What is the best course of treatment for a patient scheduled for a dilation and curettage (D&C) procedure following a miscarriage?

Management of Miscarriage with Scheduled D&C

For a patient with confirmed miscarriage scheduled for dilation and curettage (D&C), proceed with surgical evacuation as planned, as this represents the safest and most definitive management option with the lowest complication rates. 1, 2

Why Surgical D&C is the Optimal Choice

Surgical evacuation (D&C or manual vacuum aspiration) has superior safety outcomes compared to all alternatives:

• Hemorrhage rate: only 9.1% (versus 28.3% with medical management) 1, 2
• Infection rate: only 1.3% (versus 23.9% with medical management) 1, 2
• Retained tissue requiring additional procedures: only 1.3% (versus 17.4% with medical management) 1, 2
• Provides immediate resolution and certainty of complete evacuation 2

Critical Pre-Procedure Requirements

Rh Status Assessment

• All Rh-negative women MUST receive anti-D immunoglobulin to prevent alloimmunization 1, 2
• Administer 50 mcg of anti-D immunoglobulin for incomplete or complete abortion 1, 2
• This is essential because 32% of spontaneous abortions present with fetomaternal hemorrhage 1, 2

Rule Out Infection

Do NOT wait for fever to diagnose intrauterine infection - look for these warning signs: 1

• Maternal tachycardia
• Purulent cervical discharge
• Uterine tenderness
• Elevated white blood cell count

If infection is suspected, initiate broad-spectrum antibiotics immediately and proceed with urgent evacuation 1

Confirm Diagnosis

• Transvaginal ultrasound is mandatory to confirm intrauterine pregnancy and rule out ectopic pregnancy 1, 2
• Misdiagnosis of ectopic pregnancy as incomplete abortion is a critical pitfall to avoid 1, 2

Procedure Considerations

Timing

• D&C is preferred for pregnancies under 12 weeks gestation 1
• Do not delay definitive treatment if there is any clinical suspicion of infection 1

Technique

• Manual vacuum aspiration is preferable to sharp curettage when possible to reduce risk of Asherman syndrome 1, 2
• Avoid multiple or aggressive curettage procedures as they significantly increase the risk of intrauterine adhesions 1, 2

Antibiotic Prophylaxis

• Administer prophylactic antibiotics before the procedure 1
• Re-dose if blood loss exceeds 1,500 mL 1

Why Expectant Management is NOT Appropriate

Expectant management is absolutely contraindicated in this scenario: 1

• Maternal morbidity rate of 60.2% (versus 33.0% with active management) 1, 2
• Only 16% of women avoid maternal morbidity with expectant management 2
• Major risks include: intrauterine infection (38.0%), postpartum hemorrhage (23.1%), sepsis (6.8%), and maternal death (45 per 100,000) 2
• Risk of infection increases significantly after 18 hours of membrane rupture 1

Post-Procedure Care

Immediate Follow-Up

• Monitor for signs of infection: fever, foul-smelling discharge, worsening pelvic pain 1, 2
• Clinical follow-up to confirm complete resolution 1, 2
• Watch for excessive bleeding requiring intervention 2

Contraceptive Counseling

• Provide contraceptive counseling immediately post-procedure to prevent unintended pregnancy 1, 2

Long-Term Considerations

• Be aware that D&C is associated with increased risk of preterm birth in subsequent pregnancies (OR 1.29 for <37 weeks, OR 1.69 for <32 weeks) 3
• This risk increases with multiple D&Cs (OR 1.74 for preterm birth <37 weeks) 3
• Consider intrauterine adhesion prevention strategies in women with previous D&C history 4, 5

Common Pitfalls to Avoid

• Failing to administer Rh immunoglobulin to Rh-negative women - this is non-negotiable 1, 2
• Waiting for fever before treating suspected infection - use clinical judgment based on tachycardia, discharge, and uterine tenderness 1
• Misdiagnosing ectopic pregnancy as intrauterine miscarriage - always perform careful ultrasound evaluation 1, 2
• Performing overly aggressive or multiple curettage procedures - increases Asherman syndrome risk 1, 2