Ektopik Gebelik Tanı ve Yönetimi
Özet
Ektopik gebelik (EG), gebelik ürününün uterin kavite dışına yerleşmesi olarak tanımlanır ve rüptüre olması durumunda ilk trimesterdeki anne ölümlerinin başlıca nedenidir. En yaygın klinik belirtileri karın ağrısı ve vajinal kanama olup, vakaların büyük çoğunluğu fallop tüplerinin ampullar bölgesinde yerleşir. Tanısında transvajinal ultrasonografi (TVUS) ve seri serum β-hCG ölçümleri temel araçlardır; özellikle β-hCG değerinin iki günde bir <%35 artması veya plato çizmesi anormal bir gebeliğe işaret eder. Kesin tanı konulduktan sonra hastanın klinik durumuna göre bekleme yaklaşımı, medikal veya cerrahi tedavi seçenekleri değerlendirilir. Kliniği stabil ve β-hCG değerleri düşük hastalar için bekleme yaklaşımı uygulanabilirken, uygun seçilmiş hastalarda folik asit antagonisti olan Metotreksat (Mtx) ile medikal tedavi %90'lara varan başarı oranına sahiptir. Hemodinamik instabilite, batın içi kanama, yüksek β-hCG seviyeleri (≥5000 IU/L) veya fetal kardiyak aktivite varlığında ise cerrahi müdahale kaçınılmazdır. Cerrahi yaklaşımda ilk seçenek olarak laparoskopi tercih edilmeli; hastanın durumuna ve doğurganlık arzusuna göre salpingostomi veya salpenjektomi prosedürleri uygulanmalıdır. Sonuç olarak, her ektopik gebelik vakası bir obstetrik acil durum olarak bireysel düzeyde yönetilmelidir.
Ectopic pregnancy (EP) is defined as the implantation of the blastocyst outside the uterine cavity and is the leading cause of pregnancy-related maternal mortality in the first trimester when ruptured. The most common clinical manifestations are abdominal pain and vaginal bleeding, with the vast majority of cases occurring in the ampullary region of the fallopian tubes. Transvaginal ultrasonography (TVUS) and serial serum β-hCG measurements are the primary tools for diagnosis; specifically, a less than 35% increase or a plateau in β-hCG levels every 48 hours indicates an abnormal pregnancy. Once a definitive diagnosis is established, expectant management, medical, or surgical treatment options are evaluated based on the patient's clinical status. While expectant management can be implemented for clinically stable patients with low β-hCG levels, medical treatment using Methotrexate (Mtx), a folic acid antagonist, yields a success rate of up to 90% in appropriately selected patients. Surgical intervention is mandatory in cases of hemodynamic instability, intra-abdominal bleeding, high β-hCG levels (≥5000 IU/L), or the presence of fetal cardiac activity. Laparoscopy should be preferred as the first choice in surgical approaches, and salpingostomy or salpingectomy procedures should be performed depending on the patient's condition and desire for future fertility. Consequently, every ectopic pregnancy case constitutes an obstetric emergency and must be managed on an individual basis.
Referanslar
American College of Obstetricians and Gynaecologists. ACOG Replaces Practice Bulletin Number 191: Tubal Ectopic Pregnancy. Obstetrics & Gynaecology 2018;131(3): E91-E103.
Panelli D.M, Phillips C.H, Brady P.C. Incidence, diagnosis and management of tubal and non-tubal ectopic pregnancies: a review. Fertil. Res. Pract. 2015; 1:15 .
Ferraretti A.P, Goossens V, Kupka M, Bhattacharya S, de Mouzon J, Castilla J.A, et al. Assisted reproductive technology in Europe, 2009: results generated from European registers by ESHRE. Human Reproduction 2013;28(9):2318-2331.
Hacettepe Üniversitesi Nüfus Etütleri Enstitüsü. 2018 Turkey Demographic and Health Survey. Hacettepe Üniversitesi Nüfus Etütleri Enstitüsü, T.C. Cumhurbaşkanlığı Strateji ve Bütçe Başkanlığı ve TÜBİTAK, 2019, Ankara.
Alkatout I, Honemeyer U, Strauss A, et al. Clinical diagnosis and treatment of ectopic pregnancy. Obstet. Gynecol. Surv. 2013; 68:571.
Anderson F.W, Hogan J.G, Ansbacher R. Sudden death: ectopic pregnancy mortality. Obstet. Gynecol. 2004; 103:1218.
Zou S, Li X, Feng Y, et al. Comparison of diagnostic values of circulating steroid hormones, VEGF-A, PIGF and ADAM12 in women with ectopic pregnancy. J. Transl. Med. 2013; 11:44.
Wu G, Yang J, Xu W, et al. Serum beta human chorionic gonadotropin levels at day 12 after in vitro fertilization in predicting final clinical pregnancy type. J. Reprod. Med. 2014; 59:161.
Bouyer J, Coste J, Fernandez H. et all. Sites of ectopic pregnancy : a 10 year population-based study of 1800 cases. Hum. Reprod. 2022;17:3224-3230.
MaCare R, Olowu O, Rizzuto M.I et al. Diagnosis and laparascopy management of 11 consecutive cases of cornual ectopic pregnancy. Arch. Gynecol. Obstet. 2009;280:59-64.
Elito J, Camano L. Unruptured tubal pregnancy: different treatments for early and late diagnosis. Sao Paulo Med. J. 2006;124: 321-324.
Vierhout M.E, Wallenburg H.C.S. Intraligamentary pregnancy resulting in a live infant. Am. J. Obstet. Gynecol. 1985;152:878-879.
Murray H, Baakdah H, Bardell T, Tulandi T. Ectopic pregnancy diagnosis and treatment. CMAJ. 2005; 173:905.
Bouyer J, Coste J, Shojaei T, et al. Risk factors for ectopic pregnancy: A comprehensive analysis based on a large case-controlled, population-based study in France. J Epidemiol. 2003; 157:185.
Halbert S.A, Patton D.L, Zarutskie P.W, Soules M.R. Function and structure of cilia in the fallopian tube of an infertile woman with Kartagener syndrome. Hum. Reprod. (1997) 12 :55–8. 10.1093/humrep/12.1.55.
Li C, Zhao W.H, Zhu Q, et al. Risk factors for ectopic pregnancy: a multicenter case-control study. BMC Pregnancy Delivery. 2015; 15:187.
Zhang D, Shi W, Li C, et al. Risk factors for recurrent ectopic pregnancy: a case-control study. BJOG 2016; 123 Ek 3:82.
Senterman M, Jibodh R, Tulandi T. Histopathological study of bulb and isthmic tubal ectopic pregnancy. J. Obstet. Gynecol. Am. 1988; 159:939.
Attar E. Ektopik gebeliğin endokrinolojisi. Obstet Gynecol Clin. Kuzey. Am. 2004; 31:779.
Hills S.D, Owens S.M, Marchbanks P.A. et al. Recurrent chlamydial infections increase the risk of hospitalization for ectopic pregnancy and pelvic inflammatory disease. Am. J. Obstet. Gynecol. 1997; 176: 103-107.
Shaw J.L, Wills G.S, Lee K.F, et al. Chlamydia trachomatis infection increases fallopian tube PROKR2 through TLR2 and NFκB activation, resulting in a microenvironment predisposing to ectopic pregnancy. Ben J. Pathol. 2011; 178:253.
Furlong L.A. Risk of ectopic pregnancy when contraception fails. A review. J. Reprod. Med. 2002; 47:881.
Li C, Zhao W.H, Meng C.X, et al. Contraceptive Use and Risk of Ectopic Pregnancy: A Multicenter Case Control Study. PLoS. Bir. 2014; 9:e1155031.
Hendriks, E., Rosenberg, R., & Prine, L. Ectopic pregnancy: diagnosis and management. American family physician. 2020;101(10): 599-606.
Elson C.J, Salim R, Potdar N, Chetty M, Ross J.A, Kirk E.J. On behalf of the Royal College of Obstetricians and Gynecologists. Diagnosis and management of ectopic pregnancy. British Journal of Obstetrics and Gynaecology. 2016;123:15–55.
Stovall T.G, Kellerman A.L, Ling F.W, Buster J.E. In the emergency room of an ectopic pregnancy. Ann. Emerg. Med. 1990; 19:1098.
Tulandi T, Ferenczy A, Berger E. Tubal occlusion as a result of retained ectopic pregnancy: a case report. J. Obstet. Gynecol. Am. 1988; 158:1116.
Alsuleiman S.A,Grimes E.M. Ectopic pregnancy: a review of 147 cases. J. Reprod. Med.1982;27:101-106.
Berek JS., Hacker N.F.: Gynecologic Oncology, Seventh Edition. Copyright © 2021 Wolters Kluwer.
Rausch M.E, Hampilos N, McNeill W, et al. Ectopic Pregnancy. In: Handbook of Obstetric and Gynecological Emergencies, 5th edition, Benrubi GI (Ed), Lippincott Williams & Wilkins, 2018.
Xiao-Yan C, Jie L, Dang J, et al. A highly sensitive electrochemiluminescence immunoassay to detect human embryonic human chorionic gonadotropin in embryo culture medium used during the IVF-ET cycle. J. Assist. Reprod. Genet. 2013; 30:377.
Silva C, Sammel M.D, Zhou L, et al. Human chorionic gonadotropin profile for women with ectopic pregnancy. Obstet. Gynecol. 2006; 107:605.
Seeber B.E, Sammel M.D, Guo W, et al. Application of redefined human chorionic gonadotropin curves for the diagnosis of women at risk of ectopic pregnancy. Fertil Steril. 2006; 86:454.
Cole L.A. Phantom hCG and phantom choriocarcinoma. Gynecol. Oncol. 1998;71:325-329.
Rotmensch S, Cole L.A. False diagnosis and needless therapy of presumed malignant disease in woman with false-positive human chorionic gonadotropin concentration. Lancet. 2000;35:712-715.
Verhaegen J, Gallos I.D, van Mello N.M, et al. Accuracy of a single progesterone test to predict early pregnancy outcome in women with pain or bleeding: a meta-analysis of cohort studies. BMJ 2012; 345:e6077.
Connolly A, Ryan D.H, Stuebe A.M, Wolfe H.M. Re-evaluation of discriminative and threshold levels for serum β-hCG in early pregnancy. Obstet. Gynecol. 2013; 121:65.
Condous G, Kirk E, Lu C, et al. Diagnostic accuracy of varying discriminant regions for prediction of ectopic pregnancy in women with pregnancy of unknown location. Ultrason Obstet. Gynecol. 2005; 26:770.
Barnhart K.T, Gosman G, Ashby R, Sammel M. The medical management of ectopic pregnancy: A meta-analysis comparing “single dose” and “multi dose” regimens. Obstetrics & Gynaecology. 2003;101(4):778-784.
Webster K, Eadon H, Fishburn S, Kumar G. Ectopic pregnancy and miscarriage: diagnosis and initial management: Summary of updated NICE guidance. British Medical Journal. 2019; 367.
Craig L.B, Khan S. Expectant management of ectopic pregnancy. Clinical Obstetrics Gynaecology. 2012;55:461–70.
Alur-Gupta S, Cooney L.G, Senapati S, Sammel M.D, Barnhart K.T. Two doses versus single dose of methotrexate for treatment of ectopic pregnancy: A meta-analysis. American Journal of Obstetrics and Gynaecology. 2019;95-108.
Odejinmi F, Huff K.O, Oliver R. Individualisation of intervention for tubal ectopic pregnancy: historical perspectives and the modern evidence based management of ectopic pregnancy. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2017;69–75.
Trambett J.J, Enistein M.H, Banks E. et al: Uterine artery embolization in the management of vaginal bleeding from cervical pregnancy: a case series. J. Reprod. Med. 50:844 2005.
Cao S, Zhu L, Jin L, Gao J, Chen C. Uterine artery embolization in cesarean scar pregnancy: safe and effective intervention. Chin. Med. J. (Engl). 2014;127:2322-6.
Mol F, van Mello N.M, Strandell A, et al. Salpingectomy versus salpingotomy (ESEP study) in women with tubal pregnancy: an open-label, multicenter, randomized controlled trial. Lancet. 2014; 383:1483.
Yao M, Tulandi T. Current status of surgical and nonsurgical management of ectopic pregnancy. Fertil Steril. 1997;67(3):421-433.
