From the Guidelines
Curettage of the endometrial lining after a miscarriage is a crucial procedure that offers several benefits, including the prevention of complications like prolonged bleeding and infection, and it is recommended as the primary treatment for incomplete miscarriage with significant bleeding or suspected infection. The primary advantage of this procedure is the complete removal of pregnancy tissue, which helps prevent complications. This procedure, also called dilation and curettage (D&C), typically takes a short duration under local or general anesthesia and involves dilating the cervix and using a curette to remove remaining tissue. According to the latest evidence, approximately 12%–24% of pregnancies result in miscarriage, which equates to an annual incidence of miscarriage around 125,000 in the United Kingdom 1. Curettage provides tissue samples for pathological examination, which can help determine the cause of miscarriage, particularly in recurrent cases. It also accelerates the recovery process by promptly clearing the uterus, allowing menstrual cycles to normalize more quickly and potentially enabling earlier attempts at conception if desired.
Some of the key benefits of curettage include:
- Prevention of prolonged bleeding and infection
- Acceleration of the recovery process
- Reduction of the risk of retained products of conception
- Provision of tissue samples for pathological examination
- Immediate intervention to stop blood loss in cases of heavy bleeding
The procedure is usually short in duration and patients are discharged the same day assuming no complications 1. While medication management or expectant management are alternatives, curettage may be preferred in cases of incomplete miscarriage with significant bleeding, suspected infection, or when tissue analysis is important for diagnosis. It is essential to note that the risk of venous thromboembolism (VTE) is increased in pregnancy and the puerperium, and curettage may help reduce this risk by promptly clearing the uterus and reducing the risk of complications 1.
In terms of management, surgical management of miscarriage (SMM) and surgical termination of pregnancy (STOP) involve suction curettage, usually under general anesthesia 1. The initial VTE risk is calculated at the booking or initial pregnancy appointment and can be updated at any point, and treatment is usually with low molecular weight heparin (LMWH) because it does not cross the placenta and is associated with a lower risk of heparin-induced thrombocytopenia and osteoporosis 1. However, there is no overall consensus on dose or duration, and individualized risk assessment of all women is essential.
From the Research
Benefits of Curettage Endometrial Lining in Miscarriage
- The benefits of curettage endometrial lining in miscarriage include a higher chance of complete evacuation of the uterus 2, 3.
- Curettage is more effective than expectant management in women with suspected incomplete evacuation after misoprostol treatment for first-trimester miscarriage, with a success rate of 95-97% compared to 76-85% for expectant management 2, 3.
- However, expectant management is equally safe and prevents curettage for most women, with a success rate of 76-85% 2, 3.
- The use of misoprostol treatment is also effective in complete evacuation of the uterus, with a success rate of 66-86% compared to 43-61% for expectant management 4.
Comparison of Curettage and Expectant Management
- Curettage leads to a higher chance of complete evacuation but is associated with a higher risk of intrauterine synechiae and subsequent fertility issues 5.
- Expectant management is a safe and effective option, with a lower risk of complications and a success rate of 76-85% 2, 3.
- The cost-effectiveness of curettage vs. expectant management is unknown, but curettage is not cost-effective compared with expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment 6.
Considerations for Treatment
- The choice of treatment should be based on individual patient preferences and medical history, with consideration of the risks and benefits of each option 5, 2, 3.
- Misoprostol treatment is a viable option for complete evacuation of the uterus, but is associated with more pain and a higher risk of complications compared to expectant management 4.