After diagnosing a pregnancy loss, doctors sometimes offer women a choice of miscarriage treatment. The options are usually to wait for a natural miscarriage, have a D&C, or use medication to bring on the miscarriage bleeding.
If your pregnancy loss involved a medical emergency such as a ruptured ectopic pregnancy or a hemorrhage, you may have had no choice but surgery. But if you do have a choice in your treatment, each of your options has possible pros and cons depending on your situation and personal outlook.
Early in pregnancy, a miscarriage will be very similar to a heavy, crampy menstrual period. It may start with brown spotting that changes to heavier bleeding, sometimes with large blood clots. The bleeding may last up to two weeks, but it should not be heavy for that entire time. (The general rule is that if you are soaking through a menstrual pad in under an hour that you should go to the emergency room.)
The cramps in a natural miscarriage can range from mild to very strong. Your doctor can recommend painkillers to help you handle the cramping.
Some women prefer nonsurgical miscarriage because they want to avoid the ordeal of checking into the hospital, or they may feel that a D&C is too invasive. Women may also want to avoid the minor risks of complications from a D&C (these risks are very small) or they may want to collect the tissue for burial (but remember that in early pregnancy the baby will probably not be recognizable).
If a doctor diagnoses a miscarriage before any bleeding has started, a miscarriage may take days or even weeks to happen without intervention. Obviously, this can be a drawn out and emotionally difficult waiting process, but 80% to 90% of women with diagnosed miscarriage will miscarry within two to six weeks without complications.
If bleeding has started and the woman chooses to wait, she should be sure to follow her practitioner’s recommendations and probably check in for a follow-up appointment in order to be sure that everything has cleared the uterus and her hCG levels have returned to zero.
If a doctor diagnoses a miscarriage but the bleeding has not yet started and the woman prefers to avoid a D&C, the doctor may prescribe a prostaglandin medication such as misoprostol to speed the process along. In these cases, the miscarriage will happen in the same manner as a nonsurgical loss without medication, but the medication will make the process begin more quickly.
Sometimes doctors will medication to treat confirmed or probable ectopic pregnancies that are not at immediate risk of rupturing. For an ectopic pregnancy, the standard medical treatment is methotrexate.
Although these medications are safe for most women, they do carry risks of hemorrhage and severe cramping. If you choose this option, your doctor should advise you of any warning signs that might indicate you need medical attention, and you should probably not travel until your doctor evaluates you again to be sure your miscarriage is complete.
Most of the time, a surgical management of miscarriage will be a procedure called a D&C, or dilation and curettage. In a D&C, the woman checks into the hospital and after a pre-surgical workup, she gets either local or general anesthesia. Then the doctor dilates the cervix and scrapes away and/or vacuums the uterine lining. Afterward, she usually is discharged the same day with a prescription for pain medication and a recommendation to see her doctor for a follow-up appointment a few days or a week or two later.
Some doctors will perform a D&C in the office so that the woman does not need to check into the hospital.
A D&C may be necessary for a miscarriage that poses an immediate threat to the woman’s health, such as if a woman is hemorrhaging or if she has tissue retained in the uterus after a natural miscarriage. Surgical management may also be the recommended option in some ectopic pregnancies and in later pregnancy losses.
When they have a choice, sometimes women prefer a D&C over a nonsurgical miscarriage. A D&C provides the fastest closure, particularly in losses where the bleeding has not yet started. Some women may wish to avoid having a visual image of the remains of the pregnancy, and sometimes a D&C makes it easier to collect tissue for chromosome analysis to rule out chromosomal abnormalities in recurrent losses.
Some doctors also use D&C as the default medical treatment for all miscarriages for the above reasons; it can also be a more convenient way to help the woman find closure more quickly and prevent later medical complications. (Nonsurgical miscarriages are associated with a greater risk of later unplanned admission to a hospital, although 80% to 90% are able to miscarry at home without intervention.) If you prefer nonsurgical management and your doctor is recommending a D&C in the absence of a clear medical need, tell your doctor of your preference and he or she will probably accommodate your wishes.
Regardless of the management option, be sure to seek support resources and lean on your family and friends in the time of your grief. If you are having recurrent miscarriages, read up on possible causes and tests you may want to pursue before trying again.
Butler, Charles, Gary Kelsberg, and Leilani St. Anna. "How long is expectant management safe in first-trimester miscarriage?" Journal of Family Practice Oct 2005. [Online]. 24 Sept 2007.
U.S. Food and Drug Administration, "Mifeprex (mifepristone) Information." Drug Information. 29 Aug 2007. U.S. Food and Drug Administration. 24 Sep 2007.