Surgical Management

After the pages of all of the different management options is a discussion of the pros and cons of each method and the factors that play into choosing each. While you should always discuss this decision with your doctor, you should also be informed of your options.

 
In this section we describe surgical management for two different types of pregnancy: intrauterine (within the uterus, the normal location for an implanted embryo) and ectopic (when the baby has implanted somewhere outside of the uterus, typically the fallopian tube).

For a great example of one couple’s surgical management, along with many helpful suggestions, please read How to Bury Your Baby After a Miscarriage

Intrauterine pregnancy: Dilation and Curettage (D&C)

There are numerous places online that detail exactly what happens during a D&C. A good example in layman’s terms can be found here. Technically, few D&Cs (which involve scraping the uterus with a sharp instrument) are performed any more. The usual procedure for emptying a uterus because of miscarriage is called vacuum extraction or a suction D&C. D&C has come to be the generic name for all such procedures. There are also cases in which a combination of suction and curettage is used. In a nutshell, this is what to expect:

You will be instructed not to have anything to eat or drink after midnight. If you are on medications, you will be discussing which ones to take and which ones to hold.

A D&C is an outpatient procedure so unless there are complications you will not be staying overnight. You will register in the preoperative department and spend some time there getting an IV placed, receiving any sedation, etc. The nurses will make sure that everything is in order, all consents are signed, and you have questions answered. Then you will be taken into the OR. Usually there are two options for anesthesia: conscious sedation and complete sedation. In the former, you are awake, but not very aware, and you shouldn’t feel any pain. You may feel some pulling sensations during the actual procedure. In the latter you are put to sleep and you wake up in the postoperative department. The anesthesiologist will have discussed these options.

You will be positioned in the lithotomy position on the operating table (just like a regular gyn exam). Your legs will be securely propped up so you do not have to hold them there. You will be given oxygen and your vital signs will be monitored. You will have electrodes attached to your chest and arms (this doesn’t hurt) to monitor your heart. At this point you should be drifting off.

**WARNING: Possibly graphic content**

The doctor will use a speculum to open the vagina. It will stay in place the whole time. Dilators of increasing size are inserted into the cervix to widen the opening. When it is open enough a tube is passed through it into the uterus. Suction is applied through the tube to remove everything in the uterus. [Note that this is a blind procedure and the doctor stops when he ‘thinks’ he has removed everything. Sometimes this was not the case and a repeat D&C must be done.] When the doctor feels the uterus is firm enough (it will cramp very hard during the procedure) and the bleeding is within reasonable limits you will be taken to the postoperative department to recover. Everything that was removed from the uterus is collected, examined for completeness, and sent to the pathology department. The entire procedure takes only about fifteen minutes.

You will stay in recovery until you are awake, your vital signs are stable and close to the levels they were when you were admitted, you can tolerate fluids by mouth and you can urinate. Your bleeding will be monitored and if it is found to be too heavy, you may stay longer or possibly be admitted. You will be given medication for pain. You will not be able to drive yourself home so make sure you brought someone with you. You will be given detailed instructions for how to take care of yourself at home.

Bleeding may last up to two weeks (similar to that of an unassisted miscarriage) but will probably be less than a regular period since most of the superficial lining of the uterus was removed during the procedure. The rest of your care is identical to that after an unassisted miscarriage (see that section). You may be given antibiotics to take to prevent infection.

Complications are rare (less than 1 in 100) but include infection, excessive blood loss, perforation of the uterus and uterine adhesions (which may affect the ability to be pregnant again).

 

Ectopic pregnancy: Laparoscopy

Some women choose to have surgery to remove an ectopic pregnancy so that the process will end more quickly. In other cases, the doctor will recommend surgery because of the size of the ectopic pregnancy or because she suspects that you are bleeding. If your doctor believes that you have a ruptured ectopic pregnancy, you need to have surgery. Ruptured ectopics are medical emergencies and are fatal if not treated. While no one can make you have surgery if you refuse, you should know that a doctor who uses the term “ruptured ectopic” believes that surgery is necessary to save you.

Surgery is usually with a camera that allows the surgeon to operate without making a large incision on your abdomen; you will have two small incision points, one for the camera in your belly button and one for the surgeon’s tools. This is called a laparoscopy. Laparoscopies are generally outpatient procedures. Your pre-operative experience is the same as that described above in the section about D&C.

In the operating room, you will be put to sleep. A small incision will be made in your belly button and a camera will be inserted. The surgeon will look around with the camera and then make two other small incisions in line with your hipbones and below your belly button. She will clean out the blood in your belly and then remove the ectopic pregnancy.

At this point there are two options for removing the baby. A salpingectomy, or removal of the fallopian tube, is considered morally acceptable by the majority of Catholic theologians under the principle of double effect (the effect of removing the tube is to save the mother’s life, and the baby’s death results from that action and not as a direct action on the child itself). If the pregnancy is large or the tube looks very abnormal, this is the typical course of action. You can still get pregnant with a single fallopian tube.

The other option is a salpingostomy, where the baby and embryotic sac is removed after making an incision in the fallopian tube. This is the common choice if the embryotic sac is small and the fallopian tube looks relatively normal. However, the morality of having a salpingostomy is still debated among Catholic theologians. While it saves the mother’s life, it also directly targets the child itself. A salpingectomy would be the preferred choice, but there is also no explicit teaching regarding salpingostomies, so if you have an informed conscience, it could still possibly fall under morally acceptable treatment.

 Your postoperative experience is similar to that described above in the section about D&C.

Less commonly, you will have to have surgery through a large incision without a camera. This is called a laparotomy. You may have to have this type of surgery if you have too much bleeding to have surgery with the camera, if you have had abdominal surgery before, or if you have an ectopic that is outside of the fallopian tube. The surgeon will usually make a “bikini” incision and then examine your tubes and ovaries. You may have a slit made in the fallopian tube or the entire tube may need to be removed. After a laparotomy, you will be admitted to the hospital. You will usually stay for two or three days after surgery.

If you have had significant bleeding, you may need a blood transfusion. If your blood type is Rh negative, you should be given Rhogam.