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

Bacterial Vaginosis Fishy malodorous grey, non-irritant.


Loss of lactobacilli + overgrowth of anaerobes; common organisms: Gardnerella vaginalis, Bacteroides,

Risk factors: antibiotics, douching, IUCD

Amsel criteria: discharge + clue cells + positive whiff test

Complications: ↑PID, post-hysterectomy infections, 2nd-trimester miscarriage/preterm labor, chorioamnionitis, post-CS endometriti

Trichomonas vaginitis STI parasite
purulent discharge ،vulvar pruritus،strawberry cervix”

Vulvovaginal Candidiasis
: Very common; Candida albicans ~90%
RF: antibiotics, pregnancy, diabetes
Severe pruritus; discharge watery → thick;
cervix normal.