“When the fetus is dead and retained inside the uterus for a variable period , it is called missed miscarriage or early fetal demise “

The incidence of missed miscarriage can vary depending on several factors, including maternal age, overall health, and the population being studied.

1. Overall Miscarriage Rates: Approximately 10-20% of known pregnancies end in miscarriage. This includes all types of miscarriages, not just missed miscarriages.
2. Specific Incidence of Missed Miscarriage: It is estimated that missed miscarriages account for about 1-5% of all pregnancies. This percentage can vary based on the population studied and the criteria used to define missed miscarriage.
3. Maternal Age Impact: The risk of miscarriage, including missed miscarriage, tends to increase with maternal age. Women over 35 years old have a higher risk compared to younger women.
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Missed miscarriage, also known as missed abortion or silent miscarriage, refers to a situation where the embryo or fetus has died, but the body does not recognize the loss and continues to show signs of pregnancy. The etiology (causes) of missed miscarriage can vary and may include:

1. Chromosomal abnormalities: This is the most common cause of early miscarriages, including missed miscarriages. Errors in the embryo’s chromosomes can prevent it from developing normally, leading to its demise.
2. Maternal age: Advanced maternal age increases the risk of chromosomal abnormalities in embryos, which in turn raises the risk of miscarriage, including missed miscarriage.
3. Uterine abnormalities: Structural issues with the uterus, such as fibroids or septum, can interfere with the implantation of the embryo or its development, potentially leading to miscarriage.
4. Hormonal imbalances: Insufficient levels of progesterone, which is necessary to maintain pregnancy, can contribute to miscarriage. Thyroid disorders or diabetes can also affect hormone levels and increase miscarriage risk.
5. Infections: Certain infections, such as rubella, cytomegalovirus, or toxoplasmosis, can increase the risk of miscarriage if contracted during pregnancy.
6. Lifestyle factors: Smoking, excessive alcohol consumption, drug use, and exposure to environmental toxins (like certain chemicals or radiation) can all increase the risk of miscarriage.
7. Autoimmune disorders: Conditions like lupus or antiphospholipid syndrome can cause the immune system to attack the fetus, leading to miscarriage.
8. Maternal health conditions: Conditions such as diabetes, hypertension, or obesity can increase the risk of miscarriage if not properly managed during pregnancy.
9. Trauma or injury: Physical trauma to the abdomen or severe emotional stress can sometimes trigger a miscarriage, although this is less common.
10. Unknown causes: In some cases, despite thorough investigation, the cause of missed miscarriage remains unknown. This can be particularly frustrating for couples seeking answers.

CLINICAL FEATURE :

Missed miscarriage, also known as missed abortion or silent miscarriage, presents with distinct clinical features that differ from other types of miscarriages. Here are the key clinical features of missed miscarriage:

1. Lack of Symptoms: One of the defining characteristics of missed miscarriage is the absence of typical miscarriage symptoms such as vaginal bleeding and cramping. This is because the body does not immediately recognize the loss of the embryo or fetus.
2. Absence of Fetal Heartbeat: During routine prenatal care or ultrasound examination, no fetal heartbeat or fetal movement is detected. This is often the first indication that a missed miscarriage has occurred.
3. No Fetal Growth: Ultrasound imaging reveals that the embryo or fetus has stopped growing or developing. This may show as no change in size or development over subsequent ultrasound scans.
4. Persistently Positive Pregnancy Test: Blood or urine tests continue to show elevated levels of human chorionic gonadotropin (hCG), the hormone produced during pregnancy. This is because the placenta may still be intact and producing hCG, even though the embryo has not survived.
5. Retention of Pregnancy Symptoms: Some women may continue to experience symptoms of pregnancy such as breast tenderness, nausea, and fatigue. This can add to the confusion and delay in recognizing the miscarriage.
6. Emotional Impact: Discovering a missed miscarriage can have significant emotional implications for the woman and her partner. It may involve feelings of shock, grief, and uncertainty about future pregnancies.

DIAGNOSIS :

1. Clinical History and Symptoms:
   • The initial step often involves evaluating the woman’s clinical history, including her reported symptoms and any previous obstetric history (such as prior miscarriages).
   • Symptoms may include a lack of typical signs of miscarriage such as vaginal bleeding and cramping, or the persistence of pregnancy symptoms despite the absence of fetal growth.
2. Ultrasound Examination:
   • Ultrasound imaging is the primary diagnostic tool for assessing fetal viability and development. In the case of missed miscarriage, ultrasound will show:
     • No fetal heartbeat: This is a key indicator, as fetal cardiac activity can usually be detected by about 6-7 weeks gestation using ultrasound.
     • No fetal growth: The embryo or fetus will appear to have stopped growing and may be smaller than expected for the gestational age determined by last menstrual period or earlier ultrasound measurements.
     • Absence of fetal movement or activity: In a missed miscarriage, there is no observable movement or activity of the fetus during the ultrasound examination.
3. Confirmation of Diagnosis:
   • Confirmation typically involves a repeat ultrasound to ensure the findings are consistent over time, as growth assessments can sometimes be impacted by the quality of the ultrasound equipment or technician expertise.
   • Additional diagnostic criteria may include serial hCG measurements to monitor the trend of human chorionic gonadotropin (hCG) levels, which can plateau or decline in cases of missed miscarriage.

COMPLICATION :

A missed miscarriage, if not managed appropriately, can lead to several potential complications……

1. Incomplete Miscarriage:
   • If the body does not naturally expel all of the pregnancy tissue after a missed miscarriage, it can lead to an incomplete miscarriage. This can cause persistent bleeding, cramping, and an increased risk of infection.
2. Infection:
   • Retained pregnancy tissue can become a breeding ground for bacteria, leading to infection of the uterus (endometritis) or surrounding reproductive organs. Symptoms of infection include fever, pelvic pain, and abnormal vaginal discharge.
3. Excessive Bleeding (Hemorrhage):
   • In some cases, the uterus may not contract effectively to expel the pregnancy tissue, leading to heavy bleeding. This can be dangerous and require medical intervention to control bleeding and prevent complications like anemia.
4. Psychological Impact:
   • A missed miscarriage can have profound emotional effects on the woman and her partner. Grief, sadness, guilt, anxiety, and depression are common emotions experienced after a miscarriage. Counseling and emotional support are crucial during this time.
5. Future Pregnancy Concerns:
   • Depending on the underlying cause of the missed miscarriage, there may be concerns about future pregnancies. Recurrent miscarriages can be indicative of underlying health issues that may need further investigation and management.
6. Medical Procedure Risks:
   • If surgical intervention (such as dilation and curettage, or D&C) is needed to remove the pregnancy tissue, there are risks associated with anesthesia, infection, and uterine injury.
7. Ectopic Pregnancy:
   • In rare cases, a missed miscarriage can be associated with an ectopic pregnancy (where the embryo implants outside the uterus, usually in the fallopian tube). This can lead to serious complications, including rupture of the fallopian tube and life-threatening bleeding.
8. Impact on Partner and Relationships:
   • Miscarriage can also affect the partner and strain relationships, as both individuals navigate their grief and emotional responses differently.

The management of missed miscarriage depends on several factors including the woman’s health, gestational age, symptoms, and personal preferences.

1. Expectant Management:
   • Description: Expectant management involves allowing the body to naturally expel the pregnancy tissue over time, without medical or surgical intervention.
   • Indications: This approach is typically considered when there are no signs of infection, excessive bleeding, or other complications, and the woman prefers to wait for the miscarriage to occur naturally.
   • Monitoring: Regular follow-up appointments with ultrasound scans and blood tests (hCG levels) are scheduled to monitor the progress of the miscarriage.
   • Advantages: It avoids the potential risks associated with medications or surgical procedures and allows for a more gradual emotional and physical recovery.
   • Disadvantages: It can be emotionally challenging to wait for the miscarriage to happen naturally, and there is a risk of incomplete miscarriage, which may necessitate further intervention.
2. Medical Management:
   • Description: Medical management involves the use of medications, typically misoprostol (a prostaglandin analogue), to induce uterine contractions and facilitate the expulsion of pregnancy tissue.
   • Indications: This approach may be chosen if the woman prefers a more active intervention than expectant management, or if there are concerns about infection, heavy bleeding, or the emotional burden of waiting.
   • Procedure: Misoprostol can be administered orally, vaginally, or sublingually (under the tongue). The woman is monitored for several hours after administration to manage pain and assess for any complications.
   • Follow-up: Follow-up appointments are scheduled to confirm the complete expulsion of pregnancy tissue and monitor recovery.
   • Advantages: It provides a controlled way to manage the miscarriage, reducing the risk of complications compared to expectant management.
   • Disadvantages: It can cause side effects such as cramping, nausea, diarrhea, and may not always be effective in achieving complete expulsion of pregnancy tissue.
3. Surgical Management (D&C):
   • Description: Surgical management involves a procedure called dilation and curettage (D&C), where the cervix is dilated and pregnancy tissue is gently scraped or suctioned from the uterus.
   • Indications: This approach is often recommended if there are concerns about incomplete miscarriage, heavy bleeding, infection, or if the woman prefers a more definitive and rapid resolution of the miscarriage.
   • Procedure: D&C is typically performed under general anesthesia or local anesthesia with sedation. It is a short procedure that allows for immediate removal of pregnancy tissue.
   • Recovery: Most women can go home the same day after D&C, with instructions for pain management and follow-up care.
   • Advantages: It provides rapid resolution of the miscarriage, reduces the risk of infection and other complications associated with prolonged retention of pregnancy tissue.
   • Disadvantages: It carries risks such as anesthesia-related complications, uterine perforation, and potential impact on future fertility, although these risks are generally low.

The choice of management approach for missed miscarriage should be individualized based on discussions between the woman and her healthcare provider, considering medical factors, emotional considerations, and preferences. Providing compassionate support and counseling throughout the process is crucial to help the woman and her partner cope with the emotional impact of pregnancy loss.