A new study has doctors discussing ways to make miscarriage safer for women, including whether the D&C procedure could lead to preterm birth.
Having a miscarriage is a physically challenging and emotionally heartbreaking experience for any woman. Sometimes, it requires surgery, which can add further stress to an already upsetting situation. And, until recently, the dilation and curettage (D&C) procedure was probably considered the most effective means of completing the miscarriage.
Now, researchers behind a new study out of Amsterdam are warning doctors away from the procedure, indicating that it could be associated with preterm birth in future pregnancies. The scientists analyzed 21 different studies and discovered that the surgery is connected with a 29% greater chance of preterm birth (less than 37 weeks) and a 69% greater chance of very preterm birth (less than 32 weeks) in a subsequent pregnancy. Nearly 2 million women were included in the report and the risk of prematurity in future pregnancies was even higher in those with multiple past D&Cs. But if you've had the procedure don't worry too much: the overall risk was around 6% in women without a prior D&C and the procedure brought that figure up only slightly to 7.6%, the equivalent of 16 preterm births per 1,000 women with D&C.
What is a D&C?
The common surgical procedure is called upon in an estimated half of all miscarriages and takes about 15 minutes. In addition to use in miscarriage, it is also employed when terminating a pregnancy. It also can come with some other rare but serious side effects, like bleeding, infection, cervical tears, and perforations of the cervix and uterus.
Study author Dr. Pim Ankum at the Academic Medical Centre of the University of Amsterdam believes that forced dilation of the cervix may permanently (and negatively) affect tightness, thus leading to premature opening in future pregnancies. Additionally, the cervix's antimicrobial defense mechanism may be damaged during D&C.
"This study shows that the cervix and uterus have a good memory and don't forget easily," says Dr. Sheryl Ross, OB-GYN and women's health expert in Santa Monica, Calif. "Mechanically opening the cervix and disrupting the sensitive uterine environment during a D&C can have a permanent negative effect." In fact, the same goes for dilating the cervix during labor, which doctors may do if the woman's body doesn't naturally open it.
"By now, our findings represent the 'best available evidence' despite the absence of data from randomized trials," Ankum told FitPregnancy.com. "In view of our findings, it would hardly be ethical—for obvious reasons—to perform such a trial anymore." While understandable, this apparent limitation should be kept in mind when weighing the importance of these findings, in addition to the face that the studies were observational and, therefore, may not have considered potential confounders.
What are the alternatives?
So what other options do women have? According to Dr. Ankum, there are less invasive medical alternatives that may provide better health outcomes. One is misoprostol—the prostaglandin frequently used to induce labor. Although there are some side effects, including diarrhea, nausea, and sometimes fever, the treatment is well tolerated by most patients, Ankum says.
Ross adds that about 25% of all abortions prior to 9 weeks gestation are done via such medications, and that it's actually a two-part process that usually begins with mifepristone to soften the cervix before misoprostol is given orally, vaginally, or buccally (as a tablet placed between the gum and cheek) for fast absorption into the bloodstream.
"The advantages to a medical abortion are that it's not a surgical procedure, doesn't involve anesthesia, has a high success rate (95%) before 9 weeks, can be done in the privacy of your own home, and can mean avoiding long-term complications of uterine scarring, cervical weakening, and preterm labor," Ross says. The disadvantages, however, include the time it may take (days or weeks) to complete and the potential for pain with longer periods of bleeding.
Of course, doing nothing and letting nature run its course is another option. But that can be emotionally draining for some women given the level of uncertainty. Ross notes that this could also take days or weeks, if it happens at all, and may actually lead to an eventual D&C anyway.
For all expectant women, the key to avoiding potential health risks associated with miscarriage and termination is getting informed, and that means doctors must be aware of current research. Moreover, Ankum thinks D&C needs to be "seriously reconsidered."
"Clinicians should be much more aware than they are by now, that curettage probably is an important risk factor for premature birth," Ankum says. "The more so, since they are the ones playing a pivotal role in counseling women about the pros and cons of available treatment options."
Options after a D&C
If you're one of the many women who have already had one D&C, sharing that information with their ob-gyns, along with mentioning whether any complications occurred, will help them plan the best course of action and prepare for avoiding preterm labor in future pregnancies. And for those with two prior D&Cs, a supportive stitch, or cerclage, can be placed around the cervix to keep it strong and help prevent early delivery, according to Ross.