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.