# wait vs misoprostol vs d/c



## chi_mama (May 25, 2008)

I had a partial m/c 9 days ago, confirmed no heartbeat on u/s today. Have not had any spotting or cramping in 4 days. I am trying to decide what I want to do, MD gave me rx for misoprostol today but I can't decide what to do. I would love some advice from women who have done any of the above. Thanks


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## leogirl79 (May 9, 2008)

I did misoprostal. I'd do it again in a heartbeat. It was relatively quick and my story is posted below on this page. If you DO go that route get something for pain management, I used vicodin and it made it MUCH more tolerable.

I am so sorry for your loss


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## Sophiasmomma (Jun 16, 2004)

IM so sorry for your loss..here is my story and what I chose to do









I just had a D&C less than 2 weeks ago. I was 13 weeks and baby measured 12.5 with no HB









I waited 1 week to decide if I wanted to try and go naturally or have the D&C
I wanted some time to really let it all sink in and decide what was best for me. I went back to the DR again to have one last US to see the baby and get some pics.
I ended up having the D&C because I was starting to go into labor and couldnt imagine the pain and sadness.
My DR was more than understanding and caring. I went into the hospital they put me on some light anesthia and I slept right through it.
I had my Dr clear it with pathology that a funeral home was to pick my baby up and I had him/her cremated as I didnt want to leave it at the hosptial and I didnt want to have it tested. I feel very at peace since I do have my babies ashes and will one day be buried with them.


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## kaylee18 (Dec 25, 2005)

The trouble with D&C is that it has a certain risk of scarring (often downplayed, but especially with a repeat D&C or an "overly aggressive" D&C, there's an elevated risk of Asherman's Syndrome or of incompetent cervix later).

The trouble with misoprostol (Cytotec) is that it can cause overwhelming contractions and a lot of pain.

Both D&C and Cytotec carry an elevated risk of hemorrhage, and a significant risk of misdiagnosis resulting in the termination of a viable pregnancy.







The latter risk is reduced with repeat ultrasounds and hCG tests to verify the diagnosis of miscarriage.

The trouble with waiting is that it can take a long time and doesn't always work (although D&C and Cytotec can also fail). My physician was worried about infection but it turns out infection rates after D&C, Cytotec, and "expectant management" (waiting) are not significantly different from each other as found in research including the MIST trial in Britain. So waiting is not any more likely to result in infection than any treatment.

I chose waiting. I'm fine, and it's been 8 weeks since diagnosis of the failed pregnancy, but I still have gestational sacs retained despite some bleeding. I may use Cytotec in a week or so, since I am absolutely certain I have not ovulated and conceived in this time (abstinence would have precluded conception), and repeat ultrasounds and weekly hCG tests have exhaustively demonstrated that no development is occurring. If I remember right, waiting is successful 25% of the time within the first week, 50% within two weeks, and 85% within four weeks. So you would be unlikely to wait as long as I have waited without the complete resolution of the situation.


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## chi_mama (May 25, 2008)

Thanks guys, I really appreciate your thoughts...
Two things that are really concerning me, does the risk of hemorrhage increase the longer you have to wait? MW and office seem expecting me to hemorrhage (no explanation as to why)... or maybe they just reiterate the risk over and over to everyone... every conversation I have with anyone in the office ends with a 5 minute explanation about hemorrhage even though I've been warned by each individual at least twice.... or maybe I'm just being paranoid because I'm scared...
Secondly, I have a lot going on right now, I work 13 hour shifts and if I have to leave work for m/c that means shutting down the store and sending everyone home, which would be awkward b/c I haven't told anyone what is going on, and my grandad starts chemo next week so I have to take him for a bunch of appointments ect the rest of this week then a short break then things really intensify. So while usually I would prefer to take the waiting route I really need this to occur at an appriopriate time (hmm that sounds dumb, but I hope you know what I mean).... and (stupidly) I only qualify for sick leave if I have a d/c, otherwise I go without pay







(great benefits huh)
Does anyone know if there are specific risk-factors for hemorrhage?
Thanks


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## kaylee18 (Dec 25, 2005)

Quote:


Originally Posted by *chi_mama* 
Thanks guys, I really appreciate your thoughts...
Two things that are really concerning me, does the risk of hemorrhage increase the longer you have to wait?

No, it doesn't. I'm sorry they're scaring you. They're just trying to make sure you don't turn around and sue them for any reason. They think you are more likely to sue them if they don't "do anything" (even though their interventions elevate hemorrhage risk) than if they intervene. So they want to make sure they're covered as far as informing you of the risks.

Quote:

Secondly, [...] while usually I would prefer to take the waiting route I really need this to occur at an appriopriate time (hmm that sounds dumb, but I hope you know what I mean).... and (stupidly) I only qualify for sick leave if I have a d/c, otherwise I go without pay







(great benefits huh)
It is not legal for them to do that. You have a right to privacy for any illness or injury that is not caused by work. That means that if you have sick time available, they cannot apply requirements to you about explaining your medical situation to them. All you should need is a doctor's note stating that you were unable to work for medical reasons.

Spontaneous miscarriages usually do not begin very suddenly. You may be able to continue to work through one with just some pain medication and bathroom breaks, or it may get too intense for that, in which case you should have enough warning to get things closed up and to go see your doctor for a note.

Your granddad and chemo on top of everything else... never rains but it pours, huh? At least with taking him to appointments, you'd be at a medical facility a good deal of the time, and they should be understanding about anything you may need while you're there.

In your situation, I would get prescription pain medication right away, so that I would have it available rather than having to wait for an appointment and a prescription after the fact. Pain management might go a long way to making it manageable if it occurs at an inopportune time.

Quote:

Does anyone know if there are specific risk-factors for hemorrhage?
Thanks
Hemmorhage and infection are associated with non-sterile induced abortions







, which are sometimes dishonestly reported by the patient as "spontaneous miscarriage," so that's another reason care providers can be leery about expectant management. Obviously, that's not your situation, so you're in a low-risk category already.

Keeping everything out of the vagina (including tampons and physicans' hands, even with "sterile" gloves) can reduce your risks. Avoiding extremely strenuous lifting, exercise, or other work can also reduce your risk of excess bleeding, although moderate activity is not a problem (bedrest is actually worse, since it can cause deep-vein thrombosis).

You might also be reassured to know that hemorrhage is rare and, when it does occur, almost always occurs over several hours, not as one cataclysmic emergency. Your care provider should have given a rule of thumb about how to tell whether bleeding is excessive (usually it's stated in number of saturated pads per hour). Generally, there is plenty of time to get care for hemorrhage if it happens.

But don't feel bad about resenting the inconvenience. It does add insult to injury, this waiting and uncertainty. There is nothing wrong with recognizing your own needs in all of this.


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## Benjismom (Aug 24, 2002)

Chi mama:

I can't answer your specific questions about the risk of hemorrhage since I used misoprostol. But I wanted to chime in to say that I chose to use misoprostol for the precise reason you mentioned in your last post--I was incredibly anxious about starting to miscarry somewhere outside of my house (like on the subway), or when I was caring for my DS, or needing to go to the hospital unexpectedly and not having anyone to take my DS (then less than 2 years old). The ability to control the timing was the major benefit, for me, of misoprostol. I did it over a weekend when I knew my husband could take DS and my being out of commission on the couch wouldn't be a problem. The cramps were painful but not unmanageably so. I wouldn't hesitate to do it again if I were in a similar situation.

Beth
DS (8), DD (5)


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## chi_mama (May 25, 2008)

kaylee18 said:


> It is not legal for them to do that. You have a right to privacy for any illness or injury that is not caused by work. That means that if you have sick time available, they cannot apply requirements to you about explaining your medical situation to them. All you should need is a doctor's note stating that you were unable to work for medical reasons.
> 
> Benefits is telling me that I can only use sick leave if I am admitted into the hospital.


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## kaylee18 (Dec 25, 2005)

Quote:


Originally Posted by *chi_mama* 

Quote:


Originally Posted by *kaylee18* 
It is not legal for them to do that. [...]

Benefits is telling me that I can only use sick leave if I am admitted into the hospital.

That sucks, and I don't know if they're allowed to do that either. But it's possible. However, even though D&C is done in hospital, it is usually done as an outpatient procedure (day surgery). That's the way it was with my 2006 D&C (for a molar pregnancy, which is a tumor with no fetal development and no other real management option). So you might not be admitted anyway; you'd want to check with the hospital on that.

My cervix is not the same since the D&C (I've felt it regularly for years to assess stages of fertility for TTC, and my OB/GYN has confirmed the changes I detected, although she doesn't think it's a big deal), and that's one reason I'm very much trying to avoid one this time.


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## chi_mama (May 25, 2008)

Okay, well I just called benefits back and basically quoted Kaylee18 directly about medical privacy ect. and this time she said okay, fax in a MD note and we'll approve up to a week







so that's one less thing to worry about.
I think I am probably going to wait until Sunday then do the misoprostol (have 3 days off). It was prescibed to me 200 mg by mouth in the morning repeat in 12 hours but it I see a lot of people have vaginally so I may do that instead.
Thank you all for your concern and advice


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## mountainborn (Sep 27, 2006)

Kaylee18 -

Can you add some links to your research? It would be so helpful - I should be past 8 weeks and just discovered the sac stopped developing at 4 weeks. This is my third m/c and the last two were at home. I was so glad to avoid medical intervention those times and would love to do so again. I already have my share of pelvic scarring due to endometriosis and don't want to risk more. The sac is still attached and "looking good" although there is really no way it is viable, I had a positive hpt more than 4 weeks ago. I have not begun spotting at all. I'm not concerned about infection unless I begin to miscarry and it drags on, but I'd love some statistics to back up my decision. My midwife is supportive of my choices but seems to be nervous about waiting more than a week or so.

My last m/c was at 11 weeks but development had stopped at 6 weeks - I had no ultrasounds until the m/c began so we didn't know. I chose an early US this time for "peace of mind" but now I'm almost wishing I didn't have this info yet.

Quote:


Originally Posted by *kaylee18* 
The trouble with D&C is that it has a certain risk of scarring (often downplayed, but especially with a repeat D&C or an "overly aggressive" D&C, there's an elevated risk of Asherman's Syndrome or of incompetent cervix later).

The trouble with misoprostol (Cytotec) is that it can cause overwhelming contractions and a lot of pain.

Both D&C and Cytotec carry an elevated risk of hemorrhage, and a significant risk of misdiagnosis resulting in the termination of a viable pregnancy.







The latter risk is reduced with repeat ultrasounds and hCG tests to verify the diagnosis of miscarriage.

The trouble with waiting is that it can take a long time and doesn't always work (although D&C and Cytotec can also fail). My physician was worried about infection but it turns out infection rates after D&C, Cytotec, and "expectant management" (waiting) are not significantly different from each other as found in research including the MISS trial in Britain. So waiting is not any more likely to result in infection than any treatment.

I chose waiting. I'm fine, and it's been 8 weeks since diagnosis of the failed pregnancy, but I still have gestational sacs retained despite some bleeding. I may use Cytotec in a week or so, since I am absolutely certain I have not ovulated and conceived in this time (abstinence would have precluded conception), and repeat ultrasounds and weekly hCG tests have exhaustively demonstrated that no development is occurring. If I remember right, waiting is successful 25% of the time within the first week, 50% within two weeks, and 85% within four weeks. So you would be unlikely to wait as long as I have waited without the complete resolution of the situation.


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## kaylee18 (Dec 25, 2005)

MIST Trial:

Quote:

1200 women were recruited: 399 to expectant management, 398 to medical management, and 403 to surgical management. *No differences were found in the incidence of confirmed infection* within 14 days [after completion of the miscarriage] between the expectant group (3%) and the surgical group (3%) (risk difference 0.2%, 95% confidence interval − 2.2% to 2.7%) or between the medical group (2%) and the surgical group (risk difference 0.7%, 95% confidence interval − 1.6% to 3.1%).
Outcome of expectant management of spontaneous first trimester miscarriage: observational study:

Quote:

Of ...686 patients, 478 (70%) chose expectant management; of these, 12 (3%) asked for more than four weeks before deciding whether to undergo surgery, and they were given a further three weeks to decide (three completed their miscarriage after 32, 36, and 46 days). After 27 (6%) patients were lost to follow up, data from 451 patients were available for analysis (table 2). A successful spontaneous outcome with no serious complications was observed in 367 (81%) of cases. None of the 408 patients initially classified as having had a complete miscarriage reported an ectopic pregnancy or any other serious complication requiring intervention. The overall rate of spontaneous completion for cases classified as incomplete miscarriage was 201/221 (91%); the value for missed miscarriage was 105/138 (76%) and for anembryonic pregnancies 61/92 (66%) (table 2). Overall, 52% of incomplete miscarriages had resolved spontaneously by day 7 of management and 84% by day 14. The corresponding values for missed miscarriages and anembryonic pregnancies were 28% by day 7 and 56% by day 14. Complications arose in 11/1094 (1%) patients; of these, 5/208 (2%) patients had undergone immediate surgical removal of the products of conception and 6/451 (1%) were undergoing expectant management. The current odds in favour of a successful outcome for patients with an incomplete miscarriage, a missed miscarriage, and an anembryonic pregnancy are about 9:1, 3:1, and 2:1, respectively.
Patients can now be encouraged to persevere with expectant management, because of the high completion rate by day 14 from classification. The implementation of these findings will reduce the number of women undergoing surgery.
It was MIST, not MISS - I corrected it in the prior post too. Hope this helps!


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## mountainborn (Sep 27, 2006)

thank you! i actually lost the baby yesterday morning so i don't need the info for myself this time...but it is good to have on hand.


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