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

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Ectopic pregnancyDefinitionAny pregnancy
accruing outside the uterine cavity incidence
1/100one cause of maternal death.
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• Pathology-
• Commonest site
• uterine tube "ampulla".
• ovary.
• abdominal cavity.
• cervical canal.

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• Secretion of HCG gt 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.

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• Decrease progesterone hormone
• shedding of deciduas vaginal bleeding

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

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• 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.

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

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

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

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

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

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

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• 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.

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

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• ) 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 .

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• 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.

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• ?? 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.