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

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

3. 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.

4. Decrease progesterone hormone
shedding of deciduas vaginal bleeding

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

6. 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.

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

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

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

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

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

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

13. 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.

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

15. ) 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 .

16. 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.

17. ?? 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.