- for a woman who a recently miscarried naturally, or who previously had a D&C/D&E done and retained tissue remains in the womb;
- for a woman who is experiencing heavy or irregular periods, or vaginal bleeding after the menopause.
Opting for a D&C/D&E when a miscarriage is detected and has not begun is a personal choice, which has its own set of pros and cons – and there is no right or wrong choice in opting for a D&C/D&E, as long as it is the right choice for you.
Choosing to have a D&C/D&E depends upon several personal factors you need to consider:
- how far along the pregnancy might have been or what bleeding has already occurred;
- how long you have known about the impending miscarriage and the emotional toll already taken on you because of it;
- strong emotional feelings over the impending pregnancy loss;
- emotional preferences on how one feels the pregnancy should be allowed to end;
- family issues, such as care of other children in the home;
- preference for medical testing on the fetal tissue from the miscarriage, especially in recurrent miscarriage;
- work issues, such as project management and duties, and time off for the miscarriage.
What to Expect
A D&C/D&E is considered minor surgery, therefore, it is performed in a hospital or ambulatory surgery center or clinic.
In most cases, you would be given general anesthesia, which would require someone to drive you to/from the location of the procedure. You should not eat/drink anything 12 hours prior to the procedure. Sometimes, women will request local anesthesia instead – that is something that would have to be discussed with the gynecologist performing the procedure.
In the actual procedure, a speculum is inserted into the vagina to open the walls to view the cervix. A clamp-like instrument holds the cervix in place as the cervix is dilated with a series of tapered rods of increasing widths, which are inserted into the cervical opening.
If a D&C is performed, the ob/gyn will insert a specialized scraping scalpel (called a curette) to scrap the retained tissue from the uterus;
If a D&E is performed, the ob/gyn insert a hollow tube through the cervix and suction is applied to remove the retained tissue.
The procedure usually takes anywhere from five to twenty minutes to finish, depending upon how far along the pregnancy was or if the procedure is specifically to clear out retained tissue from a natural miscarriage or previous D&C/D&E.
It is normal to experience light, irregular bleeding in the days following the D&C/D&E, along with mild cramping. Naproxen or ibuprofen is usually given for relief from cramping. You may also be given a prescription for a medication to stop a hemorrhage (just as a precaution should you begin to hemorrhage after the procedure).
Most women are told to take the day of the procedure and the following day off from work (if you work), and to rest as much as possible for those two days. But, generally, physical recovery is fairly quick.
After a D&C/D&E, you should get a list of instructions with the following instructions:
- Avoid intercourse for 2 weeks. Bacteria can easily get into your uterus and cause infection until your cervix returns to normal after the dilation;
- Use only sanitary pads for bleeding. Avoid tampons for at least 2 weeks. Do not use douches;
- Be sure to return for your follow-up visit, usually 2 weeks after the procedure. Your ob/gyn should discuss all lab reports on your tissue samples, if testing of the fetal tissue is ordered. Your ob/gyn will also examine you for any signs of infection and to make sure your cervix/uterus have returned to normal size.
Problems That May Arise and Ways to Troubleshoot
Although I personally have not had any problems after either my D&E nor my D&C, there are several problems that can arise from the procedures:
- If your ob/gyn is too cautious in the procedure (especially with a D&C, since it involved a real scraping scalpel), retained tissue can remain. This tissue is usually passed without complication afterwards, although in some instances, the possible need for another procedure may arise. Sometimes, like a natural miscarriage, tissue is missed;
- Rarely, an ob/gyn can accidentally puncture the uterine wall while performing either a D&C/D&E;
- Hemorrhage is rare, but it can occur if an instrument injures the walls of your uterus. It also can occur if an undetected fibroid is cut during procedure;
- You can end up with an infection because your natural uterine environment is being invaded to do the procedure. Some ob/gyns’ prescribe antibiotics up-front to prevent it from happening - some, like my ob/gyn, do not;
- Asherman’s Syndrome, although rare, can develop later on. This syndrome involves the formation of scar tissue in the uterus, caused by aggressive scraping, repeat D&C/D&E’s, or abnormal reaction to the scraping. Thick scars can result, which can fill up the uterus completely. Abnormal bleeding/loss of periods and heavy cramping are signs of the syndrome. A sonohystogram can detect this scarring, which can be corrected surgically if diagnosed correctly.
Call your doctor immediately if you develop any of the following symptoms:
- Severe persistent pain or cramps not relieved by ibuprofen or naproxen;
- Prolonged or heavy bleeding (more than 6 hours, or requiring a change of sanitary pads several times in 1 hour);
- A foul-smelling discharge from your vagina.
I have personally experienced three miscarriages: One natural miscarriage at 4 wks 1 day (9/04), a blighted ovum which required a D&E since the miscarriage would not start on its own (11/05) and a missed miscarriage when the baby stopped growing at 6 wks 4 days, which I opted to have a D&C immediately (3/06).
Through these experiences, I have several tips that I hope can help anyone that has to go through this experience:
1. Do not let an ob/gyn pressure you into an immediate choice of a D&C/D&E. You need to take into account how you feel you need to manage this decision, and make sure the diagnosis of miscarriage is confirmed.
2. Make sure your miscarriage is confirmed by blood work AND ultrasound before you consider a D&C/D&E. My ob/gyn is very experienced, but he told me that even he has made mistakes in diagnosing a miscarriage - on rare occasions, blood work and repeat ultrasound can detect an incorrect diagnosis and the pregnancy is viable. So, having repeat betas and ultrasounds to confirm the miscarriage is crucial. With my 11/05 miscarriage, I had three beta draws and three ultrasounds to confirm the miscarriage.
3. Discuss the procedure thoroughly with your ob/gyn so you understand how the procedure is done and any questions you have are answered. Be clear on what kind of anesthesia you want - and what is allowed in the surgery center where you are having the procedure. This can be a very emotional procedure, and you need to have your concerns and questions answered before hand.
4. If you experience nausea/vomiting as a morning sickness sign like I did with my 3/06 miscarriage, even though you are miscarrying, you can ask for meds to be injected into your IV line so that, when you wake up from the procedure, the nausea subsides for you.
5. When you wake up from the procedure, be prepared for the reality that the pregnancy is now completely over. When I woke up from my D&E in 11/05, I was crying as I realized the procedure was done. Luckily for me, the nurse was very sweet and gave me tissues and allowed me to cry while she stood there holding my hand.
6. Make sure your ob/gyn leaves instructions on what you should do when you go home and if you see any problems arise after the procedure. Better yet, ask that your ob/gyn stops in to see you after the procedure is done. My ob/gyn stopped in to see me after both my D&C and D&E to make sure I was physically okay.
7. If you have children at home, ask someone to care for them for a little while as you sleep off the anesthesia and you are sure your bleeding after the procedure is within the normal range. To recover well, you need to rest.
8. Remember: After a D&C/D&E, you have now had a complete miscarriage. Your hormones usually “dump” quickly, which can potentially make you an emotional basketcase. I cried through Thanksgiving dinner in 11/05 since my D&E was done two days prior and my hormone levels were going down quickly. So, if you are having a hard time with the loss right after the procedure, it is completely normal and to be expected.
9. If you are not prepared to go back to work (if you work) after the two days home, don’t. My D&E in 11/05 was done two days before Thanksgiving, so despite the holiday, I had several days to begin to sort through the emotions. But, after my D&C was done in 3/06, I returned to work after the two days - and it was just not enough time to begin to the grief process.
10. Insist on that follow-up visit in two weeks. Some ob/gyns try to skate around it - you really need the follow up to make sure you are physically recovered and to ask questions you may have.
11. Ask for repeat betas afterwards to make sure your HCG levels are going back down to zero. For some women, it takes a few days - for others, it can take a few weeks. If you want to TTC right away, you need to make sure your HCG levels are down to zero again.
12. You are usually very fertile after a D&C/D&E - the lining is almost always cleaned out and fresh. So, if you do chose to TTC after the procedure, your odds are usually a little better for conception.
13. And, lastly, be comfortable with the decision in how to handle your miscarriage. Waiting to miscarry sometimes is not an option and you miscarry quickly. Other times, like for my 11/05 miscarriage, you are waiting for weeks for it to begin. A part of the emotional healing process is to be comfortable with how you chose to manage your miscarriage…there is no right or wrong way to do that. It just has to be right for you.