Ectopic Pregnancy
Özet
Ectopic pregnancy remains a significant cause of maternal morbidity and mortality, representing approximately 2% of all pregnancies. This condition occurs when a fertilized ovum implants outside the uterine cavity, most frequently within the fallopian tubes. Its clinical manifestations are highly variable, often complicating timely diagnosis. Classical symptoms, including abdominal pain, vaginal bleeding, and amenorrhea, occur inconsistently, emphasizing the necessity of a high index of clinical suspicion. Recent advances in molecular biology have elucidated the underlying mechanisms, highlighting the roles of microRNAs, integrins, and cadherins in aberrant implantation processes. Diagnostic strategies primarily involve serial serum β-human chorionic gonadotropin (β-hCG) assessments and transvaginal ultrasonography, which significantly enhance detection accuracy. Treatment modalities include expectant, medical, and surgical management, tailored according to patient stability, ectopic location, and reproductive desires. Methotrexate remains the cornerstone of medical therapy, while minimally invasive laparoscopic procedures dominate surgical approaches. This comprehensive review provides a detailed analysis of ectopic pregnancy, covering epidemiology, pathophysiology, clinical presentation, advanced diagnostics, and contemporary management strategies.
Ektopik gebelik, maternal morbidite ve mortalitenin önemli nedenlerinden biri olup tüm gebeliklerin yaklaşık %2’sinde görülmektedir. Fertilize ovumun uterus dışına, çoğunlukla fallop tüplerine yerleşmesi ile meydana gelir. Klinik bulguları oldukça değişken olup, klasik semptomlar arasında karın ağrısı, vajinal kanama ve adet gecikmesi bulunmakla birlikte, bu belirtiler sıklıkla atipik biçimde ortaya çıkar ve tanıda gecikmelere yol açabilir. Bu nedenle yüksek klinik şüphe ve dikkatli değerlendirme gerektirir. Son yıllarda moleküler biyolojideki gelişmeler, mikroRNA’lar, integrinler ve kadherinlerin implantasyon sürecindeki anormal rolüne dair yeni bilgiler sunmaktadır. Tanıda temel olarak seri serum β-human koryonik gonadotropin (β-hCG) ölçümleri ve transvajinal ultrasonografi kullanılmakta olup, tanı doğruluğunu önemli ölçüde artırmaktadır. Tedavi seçenekleri hastanın klinik durumu, gebeliğin yerleşim yeri ve fertilite beklentisine göre belirlenmekte olup izlem, medikal ve cerrahi yaklaşımları içermektedir. Medikal tedavinin temelini metotreksat oluştururken, cerrahide minimal invaziv laparoskopik yöntemler tercih edilmektedir. Bu derleme, ektopik gebeliğin epidemiyoloji, patofizyoloji, klinik tablo, ileri tanı yöntemleri ve güncel tedavi yaklaşımlarını ayrıntılı olarak incelemektedir.
Referanslar
Parashi S, Moukhah S, Ashrafi M. Main risk factors for ectopic pregnancy: a case-control study in a sample of Iranian women. International journal of fertility & sterility. 2014;8(2):147.
Barnhart KT. Clinical practice. Ectopic pregnancy. The New England journal of medicine. 2009;361(4):379-87.
Shaw JL, Dey SK, Critchley HO, Horne AW. Current knowledge of the aetiology of human tubal ectopic pregnancy. Human reproduction update. 2010;16(4):432-44.
Shaw J, Dey S, Critchley H, Horne A. Current knowledge of the aetiology of human tubal ectopic pregnancy. Human reproduction update. 2010;16(4):432-44.
Gariepy AM, Lewis C, Zuckerman D, Tancredi DJ, Murphy E, McDonald-Mosley R, et al. Comparative effectiveness of hysteroscopic and laparoscopic sterilization for women: a retrospective cohort study. Fertility and Sterility. 2022;117(6):1322-31.
Bouyer J, Coste J, Fernandez H, Pouly J-L, Job-Spira N. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Human reproduction. 2002;17(12):3224-30.
Haggerty CL, Gottlieb SL, Taylor BD, Low N, Xu F, Ness RB. Risk of sequelae after Chlamydia trachomatis genital infection in women. The Journal of infectious diseases. 2010;201(Supplement_2):S134-S55.
Perkins KM, Boulet SL, Kissin DM, Jamieson DJ, Group NAS. Risk of ectopic pregnancy associated with assisted reproductive technology in the United States, 2001–2011. Obstetrics & Gynecology. 2015;125(1):70-8.
Johnson NP, Hummelshoj L, Consortium WESM, Abrao M, Adamson G, Allaire C, et al. Consensus on current management of endometriosis. Human reproduction. 2013;28(6):1552-68.
Obstetricians ACo, Gynecologists. ACOG Practice Bulletin No. 193: tubal ectopic pregnancy. Obstetrics and gynecology. 2018;131(3):e91-e103.
Mol BW, Ankum WM, Bossuyt PM, Van der Veen F. Contraception and the risk of ectopic pregnancy: a meta-analysis. Contraception. 1995;52(6):337-41.
Bouyer J, Coste J, Shojaei T, Pouly J-L, Fernandez H, Gerbaud L, et al. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France. American journal of epidemiology. 2003;157(3):185-94.
Barnhart KT, Sammel MD, Gracia CR, Chittams J, Hummel AC, Shaunik A. Risk factors for ectopic pregnancy in women with symptomatic first-trimester pregnancies. Fertility and sterility. 2006;86(1):36-43.
Bouyer J, Coste J, Fernandez H, Pouly JL, Job-Spira N. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Human reproduction (Oxford, England). 2002;17(12):3224-30.
Schreiber CA, Sonalkar S. Tubal Ectopic Pregnancy. New England Journal of Medicine. 2025;392(8):798-805.
Alalade AO, Smith FJE, Kendall CE, Odejinmi F. Evidence-based management of non-tubal ectopic pregnancies. Journal of Obstetrics and Gynaecology. 2017;37(8):982-91.
Ghafouri-Fard S, Shoorei H, Taheri M. The role of microRNAs in ectopic pregnancy: a concise review. Non-coding RNA Research. 2020;5(2):67-70.
Maccani MA, Padbury JF, Marsit CJ. miR-16 and miR-21 expression in the placenta is associated with fetal growth. PLoS One. 2011;6(6):e21210.
Inan S, Giray G, Vatansever HS, Ozbilgin K, Kuscu NK, Sayhan S. Immunolocalization of integrins and fibronectin in tubal pregnancy. Acta histochemica. 2004;106(3):235-43.
Worley KC, Hnat MD, Cunningham FG. Advanced extrauterine pregnancy: diagnostic and therapeutic challenges. Am J Obstet Gynecol. 2008;198(3):297.e1-7.
Goyaux N, Leke R, Keita N, Thonneau P. Ectopic pregnancy in African developing countries. Acta obstetricia et gynecologica Scandinavica. 2003;82(4):305-12.
Kirk E, Condous G, Haider Z, Syed A, Ojha K, Bourne T. The conservative management of cervical ectopic pregnancies. Ultrasound in Obstetrics and Gynecology: The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology. 2006;27(4):430-7.
Pisarska MD, Carson SA, Buster JE. Ectopic pregnancy. Lancet (London, England). 1998;351(9109):1115-20.
Silver RM. Abnormal placentation: placenta previa, vasa previa, and placenta accreta. Obstetrics & Gynecology. 2015;126(3):654-68.
Condous G, Okaro E, Bourne T. The conservative management of early pregnancy complications: a review of the literature. Ultrasound in Obstetrics and Gynecology: The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology. 2003;22(4):420-30.
Kirk E, Papageorghiou AT, Condous G, Tan L, Bora S, Bourne T. The diagnostic effectiveness of an initial transvaginal scan in detecting ectopic pregnancy. Human reproduction. 2007;22(11):2824-8.
Hajenius PJ, Mol F, Mol BW, Bossuyt PM, Ankum WM, van der Veen F. Interventions for tubal ectopic pregnancy. The Cochrane database of systematic reviews. 2007;2007(1):Cd000324.
Lipscomb GH, Bran D, McCord ML, Portera JC, Ling FW. Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate. American journal of obstetrics and gynecology. 1998;178(6):1354-8.
Barnhart KT, Gosman G, Ashby R, Sammel M. The medical management of ectopic pregnancy: a meta-analysis comparing “single dose” and “multidose” regimens. Obstetrics & Gynecology. 2003;101(4):778-84.
Hajenius PJ, Engelsbel S, Mol BW, Van der Veen F, Ankum WM, Bossuyt PM, et al. Randomised trial of systemic methotrexate versus laparoscopic salpingostomy in tubal pregnancy. Lancet (London, England). 1997;350(9080):774-9.
Mol F, Van Mello NM, Strandell A, Strandell K, Jurkovic D, Ross J, et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. The Lancet. 2014;383(9927):1483-9.
