A missed miscarriage, also known as a missed abortion or a silent miscarriage, occurs when the fetus dies in utero but the body does not recognize the pregnancy loss or expel the pregnancy tissue. This results in an ongoing pregnancy without the symptoms of miscarriage like bleeding or cramping. A missed miscarriage is usually detected during a routine ultrasound exam and can occur anytime in the first trimester or early second trimester. Detecting a missed miscarriage can be difficult and emotionally devastating for the mother. This article will explore how doctors diagnose missed miscarriages and the signs and symptoms.
How is a missed miscarriage diagnosed?
Doctors can often detect a missed miscarriage during a routine ultrasound exam. An ultrasound uses sound waves to create images of the fetus and uterus. During the ultrasound, the doctor will look for signs of fetal development and a heartbeat. If the pregnancy is 8 weeks or greater, they expect to see a fetal pole and cardiac activity. If there is no fetal pole or heartbeat detected, it indicates the pregnancy likely failed to develop and the fetus has been lost. The uterus may still appear enlarged as if still pregnant and no bleeding or cramping will have occurred. This is because the maternal hormones have not declined yet to signal the loss.
Additional signs on an ultrasound indicating a missed miscarriage include:
- Gestational sac larger than expected for the gestational age
- Yolk sac visible but no embryo present
- Embryo is present but is not growing appropriately and shows no cardiac activity
- Flattened or elongated gestational sac instead of round
- Degenerating placenta or embryo
If a miscarriage is suspected on ultrasound, the doctor may order serial hCG blood tests to look for a drop in the pregnancy hormone levels. In a normal pregnancy, hCG levels double every 48 to 72 hours. A decrease or plateau in hCG levels along with no visible fetus indicates the pregnancy is not viable.
What are the signs and symptoms of a missed miscarriage?
One of the reasons a missed miscarriage is so difficult is there are often no signs the pregnancy is nonviable. Since the maternal hormones have not declined yet, typical miscarriage symptoms do not occur. A woman may continue to feel pregnant without realizing the fetus has been lost. Some signs and symptoms that may indicate a potential missed miscarriage include:
- Vaginal spotting or light bleeding
- Cramping or pelvic pain
- Change in breast tenderness or nausea
- Increase in pregnancy symptoms suddenly disappearing
- No longer able to detect fetal movements
Many times there are no symptoms at all until the ultrasound. The ultrasound allows visualization into the uterus to detect the fetal loss. Missed miscarriages are most common in the first trimester but can occur any time before 20 weeks gestation. Risk factors for a missed miscarriage include:
- Advanced maternal age over 35
- History of previous miscarriages
- Uterine abnormalities like fibroids or septums
- Thyroid disorders
- Diabetes
- Autoimmune disorders
- Genetic problems with the fetus
- Infections
- Lifestyle factors like smoking, alcohol use, stress, excessive caffeine
If a missed miscarriage is suspected, the doctor will perform additional testing to confirm the diagnosis and rule out other potential causes like ectopic pregnancy. Bloodwork, a complete pelvic exam, repeat ultrasounds, and genetic testing of the tissue may be done.
Comparing normal pregnancy to missed miscarriage symptoms
| Normal Pregnancy Symptoms | Missed Miscarriage Symptoms |
|---|---|
| Increase in breast size and tenderness | Breast tenderness disappears or decreases |
| Ongoing nausea and vomiting | Nausea and vomiting improve or go away |
| Fatigue and increased need for sleep continue | Fatigue and excessive sleep needs decrease |
| Sense of pregnancy continues | “Pregnant feeling” disappears |
| Fetal movement felt by mother | Lack of fetal movement |
| No bleeding or spotting | Possible light bleeding or spotting |
| HCG levels rising appropriately | HCG levels plateau or fall |
| Normal fetal heart tones on doppler | No fetal heartbeat detected on ultrasound |
As shown in the table, some of the most telling signs of a missed miscarriage compared to a normal pregnancy are disappearance of pregnancy symptoms, lack of feeling pregnant, lack of fetal movement, bleeding or spotting, and no fetal heartbeat on ultrasound.
What happens after a missed miscarriage is diagnosed?
Receiving a diagnosis of missed miscarriage can be extremely difficult and heartbreaking for a mother. Many women feel shocked, numb, devastated, or experience guilt. It is important to know a missed miscarriage is typically not preventable and is nature’s way of handling nonviable pregnancies.
After the diagnosis, the doctor will discuss the options for management which include:
- Waiting for natural passage of tissue – Nothing is done right away and the woman waits for the pregnancy to pass naturally, like a normal miscarriage. This often occurs within 1-2 weeks but can take longer. Medication may be given to help speed the process. Once the tissue has passed, bleeding and cramping will signal completion.
- Medication treatment – Medications like misoprostol are used which open the cervix and encourage the uterus to contract and expel the tissue. Contractions, cramping, and vaginal bleeding will occur until it has been mostly expelled.
- D&C procedure – A dilation and curettage (D&C) is a surgical procedure where the doctor opens the cervix and uses gentle suction and scraping to remove the pregnancy tissue. It is typically done under IV sedation or anesthesia in a hospital or clinic setting.
The doctor will discuss the benefits and risks of each option and the woman can choose what she is most comfortable with. Bleeding and cramping will occur with all options until the uterus has expelled all tissue and returned to its non-pregnant state. HCG levels will quickly drop and return to zero within 4-6 weeks. Most women can try conceiving again after one normal menstrual cycle.
Emotional healing after a missed miscarriage
Coping with a missed miscarriage can be a rollercoaster of emotions. Even though signs may be subtle or non-existent, the attachment and bonding that occur during pregnancy are still very real. The loss of dreams, hopes, and plans for the future is devastating. Many women experience guilt, anger, jealousy of normal pregnancies, depression, and anxiety after a missed miscarriage. Getting support from loved ones, counseling, spending time on self-care, journaling, joining miscarriage support groups, and allowing yourself to fully grieve can all help with emotional healing. While the physical recovery may be shorter than a normal miscarriage, the emotional recovery takes time. Be patient and kind to yourself as you work through this profound loss.
Conclusion
Missed miscarriages can be detected during routine ultrasounds showing lack of fetal development and no heartbeat, along with falling or plateaued hCG levels. Signs of a missed miscarriage are more subtle than a normal miscarriage, with symptoms like disappearing nausea, lack of feeling pregnant, or bleeding/spotting. After diagnosis, options include waiting for natural passing of tissue, medication treatment, or D&C procedure. Emotional support and allowing time to grieve are vital during the healing process after a missed miscarriage. While very difficult to diagnose and cope with, most women go on to have successful future pregnancies after a missed miscarriage.