dilatation and curettage of uterine，D&C（刮宫）
1、D&C procedure after a Miscarriage
Unfortunately, miscarriage is the most common type of pregnancy loss, according to the American College of Obstetricians and Gynecologists (ACOG). Studies reveal that anywhere from 10-25% of all clinically recognized pregnancies will end in miscarriage, and most miscarriages occur during the first 13 weeks of pregnancy.
Pregnancy can be such an exciting time, but with the great number of recognized miscarriages that occur, it is beneficial to be informed on miscarriage in the unfortunate event that you find yourself or someone you know faced with one.
The main goal of treatment during or after a miscarriage is to prevent hemorrhaging and/or infection. The earlier you are in the pregnancy, the more likely that your body will expel all the fetal tissue by itself and will not require further medical procedures. If the body does not expel all the tissue, the most common procedure performed to stop bleeding and prevent infection is a D&C.
★What is a D&C Procedure?
D&C, also known as dilation and curettage, is a surgical procedure often performed after a first trimester miscarriage. Dilation means to open up the cervix; curettage means to remove the contents of the uterus. Curettage may be performed by scraping the uterine wall with a curette instrument or by a suction curettage (also called vacuum aspiration), using a vacuum-type instrument.
★Is a D&C necessary after a miscarriage?
About 50% of women who miscarry do not undergo a D&C procedure. Women can safely miscarry on their own, with few problems in pregnancies that end before 10 weeks. After 10 weeks, the miscarriage is more likely to be incomplete, requiring a D&C procedure to be performed. Choosing whether to miscarry naturally (called expectant management) or to have a D&C procedure is often a personal choice, best decided after talking with your health care provider.
Some women feel comfort in going through a miscarriage in their own home, trusting their own body to do what it needs to. Some see this as a vital part of the healing process, eliminating the question of “what if?” about the health of the pregnancy. There are also many women who miscarry who have a history of gynecological problems and don’t want to risk the possibility of any more complications occurring from having a D&C procedure done. For most first trimester miscarriages, expectant management should be a viable option.
For some women, the emotional toll of waiting to miscarry naturally is just too unpredictable and too much to handle in an already challenging time. Healing for them may only start once the D&C procedure is done. A D&C may be recommended for women who miscarry later than 10-12 weeks, have had any type of complications, or have any medical conditions in which emergency care could be needed.
★How is a D&C procedure done?
A D&C procedure may be done as an outpatient or inpatient procedure in a hospital or other type of surgical center. A sedative is usually given first to help you relax. Most often, general anesthesia is used, but IV anesthesia or paracervical anesthesia may also be used. You should be prepared to have someone drive you home after the procedure if general or IV anesthesia is used.
* You may receive antibiotics intravenously or orally to help prevent infection.
* The cervix is examined to evaluate if it is open or not. If the cervix is closed, dilators
(narrow instruments in varying sizes) will be inserted to open the cervix to allow the surgical instruments to pass through. A speculum will be placed to keep the cervix open.
* The vacuum aspiration (also called suction curettage) procedure uses a plastic cannula (a flexible tube) attached to a suction device to remove the contents of the uterus. The cannula is approximately the diameter in millimeters as the number of weeks gestation the pregnancy is. For example, a 7mm cannula would be used for a pregnancy that is 7 weeks gestation. The use of a curette (sharp edged loop) to scrape the lining of the uterus may also be used, but is often not necessary.
* The tissue removed during the procedure may be sent off to the pathology lab for testing.
* Once the health care provider has seen that the uterus has firmed up and that the bleeding has stopped or is minimal, the speculum will be removed and you will be sent to recovery.
★What are the possible risks and complications of a D&C procedure?
* Risks associated with anesthesia such as adverse reaction to medication and breathing problems
* Hemorrhage or heavy bleeding
* Infection in the uterus or other pelvic organs
* Perforation or puncture to the uterus
* Laceration or weakening of the cervix
* Scarring of the uterus or cervix, which may require further treatment
* Incomplete procedure which requires another procedure to be performed
★What to expect after the D&C Procedure:
D and C procedures can be emotionally trying on women.Most women are discharged from the surgical center or hospital within a few hours of the procedure. If there are complications or you have other medical conditions, you may be kept longer. You will more than likely be given an antibiotic to help prevent infection and possibly some pain medication to help with the initial cramping after the procedure. Things to know about taking care of yourself at home:
* Most women can return to normal activities within a few days, and some feel good enough to return to normal non strenuous activity within 24 hours.
* You may experience some painful cramping initially, but this should not last longer than 24 hours.
* Light cramping and bleeding can be expected from a few days to up to 2 weeks. Ibuprofen is usually suggested for treating cramps.
* You should not insert anything into the vaginal area, including douche and sexual intercourse, for at least 2 weeks or until the bleeding stops. (Your health care provider should give you specific instruction for when intercourse can resume.)
* Tampons should not be used until you start your next regular period, which could be anywhere from 2-6 weeks after the D&C procedure.
* It will be unknown when ovulation will return, so once sexual intercourse is allowed, you should use a method of contraception until your health care provider says it is okay to try to get pregnant again.
* Make sure to attend your follow up appointment.
★When to contact your health care provider:
Most women experience few complications after a D&C procedure, but you should be aware of things that could signal a possible problem. Your health care provider should give you specific instructions on what you should expect, but you should contact them as soon as possible if you experience:
* Dizziness or fainting
* Prolonged bleeding (over 2 weeks)
* Prolonged cramping (over 2 weeks)
* Bleeding more than a menstrual period, or filling more than a pad an hour
* Severe or increased pain
* Fever over 100.4 °F or chills
* Foul smelling discharge
If you opted for a D&C or D&E, first you will have the procedure done. Remember that if you can, insist on some time to gather loved ones around you or to get yourself together before you do this. Don't let anyone panic you into rushing into a procedure you're not ready for. This is usually all done in one day, but if you were farther along than 14 weeks, it may be a two-day procedure, with the laminaria sticks being inserted the first day, the dilation occurring overnight, and the procedure being done the next day. If your pregnancy was very young, you may get a dilation cream instead, or even not need dilation if your cervix is already slightly open as the miscarriage is beginning.
The surgery will be pretty fuzzy to you, due to the drugs and anesthesia. You may be put completely under, or you may be given a local and laughing gas. If you are awake, you may feel some pricking or sucking sensations, but it will not be uncomfortable. You will spend a couple of hours in a recovery room to wait on the anesthesia to wear off. Some doctors will prescribe antibiotics as a precaution; but many will not unless you develop symptoms of an infection.
During the next few days, you will likely experience the following:
*Mild to medium pain in your abdomen or tenderness. Most women report no pain at all, but those pain pills are not prescribed for nothing. Hopefully you will not need them.
*Deep muscle soreness in your thighs from your position during the procedure.
*Mild to heavy bleeding with some mild cramping.
*Sun sensitivity, nausea, and weakness from the strong antibiotics.
*Heavy groggy feeling, from the anesthesia and your sadness.
Call your doctor if you experience the following:
*Any sort of abdominal pain after the second day. You could be developing an infection. Don't panic though, just call and you will get a stronger antibiotic and a check up.
*A fever that starts to approach 100 degrees. Again, infection is a possibility.
*A sudden stoppage of bleeding, then severe cramps, almost as if you are in labor. This happened to me, and I can't tell you how I panicked. I ended up passing tissue, then the bleeding resumed normally. I called the doctor and they checked on me every few hours at home, but I didn't end up having to go in (good thing, since I was 150 miles away).
*Pain, flu feelings, or overall debilitating sickness that last more than a day or two.
If you choose to wait it out for a natural miscarriage, you will most likely have a difficult wait. It may not seem real; you will harbor hope that it will never happen. Eventually the cramping and bleeding will begin, and you may react with severe grief and panic. You may feel ridiculous or morbid trying to catch tissue in a jar or plastic bag for testing. All these things are fine. Do the best you can. If all goes well, the cramps will subside and a regular blood flow will resume. Keep in mind that you may not pass all the tissue and will have to have a D&C to empty your uterus.
During the next few days you will likely experience the following:
*Cramps and bleeding, sometimes quite painful and heavy.
*Passage of tissue, resembling large blood clots in the earliest weeks up to pinkish/grayish material, possibly even in a discernable sack. Keep in mind that a three-week old embryo is only 2 mm long about like this: _ and you probably aren't seeing the actually baby, but only the yolk sack or placenta. A four-week old embryo is about a quarter inch long, more like this: __ , still probably impossible to see. Even a six-week old embryo is less than an inch long. Try not to traumatize yourself by searching for the baby. Believe me, I understand the impulse. Not seeing my baby was traumatizing in itself. And mine was fully formed at 20 weeks. Just do the best you can. If you collect the tissue, it may be refrigerated until you take it for testing. If this is your first miscarriage, it is not necessary to keep the tissue. It is rarely tested in this case. Any tissue that falls into the toilet is not testable, so you do not need to retrieve it.
★Call your doctor if you experience the following:
*Any sort of abdominal pain that lasts beyond the cramping stage. You could be developing an infection. Don't panic though, just call and you will get an antibiotic and a check up.
*A fever that starts to approach 100 degrees. Again, infection is a possibility.
*Cramps beyond endurance. You may need a pain medication or a D&C.
*Bleeding that comes heavy and fast, soaking a pad every few hours, for more than three days. If the bleeding does not slow down after that, you may have tissue that is causing hemorrhaging, and you will need a D&C.
*Bleeding that lasts longer than two weeks. A D&C may be necessary.
*Bleeding that starts and stops and starts and stops for weeks. Some tissue is still causing hormones to be created, and you will need intervention.
★Everyone will feel some of the following as the days and weeks wear on:
*A mild start and stop bleeding pattern up to two weeks. You should have a new cycle, unrelated to the first bleeding, between 4 and 7 weeks after the miscarriage. I didn't get a fresh cycle until the last day of the 7th week, so don't panic if you are still waiting. A few women need a Provera shot to jump start their cycle, but this is not terribly unusual. Call your doctor if you go much longer than 7 weeks, just for your peace of mind. You may want to start charting your temperatures after the bleeding stops to see where you are. Remember that you can get pregnant that first cycle, so use contraceptive. For more information, see the section on trying again.
*Snappy, unhappy, angry feelings. Wanting to be left alone or wanting to talk about what happened with everyone you know.
*A sense that it isn't real, that it never happened.
*Hypersensitivity to sad TV or reading materials, being revolted or angry about happy scenes of families, seeing symbols in everything you do, from gardening to dreams to what you eat.
*Anger at the baby, wishing you never knew about the pregnancy, wanting to throw out all the baby reminders, or clinging to the little angel you lost, thinking about him/her nonstop, wanting everyone to recognize that the baby was real.
*Anger and/or jealousy of other pregnant women, even friends and family, to the point you don't want to even talk with them. This is okay. I felt this way for several months.
Physically, you will recover completely from a D&C or D&E in about two weeks. The bleeding should subside, your cycle will start up again, and the hormone-induced mood swings will even out. It will still take four to seven weeks to start a totally new cycle, and you should wait at least that long before trying again.
A birth takes considerably longer to recover from. You may have shaved areas that will grow out and itch or burn. You may have stitches that will be sore for a few weeks. This recovery is like any other post-partum. Check with your doctor in how long you must wait to try again. A general rule of thumb is that you must wait a cycle for every two months you were pregnant.
A natural miscarriage can take considerably longer. You may have to wait days or even a couple of weeks before the bleeding and cramping begin. (Don't go more than two weeks without talking to your doctor about possibly getting a D&C. Studies show the longer you carry a lost pregnancy, the more likely you are to get seriously depressed, and the more likely you may have physical complications.) The actual miscarriage may only take a few days, or may drag out over several weeks.
For more information on the actual passage of tissue or how a D&C or D&E is handled, see miscarriage descriptions. Usually you will have to wait four to seven weeks for a new cycle to begin regardless of how the miscarriage happens, although a birth near term can delay your first period for several months. You should not try to conceive again during this time.
The emotional recovery is another story altogether. One thing I will point out immediately is that your level of sadness is not at all tied to how far along you were. Everyone will be surprised by their emotions. Some will be near absolute despair and wish to join their baby. Some will be unpleasantly numb and feel nothing at all. Most will swing somewhere in the middle, seemingly okay one minute, then sobbing as if it were only yesterday. All the stages of grief will almost always be visited. Shock, numbness, denial, anger, guilt, depression, and finally resolution are all emotions you will experience. They do not come in order; some stages may go on for many weeks and others only a few hours. No two people grieve the same, as you will quickly see when your partner does not react the same way as you do. Don't expect that you will "get over it" in a few weeks or even months. Don't assume that getting pregnant again will turn everything around. Don't give yourself a timetable. Just let the emotions come and go and try to keep your life going.
So, you ask, when WILL I feel better? In some ways, you never will. The complete innocence and pure joy of pregnancy will not come back. But you will feel better than you do right now. Your life will go on, you will try again, and you will survive. There is much more to happen in your life. You have to keep going to see what it is. Only when you look back on where you were will you see that you do indeed feel a little bit better. For more information on emotional recovery, see "How to Cope."
★How to Cope
The emotional recovery from a miscarriage is not easy. Few people may even know about your loss, and others may brush it aside, even your partner. You are not alone, and you may be surprised to see in these topics that what you are feeling is normal and expected.
Feelings You May Have
*Despair and suicidal thoughts
*Going crazy/Feeling neurotic
*No one understands
*My partner isn't supportive or grieving like me
*Jealousy of pregnant women
Dealing with Others
*Telling Your Friends and Family
*Telling Your Children
*When No One Will Talk about Your Loss
*When People Say Things that Upset You
*Mean and Petty People
Honoring Your Baby
*Ways to Memorialize Your Baby
*Naming the Baby
Events to Suffer Through
*Managing the Holidays
*Going back to Work
*Baby Shower Invitations
● I feel despair.
It is natural to feel despair and incredible, debilitating sadness. You may not want to get out of bed, talk to anyone, eat, or even breathe. You may think about killing yourself to be with your baby or just lying in bed until everyone gets the point and leaves you alone. I felt all these things.
You have every right to feel this way. Let it go for a day or two, even as much as a week. By then, it should start to ease a bit. Your emotions may shift to anger or defeat. But when you cry, you do eventually stop. Your mind will drift to other things occasionally. And you will start getting better.
If in a week you are not feeling somewhat better, if you are still feeling like being with your baby would be better than being here, reach out to someone, anyone, email me, call someone you know, find a miscarriage support group, go to a church, do something. Fight to get back to the surface and out of deep despair that you feel.
Remember that you still have things to live for, things out there in a future you can't see right now--children you will eventually have, either yourself or through adoption, love you will feel, friends you will make. Don't give up yet.
When is despair dangerous? When you stop thinking about committing suicide and start planning it. If you have taken any steps toward really doing it, or sorted out in your mind what would be the easiest way, please, please, get help immediately. What is happening to you isn't just the loss of your baby, it is a hormone imbalance that is affecting your thinking. It is very possible to get out of your despair with just a little bit of help from a professional. You must do this. You have a future.
● I feel angry.
You are perfectly justified. It's hard to know where exactly to direct your anger, though. God? Fate? Your doctor? Your husband? Yourself? You wonder why in hell you had to get pregnant if this was going to happen. Why did you have to carry the baby so long? Why did it have to happen to you?
Anger is one of the natural parts of the grieving process. It is a healthy emotion right now and will get you feeling stronger. But it will probably not last. Anger usually gives way very quickly to sadness and despair. Sometimes you will feel flushed with anger, and just as quickly you will be sobbing. You may feel like you are out of control. Maybe you want to smash things. I actually did smash some things. It helped for a moment or two. Then I just had to sweep it up.
All these things are real and valid feelings. And we all experienced them. You are part of a large sorority of sad and angry mothers of angels. We all understand. And we're angry too.
● This miscarriage is my fault.
I can't tell you how many women have explained to me what they did to cause their miscarriage, or to ask if their stressful job or glasses of wine were what did it. For a long time, I blamed myself too. Then I learned I had a malformed uterus. All that guilt was for nothing.
Let me be the one to tell you: YOU DID NOT CAUSE THIS MISCARRIAGE.
I don't care if you were smoking crack--those babies are born all the time. Stand up on the job all day? Doesn't matter. On bed rest but got up a couple of times to raid the refrigerator or use the bathroom (or even to go out to dinner)? Insignificant. Nature is not perfect. Our genetic code sometimes doesn't work just right. It's terrible; it's sad. I hate it. But it has nothing to do with your sins, your stress, your mistakes, your nutrition, or your relationship. There was nothing you could have done.
I know. Some of you still feel a nagging guilt. But try to put it out of your mind. It really, truly was not your fault. And most likely, it will not happen again.
● I think I'm going crazy.
Remember to give yourself time to handle your grief. IT IS REAL AND VALID. You may want to read some of the other women's miscarriage stories here or on other web sites to help you see that the crazy things you feel are normal. I did and thought many things after my miscarriage that I thought were really unhealthy or insane, including:
■ Wanting to die to be with my baby
■ Cuddling the sonogram pictures like a baby
■ Hugging the tree we planted in Casey's memory (in full view of neighbors)
■ Getting angry with myself for laughing or having a good time
■ Picking fights with my husband for no reason
■ Telling perfect strangers about my baby
It may not get much better for a long time. There will probably be a time, about 3-4 months later, that it will actually get worse. Getting pregnant again may not give you the release from grief you seek. Just give yourself time and surround yourself with people who care and understand. Forget the rest of them, for now.
If I could make one recommendation that has helped me tremendously, it would be to put together a memory box of your baby's things, even if it is only sympathy cards and a positive pregnancy test, or just letters you are writing to him/her. For several months, I went into the nursery and opened that box and cried every single day. I found that if I didn't, I felt like I was in a grief-fog all day. The memory box validates my baby's existence. Since I don't have a grave or a container of ashes, I go to it.
● No one understands
You are right. Unless they have had a miscarriage (and fairly recently at that), people you talk to will not understand what you are going through. The average person will expect you to completely "get over" the miscarriage in about two weeks. This is about the point that things may actually get worse for you, when reality has set in, and you are failing to cope. Women suffer alone with miscarriage, and even the baby's father, your own mother, your best friend, or others you thought you could rely upon will fail you. The best course is to surround yourself for a while with people who DO understand, who are going through it right with you. You can find them in local support groups (call your doctor's office or a large OB practice in your area) or join a bulletin board. See some of the topics under "dealing with others" for other ideas on how to cope with solitary grieving.
● My partner isn't supportive or grieving like me
This is the number one complaint of women. They feel sad, overwhelmed, and grief-stricken, and their partners are still watching football, going to work just fine, or even telling them to "get over it."
There are a few critical points I want to bring up about this:
■ Almost every single woman feels this way (only a very small number mention partners that are sensitive and helpful)
■ 100% of dads I've talked to or who have gotten on the board either want to know how to be strong for their wives or confess that they are grieving deeply and don't want their wives to know
■ Men (and many women) really do believe that if you stop thinking about something, the problem goes away. Thus, they say comments like "Stop thinking about it" or "You're getting obsessed about this" or "I don't want to talk about it anymore." Truly, nothing could be further from the truth. Talking about your problems is a catharsis and will help you heal faster.
■ A very natural dynamic in every couple, particularly if you live together or are married, is that only one person can fall apart at a time. If you both fall apart, no one will be making dinner, keeping the clothes washed, or manage other children, if you have them. This is an important function of the partnership, and is very rarely breached. Whoever is less sad at the moment will swallow their grief and deal with it later. The other person will feel abandoned and alone, and the partner may recognize it, but feel helpless to really get involved due to the pressure of keeping everyday life going. This time will pass, and the acute phase is usually a month or less.
● I am so jealous of pregnant women, even family and friends
This is perfectly natural, and is reported by 100% of women who have lost babies. Why you and not them? Why does your teenage niece get to have a baby when you don't? Or that woman who is still smoking? Or the five friends of yours who are pregnant right now?
You will feel surrounded by babies and pregnant women. You will see reminders of your loss everywhere. This is something you are going to have to tough out. Here are some things that might help:
■ Buy something for your baby. Or better yet, make a little memory box. (See memorializing your baby.) You will feel comforted and more like a mom yourself--because you are one!
■ Don't feel obligated to go to baby showers. Don't bother with excuses, or to explain yourself. Just send a lovely note with a gift certificate to the mall, or Target, or an online baby store, and say, "Wish I could have made it. Best wishes." Will some people be upset? If it is your best friend, or your sister-in-law, maybe. But that's okay. One of the two of you were going to get bent out of shape with this situation, so let it be the one who is about to have a joyful moment and will forget all about it in a few weeks.
■ Don't bottle it up. If pregnant co-workers or friends talk incessantly about babies, just say, "I am so happy you all have so much to look forward to. I can't wait until it is one day my turn." Then walk away! There is no need to stand around and endure the conversation. Even if they say something negative about your sensitivity, they are just projecting how guilty they feel for upsetting you. They know it's their fault. And they have no idea how hard this is for you. Often you'll find out who has had a miscarriage before, because they will seek you out with a sympathetic, understanding ear.
■ Remember that this is a joyful time for them. You too will want to shout to the rooftops when your healthy baby is born. They are having a happy moment, and in the momentum of their anticipation, they don't always remember that you are grieving that very thing that they have. When women are pregnant, and blissfully ignorant that anything could ever go wrong, they don't always put others' feelings first. Forgive them, and don't seek their company if you cannot handle it. Joining in their joy will be one of the last things you will be able to do as you heal from your loss. Laughing at a baby shower will be a sign that you are moving through your healing stages and looking forward to a happier future. This is going to be a long way down the road, and may not happen until your own little one is safely delivered. It's okay, and don't beat yourself up about it. You're a survivor, and sometimes survivors can't always act the way everyone else does.
4、The First Few Days after a Miscarriage
At this point, you will have either gotten through the surgery or the worst of the tissue passage and bleeding from a natural miscarriage.
It is best, if you can, to take off work, or enlist help with children. The more active you are in the 72 hours following the miscarriage, the heavier you will bleed. Your recovery will take longer if you cannot spend most of your time sitting or lying down. (We'll allow you to sit here and read this, but if you feel any gushes of blood while you are here, print it out and take it to bed.)
★Here are symptoms that are normal:
*Additional passage of tissue a few days after things seem to have settled down, along with strong cramps and renewed bleeding
*Start and stop bleeding patterns
*Residual cramps, sometimes quite painful
*Minor abdominal pain or muscle soreness
*Sudden stoppage of bleeding (which may return)
*Sun sensitivity or nausea if you were given antibiotics
*Continuation of pregnancy symptoms for a week or so, including breast tenderness, nausea, and frequent urination
*Grogginess, inability to get out of bed (usually due to sadness or post partum depression)
*Increased tenderness in breasts, even leakage of colostrum, or pre-milk
*If you were in the 2nd trimester or later, you may experience engorgement, which is swollen breasts filled with milk. Ease this with hot showers or bags of frozen peas. Do not pump milk out.
★These symptoms warrant a call to the doctor:
*Bleeding so heavy that you constantly change pads or feel faint
*Labor like contractions that do not go away with rest
*Fever above 100 degrees, especially if you also have flu-like symptoms of weakness or clamminess
5、Waiting for your first period
Technically, when things go perfectly, your first period will not arrive until four weeks after your hCG levels reach zero. Since most women will not be tested all the way to zero (which on your forms would show as "less than 5"), you will not know exactly when this will happen. In a normal recovery, it can take three weeks for the hormone chain to fire up again, and it will not be marked by bleeding or any physical symptom. You will only know that the new cycle worked by having a period at the end of it, between five and seven weeks after your miscarriage.
Here are the most common scenarios and symptoms that go with them. They come from a decade's worth of collecting women's experiences, from the easiest and quickest recoveries to the most elongated and complicated ones.
Remember that the day you found out about the loss is not a benchmark, nor is the day you began bleeding. The actual hormone change begins to take place either during the D&C or when the placenta pulls away from the uterus during the natural miscarriage, which is usually when the cramps and bleeding are at their worst. That is Day 1 of the recovery (but not Day 1 of a new cycle, as you will see.)
Here are the scenarios:
★The most common recovery goes like this:
Your bleeding will taper off to spotting within a week, and maybe random spotting will continue for another week. Your hCG drops steadily, usually hitting zero during the end of the spotting, or about 10 days after the miscarriage or D&C. When the spotting ends, you will get strange symptoms. If you use a fertility monitor, it may say you are ovulating, but you are not. You may see lots of cervical mucus coming out, sometimes still brown or yellow, but it is not a fertility sign either. In fact, most of the time, you will not ovulate in this cycle. You should not be trying to get pregnant, either. For why, visit the trying again section.
Some women find they have mild pregnancy symptoms, or little ovulation cramps. Many many women think they could be pregnant, because strange things are happening and their period is "late" (although almost every post-miscarriage period is late.) These symptoms are due to the body's attempts to regulate its hormones again. It may kick into gear right away, and you will get a new period in four to five weeks, or it may struggle a bit, and the period will not come for seven weeks. If you chart your temperatures, they will be all over the place. This is all perfectly normal and expected. Eventually your period arrives and can be either light or heavy. There is no "normal" right now. For more on this, or to spot trouble, see the next section on Your First Period.
★A less common, but still normal, recovery goes like this:
Your bleeding tapers off quickly, but with some spotting. You think it is over. Perhaps a week or even two will pass, and you begin to wait for your period. Then suddenly, it begins again. Strong cramping, heavy bleeding, and pain. You are scared and shocked and sad all over again. You hope it is just your period, but it is not. (You must not bleed at all for about 20 days for it to be a real period, otherwise you have not gone through the hormone chain properly.) You call your doctor, who may or may not be responsive. Most will just tell you to call them in a few days if it doesn't stop. You hang up very upset, and don't know why they don't care more about you and your predicament.
That's because within a few days, it does stop, and you are just spotting again. Here is what happened, some tissue was missed during your D&C or natural miscarriage.A bit of placenta clung to the wall of the uterus. It continued to draw a little blood, and the body continued to create very small amounts of pregnancy hormone. Eventually the body realized no baby was there and turned loose of this last bit of tissue. The miscarriage process begins again. Only now will your levels drop to zero and a new cycle begin. You cannot expect a normal period any sooner than four weeks from this, and up to seven weeks could still be normal. Your total wait time from original miscarriage to first period can creep up to nine or ten weeks and still be normal.
★A recovery that should be monitored looks like this:
The main bleeding seems to have ended, and you are spotting. And spotting, and spotting. Three weeks pass and you are still wearing panty liners. (You call your doctor, and they said give it another week.) Spotting ends. You are relieved. A few days later it begins again. You are crushed. Sometimes you get slightly heavier bleeding. You hope it is your period, then read that you have to have NO bleeding for almost three weeks first. You are crushed again. Your ordeal seems like it will never end.
You should go in for an hCG blood test. If your doctor won't do it, take a home pregnancy test. If it is still positive, call them back. Your levels should be at zero by now.
Your levels may come back at 100, or even higher. It may be zero. Your doctor still wants you to wait and see. If your levels were high and things go well, you will suddenly get another big passage of blood and tissue, and it will be over. You will still have a good case for requesting one more blood test to be sure. If this pattern continues, you may need a D&C, or in some cases, a drug called Cytotec, to induce cramping to push out left tissue.
If your levels were zero or not very high, and you still just keep spotting and spotting, you should be able to request a shot of provera or some other form of progesterone. This big dose will put your body into thinking it is nearing the end of a cycle. When the dose is done, the sudden drop in progesterone should trick your body into thinking it is time for a period, and you will bleed. This period can be terribly heavy or light, but it counts. If this has happened, it is still a good idea to wait one more cycle before trying to conceive. If it doesn't work, your doctor may put you on birth control pills for a couple of months to get your cycle regulated.
★A cycle that indicates a serious problem looks like this:
The bleeding tapered off, but then got heavy again. You are going through several pads a day. After two weeks of this you call the doctor. They tell you to see what happens. You may get a little reprieve of no bleeding or just spotting, then it begins again, as heavy as ever. You call and insist on being seen. You are feeling exhausted from the constant loss of blood and the sad ordeal just going on and on.
A blood hCG comes out high, 500 or more. The doctor tells you to wait and see, or maybe schedules another test. Your bleeding is still heavy, and sometimes you see big black gunk or tissue coming out. You feel panicky every time you go to the bathroom.
A second hCG test comes out only slightly lower than before or even higher than before. The doctor asks a few questions to rule out a new pregnancy and may do a sonogram.
The cause of this can be one of two things:
●Leftover tissue that refuses to budge. You may need a D&C or methotrexate to kill the tissue and make it come away. If left untreated, you could hemorrhage badly, eventually losing consciousness or becoming seriously iron-deficient. Scar tissue can also form should the left tissue become infected.
●Molar or partial molar pregnancy. It is very important to follow up on this and get a concrete diagnosis. Molar pregnancy can persist for months, and you absolutely cannot attempt another pregnancy until you have been without any hCG in your system for several months. Read more about molar pregnancy.
If you have start and stop bleeding for several months, I have a more complex description of the relationship between progesterone and bleeding down below.
★About follow up exams:
If you had a D&C, you will usually be called back in two weeks for a follow up exam. If you miscarried naturally, you may not need a follow up, or it could be at two or six weeks.
This exam is most likely going to hurt some. The cervix has been open and will be very tender for a while. Taking a couple of ibuprofen before you go can help. If you are able, having sex the night prior to the exam will help "break things in." You can control penetration with sex, and do it slowly, rather than have a metal speculum suddenly open you up.
This exam is your chance to ask questions. Don't be surprised if it is quick, your doctor does not have many answers, or you do not get any tests. This is pretty normal after a first miscarriage, where it is assumed you will be in the category whose next pregnancy will go perfectly (about 80%). For more on testing, see the diagnosing section.
The hardest part of the exam will be seeing other pregnant women around you, and perhaps returning to the room where you learned you lost the baby. Be prepared for this, and if you have an option (particularly in bigger practices), ask if you can be seen in the Gynecology slots, rather than the OB slots, where you should be waiting with women getting mammograms or annual exams, rather than prenatal visits. These are scheduled differently in most practices, as OB visits are short-notice slots, and annuals are set slots done in advance.
You should probably avoid sex while you are actively miscarrying, and certainly use a condom if you have sex within two weeks of the loss. This is because your cervix is slightly open and you are very susceptible to infection.
Sex will often hurt for a few weeks after the loss, although it often gets progressively better, because your cervix will be tender from being open and closed through the miscarriage. Sex can also be very emotionally difficult, as it will remind you of the whole process of pregnancy and conception. It is pretty important not to try again until you get a regular period. You can read why at the trying again section.
★Why do I start and stop bleeding and the hCG refuse to fall? It's been several months now!
Let's start with why we bleed at all. Our body, during our cycle, makes progesterone. This causes the lining in our uterus to thicken and prepare for pregnancy. When we do not get pregnant, the body cuts the progesterone level suddenly, and this dramatic loss of hormone makes us bleed.
When we are pregnant, we make even MORE progesterones, levels that go from an ordinary 12 in a cycle to 30 or more. Some get even way way higher. It varies from woman to woman. While you are pregnant, if you get any sort of hormone flux, let's say it drops temporarily from 30 to 25, you will bleed a little. This often happens when you would have expected your period. Your pregnancy can be fine as the body goes OOPS and makes more progesterone to cover the loss and baby goes along happily growing as the part of the lining he or she is using is not affected.
When the baby dies, or the body figures out it is a blighted ovum and no baby is growing, in some people it will cut off the flow of progesterone immediately. These women suddenly cramp and bleed and the body gets it all out in one shot. This is a complete miscarriage.
Other times, the body turns the tissue loose slowly, and the progesterone drops a bit, and some bleeding occurs, maybe even part of the chorion comes out as tissue, but then the body senses hCG still, so it says OOPS and boosts that progesterone again, and you stop bleeding. This is a missed miscarriage.
After a few days or a week or more, once again the body realizes no baby is growing, so it drops it again. More tissue comes out, but if the hCG is still high enough, the cycle of correcting itself continues.
Most women will get a D&C at this point, and the scraping of the uterus gets rid of all placenta, which is putting out the hCG, and so the body gets no more baby signals and you have your period.
If any placenta is left, though, the body is going to get fooled again.
At this point, usually the woman, if she has already had a D&C, will be given either:
●a shot of progesterone, to create a false "drop" so the body will start cramping and bleeding and pushing out whatever might be in there.
●birth control pills, to do the same thing when she stops taking them
In one special case, hCG's failure to drop can be caused by a molar or partial molar pregnancy. If your hCG ever goes UP after a loss, this is very likely the case. If your hCG stalls out, it might be the case and your blood hCG should be monitored by your doctor. It is unusual for molars to fall below 100, however.
6、Your First Period after a Miscarriage
One thing that is certain is that your first period will not resemble anything you've had before.
To make sure this is really your first period, make sure it has been at least four weeks since your miscarriage AND you have had about 20 days of no bleeding or spotting. For the estrogen threshold to be met, you should not be bleeding anymore. Otherwise the lining is not being rebuilt, and you are still experiencing progesterone withdrawal.
You can expect this first period anywhere from four to seven weeks in most normal cases, although you have to restart the counter if you have a renewed case of serious bleeding. See "Waiting for Period" for more on this.
There really is no "normal" for this first period. It can be:
●Very heavy (but not making you feel faint)
●Very light (but more than spotting). There should be a fair amount when you wipe.
●Terribly crampy, or not at all
●Be heavy and drop off immediately to spotting
●Be light and drop off to spotting
●Spot for several days, stop, then come full-blown with heavier bleeding
These periods are not normal, and are not actually a period:
●Light spotting that only spots for days on end
●Light spotting that comes and goes
●Heavy bleeding that makes you go through a pad every hour or two for more than a week.
Those scenarios mean the miscarriage may not have completed or your hormones are not getting back to normal and may need help.
Sometimes even if the first cycle seems normal, you start to see your cycles elongate or shorten. First remember that your cycles have changed now. Every pregnancy, regardless of outcome, changes your hormonal makeup. As long as your cycles are at least 24 days and not more than about 45, you are in the range of normal. Your cycles do not have to be the same every month, and most often they will not be.
About 60% of women will get pregnant again within the next four months, especially with earnest work toward that goal with the help of the Sperm Meets Egg Plan. Your fertility may not return immediately, but you should hold off on Clomid or other reproductive assistance for six months. After that point, you can ask for help from a doctor to see what is going on. It is not unusual to meet women who tried for a year before getting pregnant again. I personally did not ovulate in my first two cycles following my miscarriage, and got pregnant first try on the third.
It is very disheartening to see month after month go by without getting pregnant again, especially when your cycles are not the same as before. You will constantly feel you are pregnant but test negative, and you will feel certain you are having early miscarriages. This is a very very common feeling, but usually it is not true.
You will also face another problem. Post miscarriage cycles are all over the place, sometimes coming on day 22 (making women think they have a luteal phase defect) and other times coming weeks late (making women spend a fortune on pregnancy tests.) This is all a very common scenario in the months following the loss. It happened to me too. Just keep trying, and trust the pregnancy tests. They are accurate. Your hormones right now, however, are not. You should call a doctor when you go for seven weeks without a period. They can (sometimes, if they will) put you on a dose of Provera to bring on a period, or if worst comes to worst, put you on birth control pills to regulate you.
At this point, you are ready to look over the Trying Again section.
8、Trying Again after a Miscarriage
This can be the most difficult topic of all, because everyone has an opinion, and your doctor and your friend's doctor, and internet sources, and your mother, and your partner will all say different things. You will personally go from wanting to try again RIGHT NOW to never wanting to try again, sometimes in the span of five minutes. You may not agree with your doctor. Your partner may not agree with you. You are already grieving, and upset, and feeling like a failure, and thinking too long about this topic can make you feel so very much worse.
Accept that there are many opinions. Let me tell you a bit about why.
Doctors are trained to recognize that a woman needs emotional healing, but not really to help them or explain it to them, since it goes beyond their "bones and tissues" type of practice. Three months is considered the average amount of time a women will grieve hard over a loss, and will have a difficult time (and be a difficult patient) if she gets pregnant prior to that. While there are a few doctors who believe that your uterine lining must take three cycles to get back to rebuilding itself fully each time (especially after a D&C, where it gets scraped pretty thin), most doctors know that it doesn't really matter in about 80% of the cases, and getting pregnant again right away does not carry any increased physical risk or miscarriage risk.
So even among doctors, some will say the standard "wait three cycles" and might even scare you into thinking you'll have another miscarriage if you don't wait, and others will say go ahead and try again now.
As for my opinion, I've been running this site for three years, and have talked to about 2,000 women who have had miscarriages. From what I've seen, you really should wait for one cycle to complete, because if you do not, you will experience one of two situations, both of which will cause you much unnecessary grief and pain:
●If you do get pregnant again before having a period, you will not establish a reliable Last Menstrual Period date (your miscarriage date is of no use). You will run into lots of problems when you go in for your first prenatal sonograms and blood tests, causing you tons of grief (often for nothing) and can wreck your relationship with your doctor (supporting the "difficult patient" theory.)
For example, the blood test will say you are six weeks; you will insist you are eight. The sonogram will not show a fetal pole yet, but you have read that you should see a baby by now. You will think your doctor should do something, but he or she will just say your date is wrong and come back in a week. You will spend a week of torture, wondering if the baby is dead, and why do you have to wait for answers. All these things can be avoided by knowing your LMP, or preferably ovulation. Most of the time, the babies are fine, but sometimes you are having another miscarriage. Everything is murky because you don't know for sure when you got pregnant, because you didn't complete a full cycle.
●If you have retained tissue, your period will be "late" (although all post-miscarriage periods take more than four weeks and are late) and you can even have a POSITIVE PREGNANCY TEST, but you are not pregnant. This is hCG left in your system from the miscarriage, which has not completed. You may begin bleeding and cramping and think you are having another miscarriage, but you are just still going through the first one. We have had women on the site grieving over a 2nd lost baby, naming it and everything, when it turned out she only had missed tissue from the previous loss.Having a D&C does not guarantee that all the tissue was taken. About 1/4 of the women on this site with missed tissue had a D&C. If you did not wait for a real period, you will not know if a pregnancy test really means you are pregnant again, or if your loss has become a long drawn-out ordeal.
Additionally, charting and even ovulation predictor kits are not reliable tools during that first cycle after a miscarriage, and the body will put out lots of signs of fertility or lack of it as it tries to adjust itself. Women may be absolutely sure of their pregnancy's gestational age, and still be wrong! Once you get past that point, try the sperm meets egg plan to see if you can speed up the trying again process.
On the other extreme, not getting pregnant that first cycle, or for the next few, when you are fervently trying, will actually push your grief further down the line, month by month, and it can really be detrimental to healing, your life, and your relationship. Often your life will completely revolve around trying again and you will feel even more a failure, more unable to cope. This may also happen if you wait, but is more likely to pull you into a clinical depression if you are not yet dealing with your loss and are still having some hormonal upheaval.
Even if you feel like you are fine, the grief is really out there, and you need to work directly through it. I don't worry about the women who write about crying and saying they can't go on. They are working through their pain and grief. I worry about the woman who just wants to try again, and doesn't mention or think about the pain of losing a baby.
In the end, this is your life and your body, your baby, your future, and your decision. Make your choices well, and try not to look back.
★Monitoring a New Pregnancy
Some doctors will respond to your worries and bring you in for additional hCG tests and early sonograms to monitor the new baby more closely. Most will not do anything. It can be frustrating and scary to think about waiting until 8 or 9 weeks to see the doctor, when every day brings a new twinge or cramp or cervical discharge that makes you panic.
I think it is reasonable, if you have had only one loss, to still request an early blood test and a sonogram at 7 weeks to see the heartbeat. This will reassure you. If you have had more than one loss and no healthy babies yet, then you should be able to request more frequent monitoring of your hCG and progesterone levels, just to see where the pregnancies are failing. This could help give you a clue as to a cause.