Ectopic pregnancy: Definition: Any pregnancy accruing outside the uterine cavity incidence 1/100 one cause of maternal death.

Pathology:- Commonest site uterine tube "ampulla". ovary. abdominal cavity. cervical canal.

Secretion of HCG –> maintain corpus luteum to secrete estrogen and progesterone . endometrial changes. Trophoblastic cells  invade fallopian tube wall and erode blood vessels in mesosalpinx thus result : rupture  "abd. Cavity, broad ligament. embryo dies . tubal mole then absorption it.

Decrease progesterone hormone shedding of deciduas vaginal bleeding

predisposing factors : no identifiable cause : previous history of ectopic pregnancy. infertility,subinfertility . PID IUCD

clinical presentation: Acute presentation: "classical" 25% -Amenorrhea – vaginal bleeding. one side of lower abdominal pain then become generalized – diarrhea shoulder pain due to sub diaphragmatic irritation by blood "should tip pain discomfort –syncope - difficult breath. On examination: hypotension – tachycardia Signs of peritonism "abdominal distension, guarding, rebound tenderness" Cervix closed – cervical excitation tender when moving cervix.

sub acute presentation: bleeding –Amenorrhea – abnormal last light period – irregular vaginal bleeding – abdominal pain. DX : mass on fornix of vagina ??

outcomes of tubal pregnancy: tubal abortion. tubal mole tubal rupture.

Different diagnosis : threatened or incomplete miscarriage. ovarian cyst acute salpingitis .

HCG level :  1500 Iu/L raised. uls  empty uterus, no gestational sac ,TVS. Extra ovarian tubal mass . free fluid peritoneal cavity. laparoscopy.

Management: I) surgical management : - lapratomy :- indication 1. haemodynamic compromised. 2. obese patient . 3. extensive pelvic adhesion.

Advantages of lapratomy: less blood loos. reduce need for post operative pain relief. less time to return to normal activity. less time for hospitalization.

lapratomy or laparoscopy: partial salpingectomy : removing part of tube. salpingotomy "leaving the tube in place , remove the ectopic through incision. Risk for recurrent ectopic pregnancy 15% Risk of salpingotomy: Some gestational tissue may be left in place and continue to develop so follow up of HCG hormone weekly up to 10 weeks.

salpingectomy : indication 1. uncontrolled bleeding. 2. ectopic pregnancy for the 2nd time in the same tube.

) Medical management : Advantages of medical management : avoid surgical intervention. less coast. less hospitalization. Drug : Methotrexate : Classification : anti metabolite. Action : interfere with synthesis of DNA Mode : IM single does 1 mg /kg body weight . Side effect: abdominal pain after 6-7 days of administration. -could be repeat the dose .

Follow up HCG indicator of success, when there is decrease of this hormone . indication of success of medical treatment "methotrexate" decrease level of HCG, until disappear. size of ectopic diminish. no fetal cardiac activity.

?? would choose medical or surgical intervention: According to the following criteria: serum HCG less than 2000iu/L ectopic less than 2cm. no fetal cardiac activity.