Pregnancy news is a good news for the couple especially for the woman who experienced a menstrual delay and who saw the pregnancy test positive in the urine or blood. The best part is that this process reaches the end for the mother and baby with health and to return home with the baby without any problems. Often it is also the case. However, from time to time, this miraculous cell merger may not progress in a healthy way. When we diagnose in the clinic, one of the most difficult problems we share with women is pregnancy that goes wrong.
Since this process is encountered with different clinical forms in different weeks of gestation, we talk about all possibilities. Proper information, of course, provides a very serious spiritual relief. In addition to psychological trauma in the first pregnancy losses, curiosity towards the cause of the process is also very intense. However, doing research on the cause in the first loss is not an acceptable practice in any school in the world. Because the single loss does not increase the loss rates significantly for the second pregnancy. In this context, the necessary indication has not been formed for the tests with serious costs. At least two consecutive pregnancy loss; It can be considered as recurrent pregnancy abortus and can be considered in detail in terms of cause and treatment.
Definition and Classification of Abortus
Firstly, abortion by definition is the termination of pregnancy for any reason before the twentieth week of pregnancy or when the baby is under 500 gr. If the miscarriage occurs in the first 12 weeks of pregnancy, it can be defined as early abortus, and if it occurs after the 12th week, it can be defined as late abortus.
Let’s now describe a number of different clinical situations related to miscarriages:
The first is the abortion imminence (threat of miscarriage), which we encounter most frequently in the clinics. From time to time, the pain similar to mild to severe menstrual pain can be defined in the lower abdomen. However, the main finding is the presence of vaginal bleeding. Bleeding in brown colour can range from mild bleeding to severe bleeding in varying forms and amounts, and is mostly related to the severity of the bleeding-low threat. However, during mild and brown bleeding, things may not go well during the follow-up, but the woman who experiences severe vaginal bleeding can progress very well. The gestational sac is where it should be on ultrasonography. The evaluation required during follow-up will give the necessary response after the medical and psychological support is applied. So it is necessary to wait patiently. As the gestational week increases healthily, pregnancy loss rates will decrease.
The inevitable misidentification is called abortus insipience. Opening in the cervix accompanies bleeding and pain, and in this case the possibility of miscarriage will sooner or later occur. The gestational sac is displaced towards the cervix. Waiting treatment is a good option until the gestational sac is completely eliminated, but termination of pregnancy will be more appropriate if the gestational week is over 6 weeks.
In complete abortion, gestational sac is thrown out of the uterus with bleeding, pain and opening in the cervix. In general, pregnancies up to 6 weeks can be completely thrown out of the uterus in complete abortions and the intrauterine tissue can be monitored completely after abortion. Careful ultrasonography is essential to ensure that there are no parts in the intrauterine tissue. If there is a suspicion of the remaining part, intrauterine tissue should be cleaned by performing vacuum aspiration in a controlled manner.
Incomplete miscarriage is called incomplete abortion. In ultrasonography, it can be easily determined that there is a part in the intrauterine tissue and can be cleaned by curettage. If the gestational week is 6 weeks or more, we often encounter incomplete abortion.
Anembrionic pregnancy is known as an empty pregnancy. Diagnosis of the absence of yolk sac that normally accompanies the gestational sac during the 5th gestational week and still not being able to see the yolk sac and embryo during 10-15 days follow-up is diagnostic. Anembrionic pregnancies are generally the result of chromosomal anomalies and are mostly random. The chromosomes of the mother and father are mostly normal and do not tend to repeat. It is mostly diagnosed by ultrasonography, without pain or bleeding. When repeated diagnosis is assured, the patient should be told that pregnancy is no longer positive. If she accepts a patient process, the patient may be given a low miscarriage. If abortion is left after the abortion or the patient does not accept the waiting process, it will be appropriate to terminate the pregnancy by abortion.
If the embryo loses its viability in the later weeks of pregnancy, with or without bleeding, but there is no miscarriage, there is a missed abortion and the pregnancy should be terminated under suitable conditions.
Biochemical pregnancy is that clinical pregnancy does not occur if the pregnancy test in the blood or urine is positive. In this case, sperm and egg merged, necessary cell divisions tried to occur, but the blastocyst, which could not provide vital reality, could not settle into the intrauterine tissue. In this case, the levels of HCG, known as a pregnancy test in the blood, increase but after a while it starts to decrease and then pregnancy loss occurs as a result of menstrual bleeding. However, in biochemical pregnancies, a gestational sac has never been detected in ultrasonography and the patient is not considered to be scientifically miscarried. Because in order to see gestational sac in ultrasonography, HcG value should reach at least 1500. Many biochemical pregnancies will occur regardless of women and are not clinically relevant.
The case, which is defined as septic abortion, is still frequently seen in countries that are in a difficult sociocultural and especially economically difficult situation. In order to end unwanted pregnancies of women, attempts to terminate pregnancy with substances applied to their uterus by themselves or those who are not competent are associated with high complication and maternal mortality rates.
Recurrent pregnancy losses are described in detail under a separate title. You can get more information from this section.
Optional pregnancy termination is the termination of pregnancy under 10 weeks at the request of the mother and father. It should be done in hospital conditions and by specialist physicians.
Frequency of Abortus
If we include all the classifications, its frequency is quite high as 60% and many of them were not recognised by the women. However, the abort rates in pregnancies proven by ultrasonography are between 15-25%. Abort rates increase as women age increases. With increasing age, the chromosome disruptions in the egg cell increase and this affects the genetics of the embryo. Their abort rate, which is 10% at age 20, reaches 50% at age 40. As the gestational week increases, their abort rates also decrease. The highest frequency is in the first 8 weeks. Pregnancies that are incompatible with life usually end in the first 12 weeks and 80% of abortions occur in the first 12 weeks. It should also be emphasized that most of the miscarriages are related to the health of the embryo and it should be noted that the frequency mentioned above decreases over time when pregnancy is first detected by ultrasonography.
Signs/Symptoms of Abortus
Bleeding is the most common symptom of a miscarriage. Bleeding may be accompanied by pain. Clots may accompany bleeding, but tissue pieces may also come with bleeding. The impaired pregnancy, called missed abortion, can be diagnosed by ultrasonography, when it does not give any symptoms and goes to control. The severity of the symptoms will typically increase gradually in the presence of pain and bleeding. When the parts are completely thrown out of the uterus, the pressure effect will disappear and the complaints will gradually disappear.
Diagnosis in Abortus
The diagnosis of abortion is made only by ultrasonographic examination. Vaginal bleeding should always be evaluated by ultrasonography, first the exclusion of the external pregnancy, and then the week of gestation and the condition of the gestational sac and its contents should be evaluated. The diagnosis may become clear on the first ultrasonography, and re-evaluation may be required from time to time after 7-10 days. Meanwhile, depending on the amount of bleeding, the woman’s general condition assessment and other necessary examinations can also be performed. After the diagnosis is made, the abortion decision comes to the agenda and whatever the situation of the woman requires is abortion. If there is a small amount of material in the uterus, it can be tried to ensure that the parts are thrown out of the uterus by providing appropriate uterine contraction or if the piece is very dense, the tissue inside the uterus is removed by abortion. Because the internal parts can cause both prolonged bleeding and, more importantly, infection in the intrauterine tissue. This state of infection, which is called endometritis, may pass into the systemic circulation and cause severe results, and may cause intrauterine tissue adhesions in the long term and cause problems in the expectation of subsequent pregnancy. However, the total rate of complications related to miscarriage is extremely low. The amount of bleeding can vary with age, and the number of fertility. However, the gestational week is the main determining factor. The further the gestational week, the more bleeding will occur.
Causes of Abortus
The reason for the miscarriage is mainly related to the vitality potential of the embryo. If the reproductive effort remains healthy during cellular coding and divisions, healthy individuals will be born. However, if there is an unhealthy course at certain stages of development, nature will intervene and end the process before it is born. This fact is an essential factor in the birth of healthy individuals, and is actually natural selection when the abortions make sense. Loss of pregnancy is of course saddening. However, it will be comforting to accept that unhealthy pregnancy has been eliminated by looking at this eye. Because it is important to remember how much screening and research we do for pregnancies like Down syndrome that are compatible with life and can continue on their way. This logic is at the core of chromosome anomalies that are incompatible with life.
The drug and radiation related loss rate is around 1% among the causes.
We can tell 3% of parents about family genetic diseases or carriers. However, there are generally recurrent pregnancy losses.
Structural anomalies of the uterus (such as septum, double uterus, cervical insufficiency) or space occupying lesions such as myom and polyps that compress the intrauterine tissue can also lead to loss of healthy pregnancies.
Active infections such as corpus luteum insufficiency and insufficient progesterone release, very high fever, rubella, cytomegalovirus, listeria are among the causes.
Asherman’s syndrome, which expresses adhesions due to previous intrauterine infection or curettage, is also among the causes of miscarriage.
It is also the pre-existing chronic diseases of the mother. These are diabetes, lupus, thyroid diseases, kidney diseases, antiphospholipid syndrome and severe hypertension.
Apart from these, bad habits of woman lifestyle may increase the risk of miscarriage. Alcohol and drug use, smoking and very high dose caffeine are among them.
Expected Actions After Abortus
When can a pregnancy be tried again?
If abortion is not required after abortion, the woman can stop the contraceptives immediately after the next menstruation. If an abortion was required, it would be more appropriate to stop contraceptives after two cycles.
The amount of bleeding after abortion will also change according to whether or not there is an abortion. While spontaneous abortion takes 7-10 days, bleeding lasts shorter after an abortion. Sexual intercourse should be avoided as it may be the cause of infection during bleeding. It will be safe to postpone sexual intercourse for 2 weeks.
The use of antibiotics after abortion is a physician-dependent decision, and short-term antibiotics are often recommended. Pain relief needs may vary depending on the week of pregnancy and whether there is an abortion. However, although pain is mostly felt while low, there is no need for pain relief after the pregnancy crop is thrown out.
If the couple has blood incompatibility, Anti-D should be applied 6 weeks or more. Because it is not possible to know the baby’s blood group, and if it is positive, it may risk the next pregnancy as it can pass into the mother’s blood.
Taking precautions for the next pregnancy is often not possible due to the nature of miscarriage. It is a fact that it should always be remembered that pregnancies that are incompatible with life are lost in natural selection. However, if there is cervical insufficiency, cerclage can be applied in the next pregnancy. If there is septum, fibroids or polyp, the problem must be resolved surgically. Smoking, alcohol and other bad habits can be dispensed with, and metabolic disorders such as thyroid diseases and diabetes can be corrected before pregnancy.
Abortus Imminence (Abortus Threat)
**** I think it is necessary to discuss here about “abortus imminence”case, which is called the abortus threat. Changing amounts of bleeding may occur in the first half of pregnancy in 25-35% of women. While half of these women have lost pregnancy, the other half will continue to be healthy. In case of miscarriage, the cervix is necessarily closed. Often there is no pain either. Gestational sac and embryo develop properly when ultrasonography is performed at regular intervals. As the severity of bleeding increases, the severity of the threat of miscarriage may increase. In this case, the only clear approach to treatment is activity restriction and bed rest. If the bleeding is severe or continues, absolute bed rest is required, which means that you can get out of bed just to go to the toilet and eat. It is also useful not to travel.
The only real situation in which progesterone use is effective is corpus luteum insufficiency. If abortion is unavoidable, progesterone treatment will do nothing but delay the process. In the literature, data supporting routine progesterone use in early bleeding is not sufficient, but it is used quite widely. Perhaps this is not more than ‘an effort to do something’ for both family and physicians. Although progesterone treatment is not given in pregnancies continuing with health, it is suggested that the process will already be so.