Non-viable Pregnancy (Miscarriage): D&C, Natural or Hysteroscopy?
What do you do after you have been diagnosed with a non viable pregnancy (miscarriage)? There are a few options: passing it on your own or with the help of medications and surgical options like D&C or hysteroscopy. We review the advantages and disadvantages of each approach.
Fertility doctors can monitor early pregnancies
Fertility doctors are not just good at getting people pregnant. We are also experts in monitoring early pregnancies. There are many instances in which we can predict that a pregnancy is no longer viable. We can predict miscarriage with blood tests or ultrasound.
3 options for managing a nonviable pregnancy
There are three different options for managing a non-viable pregnancy:
- doing nothing
Letting a pregnancy pass on its own - Pros and cons
When a woman opts to do nothing, the hope is that the pregnancy will pass completely on its own. The advantages of this option are that it is easy and not invasive. There are a few problems with doing nothing.
First, the pregnancy may not pass on its own. Non-viable pregnancies can persist in the uterus for days, weeks or even months. If you are hoping to try to get pregnant again quickly, this can really cause a delay.
Second, the pregnancy may not pass completely. This can result in prolonged bleeding and cramping. Sometimes old pregnancy tissue can be found in the uterus months or even years after a miscarriage.
Third, if you want to do testing to look for chromosome abnormalities you won't be able to do this if you pass the tissue at home.
Medications to complete a miscarriage
There are a few medications that a woman can take that can stop the pregnancy tissue from continuing to grow; and other medications which will cause her uterus to expel the pregnancy tissue.
This is a good option to help speed the process up. But still not a good option if we want to get tissue for testing or make sure that all of the pregnancy tissue is removed from the uterus.
Surgery (D&C) to end a non viable pregnancy - Pros and cons
There are two kinds of surgical procedures that can be used to remove a pregnancy. D&C and hysteroscopy.
D&C stands for Dilation and Curettage. The opening of the uterus is called the cervical canal. The cervical canal is very narrow. In order to do surgery inside the uterus, the doctor must first stretch the opening of the uterus to make it larger. This is the dilation part. We are dilating the opening of the uterus.
Curettage is the technique used to remove tissue from inside of the uterus. Originally it referred to an instrument called a curette. A curette was used to scrape the tissue out. This is now referred to as a sharp curette. Nowadays doctors may instead use what is called a section curette. This is basically a plastic tube which is connected to a suction pump. Instead of scraping, the tissue in the uterus is suctioned out.
There are several advantages to a D&C. The process can be scheduled so you know when and where the uterus will be emptied. This avoids the problem of having bleeding and cramping starting in the middle of the night or other inconvenient time. A D&C also reduces the chances of having some pregnancy tissue that doesn't pass. A D&C is going to be a quicker method for attempting pregnancy again.
First you don't have to wait for weeks for the pregnancy to pass, and second the hCG levels drop more quickly so you can start ovulating and get pregnant again more quickly. A big advantage is that you now have placenta tissue that can be tested for chromosome abnormalities.
Maternal cell contamination - MCC - The problem with D&C
There is still one problem with the D&C however. When the doctor suctions the tissue out of your uterus, in addition to getting the placental tissue, there is also going to be uterine lining tissue, which is called decidua. When all that tissue is sent to a lab to do chromosome testing, the chromosome result you get might be the decidua and not from the pregnancy itself. This is called maternal cell contamination or MCC.
Hysteroscopy to manage a non-viable pregnancy
In order to avoid maternal cell contamination, we use another surgical technique called hysteroscopy. The hysteroscope is inserted into the uterus. I can see where the gestational sac is located, go inside the sac and remove the placental tissue directly without getting it mixed with your uterine tissue. This gives us a very clean specimen for doing chromosome testing.
We can then do a suction curettage to remove the remainder of the tissue.
Another advantage of hysteroscopy is that I can look inside afterward to make 100 % certain that there is no pregnancy tissue left behind. We recommend hysteroscopy followed by suction curettage for any couple that was having trouble getting pregnant, has had one miscarriage previously, or a history of multiple miscarriages.
In order to be sure that we can get the placenta tissue, we want to be able to see a gestational sack on ultrasound before the procedure.