Ektopik Gebelik
Özet
Ektopik gebelik, fertilize ovumun uterin kavite dışında implante olmasıyla gelişen ve üreme çağındaki kadınlarda akut karın ağrısının yaşamı tehdit eden nedenleri arasında yer alan bir obstetrik acildir. Klinik bulguların sıklıkla nonspesifik olması ve erken dönemde hemodinamik stabilitenin korunabilmesi, acil serviste tanısal gecikme riskini artırır. Tanısal yaklaşım; klinik değerlendirme, serum β-hCG ölçümleri ve transvajinal ultrasonografinin bütüncül yorumlanmasına dayanır. Gebeliğin yeri bilinmeyen gebelik grubu, rüptür açısından yüksek risk taşıdığından yapılandırılmış takip ve güvenli taburculuk kriterleri kritik önemdedir. Yönetim stratejisi temel olarak hemodinamik duruma göre belirlenir; stabil ve uygun hastalarda metotreksat ile medikal tedavi seçenekleri değerlendirilirken, instabilite veya rüptür şüphesinde gecikmeksizin cerrahi yaklaşım gereklidir. Bu bölümde ektopik gebeliğin epidemiyolojisi, risk faktörleri, klinik prezentasyonu, acil serviste tanısal algoritmalar ve güncel tedavi yaklaşımları acil tıp perspektifiyle ele alınmakta; karın ağrısı ile başvuran hastalarda klinik karar vermeyi destekleyecek pratik öneriler sunulmaktadır.
Ectopic pregnancy is an obstetric emergency in which the fertilized ovum implants outside the uterine cavity and represents a life-threatening cause of acute abdominal pain in women of reproductive age. The frequently non-specific clinical presentation and the possibility of initial hemodynamic stability increase the risk of diagnostic delay in the emergency department. Diagnostic evaluation relies on an integrated interpretation of clinical findings, serial serum β-hCG measurements, and transvaginal ultrasonography. Patients categorized as pregnancy of unknown location constitute a high-risk group for rupture and require structured follow-up and clearly defined safe discharge criteria. Management strategy is primarily determined by hemodynamic status; medical treatment with methotrexate may be considered in selected stable patients, whereas suspected rupture or instability necessitates immediate surgical intervention. This chapter reviews the epidemiology, risk factors, clinical presentation, diagnostic approach, and current management principles of ectopic pregnancy from an emergency medicine perspective, providing practical and evidence-based recommendations for patients presenting with abdominal pain.
Referanslar
American College of Obstetricians and Gynecologists. Practice Bulletin No. 193: Tubal ectopic pregnancy. Obstet Gynecol. 2018;131(3):e91–e103. doi:10.1097/AOG.0000000000002560.
Chong KY, de Waard L, Oza M, van Wely M, Jurkovic D, Memtsa M et al. Ectopic pregnancy. Nat Rev Dis Primers. 2024;10(1):94. doi:10.1038/s41572-024-00579-x.
Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011–2013. Obstet Gynecol. 2017;130(2):366–373. doi:10.1097/AOG.0000000000002114.
Tintinalli JE, Ma OJ, Yealy DM, Meckler GD, Stapczynski JS, Cline DM et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York: McGraw-Hill; 2020.
Walls RM, Hockberger RS, Gausche-Hill M, Erickson T, Wilcox S. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia: Elsevier; 2022.
Timor-Tritsch IE, Monteagudo A, Cali G, Vintzileos A, Viscarello R, Al-Khan A et al. Cesarean scar pregnancy is a precursor of morbidly adherent placenta. Ultrasound Obstet Gynecol. 2014;44(3):346–353. doi:10.1002/uog.13426.
Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Hum Reprod Update. 2014;20(2):250–261. doi:10.1093/humupd/dmt047.
Po L, Thomas J, Mills K, Zakhari A, Tulandi T, Shuman M et al. Guideline No. 414: Management of pregnancy of unknown location and tubal and nontubal ectopic pregnancies. J Obstet Gynaecol Can. 2021;43(5):614–630.e1. doi:10.1016/j.jogc.2021.01.002.
Doubilet PM, Benson CB, Bourne T, Blaivas M, Barnhart KT, Benacerraf BR et al. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med. 2013;369(15):1443–1451. doi:10.1056/NEJMra1302417.
National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. NICE guideline NG126. Published 17 April 2019; updated 23 August 2023. Available from: www.nice.org.uk/guidance/ng126 (accessed on Feb 5, 2026).
Practice Committee of the American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril. 2013;100(3):638–644. doi:10.1016/j.fertnstert.2013.06.013.
Tang L, Nie S, Ling L, Zhu Q. Predictors of treatment failure of tubal pregnancy with single-dose methotrexate regimen: a systematic review and meta-analysis. J Obstet Gynaecol. 2025;45(1):2447997. doi:10.1080/01443615.2024.2447997.
Alur-Gupta S, Cooney LG, Senapati S, Sammel MD, Barnhart KT. Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis. Am J Obstet Gynecol. 2019;221(2):95–108.e2. doi:10.1016/j.ajog.2019.01.002.
Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy. Green-top Guideline No. 21. London: RCOG; 2016. Available from: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/diagnosis-and-management-of-ectopic-pregnancy-green-top-guideline-no-21/ (accessed on Feb 2, 2026).
Hahn SA, Lavonas EJ, Mace SE, Napoli AM, Fesmire FM. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2012;60(3):381–390.e28. doi:10.1016/j.annemergmed.2012.04.021.
Referanslar
American College of Obstetricians and Gynecologists. Practice Bulletin No. 193: Tubal ectopic pregnancy. Obstet Gynecol. 2018;131(3):e91–e103. doi:10.1097/AOG.0000000000002560.
Chong KY, de Waard L, Oza M, van Wely M, Jurkovic D, Memtsa M et al. Ectopic pregnancy. Nat Rev Dis Primers. 2024;10(1):94. doi:10.1038/s41572-024-00579-x.
Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011–2013. Obstet Gynecol. 2017;130(2):366–373. doi:10.1097/AOG.0000000000002114.
Tintinalli JE, Ma OJ, Yealy DM, Meckler GD, Stapczynski JS, Cline DM et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York: McGraw-Hill; 2020.
Walls RM, Hockberger RS, Gausche-Hill M, Erickson T, Wilcox S. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia: Elsevier; 2022.
Timor-Tritsch IE, Monteagudo A, Cali G, Vintzileos A, Viscarello R, Al-Khan A et al. Cesarean scar pregnancy is a precursor of morbidly adherent placenta. Ultrasound Obstet Gynecol. 2014;44(3):346–353. doi:10.1002/uog.13426.
Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Hum Reprod Update. 2014;20(2):250–261. doi:10.1093/humupd/dmt047.
Po L, Thomas J, Mills K, Zakhari A, Tulandi T, Shuman M et al. Guideline No. 414: Management of pregnancy of unknown location and tubal and nontubal ectopic pregnancies. J Obstet Gynaecol Can. 2021;43(5):614–630.e1. doi:10.1016/j.jogc.2021.01.002.
Doubilet PM, Benson CB, Bourne T, Blaivas M, Barnhart KT, Benacerraf BR et al. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med. 2013;369(15):1443–1451. doi:10.1056/NEJMra1302417.
National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. NICE guideline NG126. Published 17 April 2019; updated 23 August 2023. Available from: www.nice.org.uk/guidance/ng126 (accessed on Feb 5, 2026).
Practice Committee of the American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril. 2013;100(3):638–644. doi:10.1016/j.fertnstert.2013.06.013.
Tang L, Nie S, Ling L, Zhu Q. Predictors of treatment failure of tubal pregnancy with single-dose methotrexate regimen: a systematic review and meta-analysis. J Obstet Gynaecol. 2025;45(1):2447997. doi:10.1080/01443615.2024.2447997.
Alur-Gupta S, Cooney LG, Senapati S, Sammel MD, Barnhart KT. Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis. Am J Obstet Gynecol. 2019;221(2):95–108.e2. doi:10.1016/j.ajog.2019.01.002.
Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy. Green-top Guideline No. 21. London: RCOG; 2016. Available from: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/diagnosis-and-management-of-ectopic-pregnancy-green-top-guideline-no-21/ (accessed on Feb 2, 2026).
Hahn SA, Lavonas EJ, Mace SE, Napoli AM, Fesmire FM. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2012;60(3):381–390.e28. doi:10.1016/j.annemergmed.2012.04.021.
