In the first 20 weeks of pregnancy, the event that less than 500 grams of embryo or fetus and all or a part of its appendages are thrown out of the uterine cavity is called abortion (1977 World Health Organization definition). In short, the termination of pregnancy for any reason before the 20th week of pregnancy is called abortion (miscarriage). Miscarriages occurring within the first 12 weeks are early abortions, 13th-20th. Those that occur in the middle of the week are also called late miscarriages. Or, with another definition, before the 20th week of pregnancy is completed (or before the baby reaches 500 grams of weight), the end of pregnancy for any reason is called miscarriage.
Termination of pregnancy for the purpose of family planning upon request within legal ends is called legal evacuation, and termination of pregnancy for another reason (the health status of the expectant mother does not allow the continuation of the pregnancy, the baby has anomalies incompatible with life or has died) is called medical evacuation.
Many conditions must be suitable for a healthy pregnancy to progress. Of course, the first condition is that the baby is healthy. Then the “nest” where the baby can continue to grow and develop should be comfortable and healthy. Finally, competition with harmful external factors should be avoided.
The baby is healthy; The normality of the genetic code depends on its proper placement in the uterus. Genetic code disorder (chromosomal abnormality) is the cause of the precious majority of early pregnancy losses (about two out of every three pregnancies). This situation can also be interpreted as a defense mechanism of nature. Essentially, unhealthy pregnancy, which is incompatible with life, is lost at an early stage (-our world would be full of disabled children if it were not lost-). Late pregnancy losses are mostly due to structural disorders of the uterus and uterine canal rather than genetic disorders. The main of these structural disorders are; cervical insufficiency, uterine wall adhesions and intrauterine anatomical disorders.
Anembryonic pregnancy (anembryonic=non-embryo meaning “empty” pregnancy; English=blighted ovum)
It is the situation where the embryo cannot be seen while the embryo should be seen compared to the gestational week in the ultrasound. If the embryo cannot be seen at approximately 6 weeks of age in abdominal ultrasonography and at approximately 5.5-6.5 weeks in vaginal ultrasonography, anembryonic pregnancy is considered. should be done!). In this case, the gestational sac may be in the appropriate size for the week, or it may be larger or smaller than usual. The embryo has died in early pregnancy due to one of the causes described below and has been resorbed (“dissolved”) or has not developed at all since the beginning. Pregnancy hormones will definitely continue to be effective for a while and it is expected that pregnancy will result in miscarriage after a while (within 1-4 weeks on average).
Medical evacuation should be performed when the diagnosis of anembryonic pregnancy is certain. In cases where there is doubt, the growth of the gestational sac can be observed in vaginal ultrasonography preferably at intervals of two to seven days, and/or it can be investigated whether the beta HCG prices increase normally (beta HCG doubles approximately every 48 hours during this period and the gestational sac grows by an average of 1.2 millimeters per day). If the gestational sac does not grow, shrinks or grows slower than necessary, the pregnancy should be terminated by rediagnosing anembryonic pregnancy.
Late pregnancy losses are mostly due to structural disorders of the uterus and uterine canal rather than genetic disorders. The main of these structural disorders are; cervical insufficiency, uterine wall adhesions and intrauterine anatomical disorders.
Impaired pregnancy
It is a similar situation with anembryonic pregnancy. This diagnosis is made in cases where the gestational sac is followed unsystematically. The gestational sac, which should be normally round, can become unsystematic in the period before the miscarriage, and again often there is a small amount of blood accumulation around the sac. The word disrupted pregnancy is often used to describe this condition. After the diagnosis is made, the pregnancy is terminated by medical evacuation.
Missed abortion -missed abortus
After a certain period of time after the embryo dies, certain issues begin to enter the blood of the expectant mother and pregnancy hormones begin to decrease in a short period of time. Subsequently, the symptoms of pregnancy gradually decrease. In the ovary where the fertilized egg cell is produced, the corpus luteum (pronounced corpus luteum) structure, which appears in the area where the cracking occurs quickly after ovulation and gives progesterone supplementation to the pregnancy in the early period, also collapses. Accordingly, the pregnancy, which loses its hormonal support, begins the processes of self-extraction with uterine contractions. These processes usually start within a few days after the embryo dies, and at the end of a week, the pregnancy artifacts are thrown out with pain and bleeding. Although the definitions are controversial, the absence of miscarriage starting 2 weeks after the death of the embryo is called missed abortus (“expected but not realized” miscarriage). This diagnosis is gradually decreasing, because nowadays when it is noticed that the embryo is dead, medical evacuation is recommended as soon as possible. This diagnosis is most often made when a dead embryo (called a fetus after 12 weeks) is seen on ultrasound, where the embryo development that should have been delayed by about two weeks compared to the last menstrual period. Treatment is medical evacuation after the necessary preliminary examinations.
IUMF: Inutero mort fetalis (=death of the fetus in the womb)
This diagnosis is made when it is observed that the fetus has died due to a random cause. After the death, the miscarriage starts on its own, often within two weeks at the latest, due to the influence of certain factors that pass into the blood of the expectant mother and the decrease in hormones. However, today, when this diagnosis is made, medical evacuation is recommended following the necessary preliminary examinations instead of waiting. It is useful to mention one more thing at this stage: When the embryo or fetus dies for a random reason, the elements that pass into the blood of the expectant mother are the factors that negatively affect the blood coagulation mechanism. The further the gestational week is when the baby dies, and the more days have passed since the death, the greater the risk of adversely affecting blood clotting. This coagulation disorder can easily be a disorder that only slowly affects and prolongs the clotting time, or it can be an important condition that results in the depletion of all clotting factors in a short time. Since this condition, called DIC (Disseminated intravascular coagulopathy, disseminated intravascular coagulation), may even cause death due to bleeding, when it is determined that the baby is dead, it is preferred to evacuate the pregnancy without waiting too long after the necessary preliminary examinations are made. Publicly, this situation is known as “dead baby poisoning the mother”. To investigate the possibility of DIC, tests that favor blood coagulation should be performed in all cases where the fetus has died. It is also valuable to have fresh blood available in accordance with the patient’s blood set before evacuation, especially in high-risk situations (large pregnancy, long suspected fetal death).
Spontaneous (spontaneous) abortion
When a disrupted pregnancy or anembryonic pregnancy occurs, as described above, when the baby dies, the physiological systems come into play and aim to evacuate the uterus to its pre-pregnancy state. This manifests itself in the first 20 weeks of pregnancy in the form of bleeding, pain and concomitant “pieces” dropping. As the gestational week progresses, the amount of blood lost increases and the volume of the falling “pieces” becomes larger. In the examination, the cervix (cervix) is open and it is observed that blood and pregnancy artifacts come out. The lower movement is initiated by the body itself.
In case the abortion action starts and ends by itself, the term complete abortion (completed abortion) is used. Complete abortion often occurs in miscarriages, especially in pregnancies before the first 6 weeks or older than 16 weeks. If the bleeding is observed to be less in the examination and preferably the uterus is completely emptied in the vaginal ultrasonography, additional intervention may not be required.
In some cases, abortion begins, but self-emptying of the uterus takes a long time and sometimes complete ejaculation does not occur at all. This situation is called incomplete abortion (incomplete abortion). Especially in cases where 6 weeks to 14 weeks of pregnancy result in miscarriage, since the membranes and the newly developing placenta are firmly attached to the uterus, uterine contractions have difficulty in removing these structures from their place. As the miscarriage continues, bleeding continues as the uterus has not been fully emptied. In these cases, abortion is required both to stop the bleeding and to prevent the modules remaining inside from causing infection. Abortion is the name given to the process of cleaning the modules remaining in the uterus with mostly plastic tubular instruments until the 10th week, depending on the gestational week. Plastic pipes pull the “pieces” attached to the uterine wall out of the uterus, due to the absorbent effect of the vacuum attached to their posterior parts and because the ends are relatively sharp. In some cases, the one-to-one process may need to be done by gently scraping with the help of metal tools called curettes.
Rest placenta (“fragmentation”) It is the name given to the retention of the placenta and some other pregnancy-related modules in the uterus after abortion or legal discharge. Abortion is often preferred to stop bleeding and prevent infection.
Are the pregnancy tests sold in pharmacies reliable? Also see: Pregnancy test time
There are two problems with these tests: First of all, since these tests detect beta HCG in the urine, beta HCG in the blood reaches a clear level and can also be found in the urine. Until it reflects, they can give a negative result even though there is pregnancy. Depending on the sensitivity of the test, detection of beta HCG in the urine may not occur until one week to 10 days after a missed period. Another problem is that the hormone called LH, which is responsible for the management of ovulation, is structurally very similar to beta HCG, and tests that work with old technology may mistakenly assume that LH is beta HCG and give a positive pregnancy result. These types of tests can mislead by giving positive results, especially when applied during the period when LH physiologically rises before ovulation. Therefore, it is more appropriate to learn about the characteristics of the test you buy from the market and to have sensitive tests used in clinics or hospitals whenever possible. Serial beta HCG measurements in the blood give valuable information about whether the pregnancy is healthy or not. In a normal intrauterine pregnancy, the beta HCG level is expected to increase approximately twice (although it is not a rule) in the 48-hour average. When there is no increase or decrease, ectopic pregnancy or impaired pregnancy may be the subject of words. The definitive diagnosis is of course made together with clinical and ultrasonographic findings. When the beta HCG level in the blood is found to be very high compared to the week (even higher than it should be in multiple pregnancies), an unusual condition such as molar pregnancy or Down syndrome may be suspected. A definitive diagnosis is made by using other diagnostic formulas together.
Ultrasonography and early pregnancy detection
Transvaginal ultrasonography gives more reliable information, especially in the early stage, compared to abdominal (abdominal) ultrasonography, and pregnancy structures can be seen one week earlier than the abdominal way when viewed vaginally. Features such as the diameter of the gestational sac, whether the gestational sac is in order or not, the size and characteristics of the structure called yolk sac (yolk sac can be read), the length of the fetus and whether the heartbeat can be observed, and the heart rate of the fetus provide valuable information about the course of pregnancy. Evaluation of these together or in succession at certain intervals can be a guideline for the pregnancy status in expectant mothers with a low risk of miscarriage. If the beta HCG value is 1500 IU/l but the gestational sac cannot be seen in the transvaginal ultrasound, and the gestational sac cannot be seen in the trans-abdominal ultrasound even though it is 6000 IU/l, ectopic pregnancy may be the issue. In the transvaginal ultrasound again, the gestational sac is 13-15 mm. and although the yolk sac structure can not be observed now, the sac is 17-25 mm. and the fact that the embryo could not be observed despite being larger suggests that the pregnancy is not healthy.
What is the risk of recurrence of abortion?
First of all, let us remind you that even if there is no risk factor at the time of pregnancy, the probability of abortion in the first trimester is around 10-15%. The risk of miscarriage again in the next pregnancy of a woman who has had a miscarriage once is 20-25%. For a woman who has had three or more miscarriages, the risk of miscarriage again in a new pregnancy is approximately 40-50%.
Although the risk of a new pregnancy resulting in a miscarriage increases as the number of miscarriages increases, statistics show that the probability of giving birth to a healthy baby again is in the middle of 50% to 75% according to various sources, even for expectant mothers who have had three or more miscarriages. shows that.
How soon after miscarriage can one get pregnant?
If you have experienced a miscarriage once, if your miscarriage is not due to pregnancy, if there is no unusual condition such as heavy bleeding or infection after the miscarriage, if you do not have a disease that requires treatment, the miscarriage you experience is probably a non-recurrent miscarriage and it is advanced. It’s not something that needs scrutiny. When you feel ready for a new pregnancy spiritually, you can get pregnant again from the next period.
If you are in a different situation from the above (such as multiple miscarriages, molar pregnancies, post-miscarriage problems, presence of a chronic disease), you should get pregnant after consultation with your physician and after the necessary examinations and treatments
Habitual abortion (recurrent miscarriages) )
It is the name given to a woman’s miscarriage at least twice (three times in some schools) consecutively.
What causes miscarriage?
Pregnancy begins as soon as the oocyte (egg cell) is fertilized. The fertilized egg cell travels through the Fallopian tube and reaches the uterus, where it settles in the most suitable place. After this implantation, beta HCG secretion begins.
One of the most valuable duties of nature is to ensure that the most complete living things benefit from the finite resources that the earth offers to living things. For this, natural systems come into play at every stage of the formation of new living things, and even after living things are born, at every stage of life, and all living things are put to a test, the “wrongful” ones are eliminated and “room” is made for the perfect ones. “The most perfect” is used here to mean the most perfect genetically, structurally and functionally. This physiological system, called natural selection, finds organisms that are “wrong” and, as we explained above, tries to correct the flaws it has made, in a sense, in order to make room for the complete ones. In the narrowest sense, “low” can be seen as one of the manifestations of this physiological mechanism.
One of the most valuable features of natural selection’s low action is thankfully that it can come into play in the earliest periods. The system functions more conveniently when the error is now eliminated before large dimensions are reached. For this reason, although we have defined the term “miscarriage” as an event that occurs within the first 20 weeks, in fact, miscarriages occur most frequently in the first days of pregnancy, and a valuable part of them now occurs before pregnancy symptoms such as menstrual delay occur, that is, before the woman perceives that she is pregnant. . Soon after fertilization, the process begins and the fertilized but “poor quality” egg cell tries to be destroyed quickly. This process works so delicately that approximately 25% of pregnancies formed from this stage to the fourth week of pregnancy with a missed period end in miscarriage. We understood this fact after the beta HCG hormone measurement methods were developed. As we explained above, beta HCG secretion, which starts soon after implantation (settling in the uterus), can be measured with sensitive laboratory examinations, and now the diagnosis of pregnancy can be made by observing that the beta HCG secretion increases without delay in the menstrual cycle (For example, for a woman who has a menstrual period every 28 days, 24-26 days of her period. on the day). At this stage, since the biological pregnancy has not started and a pregnancy is diagnosed according to the blood biochemistry (ie, according to the increase in beta HCG), the pregnancy is called “chemical pregnancy”.
Another feature of natural selection is that it maintains its attitude towards correcting its mistakes in a “stubborn” form. Follow-up continues even after the woman has a missed period, and approximately 15% of diagnosed pregnancies end in miscarriage in the later weeks of pregnancy. This means that about 40% of pregnancies that occur end in miscarriage! This is not because nature makes a lot of mistakes, but because it does not “forgive” even the smallest mistakes. As a result, if all pregnancies could go on without miscarriage, the Earth would be filled with a generation of people with disabilities.
As the gestational week progresses, the probability of pregnancy resulting in miscarriage decreases. Because the natural selection process often catches and terminates “wrong pregnancies” in early pregnancy weeks. Indeed, 80% of miscarriages occur in the first 12 weeks of pregnancy and after this week, the risk of miscarriage gradually decreases. Some studies show that if the baby’s heartbeat is observed in the ultrasonography, the risk of miscarriage drops to 3%.
Of course, this natural selection process that we have explained above is not the cause of every miscarriage. In particular, a valuable portion of recurrent miscarriages may also occur due to some structural defects in women (such as uterine deformities), hormonal imbalances (such as polycystic ovary, thyroid dysfunctions), genetic defects in females and/or males (such as balanced translocations). . Below you will find a more extensive list of these reasons.
However, we can definitely say this: More than 50% of miscarriages occurring in early pregnancy occur due to chromosomal anomalies that occur coincidentally in the baby and do not have repetitive features. The smaller the gestational week during the miscarriage, the higher the probability of this being the cause. Therefore, miscarriage can be considered as a condition that women of reproductive age often experience and often does not recur.
Natural selection, of course, cannot detect every production error and some pregnancies continue even though they were produced wrongly. When the natural selection process catches these defects in the later weeks of pregnancy, it can manifest itself in the form of late miscarriages or premature births, and dead births. In fact, this is the reason for some of the premature births.
When natural selection cannot catch the defective production until birth, it can catch it in the newborn period. One of the valuable causes of newborn deaths is babies born with anomalies.
Who is at higher risk of miscarriage?
The higher the age of the mother (and father-to-be) at the time of conception and the higher the number of pregnancies the woman has had before, the higher the risk of miscarriage. This is natural, because as age increases, the possibility of genetic defects in gamete cells (egg cells in women, sperm in men) and the possibility of passing this defect to a fertilized cell increases. While the risk of miscarriage is approximately 10% in mothers younger than 20 years of age (low rate of pregnancies diagnosed with pregnancy), this risk is around 30% in those older than 40 years of age. The risk of miscarriage doubles in pregnancies where the age of the father-to-be is over 40.
Apart from the age of the expectant mother and father, which is the most valuable factor, some hormonal diseases (polycystic ovary, hypothyroidism (underactive thyroid gland)), chronic diseases (especially heart, liver and kidney diseases, some autoimmune diseases, tuberculosis, cancer, advanced anemia), gynecological diseases (uterine deformities, uterine adhesions, fibroids, some untreated types of vaginitis, smoking and alcohol use, and being constantly exposed to some occupational issues also increase the risk of miscarriage.) ) The risk of a new pregnancy resulting in miscarriage also increases slowly in expectant mothers whose previous pregnancies ended in miscarriage. In two or more previous miscarriages, the risk of a new miscarriage also increases as the number of previous miscarriages increases. Even though a pregnancy also has an increased risk of miscarriage, statistics show three or more shows that the odds of delivering a healthy baby, even in expectant mothers who have had more miscarriages, are between 55% and 75%.
Pregnancy occurring in the first trimester after giving birth in a pregnant woman who has just given birth has a relatively high risk of resulting in miscarriage.
How does miscarriage manifest?
The “must have” symptom of miscarriage is bleeding. In very early weeks of pregnancy, bleeding may not be accompanied by pain, and “piece drop” may not be perceived by mixing with menstruation due to the small size of the “pieces”.
What is the threat of miscarriage? Abortion Imminens
In case of bleeding or bloody discharge in the first half of pregnancy, a miscarriage threat is diagnosed when the gynecological examination makes sure that the bleeding does not originate from a place other than the uterus. In some expectant mothers, hemorrhoids bleeding, bleeding in the urinary tract, or bleeding that occurs especially after sexual intercourse due to a disease in the cervix may also be considered as a miscarriage threat as a result of insufficient evaluation. Therefore, a full gynecological and genital examination should not be neglected without promptly making the diagnosis of “threat of miscarriage”. Many expectant mothers are reluctant to this examination. However, there is no scientific data that gynecological examination and/or ultrasound cause abortion. Other causes of bleeding in the early stages of pregnancy should never be ignored. Among these, the most valuable ones are ectopic pregnancy, mole pregnancy, benign and malignant tumors, bleeding from the digestive system or urinary tract.
Bleeding during the expected menstrual period (“seeing over”), bleeding during implantation (one week before the expected period), bleeding due to the placenta taking over the corpus luteum functions around the 8th week are also rare in a healthy pregnancy. It may be the cause of the “staining”.
The threat of miscarriage is a condition that occurs in 20-25% of all pregnancies and results in 40-50% miscarriage, especially in early gestational weeks. Threatened miscarriage bleeding is often mild but can last for days or even weeks. The greater the extent of bleeding, the greater the threat of miscarriage resulting in miscarriage. Expectant mothers who have a real threat of miscarriage have a relatively higher chance of experiencing an unusual situation such as premature birth and growth retardation in the baby in the later weeks of pregnancy. For this reason, it is appropriate for expectant mothers with this diagnosis to be followed more closely during the pregnancy period and in the period immediately after delivery.
In order to diagnose the threat of miscarriage, the cervix should be observed to be closed in the gynecological examination and the baby’s heartbeat should be observed in the ultrasound. In the early weeks of pregnancy, when the baby’s heartbeat is too small to be observed with ultrasound or even the embryo cannot be seen now, it should be observed that the proper structure of the gestational sac continues in the uterus.
What to do in case of threat of miscarriage?
When a threat of miscarriage is diagnosed, sexual interest is prohibited as it can trigger uterine contractions. There is no scientific data that the measures taken in the threat of miscarriage, including rest, are absolutely successful. Although progesterone treatment is frequently applied, we do not have enough scientific knowledge to say that it is also effective, but it is frequently applied due to controversial results. Some studies even show that this treatment delays a pregnancy-related miscarriage that may be problematic in itself, which is impossible to prevent.
Anti-D immunoglobulin (Rhogam, meaning “incompatibility needle”), which should definitely be administered after abortions, should not be neglected in couples with blood incompatibility.
Tests to determine whether the pregnancy is healthy or not
Beta HCG
Beta-HCG begins to pass into the blood approximately 6 days after pregnancy occurs (in the first hours after the pregnancy settles into the endometrium). Sensitive pregnancy tests can now detect beta HCG in the blood on the 24th day after the last menstrual period (for someone with regular menstrual cycles and every 28 days) in a menstrual-free cycle. When the expected period is delayed, the rate of beta HCG in the blood is about 50-600 IU/l. This is level 8-10. After reaching a maximum level of 100,000 IU/l in the middle of weeks, it gradually decreases and remains at a level of approximately 10,000 from the 20th week until the end of pregnancy. Since the beta-HCG measurement can be in very wide ranges, it does not inform the gestational week as precisely as ultrasound! Therefore, an idea can be given about the health status of a pregnancy, which can be seen and monitored not only by blood and urine tests, but also by ultrasound.
Other tests will be requested by your doctor during your pregnancy follow-up, depending on the situation.
