Surgical Management Of Miscarriage

Surgical management includes dilatation and curettage (D&C, using a sharp metal curette) and suction curettage (using a metal or more commonly plastic cannula and a vacuum, via an electric or foot-pump, or with a hand-held manual vacuum device). D&C has been replaced by suction curettage as the usual surgical technique for early fetal demise, but is still used for the management of incomplete miscarriage.28 Suction curettage for incomplete miscarriage has however been shown to be associated with less blood loss and pain than sharp curettage.29

In a meta-analysis of women undergoing surgical curettage as the control group in RCTs of expectant and medical management of pregnancy failure, the rate of complete evacuation was 97%.26 This makes it the most efficacious option in the management of miscarriage.

Surgical curettage, however, is not without complications. These include: cervical damage; perforation; intra-abdominal trauma; intrauter-ine adhesions; haemorrhage; and the potential to introduce infection as a result of uterine instrumentation. There are also the risks associated with a general anaesthetic. Some practical points relating to surgical management are detailed in Table 6.3.

Table 6.3. Surgical curettage

Cervical/urethral swab for Chlamydia (or urinary

PCR if heavy bleeding)

Misoprostol vaginal 400 mg 2 hours before

procedure

Anaesthesia

- General

- Spinal

- Local (paracervical ± sedation)

Dilatation of cervical canal (to maximum of

Hegar 12)

Vacuum aspiration using Karmen or Corey

curette

Check cavity is empty using curette

Ensure bleeding has subsided

Analgesia

Send all tissue obtained for histological analysis

250 IU anti-D if Rhesus negative

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