Patients have many treatment options after a miscarriage — so why do doctors keep using the most invasive one?
“Your baby has no heartbeat.”
I stared at the doctor in shock, my eyes instantly stinging with tears as his words sunk in.
I looked back and forth from the devastated look on my husband’s face to the sonogram screen, silently pleading for that tiny little black and white flicker to suddenly appear, unable to believe this was really happening.
How could the baby, who was developing so well for the last nine weeks, just be gone?
Within moments of hearing those devastating words, I was told I would have to have a D&C, that this was my only treatment option.
Ten to twenty-five percent of all pregnancies end in miscarriage. In some cases a woman may wait and see if the body naturally expels the tissue, but this is not a viable or recommended option for many people. This is when a dilation and curettage (D&C) may be needed. A D&C is a surgical procedure, typically done in the first trimester, to remove tissue from inside your uterus after a miscarriage. The patient is placed under general anesthesia — or, in very rare cases, under heavy sedation — while the procedure is done. (There is also a D&E procedure that removes tissue and also requires anesthesia, but this is typically used after the first trimester.)
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Historically, the D&C has been the dominant treatment method for people after a miscarriage, and it has generally been considered safe — and for some, it may be necessary. But there is an increased risk of complications whenever anesthesia is used, due to potential reactions to the medication and resulting breathing problems. And for those who already have a history of reacting unfavorably to anesthesia, this can add additional complications.
Recent studies have also found that there may be more risks to a D&C than previously thought. Researchers from the European Society of Human Reproduction and Embryology analyzed 21 different studies on D&Cs and discovered that the procedure is connected with a 29% greater chance of preterm birth (defined as birth occurring before 37 weeks) and a 69% greater chance of very preterm birth (less than 32 weeks) in a future pregnancy. This study of almost 2 million women also found the risk of prematurity was even higher in women with several previous D&Cs.
This is not intended to cause alarm in women who have already had a D&C, or to endorse one procedure over another — but patients should always be advised of every option available to them, not just the standard D&C.
Manual vacuum aspiration (MVA), for instance, is a safe treatment option in an early miscarriage. In this procedure the cervix is numbed and tissue is removed with a hand-held device (MVA) or a small electric device (referred to as an EVA). The procedure lasts, at most, 10 minutes. The patient remains completely awake and alert the whole time, and it is now the recommended method of treatment for early miscarriages by the World Health Organization. The Journal of American Science also reports that the MVA is effective, less time consuming, and less costly, and since it doesn’t require general anesthesia, the risk of complications is less than a D&C.Patients should always be advised of every option available to them, not just the standard D&C. Click To Tweet
Another study published in The International Journal of Obstetric and Gynecology reports that the MVA is “an alternative to the standard surgical curettage, performed under local anesthetic. It is a safe, and possibly cost-effective procedure, with advantages for both the patient and the health-care system.”
There is also a medication option where a patient is given misoprostol, a drug that causes the tissue to pass. Patients take the pills at home and often have to follow up with their doctor afterwards to ensure the procedure was effective.
I was not informed of these other options after my own miscarriage by any provider, including my doctor, a highly-regarded physician in New York City, and the staff at the surgical center. As a clinician that has worked in a medical setting, and with patients who have miscarried, I was already aware that other options to the D&C existed, but none of my providers discussed these with me. At one point I was even told by staff at the center that “if you have a miscarriage then you have to get a D&C.”
When I met with the “counselor,” employed by the surgical center to speak with patients before they see the doctor to inform them of treatment options and review consent forms, they only brought the information and consent forms for the D&C and said nothing about the MVA or the option to take misoprostol at home.
I continued to refuse the D&C. Having had difficulty with anesthesia in the past, I saw no need to have this if it wasn’t absolutely necessary, and finally, after going through multiple staff members and supervisors, I was given the proper consent forms for an MVA and was taken to one of the on-duty doctors who confirmed that an MVA is an applicable treatment option in an early miscarriage.
In speaking with many other women who have also been in this situation, they too shared stories of not being informed that there were other options, and many told me they had never been told that the MVA procedure even existed.
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There are compelling reasons why patients might not be getting a full picture of their options after a miscarriage, the location of where the procedure is performed being one. Many D&Cs continue to be performed in hospital operating rooms, despite the advances in miscarriage management, and even though, with the exception of certain complicated cases, there is no longer a medical need that necessitates a patient going to the hospital after a miscarriage for a D&C.
This is often due to physician preference rather than what the patient wants. Studies have shown that medical providers’ attitudes toward newer treatment have remained stagnant, that many physicians still utilize the older D&C method and still prefer to treat pregnancy loss in the hospital operating room, according to research published by the Guttmacher Institute and the National Institutes of Health.
Even if a D&C is the right treatment option for a woman, it isn’t medically necessary for this to be done in the hospital and it can be performed in other medical settings, such as a surgical center or a private doctors office. Requiring people to go to the hospital OR (operating room) often adds significant stress, time, and cost to an already painful situation.
New York City-based physicians, Drs. Priypa Praditpa and Anne R. Davis, concluded in at 2015 study, “Manual vacuum aspiration: A safe and effective treatment for early miscarriage,” that the MVA is not only a safe procedure, but that “for too long, patients have blamed themselves for a miscarriage and physicians have relied on the D&C in the OR. Changes in the culture surrounding miscarriage are long overdue.”At one point I was even told by staff at the center that ‘if you have a miscarriage then you have to get a D&C.’ Click To Tweet
The financial aspect to the D&C likely plays a role and provides an incentive to which procedure doctors perform and where they perform it. Providers can bill insurance companies at a higher rate once anesthesia is administered and even more so if it is done in a hospital. Anesthesiologists typically bill at a base rate and then at each 15-minute interval while the patient is under their care.
Both the MVA and the medication option are considerably less expensive than a D&C, with the average cost of an MVA being less than half the cost of a D&C in the OR — $968 for the MVA, compared to $1,965 for the D&C, according to Praditpa and Davis’s research. The Healthcare Bluebook also lists the “fair” billable price for a provider to charge for a D&C as $2,728, though that can go all the way up to $6,820.
For uninsured women, the cost of a D&C can be staggering; though prices vary depending on provider and location, they often range from $4,000 to $9,000. Insured women have also reported exorbitant out-of-pocket expenses after a D&C, ranging from several hundred dollars to well over a thousand depending on their individual insurance plans. This further skews the incentive for medical providers to offer more economical treatment options.
But it’s not just about money or location. A miscarriage is already an emotional and painful time and it is every woman’s right to know all of their treatment options so they, not the medical staff or office billing manager, can make the best decision for their body — a decision based not on increasing profit or perpetuating unnecessary medical procedures, but on their individual needs.