PH: Preeklampsi-hellp, EH: Eklampsi-hellp, I:Enfeksiyon, K: Kanama, P:preeklampsi, TTP: Trombotik trombositopenik purpura, AFLP: gebeli in ya l karaci eri
5. TARTI MA
Böbrek yetmezli i gebeli in yüksek morbidite ve mortaliteyle sonuçlanan ciddi komplikasyonlar ndan biridir. Obstetrik dönemde gebelerde görülen ba l ca ABY nedenleri; preeklampsi, eklampsi, HELLP sendromu, sepsis, kanamalar (antepartum, postpartum) ve nadirde olsa obstürüksiyon, AFLP, TTP/HÜS tür. ABY nin etyolojisi belirgin bir ekilde geli mi ve geli mekte olan ülkelerde farkl l k arzetmektedir. Bu durum çevresel ve sosyoekonomik yap ile s k bir ili ki içindedir (7). Yakla k olarak bütün gebeliklerin % 2-8 inde preeklampsi geli mektedir (35). Preklampsili ve
eklampsili hastalardaki HELLP sendromu insidans %19,3 tür (36) . Obstetrik ABY li hastalar n %36-50 sinden preeklampsinin a r bir formu olarakta kabul edilen HELLP sendromu sorumlu tutulmaktad r (92,93). Çal mam zdaki ABY li hastalar n
%62 sinden preklampsi-hellp in sorumlu oldu u görülmektedir. Geli mi ülkelerde obstetrik nedenli ABY nin tüm A
gerileme Türkiye nin kürtajla ilgili liberal politikalar , sosyo-ekonomik artlar n düzelmesi ve bu vakalar n erken tespit edilmesine atfedilmektedir (6,7). Çal mam zda septik abortusa veya enfeksiyona ba l ABY s kl %18 olarak bulundu. Bu oran n yüksekli ini biz hastalar m z n sosyo-ekonomik düzeyi, çevresel artlar ve halen hastalar m z n ço unun do umlar n sa l k kurumlar d nda yap lmas na ba l yoruz.
Uta ve arkada lar n n (7) 1983 1990 ve 1991-1997 y llar aras ndaki ABY olgular n n n s kl n ve demografik özelliklerini inceleyen bir çal mas nda her iki dönemdeki obstetrik nedenli ABY olgular total olarak incelendi inde ise etyolojik nedenler ve oranlar s ras yla; Eklampsi-HELLP %%65.7, Postpartum hemoraji %14.3, septik abortus %11,4, postpartum ABY %8,6 olarak bulunmu tur. Bu çal madaki Eklampsi ve HELLP olgular n n oran (%65,7) bizim çal mam zdaki Preeklampsi- Eklampsi-HELLP olgular n n oran ile ( %68) benzer bir sonuçtur. Gül ve arkada lar n n yapt bir çal mada 31 ki ilik gebeli e ba l ABY olgular nda HELLP sendromunun %64,5 inden sorumlu oldu unu bulmu lard r (96). Selçuk ve arkada lar n n 1989-1999 y llar aras nda gebeli e ba l ABY geli en 39 hastal k serisinde etyolojik hastal klar s ras yla; HELLP sendromu %36, post partum kanama %26, preklampsi/Eklampsi %15, Ablasyo plasenta % 10 olarak saptanm t r. Bu çal madada görülmektedirki vakalar n yar s (%51) Preklampsi/HELLP-eklampsi olgular d r (94). Prakash ve arkada lar n n Hindistandaki çal mas nda; 1982-1991 y llar aras nda preeklampsi-eklampsi obstetrik ABY olgular n n %23 ünden ve sepsis %9,23 ünden sorumlu iken, 1992-2002 y llar aras nda ise preeklampsi-eklampsi %14,4 ünden ve sepsis ise % 8 inden sorumlu bulunmu tur. Her iki periyota postpartum nedenler %61,5 ve %72 ile ilk s rada yer alm t r (95). Sibai ve arkada lar n n yapt bir çal mada ise 1977 1989 y llar aras nda geli en 31 ki ilik ABY olgular n n 18 inden (%58) preeklampsi-eklampsi sorumlu bulunmu tur (31). Kennedy ve arkada lar n n yapt çal mada ise gebeli e ba l 62 olguluk ABY nin 20 sini ( %32) preklampsi-eklampsi olgular olu turmaktad r (97). Çal mam zdaki 50 ABY li olgunun etyolojik nedenleri incelendi inde %50 sinden Preeklampsi-HELLP, %12 sini Eklampsi-HELLP, %6 s n pure Preeklampsi, %18 nfeksiyon, %6 s n kanamalar ve %8 ini di er nedenler (AFLP, TTP) olu turmaktad r. Olgular m zda dikkat çeken bir özellik ayn klinik tablonun de i ik varyantlar olan ve neredeyse iç içe geçmi Preeklampsi-Eklampsi-HELLP olgular n n vakalar n %68 ini olu turmas d r.
Preeklampsi ve HELLP sendromuna ba l olarak geli en ABY olgular n n takipi kritik bir öneme sahiptir çünkü literatürde %1,1- %23 ve %12-34 gibi de i ik maternal mortalite oranlar bildirilmektedir. Tüm etyolojik nedenler hesaba kat ld nda ise gebeli e ba l ABY olgular nda maternal mortalite oran %8,3 32 kadard r..
(4,28,93,98,99). ABY olgular m z n 6 s nda (%12) anne ölümü oldu. Bunlardan 3 ü
Eklampsi-hellp, ikisi sepsis, biri AFLP tan s alan olgulard ve ölüm nedenleri; intraserebral hemoraji, D C, solunum yetmezli i ve multi organ yetmezli i idi. Sibai ve arkada lar n n çal mas nda ise ölen üç (%9,6) hastan n ikisi eklampsi di eri ise kronik hipertansiyon zemininde geli en preklampsi hastas idi, ölüm nedenleri olarak pumoner emboli, serebral hemoraji ve ARDS tespit edilmi ti (31). Selçuk ve arkada lar n n çal mas nda ise ölen dört (%10) hastan n biri HELLP sendromu di er üçü ise eklampsi, postpartum hemoraji hastalar idi, ölüm nedenleri olarak serebral hemoraji, serebral emboli, D C ve ARDS olarak belirtilmi ti ayr ca perinatal mortalite oran %28 olarak saptanm t . (93). Daha önceki yap lan çal malarda perinatal mortalite oran ise %28 - 55 dolaylar ndad r (92,93,100). Çal mam zdaki oran % 44 olarak bulunmu tur. Maternal ve perinatal mortalite oran m z literatürle uyumlu bulunmu tur.
Çal mam zdaki ABY li olgular m z n % 26 s (hipervolemi, hiperpotasemi, asit-baz düzensizlikleri, üremik koma gibi nedenlerden dolay ) hemodialize al nm t r. Gül ve arkada lar n n yapt çal mada %35, Selçuk ve arkada lar n n çal malar nda ise hastalar n %66 s na dializ tedavisi uygulanm t r. Daha önceki çal malarda bu oran % 10-66.6 civar nda olup dializ endikasyonlar benzerlik göstermektedir
(28,40,93,97,100).
Literatürde gebeli e ba l ABY olgular nda kal c böbrek hasar oran %3-17 olarak görünmektedir (28,40,93,99). ki ayr çal mada ise ortalama 3-4 y ll k takiplerde KBY saptanmam (31,93). Çal mam z n amaçlar ndan biri obstetrik nedenli ABY olgular m z n üçer ayl k periyotlarla böbrek fonksiyonlar ndaki de i ikliklerin takibi ile irreversible böbrek fonksiyon kayb oran n bulmakt . Hastalar m z n % 8 inde KBY geli mekte olup bunlar n üçü orta derecede KBH biri ise SDBY kabul edilip Hemodializ program na al nm t . Sonuçlar m z genel literatürle benzerdir (28,40,93,99).
Preeklampsi ve eklampsili kad nlarda ablasyo plasenta, trombositopeni, D C, pulmoner ödem ve aspirasyon pnömonisi gibi a r komplikasyonlar n riski 3 -25 kat
artmaktad r. Ayr ca bu hastalarda mekanik ventilasyon ve kan transfüzyonu daha fazla s kl kta yap lmaktad r. Ölü do um riskide normal gebelik geçiren kad nlara oranla 5 kat artmaktad r (101). Çal mam zda 50 hastam z n 29 sinde ( %58) çe itli komplikasyonlar geli ti. Bu komplikasyonlar ve s kl klar s ras yla; ablasyo plasenta %22, solunum yetmezli i %18, D C %10, intra serebral hemoraji %4, koroner disseksiyon %2, Delirium %2. Ayr ca hastalar m z n % 72 sinde kan ve kan ürünleri (eritrosit süspansiyonu, trombosit, taze donmu plazma, albümin) transfüzyonu yap ld . Hastalar n %18 i mekanik ventilasyona ba land . Gül ve arkada lar n n yapt çal mada komplikasyonlar ve s kl s ras yla ablasyo plasenta % 40,7, D C %10, pulmoner ödem %10 olarak bulunmu tur. (96). Sibai ve arkada lar n n yapm oldu u çal mada ise komplikasyonlar ve oranlar s ras yla ablasyo plasenta %51, pulmoner ödem %60, serebral ödem %12, malign hipertansiyon %35 ve D C %77 olarak bildirilmi tir (31). Çal mam zdaki iki hastam zda geli en delirium ve koroner arter disseksiyonu gibi maternal komplikasyonlar n daha önceki çal malardaki maternal komplikasyonlar gözden geçirildi inde ilk oldu u söylenebilmektedir.
Hastalar m z n %28 primipar ve %72 si ise multipar d ve ortalama gebelik haftas ise 32,7 ± 6,4 ve maternal ya ortalamas 32,4 ± 5,7 y l idi. Drakeley ve arkada lar n n 72 obstetrik ABY li hastalar ndaki hastalar n %43 ü primipar, % 57 si multipar ve gebelik haftas ortalamas ortalama 32 hafta kreatinin ortalamas ise 3,85 mg/dL olarak bulunmu tur (92). Sibai ve arkada lar n n 31 hastal k serisinde hastalar n %38 i primipar, %62 si multipar maternal ya ortalamas 23,5 ±5,7 y l, serum kreatinin ortalams 8±3,6, gebelik haftas ortalams 33,1±5,9 hafta olarak bulunmu tu (31). Oranlar büyük oranda benzelik ta makla birlikte çal mam zdaki multiparlar n oran n n yüksekli i dikkat çekicidir.
Sonuç olarak hasta populasyonumuzda obstetrik nedenli ABY gerek maternal gerekse fetal mortalite ve morbidite oranlar dikkate al nd nda önemini korumaktad r. Dolay s yla hasta populasyonumuzun sosyo-ekonomik düzeyi ve hastalar n kültürel düzeyi dikkate al narak koruyucu hekimlik hizmetlerinin art r lmas , tam donan ml prenatal-antenatal bak m ünitelerinin say s n n art r lmas gerekmektedir. Ayr ca kad n do um klinikleri ve hastanelerinde böbrek fonksiyonlar aç s ndan riskli hastalar n nefroloji, reaminasyon ve pediatri uzmanlar i birli iyle takip edilmesi gereklidir.
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