N gazed worriedly at the monitor screen while I searched intensely for the foetal heart beat by moving the ultrasound transducer around on her lower abdomen. This was her second antenatal visit at 12 weeks of gestation.
My heart sank when I could not see any flickering on the screen. After 15 minutes of search, I finally told N and her husband the bad news. Her baby had passed on.
“Doc, I can’t understand this. I didn’t bleed. I didn’t feel any pain. I still have the sore breasts and morning sickness,” she started to sob uncontrollably. “Could it be that I went cycling and jogging the last few days? Could that have caused the miscarriage?” she asked. During her first antenatal visit 3 weeks ago, her baby’s heart was flashing clearly on the screen and N could hear and see her baby’s heart beating.
N was suffering from a silent miscarriage, known medically as “missed abortion” or “missed miscarriage”, in which the body fails to recognize that the fetus is dead or has not developed. The body also fails to expel the pregnancy tissue, which continues to produce the pregnancy hormones. As a result, some of the pregnancy symptoms and signs may persist for a while.
How common is missed miscarriage?
About 1-5% of all pregnancies will result in a missed miscarriage.
What are the causes and risk factors of missed miscarriage?
Causes of missed miscarriage are not fully understood. About 70 to 80 percent of miscarriages are the result of faulty genes. It is nature’s way of cutting down the number of malformed babies.
Other risk factors include:
Infections, including sexually transmitted infections
Diabetes or thyroid disease
Malformations of the womb
Smoking tobacco or drinking alcohol
Autoimmune disorder such as Systemic lupus erythematosus (SLE)
Miscarriage is not caused by physical exertion. A recent research review published in 2019 concluded that "prenatal exercise is not associated with increased odds of miscarriage.”
What are the symptoms of a missed miscarriage?
Missed miscarriage usually has no symptoms. Occasionally, there may be a brownish or pinkish discharge. Early pregnancy symptoms, such as nausea and breast soreness may persist for a while, lessen or disappear. This is different from a typical miscarriage, which usually presents with heavier bleeding and abdominal cramps.
How is a missed abortion diagnosed?
A missed abortion is usually diagnosed by the absence of foetal heartbeat on ultrasound examination. Blood levels of the pregnancy hormone B-hCG may not rise at a typical rate seen in normal pregnancy.
What are the treatment options?
There are several treatment options in managing missed abortion including:
Expectant management: This is a wait-and-see approach. Usually if a missed miscarriage is left untreated, the foetal tissue may pass out within three or four weeks. This may be emotionally difficult for the patient. Sometimes, the expulsion may not be complete and evacuation of the uterus may be needed.
Medical treatment: Medication is used to hasten the process of expelling the foetal tissue. It can be taken in oral form or by insertion of a pessary in the vagina. Again, the process may be incomplete and surgical treatment may be necessary.
Surgical treatment: The minor procedure is called evacuation of the uterus using vacuum suction. During this procedure, the cervix is dilated and foetal tissue is removed via suction by a plastic tube.
I reassured N that her physical exertion had no relation to the foetal demise. After explaining the various treatment options, N chose to have the surgical treatment, which was done successfully. I also told her husband that her emotional recovery may take longer than her physical recovery. He should be around to listen and support her in her grieving process.