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Old 01-27-2011, 12:39 PM   #1
karidpt
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Exclamation PLEASE READ before getting a D&C

D&C Information:
D = Dilation – stretching open of the cervix
C = Curettage – a curette (long handled metal spoon-like device) is used to scrape, empty, sample or remove contents from within the uterus.

For “a suction D&C”, which is used for removing retained tissue from miscarriage or following delivery, hemorrhage, or for an elective pregnancy termination, suction is applied through a hollow plastic tube (a suction curette). A metal spoon-like curette, may also be used in conjunction with this procedure.

Both suction and blunt curettage caused a significant percentage of endomyometrial injury on a pregnant and recently pregnant uterus (44% and 35% respectively). However, it was found in this study by Beuker, et al, that suction curettage yielded more endomyometrial injury than blunt curettage. It is assumed that suction is safer than blunt, and this finding contradicts that assumption. It would be of benefit, to have studies which look into this matter and compare suction and blunt curettage.

Since doctors do not see the inside of the woman’s uterus when performing this D&C surgery it is often labeled a “blind surgery”. This can lead to removing too little (leaving behind RPOC which may lead to needing another procedure) and can also lead to going too deeply, (such as damaging the basal layer of endometrium or removing superficial myometrium--uterine muscle).

Ultrasound may be used to visualize tissue instead of a “blind” procedure, but varies depending on the reason for the D&C. If the D&C is for a miscarriage, early pregnancy termination, or small retained placental fragments, the tissue may not be visualized by transabdominal ultrasound during surgery. On the other hand this tissue can usually be seen via vaginal ultrasound; however this would not help in the case of intraoperative ultrasound, only pre and postoperative purposes

Risks:
With any medical procedure, there are risks, and these should be weighed and compared against the risks and benefits of the other treatment options as you discuss them with your doctor.

1. Anesthesia – there are risks associated with general, spinal or local anesthesia.
2. Uterine perforation/puncture – can lead to uterine rupture in future pregnancies and can expose the bladder and/or intestines to injury.
3. Hemorrhage (greater than 500 cc of blood loss)– immediate or delayed and is potentially life threatening; note that a suction D&C can also stop, at least temporarily, hemorrhage.
4. Infection – can require hospitalization and can be life threatening.
5. Asherman’s Syndrome – Intrauterine adhesions or scarring of the uterus, which can cause decreased or absent periods, cyclical cramping/pain, recurrent miscarriages and infertility, and can result in endometriosis or hematometra (a collection of blood trapped within the uterus).
(Go to www.ashermans.org for more information.)
6. Blocked Tubal Openings – caused by scarring, infection or a combination, and can result in infertility or ectopic pregnancies.
7. Retained products of conception –because this is a blind procedure, it can result in a repeated D&C and/or infection, however, a post D&C ultrasound reduces this risk further.
8. Cervical damage – tears or damage to the cervix and internal os (entrance to the uterus) can result from the dilation process which can affect future pregnancies. There is a correlation between the degree of dilation and birth weight. According to Slater, the greater the dilation, the lower the birth weight. This risk may be decreased by the use of misoprostol or laminaria.
9. Cervical Insufficiency (CI) – forced dilations, repeated dilations or dilation greater than one centimeter can result in CI, or the cervix dilating prematurely during future pregnancies and thus resulting in pre-term deliveries.

Complications:
IMMEDIATE COMPLICATIONS:
• Severe lower abdominal pain, discharge, fever, chills immediately after surgery.
• Heavy bleeding: bleeding through a pad every 1-2 hours for several hours, passing clots the size of a golf ball or larger.
• No bleeding in the days following a D&C may indicate obstruction of the cervix. If this occurs, there may be pain or cramping and the abdomen may swell. Note: Many women with Asherman’s Syndrome have no bleeding the day after surgery and the following days, but it has not yet been studied. Scar formation does begin immediately following injury and if there was significant trauma to the cervix and internal os (entrance to the uterus), the swelling and scar formation could inhibit blood from exiting.
LONG TERM COMPLICATIONS:
• Periods do not resume within 6-8 weeks following the D&C or change in quality (darker) and/or quantity (lighter, shorter). These are symptoms of Asherman’s Syndrome.
• Recurrent miscarriages (due to cervical insufficiency or intrauterine adhesions/Asherman’s Syndrome)
• Infertility (due to Asherman’s Syndrome)
• Bleeding during pregnancy, placental attachment issues (placenta previa, placenta accreta, placenta percreta, placenta increta), postpartum hemorrhage in future deliveries.

Future Fertility:
Panpaprai and Boriboonhirunsarn (2007) found that a previous dilation and curettage puts a woman at higher risk for retained placenta and that pregnant women should be notified of this increased risk

According to Zwart et al (2007), obstetricians should be aware of the risk of scarring in the uterus (Asherman’s Syndrome) after a D&C and that such scarring can lead to abnormal placental attachment, such as: placenta previa, placenta accreta, placenta increta and placenta percreta.

Myometrium (uterine muscle) was found in curettage specimens from 35% of miscarriages, which puts women at a higher risk of developing Asherman’s syndrome.

When a D&C is performed, the endometrium (the internal lining of the uterus) is scraped and/or suctioned. The endometrium has two layers (see illustration above): the upper layer which is closer to the uterine cavity is called the functional layer and this is shed during a menstrual period; the deeper layer is called the basal layer and this layer remains during and after menses and is the source for the regrowth of the functional layer. The basal layer is partially embedded in the myometrium. If the basal layer is traumatized, irreversible damage can result.

Prevention:
Prevention of Asherman's Syndrome
Since the risk of Asherman's Syndrome is high (as we presented earlier) on the recently pregnant (following miscarriage or postpartum) uterus, those who aim to prevent Asherman’s Syndrome from occurring, recommend that a D&C in the postpartum or postabortion period, should be avoided if at all possible. Of course, this treatment decision can only be made with your personal doctor, according to your individual case.

The most recent and most comprehensive paper on Asherman's Syndrome, (Yu, et al, 2008) reviews 148 articles on Asherman's Syndrome. Yu presents, that since the risk of developing AS during this delicate time is so great, and since prevention is always better than treatment; D&Cs should be avoided as much as possible on the gravid uterus.


Other Surgical Options:
Hysteroscopy is the only way to visualize the inside of the uterus directly and thus is more accurate in identifying internal structures such as RPOCs, polyps, IUA, etc. than is ultrasound (10). A hysteroscope is placed into the uterus through the cervix. A liquid (such as saline) or gas (such as carbon dioxide), is used to distend the uterine cavity, so that its interior and contents can be viewed clearly. It is also possible to perform surgery, an operative hysteroscopy, using this telescope and miniature surgical instruments (other than a curette or suction device). Not many physicians are comfortable with hysteroscopic surgery as it is a more specialized surgical procedure--especially in the face of uterine bleeding and/or retained products of conception--the trend towards less blind and more “targeted” surgery is underway. If you like this option, seek out someone who performs hysteroscopic surgery consistently and have that surgeon perform your procedure as opposed to your doctor.

An article by Goldenberg, researched using hysteroscopy to treat RPOCs post miscarriage and postpartum. The procedure was very short with a 10 min avg, and was found to be very effective, based upon removing RPOCs as evidenced by reduced bleeding and follow up diagnostics . A further study, in which Goldenberg was involved in, in 2001, compared blind D&C with hysteroscopic guided curettage for the efficacy of removing retained tissue. This study, by Cohen, et al, found that 20.8% of patients with the blind D&C needed a repeat procedure (this second procedure used hysteroscopic guidance) and that none of the patients who had initial treatment with hysteroscopically guided curettage needed a repeat procedure. Both of these studies demonstrate the benefits for the use of a hysteroscope to treat RPOCs.

If having a D&C:
Request that ultrasound be used (before, during, after) to guide your D&C.

In March’s 2006 article, he proposes a prophyllactic approach following a high risk D&C, “to prevent intrauterine scarring following a D&C performed for postpartum hemorrhage 2-4 weeks after delivery, when the uterus is most vulnerable to scarring, I would propose to the patient that she not breast-feed, that a splint be placed in her uterus, and that she receive estrogen therapy. Although there are no studies on the efficacy of this prophylactic approach, these measures may help prevent the development of intrauterine adhesions, which are quite difficult to cure.”.



All of the information was found on www.dandcnow.info.
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Kari (30) DH (29)
Dx: Thin PCOS 2008, Ashermans Syndrome 2011
DD: 11/8/09 (most beautiful girl in the world)
DS: 3/31/13 (my little heartbreaker)
Surprise!!! Due date: 6/10/13





"God's delays are not God's denials." P.U.S.H. (Pray Until Something Happens)

Last edited by karidpt; 04-18-2011 at 11:27 PM.
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Old 01-27-2011, 01:13 PM   #2
megs&david
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Kari- I'm so, so sorry that you are having to go through all this. As if a m/c isn't hard enough. I will be praying that your first surgery is your only. So glad you were able to talk to that doctor. I think it will be beneficial to go to someone who is the leading expert. I had heard of Asherman's when I had my first m/c. I refused a D&C for that reason for both m/c's b/c I was terrified of having even more complications. I'm so lucky that natural m/c worked for me both times. Again, i'm so sorry! Wish there was some way I could help!
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Old 01-27-2011, 01:32 PM   #3
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Thank you! Sometimes natural isn't an option and I know it has it's risks too, but if you can - I definitely would do it naturally. Then if you have to get a D&C, you can ask for ultrasound for guidance pre and post. Or a hysteroscopy vs. D&C. Or they could place a stent/ballon in the uterus after D&C to prevent scarring and have antibiotics and HRT. I was never informed of these options.

I have got the ball rolling and almost have all of my medical records to Dr. March, so hopefully this will happen soon before my scarring gets any thicker!
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Kari (30) DH (29)
Dx: Thin PCOS 2008, Ashermans Syndrome 2011
DD: 11/8/09 (most beautiful girl in the world)
DS: 3/31/13 (my little heartbreaker)
Surprise!!! Due date: 6/10/13





"God's delays are not God's denials." P.U.S.H. (Pray Until Something Happens)
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Old 01-27-2011, 11:07 PM   #4
AnglWngz
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Kari, thank you for sharing this. I am sorry for what you are going through. I can't imagine having to deal with this on top of having PCOS. I have beent thinking of you and pray that the surgery goes well. Best wishes to you.

I am currently m/c'ing and it's not going well. My HCG levels actually increased a little. My dr is giving me til Mon to m/c naturally. I'll have another u/s on Mon afternoon. The dr wants to do a D&C afterwards. I am hoping my body will do what it is supposed to do so I can avoid the procedure. I am scared and really struggling with this loss.
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Our newest Angel 10/18/2011
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You have left us too soon
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I hold you forever in my heart
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Old 01-28-2011, 02:01 PM   #5
karidpt
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Quote:
Originally Posted by AnglWngz View Post
Kari, thank you for sharing this. I am sorry for what you are going through. I can't imagine having to deal with this on top of having PCOS. I have beent thinking of you and pray that the surgery goes well. Best wishes to you.

I am currently m/c'ing and it's not going well. My HCG levels actually increased a little. My dr is giving me til Mon to m/c naturally. I'll have another u/s on Mon afternoon. The dr wants to do a D&C afterwards. I am hoping my body will do what it is supposed to do so I can avoid the procedure. I am scared and really struggling with this loss.
I am so sorry for your loss. Are you taking the medication ton help it along? I hope this process gets easier for you. Thinking of you!
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Kari (30) DH (29)
Dx: Thin PCOS 2008, Ashermans Syndrome 2011
DD: 11/8/09 (most beautiful girl in the world)
DS: 3/31/13 (my little heartbreaker)
Surprise!!! Due date: 6/10/13





"God's delays are not God's denials." P.U.S.H. (Pray Until Something Happens)
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Old 04-18-2011, 11:24 PM   #6
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Just wanted to bump this thread for those considering D&C. Thinking of you ladies and our angels babies always!
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Kari (30) DH (29)
Dx: Thin PCOS 2008, Ashermans Syndrome 2011
DD: 11/8/09 (most beautiful girl in the world)
DS: 3/31/13 (my little heartbreaker)
Surprise!!! Due date: 6/10/13





"God's delays are not God's denials." P.U.S.H. (Pray Until Something Happens)
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Old 05-31-2011, 08:06 PM   #7
karidpt
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Bumping up
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Kari (30) DH (29)
Dx: Thin PCOS 2008, Ashermans Syndrome 2011
DD: 11/8/09 (most beautiful girl in the world)
DS: 3/31/13 (my little heartbreaker)
Surprise!!! Due date: 6/10/13





"God's delays are not God's denials." P.U.S.H. (Pray Until Something Happens)
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Old 06-20-2011, 09:37 PM   #8
karidpt
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Default Posted as its own thread, but wanted to include it here

Approaches to managing a miscarriage:

There are several approaches to managing a miscarriage.

From the least invasive to the most invasive, they are:

1) Expectant Management: Let's wait and see.

2) Medical Management: Using medications (either tablets or injectables) to help pass retained products of conception (RPOC). Such medications include: misoprostol (Cytotec) and methylergonovine (Methergine). These medications are also used to help manage retained placental fragments after childbirth. Methylergonovine is specifically used to control postpartum hemorrhage while misoprostol is used to soften the cervix and induce uterine contractions. These products can also be used for elective abortion. I mention this because some pharmacists will not dispense them (due to them being used for abortion). I recommend asking your doctor which pharmacy to go to, to fill the prescription should your doctor decide to go this route. This works about 95% of the time.

3) Gestational sac aspiration: An office procedure which removes a very early pregnancy so that the doctor can analyze the embryo for any chromosomal abnormalities, etc. It is considered less invasive than a suction D and C.

4) D and C (dilation and curettage), suction D and C, and D and E (dilation and evacuation)
• all carry high chances of acquiring Asherman's.However, in the case of life threatening infection or hemorrhage (rare, but some experience these), it may be the only treatment option at that level. It is very difficult for doctors to see (using abdominal ultrasound) small retained fragments and it is also difficult to see in the face of a cloudy or bleeding uterus via hysteroscopy. You can ask if you can have an ultrasound guided D and C if it comes down to that. You can also ask for a hysteroscopy, but various doctors may or may not want to/be able go that route. You can also ask for a vaginal ultrasound before and after the D and C.
• Also, if you have to have a D and C, ask if you can have a splint put in with estrogen therapy, that is considered a prophylactic approach to prevent any intrauterine scaring.

In most cases, doctors can avoid having to do a D and C to manage a miscarriage. Chances are very low that you will need to have a D and C.

Again you should always discuss your own personal medical condition with your doctor and should not delay in seeking treatment because of something that you have read here. It is also important that the medications described here only be taken under the supervision of a physician.

This is just an outline of information. It is good to know that there are alternatives to a D and C.

Here is a summary of suggestions (as a non MD) if you find yourself in this situation:

1. Don’t have a D&C for a miscarriage (unless absolutely necessary) as it can cause damage especially if you have had Asherman’s Syndrome previously. Also, your endometrium may get thinner each time you have a D&C.

2. Misoprostol helps clear out most of the uterine contents. It is more painful than a D&C but worth it in the long run- unless you are not interested in preserving your fertility. NOTE: If you have had a previous Cesarean section or uterine perforation or severe AS, discuss with your ObGyn to see if misoprostol is safe for you (or you may need to take a lower dose). http://www.misoprostol.org/

3. If you have retained tissue you can have a hysteroscopy (not a blind D&C!!) to remove it. In most cases if you have had a missed miscarriage you will need to either use misoprostol or, alternatively, wait to miscarry before hysteroscopy can be effective, otherwise there is just too much tissue and blood to work with.


There are also some implications that can be speculated:

1. It may take a few hours for the placenta to deliver when using misoprostol post AS if you are beyond the first trimester.

2. If you have retained products after every future miscarriage. Hysteroscopic removal of tissue allows the doctor to view your uterus as he/she clears it. Note: Hysteroscopy itself can cause complications if undertaken by an unexperienced or unskilled doctor. Please see only a highly experienced specialist.

3. You should anticipate that you may have placenta accreta in a future pregnancy particularly if the placenta does not deliver when expected or you have had confirmed RPOC.
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Old 11-08-2011, 01:05 PM   #9
karidpt
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Bumping up
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Kari (30) DH (29)
Dx: Thin PCOS 2008, Ashermans Syndrome 2011
DD: 11/8/09 (most beautiful girl in the world)
DS: 3/31/13 (my little heartbreaker)
Surprise!!! Due date: 6/10/13





"God's delays are not God's denials." P.U.S.H. (Pray Until Something Happens)
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