{"id":653,"date":"2021-02-04T11:03:49","date_gmt":"2021-02-04T11:03:49","guid":{"rendered":"http:\/\/drozkanozdamar.com\/?p=653"},"modified":"2021-06-10T20:53:54","modified_gmt":"2021-06-10T20:53:54","slug":"tekrarlayan-gebelik-kayiplari","status":"publish","type":"post","link":"https:\/\/drozkanozdamar.com\/?p=653","title":{"rendered":"Tekrarlayan Gebelik Kay\u0131plar\u0131"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"653\" class=\"elementor elementor-653\" data-elementor-settings=\"[]\">\n\t\t\t\t\t\t<div class=\"elementor-inner\">\n\t\t\t\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-318060d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"318060d\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-6835951\" data-id=\"6835951\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3d36f70 elementor-widget elementor-widget-text-editor\" data-id=\"3d36f70\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-text-editor elementor-clearfix\">\n\t\t\t\t\t<p><strong>TEKRARLAYAN GEBEL\u0130K KAYIPLARI<\/strong><\/p>\n<p>Tekrarlayan gebelik kay\u0131plar\u0131n\u0131n tan\u0131m\u0131nda farkl\u0131 kriterler ve tan\u0131mlamalar kullan\u0131lmaktad\u0131r.<\/p>\n<p>Genel olarak kabul edilen tan\u0131mlama; 20. gebelik haftas\u0131ndan \u00f6nce klinik olarak tan\u0131 konmu\u015f 3 veya daha fazla ard\u0131\u015f\u0131k gebelik kayb\u0131 iken ASRM\u2019nin yapm\u0131\u015f oldu\u011fu tan\u0131mlama ise&nbsp; ultrasonografi veya histopatoloji ile tan\u0131 konmu\u015f 2 veya daha fazla klinik gebeli\u011fin kayb\u0131d\u0131r.<\/p>\n<p>Gebelik kay\u0131plar\u0131n\u0131n \u00e7o\u011fu farkedilmemektedir. Hassas hCG \u00f6l\u00e7\u00fcmlerinin kullan\u0131ld\u0131\u011f\u0131 son \u00e7al\u0131\u015fmalarda implantasyondan sonraki gebelik kay\u0131plar\u0131n\u0131n ger\u00e7ek oran\u0131 %31 olarak bulunmu\u015ftur. SAT\u2019tan itibaren, klinik olarak farkedilen gebeliklerin %15-20\u2018si&nbsp; 20. haftadan \u00f6nce kay\u0131pla sonu\u00e7lan\u0131r. Gebelik kayb\u0131n\u0131n tekrarlama riski;<\/p>\n<ul>\n<li>Bir canl\u0131 do\u011fum varsa : %15<\/li>\n<li>Bir abortus varsa : %30<\/li>\n<li>2 abortus varsa : %30-40<\/li>\n<li>3-4 abortus varsa : %40-50<\/li>\n<\/ul>\n<p>olarak kabul edilmektedir.<\/p>\n<p>Gebelik kayb\u0131 riski; 40 ya\u015f\u0131ndan sonraki risk 20 ya\u015f\u0131ndaki bir kad\u0131n\u0131n 2 kat\u0131d\u0131r.&nbsp; Neden sadece an\u00f6ploid konsepsiyonlar\u0131n artmas\u0131 de\u011fildir. Uterin kan ak\u0131m\u0131n\u0131 azalmas\u0131, kronik enfeksiyonlar, LPD etken olabilir. \u0130mplantasyonda \u00f6nemli bir role sahip olan endometrial glikoproteinler ve integrinler de artan ya\u015fla birlikte azalmaktad\u0131r. Bir sonraki gebeli\u011fin ba\u015far\u0131s\u0131 ile ya\u015f-gebelik kayb\u0131 say\u0131s\u0131 aras\u0131ndaki ili\u015fki tablo 1 de verilmi\u015ftir.<\/p>\n<p><\/p>\n<p><\/p>\n<p>Tablo 1: Bir sonraki gebeli\u011fin ba\u015far\u0131s\u0131 ile ya\u015f-gebelik kayb\u0131 say\u0131s\u0131 aras\u0131ndaki ili\u015fki<\/p>\n<table width=\"473\">\n<tbody>\n<tr>\n<td colspan=\"2\" width=\"94\">\n<\/td>\n<td colspan=\"6\" width=\"378\">\n<p><strong>Gebelik kayb\u0131 say\u0131s\u0131<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" width=\"94\">\n<\/td>\n<td colspan=\"2\" width=\"95\">\n<p>2<\/p>\n<\/td>\n<td width=\"94\">\n<p><strong>3<\/strong><\/p>\n<\/td>\n<td colspan=\"2\" width=\"95\">\n<p><strong>4<\/strong><\/p>\n<\/td>\n<td width=\"94\">\n<p><strong>5<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td rowspan=\"3\" width=\"39\">\n<p><strong>Y<\/strong><\/p>\n<p><strong>A<\/strong><\/p>\n<p><strong>\u015e<\/strong><\/p>\n<\/td>\n<td width=\"55\">\n<p><strong>20<\/strong><\/p>\n<\/td>\n<td width=\"95\">\n<p>92<\/p>\n<\/td>\n<td colspan=\"2\" width=\"95\">\n<p>90<\/p>\n<\/td>\n<td width=\"95\">\n<p>88<\/p>\n<\/td>\n<td colspan=\"2\" width=\"95\">\n<p>85<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"55\">\n<p><strong>30<\/strong><\/p>\n<\/td>\n<td width=\"95\">\n<p>84<\/p>\n<\/td>\n<td colspan=\"2\" width=\"95\">\n<p>80<\/p>\n<\/td>\n<td width=\"95\">\n<p>76<\/p>\n<\/td>\n<td colspan=\"2\" width=\"95\">\n<p>71<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"55\">\n<p><strong>40<\/strong><\/p>\n<\/td>\n<td width=\"95\">\n<p>69<\/p>\n<\/td>\n<td colspan=\"2\" width=\"95\">\n<p>64<\/p>\n<\/td>\n<td width=\"95\">\n<p>58<\/p>\n<\/td>\n<td colspan=\"2\" width=\"95\">\n<p>52<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"39\">&nbsp;<\/td>\n<td width=\"55\">&nbsp;<\/td>\n<td width=\"95\">&nbsp;<\/td>\n<td width=\"1\">&nbsp;<\/td>\n<td width=\"94\">&nbsp;<\/td>\n<td width=\"95\">&nbsp;<\/td>\n<td width=\"1\">&nbsp;<\/td>\n<td width=\"94\">&nbsp;<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Tekrarlayan gebelik kay\u0131plar\u0131; t\u00fcm kad\u0131nlar\u0131n %1-3\u2019\u00fcnde g\u00f6r\u00fcl\u00fcr.<\/p>\n<p><strong>TGK subtipleri:<\/strong><\/p>\n<p><strong>Primer TGK: <\/strong>Viabiliteye ula\u015fmam\u0131\u015f tekrarlayan gebelik kay\u0131plar\u0131.<\/p>\n<p><strong>Sekonder TGK: <\/strong>\u00d6nceden canl\u0131 do\u011fumu \u00f6yk\u00fcs\u00fc olan ve tekrarlayan gebelik kayb\u0131 olan kad\u0131nlar.<\/p>\n<p><strong>Tersiyer TGK: <\/strong>Multiple spontan d\u00fc\u015f\u00fckleri olup arada normal gebeli\u011fi olan kad\u0131nlar.<\/p>\n<p><strong>Etyoloji<\/strong><\/p>\n<p><strong>Genetik fakt\u00f6rler&nbsp;&nbsp; %5<\/strong><\/p>\n<p>Kromozomal<\/p>\n<p>Multifakt\u00f6ryel<\/p>\n<p><strong>&nbsp;<\/strong><strong>Anatomik<\/strong> <strong>fakt\u00f6rler<\/strong> <strong>%12<\/strong><\/p>\n<ol>\n<li><strong>Konjenital <\/strong><\/li>\n<li>\u0130nkomplet M\u00fcllerian f\u00fczyon veya septum<\/li>\n<\/ol>\n<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; reabsorbsiyonu<\/p>\n<ol>\n<li>Dietilstilbesterol maruziyeti<\/li>\n<li>Uterin arter anomalileri<\/li>\n<li>Servikal yetmezlik<\/li>\n<li><strong> Akkiz<\/strong><\/li>\n<li>Servikal yetmezlik<\/li>\n<li>Sine\u015fi<\/li>\n<li>Leiomyomlar<\/li>\n<li>Endometrisis, adenomyosis<\/li>\n<\/ol>\n<p><strong>Endokrin fakt\u00f6rler %17<\/strong><\/p>\n<ol>\n<li>Luteal faz yetmezli\u011fi<\/li>\n<li>Tiroid hastal\u0131klar\u0131<\/li>\n<li>Diabetes mellitus<\/li>\n<li>Prolaktin bozukluklar\u0131<\/li>\n<\/ol>\n<p><strong>Enfeksiy\u00f6z fakt\u00f6rler&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; %5<\/strong><\/p>\n<p><strong>\u0130mm\u00fcnolojik fakt\u00f6rler<\/strong><strong>&nbsp;&nbsp;&nbsp; <\/strong><strong>%50<\/strong><\/p>\n<ol>\n<li><strong> Humoral Mekanizmalar<\/strong><\/li>\n<li>Antifosfolipid antikorlar<\/li>\n<li>Antisperm antikorlar<\/li>\n<li>Antitrofoblast antikorlar<\/li>\n<li>Blokan antikor eksikli\u011fi<\/li>\n<li><strong> H\u00fccresel Mekanizmalar<\/strong><\/li>\n<li>Reprod\u00fcktif antijenlere TH1 selluler imm\u00fcn yan\u0131t (embryo\/trofoblast-toksik fakt\u00f6rler\/sitokinler)<\/li>\n<\/ol>\n<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; b.TH2 sitokin, growth fakt\u00f6r ve onkojen eksikli\u011fi<\/p>\n<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; c.Supres\u00f6r h\u00fccre ve fakt\u00f6r eksikli\u011fi<\/p>\n<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; d.Major histokompabilite antijen ekspresyonu<\/p>\n<p><strong><em>Di\u011fer fakt\u00f6rler&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <\/em><\/strong><\/p>\n<ol>\n<li>\u00c7evresel etkenler<\/li>\n<li>\u0130la\u00e7lar<\/li>\n<li>Plasental anomaliler<\/li>\n<li>Medikal Hastal\u0131klar<\/li>\n<\/ol>\n<p><strong>TGK\u2019lar\u0131n\u0131n varsay\u0131lan nedenlerinden sadece 3 tanesi geni\u015f \u00e7evrelerce kabul g\u00f6rm\u00fc\u015ft\u00fcr. <\/strong><\/p>\n<p>1) Parental kromozomal anomaliler<\/p>\n<p>2) Antifosfolipid antikor sendromu<\/p>\n<p>3) Uterin anomalilerin bir b\u00f6l\u00fcm\u00fc<\/p>\n<p><strong>Ku\u015fkulan\u0131lan fakat kan\u0131tlanmam\u0131\u015f di\u011fer nedenler ise<\/strong><\/p>\n<p>1) Alloimm\u00fcnite<\/p>\n<p>2) Endokrinopatiler<\/p>\n<p>3) \u00c7e\u015fitli infeksiyonlar<\/p>\n<p>4) \u00c7evresel toksinler<\/p>\n<p>Art\u0131k <strong>trombofililerin <\/strong>spontan d\u00fc\u015f\u00fckler de dahil olmak \u00fczre gebelik kayb\u0131 i\u00e7in \u00f6nemli bir risk art\u0131\u015f\u0131yla <strong>ili\u015fkili olmad\u0131\u011f\u0131<\/strong> g\u00f6z\u00fckmektedir.<\/p>\n<p>Gebelik kay\u0131plar\u0131n\u0131n zamanlamas\u0131 etyolojik sebep a\u00e7\u0131s\u0131ndan ipucu verebilir;<\/p>\n<ul>\n<li>otoimm\u00fcn hastal\u0131klar ve anatomik sorunlar daha \u00e7ok 2.trimester kay\u0131plar\u0131na neden olurken,<\/li>\n<li>genetik fakt\u00f6rler ve endokrin nedenler s\u0131kl\u0131kla embryonik (erken gebelik) kay\u0131pla sonu\u00e7lan\u0131r.<\/li>\n<li>\u0130diopatik TGK olan bireylerde d\u00fc\u015f\u00fckler ayn\u0131 gebelik haftalar\u0131nda meydana gelmektedir.<\/li>\n<\/ul>\n<p>TGK ile sporadik gebelik kay\u0131plar\u0131n bir\u00e7ok nedeni benzerlik g\u00f6stermesine kar\u015f\u0131n, g\u00f6rece s\u0131kl\u0131klar\u0131 iki kategori aras\u0131nda farkl\u0131l\u0131k g\u00f6stermektedir.<\/p>\n<p>\u00d6rne\u011fin; TGK\u2019daki ilk trimester kay\u0131plar\u0131nda genetic anomali bulunma s\u0131kl\u0131\u011f\u0131, sporadik kay\u0131plardan anlaml\u0131 oranda daha d\u00fc\u015f\u00fckt\u00fcr.<\/p>\n<p><strong>Genetik nedenler<\/strong><\/p>\n<ul>\n<li>TGK lar\u0131n\u0131n yanl\u0131zca %2-5\u2019ini olu\u015fturmaktad\u0131r.<\/li>\n<li><strong>Tetkik = <\/strong>Her iki ebeveynin karyotip de\u011ferlendirmesi gerekli olarak kabul edilmektedir.<\/li>\n<\/ul>\n<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Gebelik \u00fcr\u00fcn\u00fcn\u00fcn incelenmesi k\u0131s\u0131tl\u0131l\u0131klar\u0131 nedeniyle \u00f6nerilmiyor<\/p>\n<ul>\n<li><strong>Y\u00f6netim: <\/strong>Anormal karyotipli \u00e7iftlere IVF sonras\u0131 preimplantasyon genetic tan\u0131 y\u00f6ntemi uygulanabilir.<\/li>\n<\/ul>\n<p><strong>Parental Karyotipleme<\/strong><\/p>\n<p>Yap\u0131lm\u0131\u015f geni\u015f hasta serili bir \u00e7al\u0131\u015fmada TGK s\u0131 olan \u00e7iftlerin (8208 kad\u0131n ve 7834 erkek)&nbsp;<\/p>\n<ul>\n<li>%2.9\u2019unda kromozom anomalisi saptanm\u0131\u015ft\u0131r ve<\/li>\n<li>bu oran genel populasyonda g\u00f6r\u00fclen s\u0131kl\u0131ktan 5 kat fazlad\u0131r.<\/li>\n<\/ul>\n<p>Saptanan anomalilerin;<\/p>\n<ul>\n<li>%50\u2019sini dengeli resiprokal translokasyonlar<\/li>\n<li>%24\u2019\u00fcn\u00fc Robertsonian translokasyonlar<\/li>\n<li>%12\u2019sini 47,XXY (Klienfelter sendromu) gibi X kromozom mozaisizmi olu\u015fturmaktad\u0131r.<\/li>\n<\/ul>\n<p><strong>Gebelik \u00fcr\u00fcn\u00fcn\u00fcn incelenmesi<\/strong><\/p>\n<ul>\n<li>Rutin \u00f6nerilmiyor<\/li>\n<li>ard\u0131\u015f\u0131k d\u00fc\u015f\u00fckten sonra fetal dokunun kromozomal anomaliler a\u00e7\u0131s\u0131ndan incelenmesi baz\u0131 kaynaklar taraf\u0131ndan \u00f6nerilmektedir.<\/li>\n<li>Bunun nedeni;<\/li>\n<li>karyotip anomalisinin sporadik gebelik kayb\u0131n\u0131 d\u00fc\u015f\u00fcnd\u00fcrmesi ve dolay\u0131s\u0131yla sonraki gebelikte fetal kay\u0131p i\u00e7in artm\u0131\u015f bir risk \u00f6ng\u00f6rmemesidir. Buna kar\u015f\u0131n normal karyotipli d\u00fc\u015f\u00fck materyali farkl\u0131 nedenleri d\u00fc\u015f\u00fcnd\u00fcrerek erken inceleme gereklili\u011fini ortaya koyabilir.<\/li>\n<li>Rutin karyotiplemeye kar\u015f\u0131 \u00e7\u0131kanlar ise;<\/li>\n<li>1) y\u00fcksek maliyeti<\/li>\n<li>2) yan\u0131lt\u0131c\u0131 sonu\u00e7 olas\u0131l\u0131\u011f\u0131d\u0131r. Bu \u00f6zellikle anormal h\u00fccrelerin plasental mozaisizmi olan gebelikten elde edilmesi durumunda do\u011frudur. Bunun yan\u0131nda tespit edilen 46XX karyotipin maternal dokularla kontaminasyonu yans\u0131tabilir.<\/li>\n<li>Sonu\u00e7 olarak; gebelik \u00fcr\u00fcnlerinin karyotiplemesi tam olarak fetal karyotipi yans\u0131tmayabilir. Maliyeti ve sa\u011flad\u0131\u011f\u0131 bilginin k\u0131s\u0131tl\u0131 olmas\u0131 nedeniyle bu uygulama rutin olarak \u00f6nerilmemektedir.<\/li>\n<\/ul>\n<p><strong>Tedavi:<\/strong><\/p>\n<ul>\n<li>Anormal karyotipli \u00e7iftlere IVF sonras\u0131 preimplantasyon genetic tan\u0131 y\u00f6ntemi uygulanabilir.<\/li>\n<li>Translokasyon oldu\u011fu bilinen \u00e7iftlerle yap\u0131lm\u0131\u015f \u00e7al\u0131\u015fmada; PGT\u2019nin<\/li>\n<li>1) ba\u015far\u0131l\u0131 gebelik oran\u0131n\u0131 artt\u0131rd\u0131\u011f\u0131<\/li>\n<li>2) gebe kalma zaman\u0131n\u0131 k\u0131saltt\u0131\u011f\u0131 bulunmu\u015ftur. B\u00f6yle olsa bile dengeli translokasyonu olan \u00e7iftlerin prognozu herhangi bir giri\u015fim olmadan da genellikle iyidir.<\/li>\n<li>\u0130dyopatik (A\u00e7\u0131klanamayan) TGK olan \u00e7iftlere, karyotip normal olsa bile PGT incelemesini \u00f6neren g\u00f6r\u00fc\u015fler vard\u0131r.<\/li>\n<li>Bunun nedeni kontrol grubuyla kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda TGK \u00f6yk\u00fcs\u00fc olan kad\u0131nlar\u0131n embryolar\u0131nda daha y\u00fcksek oranda an\u00f6ploidi bulunmas\u0131d\u0131r.<\/li>\n<li>Ancak yap\u0131lm\u0131\u015f geni\u015f bir prospektif kohort \u00e7al\u0131\u015fman\u0131n sonu\u00e7lar\u0131 bu uygulamay\u0131 desteklememektedir.<\/li>\n<li>ASRM; kromozomal olarak normal \u00e7iftlere PGT\u2019yi \u00f6nermiyor.<\/li>\n<\/ul>\n<p><strong>Anatomik Fakt\u00f6rler<\/strong><\/p>\n<p>TGK olgular\u0131n\u0131n %15\u2019inde konjenital veya edinsel uterus anomalisi olabilmektedir.<\/p>\n<p><strong>Edinsel anomaliler: <\/strong><\/p>\n<p><strong>1) Uterin nedenler: <\/strong><\/p>\n<ul>\n<li>intrauterine sine\u015fi,<\/li>\n<li>leimyom (kaviteyi distorsiyonu yapan myomlar)<\/li>\n<li>endometrial polip gibi baz\u0131 edinsel uterin anomaliler gebelik kayb\u0131n\u0131 artt\u0131r\u0131rlar.<\/li>\n<\/ul>\n<p><strong>2) Servikal yetmezlik: <\/strong><\/p>\n<ul>\n<li>Yetersiz serviks ilk trimester gebelik kayb\u0131na neden olmayan fakat ikinci trimesterde artm\u0131\u015f gebelik kayb\u0131 riskine neden olmaktad\u0131r.<\/li>\n<li>Genellikle 16 ile 18.haftadan sonra a\u011fr\u0131s\u0131z servikal dilatasyonu takiben do\u011fumla kendini g\u00f6sterir<\/li>\n<\/ul>\n<p><strong>Konjenital Anomaliler<\/strong><\/p>\n<ul>\n<li>TGK\u2019i olan hastalar\u0131n yakla\u015f\u0131k %17sinde;<\/li>\n<li>infertil kad\u0131nlar\u0131n %7.3\u00fcnde ve<\/li>\n<li>genel populasyondaki kad\u0131nlar\u0131n %6.7sinde uterin anomali bulundu\u011fu sonucuna varm\u0131\u015flard\u0131r.<\/li>\n<\/ul>\n<table width=\"755\">\n<tbody>\n<tr>\n<td width=\"377\">\n<p><strong>Uterin anomali<\/strong><\/p>\n<\/td>\n<td width=\"377\">\n<p><strong>Spontan gebelik kayb\u0131 (1.ve 2.tr) %<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"377\">\n<p><strong>bikornis<\/strong><\/p>\n<\/td>\n<td width=\"377\">\n<p>40-70<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"377\">\n<p><strong>septum veya unikornis<\/strong><\/p>\n<\/td>\n<td width=\"377\">\n<p>35-85<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"377\">\n<p><strong>didelfis<\/strong><\/p>\n<\/td>\n<td width=\"377\">\n<p>40<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>TGK olgular\u0131nda uterin septum en s\u0131k g\u00f6r\u00fclen ve en k\u00f6t\u00fc prognostik sonu\u00e7lara sahip uterin anomalidir. Septum olan olgularda d\u00fc\u015f\u00fck riski %60\u2019a kadar artabilmektedir. Septumun kanlanmas\u0131n\u0131n azalmas\u0131 d\u00fc\u015f\u00fck implantasyonun olas\u0131 nedenidir.<\/p>\n<p>Yap\u0131lm\u0131\u015f \u00e7al\u0131\u015fmalarda uterin septumun histeroskopik rezeksiyonu ile TGKs\u0131 olan olgularda gebelik kayb\u0131n\u0131n anlaml\u0131 derecede azald\u0131\u011f\u0131 belirtilmi\u015ftir.<\/p>\n<p>Uterus bikornis; %40-70 oran\u0131nda 1. ve 2.tr gebelik kayb\u0131 g\u00f6r\u00fclmektedir. Baz\u0131 cerrahi prosed\u00fcrler tan\u0131mlanm\u0131\u015f olsa da etkinli\u011fi kan\u0131tlanmam\u0131\u015ft\u0131r.<\/p>\n<p><strong>Tan\u0131<\/strong><\/p>\n<p>Transvajinal 3D ultrasonografi, HSG ve MR tan\u0131da kullan\u0131lmaktad\u0131r.<\/p>\n<p><strong>Tedavi<\/strong><\/p>\n<ul>\n<li>Uterin septum rezeksiyonu<\/li>\n<li>Myomektomi<\/li>\n<li>Polipektomi<\/li>\n<\/ul>\n<p><strong>Endokrin Nedenler<\/strong><\/p>\n<p>TGK\u2019n\u0131n %8-12\u2019si endokrin fakt\u00f6rler sonucu olu\u015fur.<\/p>\n<p><strong>Nedenler;<\/strong><\/p>\n<ul>\n<li>Luteal faz defekti (LFD)<\/li>\n<li>PCOS<\/li>\n<li>Tiroid hastal\u0131klar\u0131<\/li>\n<li>DM<\/li>\n<\/ul>\n<p><strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; LFD<\/strong><\/p>\n<p>\u0130mplantasyon zaman\u0131nda endometriumun yetersiz geli\u015fimi LFD olarak adland\u0131r\u0131l\u0131r.<\/p>\n<p>Gebelik kayb\u0131n\u0131n bir nedeni olup olmad\u0131\u011f\u0131 tart\u0131\u015fmal\u0131d\u0131r.<\/p>\n<p>LFD, genellikle korpus luteumdan yetersiz progesterone sekresyonuna dayand\u0131r\u0131l\u0131r. Bu, normal folik\u00fclogenez ve luteal fonksiyonu \u00f6nleyen endokrin bozukluklar nedeniyle olabilir.<\/p>\n<p>Bu bozukluklar hiperprolaktinemi, tiroid bozukluklar\u0131 ve PCOS\u2019dur.<\/p>\n<p>LFD oldu\u011fu varsay\u0131ld\u0131\u011f\u0131nda tedavi,<\/p>\n<ul>\n<li>progesterone deste\u011fi,<\/li>\n<li>korpus luteum deste\u011fini artt\u0131rmak i\u00e7in hcg uygulamas\u0131 ya da<\/li>\n<li>ek korpus luteum olu\u015fturan CC gibi ovulasyon ind\u00fcksiyonu ila\u00e7lar\u0131ndan olu\u015fur.<\/li>\n<\/ul>\n<p>Yap\u0131lm\u0131\u015f bir derlemede erken gebeli\u011fin ortas\u0131na kadar verilen progesterone deste\u011finin gebelik kayb\u0131 riskini azaltmad\u0131\u011f\u0131 sonucuna varm\u0131\u015flard\u0131r.<\/p>\n<p>LFD i\u00e7in progesterone replasman\u0131 tart\u0131\u015fmal\u0131 olmas\u0131na ragmen; \u00f6rne\u011fin over t\u00fcm\u00f6r\u00fc i\u00e7in korpus luteumu \u00e7\u0131kar\u0131lan hastalarda 8-10.haftaya kadar progesterone kullan\u0131m\u0131 a\u00e7\u0131k\u00e7a endikedir.<\/p>\n<p><strong>Polikistik Over Sendromu (PKOS)<\/strong><\/p>\n<ul>\n<li>PKOS\u2019u olan kad\u0131nlar\u0131n genellikle gebelik kayb\u0131 i\u00e7in artm\u0131\u015f riske sahip olduklar\u0131 kabul edilir. Ancak bu ili\u015fki son zamanlarda sorgulanmaktad\u0131r.<\/li>\n<li>PCOSlu kad\u0131nlarda d\u00fc\u015f\u00fck riski %20-40 kadar y\u00fcksek olabilir.<\/li>\n<li>TGK olan kad\u0131nlarla yap\u0131lan bir \u00e7al\u0131\u015fmada tan\u0131 i\u00e7in Roterdam kriterleri kullan\u0131ld\u0131\u011f\u0131nda %8-10\u2019unda PKOS saptanm\u0131\u015ft\u0131r. PKOS\u2019un bu s\u0131kl\u0131\u011f\u0131 genel yeti\u015fkin kad\u0131n populasyonundakiyle benzerlik g\u00f6stermektedir.<\/li>\n<\/ul>\n<p>PKOS ve gebelik kayb\u0131 aras\u0131ndaki potansiyel ili\u015fkiyi a\u00e7\u0131klamak i\u00e7in bir\u00e7ok mekanizma \u00f6ne s\u00fcr\u00fclmektedir.<\/p>\n<p>Bu a\u00e7\u0131klamalar;<\/p>\n<ul>\n<li>Artm\u0131\u015f serum LH, androjenler veya insulin seviyelerinin over fonksiyonlar\u0131 \u00fczerindeki etkisi yer almaktad\u0131r.<\/li>\n<li>Endometrial LH resept\u00f6rlerinin bu LH y\u00fcksekli\u011fi nedeniyle a\u015f\u0131r\u0131 \u015fekilde uyar\u0131lmas\u0131 implantasyonu bozabilir.<\/li>\n<li>Kronik olarak artm\u0131\u015f LH d\u00fczeylerinin oosit geli\u015fimini k\u00f6t\u00fc y\u00f6nde etkileyebilece\u011fidir.<\/li>\n<li>Kabul edilen \u00fc\u00e7\u00fcnc\u00fc mekanizma; LH\u2019n\u0131n ba\u015flatt\u0131\u011f\u0131 folik\u00fcler atreziye ve k\u00f6t\u00fc oosit geli\u015fimine neden oldu\u011fu bilinen intraovaryen androjen d\u00fczeylerinin artmas\u0131d\u0131r.<\/li>\n<\/ul>\n<p><strong>PKOS tedavi<\/strong><\/p>\n<p>Hiperins\u00fclineminin gebelik kayb\u0131na etkisini g\u00f6steren bilgiler olduk\u00e7a g\u00fc\u00e7l\u00fcd\u00fcr.<\/p>\n<p>RCT \u00e7al\u0131\u015fmalarda metformin tedavisi ile gebelik kayb\u0131 riskinde d\u00fczelme bulunmam\u0131\u015ft\u0131r.<\/p>\n<p>G\u00fcn\u00fcm\u00fczde PCOS\u2019lu kad\u0131nlarda, \u00f6zellikle insulin direnci bulunmayanlarda sadece gebelik kayb\u0131n\u0131 tedavi etmek i\u00e7in rutin metformin tedavisi \u00f6nerilmemektedir.<\/p>\n<p><strong>Diabetes Mellitus<\/strong><\/p>\n<ul>\n<li>\u0130ns\u00fcline ba\u011fl\u0131 diabetes mellitusta, hem spontan gebelik kayb\u0131 hem de major konjenital anomali oranlar\u0131 artm\u0131\u015ft\u0131r.<\/li>\n<li>Bu riskler konsepsiyon s\u0131ras\u0131ndaki ve gebeli\u011fin erken d\u00f6nemindeki metabolic kontrol\u00fcn derecesiyle yak\u0131ndan ili\u015fkilidir.<\/li>\n<li>Vurgulanmas\u0131 gereken nokta ideal metabolik kontrol\u00fcn sa\u011flanmas\u0131 durumunda bu risklerin azalmas\u0131d\u0131r.<\/li>\n<li>Yap\u0131lm\u0131\u015f \u00e7al\u0131\u015fmalarda kontrol\u00fc \u00e7ok iyi olan kad\u0131nlardaki gebelik kayb\u0131 oranlar\u0131n\u0131n diabeti olmayan kad\u0131nlarla benzer oldu\u011funu g\u00f6zlemlemi\u015flerdir.<\/li>\n<\/ul>\n<p>TGK olgular\u0131nda; DM a\u00e7\u0131s\u0131ndan tarama<\/p>\n<ul>\n<li>kan glukoz ve<\/li>\n<li>HbA1c de\u011ferleri ile yap\u0131lmaktad\u0131r.<\/li>\n<\/ul>\n<p><strong>Kimleri tarayal\u0131m?<\/strong><\/p>\n<p>Bilinen veya hastal\u0131\u011f\u0131n klinik bulgular\u0131n\u0131 g\u00f6steren (polidipsi, poli\u00fcri, kilo kayb\u0131, halsizlik,ayaklarda uyu\u015fma, iye, mantar enfeksiyonu) olgular d\u0131\u015f\u0131nda rutin olarak \u00f6nerilmemektedir<\/p>\n<p><strong>&nbsp;<\/strong><\/p>\n<p><strong>Hipotiroidizm<\/strong><\/p>\n<ul>\n<li>Ciddi iyot yetersizli\u011fi veya a\u015fikar hipotiroidi subfertiliteye ve gebelik kayb\u0131 i\u00e7in risk art\u0131\u015f\u0131na neden olur; fakat subklinik hipotiroidinin etkisi net de\u011fildir.<\/li>\n<li>Ayr\u0131ca tiroid hormon yetersizli\u011finin TGK \u00fczerine etkisi ara\u015ft\u0131r\u0131lmam\u0131\u015ft\u0131r.<\/li>\n<li>Tiroid oto-ac pozitifli\u011fi olan olgularda (\u00f6tiroid olsa bile) artm\u0131\u015f fetal kay\u0131p bildirilmi\u015ftir (tart\u0131\u015fmal\u0131).<\/li>\n<\/ul>\n<p>Semptomatik kad\u0131nlarda tiroid fonksiyon testlerinin de\u011ferlendirilmesi gerekli olmas\u0131na ra\u011fmen, TGK olan t\u00fcm kad\u0131nlarda taranmas\u0131 tart\u0131\u015fmal\u0131d\u0131r.<\/p>\n<p>\u00d6yk\u00fcde tiroid hastal\u0131\u011f\u0131 olan veya tiroid disfonksiyon semptomlar\u0131 olan olgularda TFT bak\u0131lmal\u0131.<\/p>\n<p>Tedavi: A\u015fikar tiroid hastal\u0131\u011f\u0131 olanlarda tedavi verilmelidir.<\/p>\n<p><strong>Enfeksiy\u00f6z nedenler<\/strong><\/p>\n<ul>\n<li>Az say\u0131da enfeksiyon erken gebelik kayb\u0131 ile kesin ili\u015flidir. Infeksiyonlar\u0131n \u00e7o\u011funun sporadik olmas\u0131 veya koruyucu maternal antikorlar\u0131 uyarmas\u0131 nedeniyle TGK\u2019na neden olma olas\u0131l\u0131klar\u0131 daha da azd\u0131r.<\/li>\n<li>TGK\u2019a sebep oldu\u011fu kan\u0131tlanm\u0131\u015f enfeksiy\u00f6z ajan bulunmamaktad\u0131r<\/li>\n<li>Asemptomatik kad\u0131nlarda infeksiyon i\u00e7in rutin tarama yap\u0131lmas\u0131 ve ampirik antibyotik tedavisi \u00f6nerilmemektedir.<\/li>\n<li>\u0130nceleme; klinik servisit, kronik veya tekrarlayan bakteriyel vajinozis olgular\u0131yla s\u0131n\u0131rland\u0131r\u0131lmal\u0131d\u0131r.<\/li>\n<\/ul>\n<p><strong>\u0130mm\u00fcnolojik nedenler<\/strong><\/p>\n<p>TGK\u2019\u0131 olan olgular\u0131n %20\u2019sinde neden olarak kar\u015f\u0131m\u0131za \u00e7\u0131kmaktad\u0131r.<\/p>\n<p>1) Alloimm\u00fcn nedenler<\/p>\n<p>2) Otoimm\u00fcn nedenler<\/p>\n<p>\u0130mm\u00fcnolojik sistem;<\/p>\n<ul>\n<li>Komplike bir sistemdir.<\/li>\n<li>Hastal\u0131klara kar\u015f\u0131 ilk devreye giren sistemdir.<\/li>\n<li>\u0130mm\u00fcn sistem proteinleri normal veya yabanc\u0131 olarak alg\u0131lar.<\/li>\n<li>Yabanc\u0131 bir proteine kar\u015f\u0131 verilen imm\u00fcn yan\u0131t antijenin n\u00f6tralize edilmesi veya tahrip edilmesidir.<\/li>\n<\/ul>\n<p><strong>Alloimm\u00fcn bozukluklar<\/strong><\/p>\n<p>Teorik olarak normal gebelik;<\/p>\n<p><strong>embryonik dokulardaki Paternal orjinli antijenelere kar\u015f\u0131; <\/strong>maternal imm\u00fcnolojik tan\u0131ma ve yan\u0131t (s\u0131zl\u0131k) gerektirir.<\/p>\n<p>\u0130leri s\u00fcr\u00fclen mekanizmalar;<\/p>\n<ul>\n<li>Maternal antipaternal lenfositotoksik a.c \u00fcretimi<\/li>\n<li>Maternal h\u00fccresel imm\u00fcn yan\u0131t\u0131 \u00f6nleyen; bloke edici antikorlar\u0131n yetersizli\u011fi<\/li>\n<li>Anne baba aras\u0131ndaki maj\u00f6r histokompatibilite kompleks insan l\u00f6kosit antijenlerin artm\u0131\u015f benzerli\u011fi paternal kaynakl\u0131 fetal antijenlerin anne taraf\u0131ndan tan\u0131nmas\u0131n\u0131 engellemekte ve yetersiz baz\u0131 bloke edici a.c \u00fcretimine neden olmaktad\u0131r.<\/li>\n<li>HLA-G; NK h\u00fccre resept\u00f6rlerine ba\u011flan\u0131r ve NK h\u00fccre aktivitesini engeller. (HLA-G seviyesinde azalma)<\/li>\n<\/ul>\n<p>Maternal fetal aray\u00fczdeki lokal imm\u00fcn fakt\u00f6rlerdeki d\u00fczensizlik (sitokin reg\u00fclasyon bozuklu\u011fu<\/p>\n<ul>\n<li>Desiduada artm\u0131\u015f NK h\u00fccreler<\/li>\n<li>Th lenfositleri i\u00e7eren antijenik imm\u00fcn yan\u0131t\u0131n iki temel \u00e7e\u015fidi vard\u0131r.<\/li>\n<li>Normal gebelikte Th2\/Th1 oran\u0131 bask\u0131nd\u0131r; TGK olgularda tam tersi<\/li>\n<\/ul>\n<p><strong>Tan\u0131=<\/strong> Problemli<\/p>\n<p><strong>Tedavi=<\/strong>tan\u0131mlanm\u0131\u015f tedavilerin etkinlikleri g\u00f6sterilememi\u015ftir.<\/p>\n<p><strong>Otoimm\u00fcn nedenler<\/strong><\/p>\n<p>Antifosfolipid antikor sendromu<\/p>\n<p>Antifposfolipid antikorlar<\/p>\n<ul>\n<li>Lupus antikoag\u00fclan\u0131<\/li>\n<li>Antikardiyolipin antikorlar\u0131<\/li>\n<li>Anti-\u03b22 glycoprotein I antikorlar\u0131<\/li>\n<\/ul>\n<p>APA;<\/p>\n<ul>\n<li>Uteroplasental damarlarda tromboz, daha sonra plasental enfarkt gebelik kayb\u0131na yol a\u00e7ar.<\/li>\n<li>APA\u2019lar trombozdan ba\u011f\u0131ms\u0131z olarak trofoblast fonksiyonunu bozarlar.<\/li>\n<\/ul>\n<p>Antifosfolipid antikor sendromu tan\u0131 kriterleri<\/p>\n<p><strong>Laborat<\/strong><strong>uar bulgular\u0131<\/strong><\/p>\n<ul>\n<li>Anti-cardiolipin (aCL) antikorlar: IgG veya IgM, 2 kez veya&nbsp; daha fazla, en az 12 hafta aral\u0131klarla orta veya \u00fcst derece y\u00fcksek seviyelerinin \u00f6l\u00e7\u00fcm\u00fc<\/li>\n<li>Lupus anticoagulant (LA) antikorlar: 2 kez veya daha fazla, en az 12 hafta aral\u0131klarla<\/li>\n<li>Anti-\u03b22 glycoprotein I (IgG or M) 2 kez veya daha fazla, en az 12 hafta aral\u0131klarla<\/li>\n<\/ul>\n<p><strong>Klinik<\/strong> <strong>bulgular<\/strong><\/p>\n<ul>\n<li>Vask\u00fcler tromboz <em>veya<\/em><\/li>\n<li>Fetus kayb\u0131 10. veya 10. haftadan sonra <em>veya<\/em><\/li>\n<li>34 hafta veya \u00f6ncesinde erken do\u011fum eklampsi\/preeklampsi nedeniyle <em>veya<\/em><\/li>\n<li>10 haftadan \u00f6nce 3 veya daha fazla gebelik kayb\u0131<\/li>\n<\/ul>\n<p>APAS olan olgularda gebelikte kar\u015f\u0131la\u015f\u0131lan problemler<\/p>\n<ul>\n<li>Spontan gebelik kayb\u0131<\/li>\n<li>TGK (%5-20 sinde)<\/li>\n<li>Vask\u00fcler tromboz (arteriel-ven\u00f6z)<\/li>\n<li>PE (risk 5-8 kat artmaktad\u0131r)<\/li>\n<li>IUGR ( APAS olgular\u0131n\u0131n %15-30\u2019unda)<\/li>\n<\/ul>\n<p>APAS a\u00e7\u0131s\u0131ndan kimleri tarayal\u0131m?<\/p>\n<ul>\n<li>A\u00e7\u0131klanamayan arteryel veya ven\u00f6z tromboz \u00f6yk\u00fcs\u00fc olan olagular<\/li>\n<li>Gebelik boyunca yeni olu\u015fan arteriel veya ven\u00f6z tromboz<\/li>\n<li>\u00f6nceden testleri yap\u0131lmam\u0131\u015f VTE \u00f6yk\u00fcs olan olgular<\/li>\n<li>Bir fetal kay\u0131p veya &gt;= 3 rek\u00fcrren embryonik veya fetal kay\u0131p<\/li>\n<\/ul>\n<p>APAS tedavisi;<\/p>\n<p>TGK olgular\u0131nda APAS saptand\u0131\u011f\u0131nda tedavide ama\u00e7;<\/p>\n<p>1) gebelik kayb\u0131n\u0131 \u00f6nlemek<\/p>\n<p>2) gebelikte tromboz geli\u015fimini \u00f6nlemek<\/p>\n<p>APAS\u2019\u0131 olup TGK veya sporadik fetal kay\u0131p \u00f6yk\u00fcs\u00fc olan olgularda Profilaktik doz heparin ve aspirin tedavisi gebelik kayb\u0131n\u0131 %50 oran\u0131nda azalt\u0131r.<\/p>\n<p>TGK veya sporadik fetal kay\u0131p \u00f6yk\u00fcs\u00fc yok sadece APAS\u2019\u0131 olan gebelerde tromboz i\u00e7in sadece heparin profilaksisi kullan\u0131lmal\u0131d\u0131r.<\/p>\n<p><strong>Di\u011fer Fakt\u00f6rler<\/strong><\/p>\n<p>\u00c7evresel Fakt\u00f6rler:<\/p>\n<p>bir \u00e7ok ba\u011f\u0131ms\u0131z de\u011fi\u015fken oldu\u011fundan yorum yapmak zordur.<\/p>\n<p>Radyasyon\/Antineoplastik Ajanlar:<\/p>\n<p>Tan\u0131sal ama\u00e7l\u0131 X-ray fetal demise <u>yapmaz<\/u>. Methotrexate\u2019in trofoblastlara affinitesi vard\u0131r.<\/p>\n<p>Sigara\/Alkol: SA riskini art\u0131r\u0131r (?). G\u00fcnde 1 paket sigara i\u00e7en ve 1 duble alkol alan kad\u0131nlarda SA riski 4 kat fazla bulunmu\u015ftur.<\/p>\n<p><\/p>\n<p>Kimyasal Maruziyetler: Anestezik gazlar, arsenik, anilin, benzen, etilen oksit, formaldehid, tetrakloroetilen ve kur\u015fun SA riskini art\u0131r\u0131r. Kemoterap\u00f6tik ajanlar\u0131 haz\u0131rlayan hem\u015firelerde de SA riski fazlad\u0131r.<\/p>\n<p>Doktorlar, anestezistler, lab \u00e7al\u0131\u015fanlar\u0131, ila\u00e7 end\u00fcstrisi i\u015f\u00e7ilerinde SA riski y\u00fcksek bulunmam\u0131\u015ft\u0131r.<\/p>\n<p><strong>A\u00e7\u0131klanamayan TGK<\/strong><\/p>\n<p>TGK\u2019I olan (en az 2 gebelik kayb\u0131)<\/p>\n<p>normal karyotip,<\/p>\n<p>pelvik sonografi ile g\u00f6r\u00fcnt\u00fclenebilen uterin malformasyonu olmayan,<\/p>\n<p>antifosfolipid antikoru negatif olan ve<\/p>\n<p>Endokrinolojik olrak patoloji saptamnamayan olgular olarak tan\u0131mlanmaktad\u0131r.<\/p>\n<p>Bu olgularda ampirik tedavilerin (heparin, aspirin) faydal\u0131 etkileri g\u00f6sterilememi\u015ftir.<\/p>\n<p>\u0130zlemde;<\/p>\n<ul>\n<li>Emosyonel destek \u00e7ok \u00f6nemlidir.<\/li>\n<li>\u0130lk trimester boyunca haftal\u0131k muayene ve USG ile gebeli\u011fin normal seyretti\u011fi hastaya g\u00fcven kazand\u0131r\u0131r, ektopik gebeli\u011fi ekarte (risk 4 kat fazlad\u0131r) ettirir.<\/li>\n<li>USG ile FKA saptand\u0131\u011f\u0131nda SA riski %3-5\u2019e d\u00fc\u015fer.<\/li>\n<li>\u00d6nceki gebeliklerde SA\u2019un olu\u015ftu\u011fu hafta geride b\u0131rak\u0131ld\u0131\u011f\u0131nda risk olduk\u00e7a azal\u0131r.<\/li>\n<li>Gebelik haftas\u0131ndan sonra rutin obstetrik bak\u0131m verilir.<\/li>\n<\/ul>\n<p><\/p>\n<p><strong>&nbsp;<\/strong><\/p>\n<p><\/p>\n<p><strong>&nbsp;<\/strong><\/p>\n<p><\/p>\n<p><\/p>\n<p><\/p>\n<p><\/p>\n<p><strong>&nbsp;<\/strong><\/p>\n<p><\/p>\n<p><strong>&nbsp;<\/strong><\/p>\n<p><\/p>\n<p><\/p>\n<p><\/p>\n<p><strong>&nbsp;<\/strong><\/p>\n<p><\/p>\n<p><\/p>\n<p><\/p>\n<p><\/p>\n<p><strong>&nbsp;<\/strong><\/p>\n<p><\/p>\n<p><\/p>\n<p><strong>&nbsp;<\/strong><\/p>\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>TEKRARLAYAN GEBEL\u0130K KAYIPLARI Tekrarlayan gebelik kay\u0131plar\u0131n\u0131n tan\u0131m\u0131nda farkl\u0131 kriterler ve tan\u0131mlamalar kullan\u0131lmaktad\u0131r. Genel olarak kabul edilen tan\u0131mlama; 20. gebelik haftas\u0131ndan \u00f6nce klinik olarak tan\u0131 konmu\u015f 3 veya daha fazla ard\u0131\u015f\u0131k gebelik kayb\u0131 iken ASRM\u2019nin yapm\u0131\u015f oldu\u011fu tan\u0131mlama ise&nbsp; ultrasonografi veya histopatoloji ile tan\u0131 konmu\u015f 2 veya daha fazla klinik gebeli\u011fin kayb\u0131d\u0131r. Gebelik kay\u0131plar\u0131n\u0131n \u00e7o\u011fu farkedilmemektedir. [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":1010,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[34],"tags":[],"class_list":["post-653","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-gebelik"],"_links":{"self":[{"href":"https:\/\/drozkanozdamar.com\/index.php?rest_route=\/wp\/v2\/posts\/653","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drozkanozdamar.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/drozkanozdamar.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/drozkanozdamar.com\/index.php?rest_route=\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/drozkanozdamar.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=653"}],"version-history":[{"count":5,"href":"https:\/\/drozkanozdamar.com\/index.php?rest_route=\/wp\/v2\/posts\/653\/revisions"}],"predecessor-version":[{"id":1024,"href":"https:\/\/drozkanozdamar.com\/index.php?rest_route=\/wp\/v2\/posts\/653\/revisions\/1024"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/drozkanozdamar.com\/index.php?rest_route=\/wp\/v2\/media\/1010"}],"wp:attachment":[{"href":"https:\/\/drozkanozdamar.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=653"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/drozkanozdamar.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=653"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/drozkanozdamar.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=653"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}