Abortus (Gebelik Kaybı)
Özet
Abortus (gebelik kaybı), gebelik materyalinin 20. haftadan önce kaybedilmesi veya sonlandırılması ya da fetüsün 500 gramın altında doğmasıdır. Klinik olarak tanısı konmuş gebeliklerin %8-20’si abortus ile sonuçlanmaktadır. Meydana geliş zamanı, şekli ve klinik durumuna göre subklinik, erken, geç, spontan, terapötik, istemli, komplet, inkomplet, imminens, insipiens, missed, tekrarlayan ve septik abortus olarak sınıflandırılır. Spontan düşüklerin yaklaşık yarısında kromozomal anomaliler görülürken, diğer yarısı öploid düşüktür. Kromozom bozukluklarında en sık otozomal trisomiler, özellikle de 16. kromozom trisomisi saptanır. Maternal faktörler arasında apendisit, toksoplazmozis gibi enfeksiyonlar, luteal faz defekti, diyabet, hipotiroidi gibi endokrin anomaliler, kronik hastalıklar, ileri yaş, obezite, travma, uterus anomalileri, sigara, alkol ve kafein tüketimi ile çevresel toksinler yer alır. Paternal tarafta ise artan baba yaşı ve sperm anomalileri düşüğe yol açabilir. Laboratuvar tanısında hCG titresinin yetersiz artışı, progesteron ve estradiol düzeylerinde azalma takip edilir. Abortus imminenste gözlem tedavisi yapılırken, diğer abortus türlerinde tıbbi veya cerrahi (aspirasyon küretajı) yöntemlerle uterusun boşaltılması gerekir. Anne Rh negatif ise işlem sonrası anti-D immünglobin uygulanmalıdır.
Abortion (pregnancy loss) is defined as the loss or termination of pregnancy before the 20th gestational week or the birth of a fetus weighing less than 500 grams, complicating approximately 8% to 20% of clinically recognized pregnancies. Miscarriages are classified based on timing, clinical presentation, and completion status into subclinical, early, late, spontaneous, therapeutic, voluntary, complete, incomplete, imminent, incipient, missed, recurrent, and septic abortions. Etiologically, half of spontaneous miscarriages exhibit chromosomal abnormalities—predominantly autosomal trisomies, with trisomy 16 being the most fatal and frequent—while the remaining half are euploid. Maternal risk factors include acute infections, endocrine disorders like luteal phase defects and diabetes, chronic illnesses, obesity, uterine anatomical anomalies, advanced age, physical trauma, and environmental exposures such as smoking, alcohol, or heavy caffeine intake. Paternal factors encompass advanced paternal age and sperm abnormalities. Diagnostic evaluation relies on subnormal hCG doubling parameters along with decreased progesterone and estradiol levels. While threatened abortion requires observational management, other types necessitate uterine evacuation via medical or surgical aspiration curettage, supplemented by anti-D immunoglobulin administration in Rh-negative mothers to prevent alloimmunization.
Referanslar
Cunningham, F., et al., Chapter 6. 25 ed. Obstetrics Williams. 2014: Mc Graw–Hill Companies. 350-376.
Clark DA, Coulam CB, Daya S, Chaouat G. Unexplained sporadic and recurrent miscarrage in the new millennium: a critical analysis of immune mechanisms and treatments. Hum Reprod Update 2001;7(5):501-11
Wilcox AJ, Weinberg CR, O'Connor JF, Baird DD, Schlatterer JP, Canfield RE.et al. Incidence of early loss of pregnancy. N Engl J Med. 1988;319(4):189-94.
Caroline E, O’ Brien O and K. Guidelines on the diagnosis andmanagement of abortus. Farquharson RG, Stephenson MD. Early pregnancy. 1st ed. New York: Cambridge University Press. 2010.P.129
Barnhart, K.T., Ectopic pregnancy. New England Journal of Medicine, 2009. 361(4): p. 379-387.
Tulandi, T. and H. Al-Fozan, Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation. UpToDate Inc 2013.
Obstetricians, A.C.o. and Gynecologists, ACOG Practice Bulletin No. 135: second- trimester abortion. Obstet Gynecol, 2013. 121(6): p. 1394-406.
Creinin, M.D., et al., Early pregnancy failure—current management concepts. Obstetrical & gynecological survey, 2001. 56(2): p. 105-113. 9.Aksu, F., et al., Terapötik abortus. Cerrahpaşa j med, 1998. 29(4): p. 175-179.
Kavanagh, A., et al., ‘Abortion’or ‘termination of pregnancy’? Views from abortion care providers in Scotland, UK. BMJ sexual & reproductive health, 2018. 44(2): p. 122-127.
Özgünen, T. F. (2007). Abortus; düşükler: sınıflandırma, genel bilgiler ve kliniktablo. Turkiye Klinikleri Journal of Surgical Medical Sciences, 3(5), 1-6.
Condous G , Okaro E, Khalid A, et al: Do we need to follow up completemiscarriages with serum human chorionic gonadotrophin levels? BJOG 1 1 2:827, 2005
Kim C, Barnard 5 , Neilson JP, et al: Medical treatments for incomplete miscarriage.Cochrane Database Syst Rev 1 : CD007223, 20 1 7
Everett, C., Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study from general practice. Bmj, 1997. 315(7099): p. 32-4.
Lykke JA, Dideriksen L, Lidegaard 0, et al: First-trimester vaginal bleeding and complications later in pregnancy. Obstet Gynecol 1 1 5:935, 20 1 0
Saraswat L, Bhattacharya S, Maheshwari A, et al: Maternal and perinatal outcome in women with threatened miscarriage in the irst trimester: a systematic review. B]OG 1 1 7:245, 20 1 0
Doubilet PM, Benson CB, Bourne T , e t al: Diagnostic criteria for nonviable
Lane BF, Wong-You-Cheong J], Javitt MC, et al: ACR Appropriateness Criteria irst trimester bleeding. Ultrasound Q 29(2) :91 , 2013
Wu, H.L., et al., Misoprostol for medical treatment of missed abortion: a systematic review and network meta-analysis. Sci Rep, 2017. 7(1): p. 1664
Bhattacharya S, To wne nd J , Bhattacharya S: Recurrent miscarriage: are threemiscarriages one too many? Analysis of a Scottish population-based database of 1 5 1 ,02 1 pregnancies. Eur J Obstet Gynecol Reprod Bioi 1 50:24, 20 1 0
Brigham SA, Conlon C , Farquhason RG: A longitudinal study o f pregnancy outcome following idiopathic recurrent miscarriage. Hum Reprod 1 4( 1 1 ) :2868, 1 999
DaifJL, Levie M, Chudnof S, e t al: Group A streptococcus causing necrotizing fasciitis and toxic shock syndrome after medical termination of pregnancy. Obstet Gynecol 1 1 3 (2 Pt 2): 504, 2009
Meites E, Zane S , Gould C: Fatal lostridium sordeLiii infections after medical abortions. N Engl J Med 363 ( 1 4) : 1 382, 20 1 0
Eschenbach DA: Treating spontaneous and induced septic abortions. Obstet Gynecol 1 2 5 (5) : 1 042, 20 1 5
Warren, J.E. and R.M. Silver, Genetics of pregnancy loss. Clinical obstetrics and gynecology, 2008. 51(1): p. 84-95
Wyatt, P.R., et al., Age-specific risk of fetal loss observed in a second trimester serum screening population. American journal of obstetrics and gynecology, 2005. 192(1): p. 240-246.
Jenderny J : Chromosome aberrations i n a large series o f spontaneous miscarriagesin the German population and review of the literature. Mol Cytogenet 7:38, 20 1 4
Eiben B , Bartels I , Bahr-Prosch S , et al: Cytogenetic analysis of 50 spontaneous abortions with the direct-preparation method of chorionic villi and its implications for studying genetic causes of pregnancy wastage. Am J Hum nGenet 47:656, 1 990
Penta, M., et al., Infectious agents in tissues from spontaneous abortions in the first trimester of pregnancy. The new microbiologica, 2003. 26(4): p. 329-337.
Castañeda, R., et al., Endemic goiter in pregnant women: utility of the simplified classification of thyroid size by palpation and urinary iodine as screening tests. BJOG: an international journal of obstetrics and gynaecology, 2002. 109(12): p. 1366-1372.
van den Boogaard, E., et al., Significance of (sub)clinical thyroid dysfunction and thyroid autoimmunity before conception and in early pregnancy: a systematic review. Hum Reprod Update, 2011. 17(5): p. 605-19.
Greene MF. Spontaneous abortions and major malformations in women with diabetes mellitus. Semin Reprod Endocrinol 1999; 17: 127-136.
Sher KS, Jayanthi V, Probert CS, Stewart CR, Mayberry JF. Infertility, obstetric and gynaecological problems in coeliac sprue. Dig Dis 1994; 12: 186-190.
Maconochie, N., et al., Risk factors for first trimester miscarriage—results from a UK‐population‐based case–control study. BJOG: An International Journal of Obstetrics & Gynaecology, 2007. 114(2): p. 170-186.
Dranitsaris, G., et al., Are health care providers who work with cancer drugs at an increased risk for toxic events? A systematic review and meta-analysis of the literature. Journal of oncology pharmacy practice, 2005. 11(2): p. 69-78.
Krieg SA, Shahine LK, Lathi RB: Environmental exposure to endocrinedisrupting chemicals and miscarriage. Fertil Steril 1 06 (4) :94 1 , 20 1 6
Li TC, Mortimer R, Cooke ID.Myomectomy: a retrospective study to examine reproductive performance before and after surgery. Hum Reprod 1999 Jul 14:1735-40
Rikken JF, Kowalik CR, Emanuel MH, Mol BW, Van der Veen F, van Wely M, Goddijn M. Septum resection for women of reproductive age with a septate uterus.Cochrane Database Syst Rev. 2017 Jan 17;1(1):CD008576. doi: 10.1002/14651858.CD008576.pub4.
Live births after Asherman syndrome treatment.Hanstede MMF, van der Meij E, Veersema S, Emanuel MH.Fertil Steril. 2021 Oct;116(4):1181-1187. doi: 10.1016/j.fertnstert.2021.05.099. Epub 2021 Jun 12.PMID: 34130799
Goldberg JM, Falcone T. Effect of diethylstilbestrol on reproductive function. Fertil Steril 1999; 72: 1-7.
mazze l, Kallen B : Reproductive outcome after anesthesia and operationduring pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol1 6 1 : 1 1 78, 1 989
Sartorius GA, Nieschlag E: Paternal age and reproduction. Hum Reprod Update 1 6 ( 1 ) :65, 20 1 0
Barnhart, K.T., et al., Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstetrics & Gynecology, 2004. 104(1): p. 50- 55.
Akkurt, M.Ö., et al., Histopatolojik Olarak Ektopik Gebe Olduğu Kanıtlanan Hastalarda Serum Ca-125, Östradiol ve Progesteron Düzeyleri. Jinekoloji- Obstetrik ve Neonatoloji Tıp Dergisi, 2015. 12(4): p. 140-143.
Tang OS, Gemzell-Danielsson K, H o PC: Misoprostol: pharmacokinetic proiles,efects on the uterus and side-efects. Int ] Gynaecol Obstet 99 Suppl2:S 1 60, 2007
O 'Connell K, Jones HE, Simon M , e t al: First-trimester surgical abortion practices:a survey of National Abortion Federation members. Contraception 79(5):385, 2009
Fung Kee Fung, K., Eason, E., Crane, J., Armson, A., De La Ronde, S., et al (2003). Prevention of Rh Alloimmunization. J Obstet Gynaecol Can, 25(9): 716-719
