Ectopic pregnancy
implantation of the embryo outside the uterine cavity (most commonly in the fallopian tube). It is not viable (usually) and can be life-threatening

Ampulla 80% (most common)

isthmus
early rupture and acute pain, but bleeding is usually less catastrophic than interstitial.

Interstitial pregnancy late rupture
• It is supplied by both uterine and ovarian arterie
When rupture occurs → massive, sudden hemorrhage → highest mortality.

Abdominal pregnancy is a rare ectopic pregnancy, usually secondary to tubal rupture, and carries a high risk of massive hemorrhage.due to Abnormal placental location

Surgical management is the treatment of choice
• Fetus is removed

• Placenta:
• If attached to vital organs → left in situ to avoid catastrophic hemorrhage
• Methotrexate may be used for placental resorption

Heterotopic pregnancy is the simultaneous presence of an intra-uterine pregnancy and an ectopic pregnancy in the same patient.
Much more common with assisted reproductive techniques (IVF/ART)

Risk Factors of Ectopic Pregnancy
1Structural Risk Factors
2Functional Risk Factors

Pelvic inflammatory disease (PID) mcc
Previous ectopic pregnancy
Endometriosis
Congenital anomalies of fallopian tube
Adhesions after ruptured appendicitis or surgery
Tubal surgery (ligation, reversal, anastomosis)

Progestin-based contraception (slows tubal peristalsis)
Smoking (impairs ciliary movement)
• Advanced maternal age (>35 years)

Clinical Presentation of Ectopic Pregnancy
Sub-acute Presentation
classical triad:
• Amenorrhea
• Abdominal pain
• Vaginal spotting

Acute Ruptured Ectopic Pregnancy
Sudden onset of severe abdominal pain
• Dizziness or loss of consciousness
• Shoulder pain (due to irritation of phrenic nerve by blood in abdomen)
• Vaginal bleeding or spotting with amenorrhea
• Signs of shock may be present

Physical Examination
General Examination
Tachycardia
• Hypotension
→ indicates hemodynamic instability in ruptured ectopic pregnancy

Abdominal Examination
Abdominal distension
• Positive rebound tenderness due irritation

Gynecological Examination
Minor cervical bleeding
• Cervical motion tenderness
• Slightly enlarged, globular uterus
• Adnexal mass may or may not be present

In normal pregnancy: β-hCG almost doubles every 48 hours
• In ectopic pregnancy: rise is suboptimal (slow)

Used to:
• Detect intra-uterine pregnancy
• Look for free fluid in peritoneal cavity
• Most reliable diagnosis:
• Extra-uterine gestational sac with embryo

Single echogenic rim
• More common findings:
• Empty ectopic sac
• Heterogeneous adnexal mass
• Free fluid in pouch of Douglas = non-specific

Management of Ectopic Pregnancy
Stability of the patient
2. Availability of resources
3. Patient’s desire for future fertility

Medical management is preferred for early ectopic pregnancy

• Surgery is reserved for:
• Hemodynamically unstable patients
• Uncertain diagnosis
• Failure of medical treatment

Laparotomy:
• Preferred in hemodynamically unstable patients
• Allows rapid control of bleeding
• Laparoscopy:
• Superior to laparotomy
• Gold standard in hemodynamically stable patients

Type of Tubal Surgery
Salpingectomy:
• Removal of the entire tube
• Indicated when:
• Significant tubal damage
• Patient previously sterilized and does not desire fertility
• High likelihood of retained products

Salpingotomy:
• Removal of ectopic pregnancy with suturing of the tube


• Salpingostomy:
• Removal of ectopic pregnancy leaving the tube open to heal secondarily

Methotrexate1mg/kg

Systemically
• Or locally (under laparoscopic or ultrasound guidance)
Hemodynamically stable patient
• Early ectopic pregnancy
• No active bleeding
• Small ectopic mass less then4cm
.No fetal cardiac activity
.able to return to follow up

Normal vaginal flora mainly lactobacilli; normal vaginal pH < 4.5 (lactic acid from glycogen under estrogen effect

Discharge increases in pregnancy, mid-cycle, with combined OCPs.

higher pH increases infection risk (prepubertal, postmenopausal, after systemic antibiotics, after total hysterectomy