Recurrent pregnancy losses
Let’s start the definition of this concept with the definition of the World Health Organization: Abortus; an embryo or fetus under 500 g is aborted or removed from the mother.
50% of pregnancies result in abortion before or expected menstrual period. This is of course a phenomenon women are not aware of and it is the earliest period of natural selection. However, we do not accept these abortions as a risk factor for medical reasons.
The frequency of miscarriage is reported as the gestational sac is recognizable after menstrual delay.
90% of abortions occur before 12-14 weeks. So “legendary first 3 months” is a real concept. The probability of miscarriage decreases to as little as 2.5% between 9-14 weeks. In fact, the most risky period is up to 8 weeks.
Definition of recurrent pregnancy losses
The definition of recurrent pregnancy loss is; is when the woman has 3 or more miscarriages. In these cases, 3 abortions are expected to be investigated medically, but the investigation process can be started after 2 abortions. However, no cause can be found in 50% of couples. However, statistics give pregnancy rates up to birth without any treatment in 60-70% of these couples.
Risk factors of recurrent pregnancy losses
The majority of risk factors, which include the number of abortus, female age, smoking and alcohol use, genetic factors, anatomical disorders in the female genital system, hormonal factors, coagulation disorders, autoimmune diseases, microbiological factors and low ovarian reserve, can also be the main cause.
Statistical risk ratios caused by the increase in the number of abortions: 15% after one miscarriage, 24% after the second miscarriage, 43% after the third miscarriage and 54% after the 4th miscarriage.
Timing of recurrent pregnancy losses
The week of gestation in which the abortion takes place is also very important when determining the risk of recurrence of miscarriage. In this context, if the miscarriage occurred before 10 weeks, the risk of miscarriage is the least. The group with the highest increased risk is the female group that had previously miscarried between 16-27 weeks, the risk increases 20 times for this group, and if it has been lost after 28 weeks, the risk increases 5 times. Women who have previously had a healthy and mild birth also have a reduced likelihood of miscarriage after miscarriage.
Causes of recurrent pregnancy losses
- Genetic causes and chromosomal abnormalities:
It is the most common reason for recurrent pregnancy losses and is seen at the rate of 50%. In this ratio, most often random chromosome sequencing is erroneous. In 2-4%, the disorder defined as balanced translocation is detected in the mother or father. Balanced translocation is 2 times more likely to come from women and, if it comes from women, is more likely to be lower. If translocation has occurred in the same chromosome, we cannot talk about the possibility of the baby being normal. Balanced translocation has been determined in the mother or father and if pregnancy is continuing, the genetic unit can be consulted with the genetic unit, discussing the risks and benefits with the couple and conducting a genetic examination for the fetus. These examinations are chorionic villus biopsy, amniocentesis or cordocentesis. Or it should not be forgotten that the probability of a healthy baby is 70% in couples with balanced translocation in the father. In addition, the chromosome can be looked after by using the genetic unit, the embryo is obtained by the IVF method, and chromosome anomaly is tried to be prevented by transferring the healthy embryo (Preimplantation genetics). The cell obtained from the embryo may not reflect the entire structure. The choice of healthy ovum (egg) is more possible in the natural cycle, and the unhealthy product is lost by natural selection. Nevertheless, preimplantation genetical diagnosis with the couple can always be discussed.
- Anatomical reasons:
The most common cause in this group is congenital anomalies of the uterus (uterus), in a study performed by three-dimensional ultrasonography, the frequency of congenital abnormalities of the uterus is given as 24%. The most common of these is the septum (curtain) in the uterus. If the uterine septum is present, the woman may not become pregnant, pregnancy may end with a miscarriage or premature birth may occur.
Cervical insufficiency is the painless opening of the uterus silently due to its structural or functioning deficiencies, and generally the losses occur after 12 weeks.
Myomas may also have a low cause, but the location (especially submucous myomas), location, size and numbers of the fibroids gain importance in determining the risk.
Adhesions occurring in the intrauterine tissue, which are also among the anatomical causes, are important causes that cause miscarriage and miscarriage. Adhesions may be due to previous curettage, fibroid surgery, hysteroscopic polyp surgery, and tuberculosis.
- Endocrine (hormonal) reasons:
These include the luteal phase failure, polycystic ovarian syndrome, thyroid hormone disorders and diabetes mellitus. In the luteal phase insufficiency, it is mentioned that the progesterone hormone is released after ovulation and provides the development of the endometrium and the acceptance of pregnancy. However, its citation is controversial and, according to many authorities, it has no place among the causes of miscarriage. Likewise, its place among the low causes of disorders in thyroid hormone release is controversial. However, there are also studies showing that keeping TSH level below 2.5 reduces the low rates. In cases with high TSH value, it is useful to evaluate thyroid functions and anti-thyroid hormones. Here are two clear endocrine causes; polycystic over syndrome and diabetes. In polycystic over syndrome, current insulin resistance shot and LH hormone elevation are shown as the reason, while diabetes increases the risk of low blood sugar rates. The easiest, cheapest and effortless approach will be to provide weight loss before pregnancy. Reducing body mass index greatly reduces insulin resistance.
- Coagulation and immune system disorders:
The first of these factors, autoimmune diseases, ie immune system problems, lupus anticoagulant and anticardiolipin antibodies may increase and increase the risk of miscarriage. Coagulation disorders are called thrombophilia. This group includes factor 5 Leyden mutation, anti prothrombin antibodies, anti B2 glucoprotein antibodies and controversial protein C, protein S level deviations, MTHFR gene mutation, homocysteine and antithrombin 3 antibodies. Whether there is a history of thrombosis in the woman or her family should be screened. The place of heparin treatment in this group is clearer.
- Maternal age:
There is an increased risk of miscarriage in advanced maternal age. The increased risk of miscarriage in women 30 years and men after 40 years may be related to changes in the structure of ovum and sperm.
It is absolutely useful in making vaginal cultures and it is an easy test. Because chlamidia, ureoplasma and mycoplasma infections, which persist in the vagina for a long time, increase the low risks.
- Environmental Reasons: Smoking and alcohol falls under this group
- Psychological Reasons:
This issue is controversial. It is known that the rate of depression increases in abortions of two or more. However, it will not be clear whether depression leads to miscarriage or miscarriage leads to depression.
Diagnosis and treatment in recurrent pregnancy losses
For diagnosis and treatment, at the first stage, a genetic examination should be made on the low or low abortion material, and if necessary, a chromosome analysis of the mother and father should be made and genetic counseling should be given. Here, preimplantation pregnancy can be applied if necessary.
In anatomic factors, the diagnosis of septum or adhesion can be made by medicated uterine film (hysterosalpingography), sonohysterography or hysteroscopy. Both conditions can be treated by hysteroscopic method. Myomectomy operation should be performed if the low cause is localized, size or number risky myomas. If it is thought to be cervical insufficiency, cervical cerclage should be applied after 12 weeks.
If hormonal factors are involved, insulin resistance should be corrected in polycystic ovarian syndrome, thyroid hormones should be brought to an ideal level, blood glucose levels should be kept at ideal intervals in diabetic women and supplemented with progesterone hormone if luteal phase failure is considered.
There are autoimmune diseases; If lupus anticoagulant or anticardiolipin antibodies are positive, heparin and aspirin should be started. In coagulation disorders, heparin and aspirin are also recommended.
The risk is easily eliminated by choosing the appropriate antibiotic in the treatment of infection.
Smoking and alcohol should definitely be abandoned
Seeking psychological help should not be avoided.
When a cause can be identified and treated, the probability of getting the pregnancy healthy until the end can reach 90%. However, the failure to determine the cause drags both the patient and his physician into chaos and may lead to unnecessary and excessive treatment approaches from time to time. In this case, after taking the necessary precautions, it should not be forgotten that there is already a 70% probability of healthy pregnancy and birth without any treatment.