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Miscarriage

Lesson 2 of 5

Natural vs. Medical vs. Surgical Miscarriage Management?

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Options for Managing Miscarriage

When a pregnancy ends, the embryo or fetus and all related tissues from that pregnancy need to come out of the uterus. Sometimes, this tissue is discharged spontaneously, even before a doctor has formally diagnosed a miscarriage.

But that’s not always the case. In this section, we’ll cover the options and trade-offs for how to remove remaining pregnancy tissues. There isn’t one best way to miscarry. It’s important (and beneficial) for the patient and doctor to work together to decide which method is most appropriate for the particular circumstance at hand.

When the body doesn’t expel the pregnancy tissues on its own, the two primary questions are whether someone would prefer having surgery to remove the pregnancy tissue or whether they would prefer to expel the tissue vaginally without surgery. In the coming chapters, we’ll explore the trade-offs of each option.

Natural Miscarriage or Expectant Management

Natural miscarriage or expectant managment essentially just means waiting for the body to expel the pregnancy on its own (without the help of medication to speed up the process.) If someone has been taking progesterone, that medication would be stopped to allow the miscarriage to happen.

This approach requires returning to the doctor to double check that all of the pregnancy tissues have, in fact, passed.

Benefits of Natural Miscarriage

Natural miscarriage allows the body to discharge all tissues on its own naturally, with no intervention. For people who want to avoid medical intervention, this option allows miscarriage to take place a non-medicalized setting and for nature to take its course.

It has the added benefit of being free from some of the risks those interventions can have, like scar tissue from surgery or side effects from the medication. You also run no risk of ending a viable pregnancy if in the small chance a misdiagnosis happens.

Negatives of Natural Miscarriage

The timing of natural miscarriage is highly unpredictable—it may take days or weeks. This means that if you’re not able or not willing to put your life on hold until it happens, you could end up miscarrying in any number of less-than-ideal places.

Next, miscarrying naturally can be painful. The unpredictable and potentially long time horizon, plus the potential for physical pain, might be a lot to handle for someone who is already suffering emotionally during a miscarriage.

Genetically testing products of conception can give you information about why this miscarriage happened. Miscarrying naturally outside of a doctor’s office doesn’t make collecting this tissue impossible, but it does make it more difficult. We’ll explain more about genetic testing and collecting products of conception in a later lesson.

Finally, there are risks to miscarrying naturally. If it doesn’t work, meaning the tissue doesn’t all pass on its own, there could be heavy bleeding or hemorrhaging that could require an emergency D&C surgery. However, the risk of hemorrhage that requires emergency intervention is typically quite small.

The timeline of natural miscarriage is varied. Doctors have different opinions on how long a patient should wait for their body to miscarry naturally before escalating to either medications or surgery. However, the timeline should be measured from when the loss happened, not just from when the loss was diagnosed. So in an early loss, some physicians suggest waiting three to four weeks before taking an alternative approach.

On the other hand, if a miscarriage is diagnosed and it can be measured the loss occured four weeks prior, then it may not make much sense to wait an additional four weeks for the body to pass the tissues naturally.

Below is a quick summary of the trade-offs of natural miscarriage.

Medications to Assist Miscarriage

When a miscarriage has been diagnosed, medications can help cause the uterus to contract and expel the pregnancy tissues.

Below, you can see what the medication treatment route might include.

Of course, there are positives and negatives of using medications to assist miscarriage.

Benefits of Medically Induced Miscarriage

The first benefit of using medications is it makes the timeline of miscarriage much more predictable than miscarrying naturally, and it starts quickly upon first dose—usually happening within hours of administration. This gives greater control over the time and place where your miscarriage will happen.

Next, medically induced miscarriage is highly effective, and it will likely prevent the need for a surgical intervention. Let’s look at two different protocols.

Cytotec (Misoprostol)

In the United States, the drug typically used for medical management of miscarriage is Cytotec (misoprostol) which are pills administered vaginally. A follow-up appointment should be scheduled to confirm that the gestational sac has passed within 12 hours of administration. Seventy-one percent of the time, only one dose is needed to complete the miscarriage process. However, if the first course of medication fails to work, a doctor will often order a second dose, bringing miscarriage completion rates up to 84%.

Mifepristone + Misoprostol

More recently, a study in the New England Journal of Medicine showed that the combination of mifepristone (also known as RU-486) taken orally as a pre-treatment to misoprostol was more effective to help the body pass the pregnancy tissues than just using misoprostol alone—nearly 18% more effective after a single dose. Again, a follow-up appointment should be made to be certain the body has fully passed all pregnancy tissues.

Negatives of Medically Induced Miscarriage

With the completion rates using misoprostol falling between 71%–84%, there’s still a chance that this strategy won’t work, and surgical intervention will be required. That’s true on top of the fact that medicated miscarriage is often reported to be more painful than natural miscarriage.

And as you can see from the data below in the New England Journal of Medicine, compared with surgery, medication is certainly associated with more pain, vomiting, and other adverse events.

Below is a quick summary of the trade-offs of using medications to assist miscarriage.

Surgery for Miscarriage

The next option is to have the pregnancy tissue removed with surgery. As you’ll see below, there are a number of decisions you’ll need to make, and a few things you’ll want to prioritize, if this is the path you choose.

Before we dive into the nuances of surgery (like risks, technique, tools, and doctor experience), this is how we would characterize the trade-offs:

Comparing Aspiration vs. D&C

There are two main types of surgery for miscarriage management: aspiration and dilation and curretage, or D&C.

Aspiration is when a straw-like instrument is placed in the uterus, and the contents are aspirated out (gentle suctioning).

A D&C is similar to aspiration—following aspiration, a scraping of the uterus, or curettage, is performed. More and more, aspiration is being used over D&C procedures due to increased risk of scarring from the scraping. We’ll talk more about this later.

There are two machines used for surgery: manual vacuum aspiration or electric vacuum aspiration. Typically, a manual vacuum is used in a clinical setting with local anesthesia. Electric vacuum machines are most commonly used in an operating room, while the patient is under general anesthesia, and are conventionally used during a D&C procedure.

Risks of D&C

The main risk of D&C is scar tissue to the uterine lining which could make it harder to carry pregnancies in the future.

In the past, scraping the inside of uterus was thought to increase the chance of removing all the pregnancy tissues. In reality, this is at the high cost of possibly scarring the uterine lining—and removing more than should be removed. Usually, a gentle aspiration is all that is needed while leaving the remainder of the uterus healthy and intact.

Another risk is perforating the uterus and injuring other internal structures outside of the uterus is also possible.

Lastly, even after the scraping, products of conception could still be left behind, and so a follow-up procedure could be necessary.

Overall, doctors with clinical experience say that the amount of scarring might be under-reported, because it’s uncommon to look for scar tissue after the procedure.

Crucial Tips if Using D&C

As discussed, there are real risks to a D&C if it’s not done well, so it’s important to advocate for yourself and ensure that you’re in the best hands. Here are some questions you’ll want to ask:

  • Will the doctor be using ultrasound guidance? Ultrasound guidance is significantly better, so it’s important to ensure that the procedure will be guided by ultrasound.
  • Will the doctor be using a sharp curettage technique? This technique has a higher risk of damaging the uterine lining, so it’s best to find a doctor who will avoid using a sharp curettage.
  • How experienced is the doctor in terms of performing D&C procedures? The bare minimum to look for is a doctor who performs at least one per month.
  • Will local anesthesia or general anesthesia be used? This could be an important question for you to answer for your own emotional wellbeing and preferences—just know that both options are possible.

Managing Ectopic Pregnancies

Ectopic pregnancies are pregnancies that happen in locations outside the uterus. They can be incredibly dangerous, potentially life-threatening situations.

Physicians and patients need to be on the lookout for signs of ectopic pregnancies — namely, if a patient experiences intense pain during early pregnancy, a doctor should be consulted immediately.

An ectopic pregnancy located in the fallopian tube is called a tubal pregnancy. If this type of ectopic pregnancy is detected very early, it can often be treated using a medication called methotrexate, which is a chemotherapy drug. This medication is more effective the earlier it’s started.

However, if the tubal pregnancy is further along, surgery will probably be necessary to either open the fallopian tube to remove the pregnancy or, more likely, to remove the fallopian tube entirely.

If a tubal pregnancy has already ruptured, that is a medical emergency, and surgery must happen immediately.

Follow-up Care After Miscarriage

Regardless of which approach is used to address a miscarriage, the work is not done. It’s crucial that a doctor takes two more steps to give the best chance for a healthy and successful pregnancy the next time conception occurs:

Ensure hCG levels in the blood have returned pre-pregnancy levels
Confirm no fetal tissue remains in the uterus

There is wide variability in terms of how soon a person’s hCG levels will return to zero. The pregnancy tissues can pass or be removed, but if a small cluster of cells remain that are still making the hCG, it could take a while for those levels to return to zero. There is no urgent need to intervene if the hCG levels are falling on their own.

Second, the preferred method to check the uterine cavity for remaining fetal tissue is a hysteroscopy—which uses a camera—as it can detect not only fetal tissue but also scarring. Although it’s not as thorough, an ultrasound or transvaginal ultrasound is also an acceptable method if a thin lining can be seen across the whole uterus.

If the hysteroscopy or ultrasound reveals pregnancy tissue still in the uterine cavity, there are multiple approaches to remove the tissue.

One approach is to wait one or two menstrual cycles to see if the remaining tissue passes naturally with menstruation.

The next option is a hysteroscopy to gently remove the remaining tissue.

Finally, a D&C could be another approach; however, if you had one D&C already, and the first D&C missed the tissue, a subsequent procedure may also fail. Additional risk of injury to the uterus may not be desirable or necessary in all cases.