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.

treatment): Topical azoles (clotrimazole/miconazole) or fluconazole)

Genital ulcers & warts
HSV
Usually HSV-2; primary painful ulcers, grouped vesicles. Confirm by culture or antibody assay. Treat: acyclovir 400 mg

Primary syphilis
Painless, hard ulcer (chancre)
• Indurated margins
• Appears at site of infection
• Heals spontaneously in 3–6 weeks

Secondary syphilis
Maculopapular rash (including palms & soles)
• Generalized lymphadenopathy
• Fever, malaise, sore throat

Screening VDRL
• RPR
Confirmatory Treponemal tests

Treatment
Benzathine penicillin G
• 2.4 million units IM – single dose

Endocervicitis
50% caused by Neisseria gonorrhoeae or Chlamydia trachomatis.
Dyspareunia
• Mucopurulent discharge
• On speculum: yellow/green purulent discharge from the cervix
• Cervical ectropion (friable, bleeds on contact)

Cervical swab → PCR for gonorrhea & chlamydia

Dual therapy due to resistance.
• Ceftriaxone 250 mg IM single dose
PLUS
• Azithromycin 1 g single dose OR Doxycycline 100 mg BID 7 days

Partner must be treated.

Pelvic Inflammatory Disease
Clinical diagnosis of infection of endometrium, fallopian tubes, ovaries.
Severe cases may progress to peritonitis.

Ascending STIs, mainly gonorrhea & chlamydia