This document discusses bleeding in early pregnancy and covers various topics including causes of obstetric hemorrhage, definitions and types of miscarriage, risk factors for miscarriage, ectopic pregnancy, and recurrent pregnancy loss. Specifically, it defines threatened, inevitable, complete, incomplete, cervical, and missed miscarriages as well as septic abortion. For each type of miscarriage, the document outlines clinical presentation, investigations, complications and treatment approaches. It also briefly discusses the definition, incidence, etiology, clinical picture and treatment of recurrent pregnancy loss.

1. Bleeding in
Early Pregnancy
Presented by
Dr. Ahmed Ali Zein El-Abdein El-Nizamy
Lecturer of Obstetrics and Gynecology
Faculty of Medicine
Suez University

2. Bleeding in Early
Pregnancy
Objectives:
All medical student by the end of this lecture supposed to :
• 1- List causes of obstetrics hemorrhage.
• 2- Demonstrate the difference between types of Miscarriage.
• 3- Illustrate the management of recurrent pregnancy loss.
• 4- Distinguish the ectopic pregnancy and its management.

3. Bleeding in Early
Pregnancy
• Items to be covered: Part 1:
• 1- Causes of obstetric hemorrhage:
• 2- Definition of miscarriage.
• 3- Types of Miscarriage.
• 4- Risk factors.
• 5- Etiology.
• 6- Pathogenesis.
• 7- Clinical picture of each type of Miscarriage.
• 8- Investigations.
• 9- Treatment of each type.
• 10- Recurrent Pregnancy Loss.

4. Bleeding in Early
Pregnancy
• Items to be covered:
Part 2: Ectopic Pregnancy
• 1- Definition & Incidence of Ectopic Pregnancy.
• 2- Site.
• 3- Etiology.
• 4- Pathology.
• 5- Fate and types of ectopic pregnancy.
• 6- Clinical Picture.
• 7- Investigations.
• 8- Treatment modalities of Ectopic Pregnancy.

5. Part 1
Abortion & Miscariage

6. Bleeding in Early
Pregnancy
Obstetric Hge
Early Preg.
1- Abortion.
2- Ectopic
3- Vesicular
Mole
Other causes
Antepartum Hge
Placental Extra-Placental
Postpartum Hge
Complications of
3rd stage of labor.

7. Bleeding in Early
Pregnancy
• Bleeding in early pregnancy:
• A- Main causes:
• 1- Abortion.
• 2- Ectopic Pregnancy.
• 3- Vesicular Mole.
• B- Other causes:
• 1- General causes : bleeding tendency, HTN.
• 2- Local Gynecological causes : ulcer.
• 3- Trauma : sexual abuse.
• 4- Malignancy.
• 5- Hartman Sign & Decidual Hge.

8. Abortion & Miscarriage
• 1- Definition:
• Termination or interruption of Pregnancy before age of fetal
viability.
Acc to WHO definition < 20 wks. (500 gm)
UK < 24 wks.
Egypt < 28 wks. ( 1000 gm).
• 2- Incidence:
• Varies according to the type of miscarriage.
• 3- Types :
A- Spontaneous : Miscarriage.
B- Induced : Abortion.

9. Abortion & Miscarriage
• 3- Types:
• A- Miscarriage: spontaneous Abortion.
A-
• Threatened Abortion.
B-
• Inevitable Abortion : complete, incomplete, cervical.
C-
• Missed Abortion
D-
• Septic Abortion
E-
• Habitual Abortion ( RPL )

10. Abortion & Miscarriage
• 3- Types:
• B- Abortion : Induced
• 1- Therapeutic Abortion.
• 2- Non Medical Abortion
Elective.
Criminal.

11. Spontaneous Miscarriage
• 1- Incidence: 15 %
• 80% in the 1st trimester esp. < 8 wks “Window Gap”
• Incidence may be more than that due to subclinical miscarriage
or deficient notification “ illegal abortion ”
• 2- Risk factors for Miscarriage:
• A. Patient factors: ↑ age & Parity , extremes in BMI , low
socio-economic class, heavy smoking, Alcohol consumption
and low plasma Folate Level.
• B. Obstetric factors:
• Past history of miscarriage, CFMF, long time infertility due to
underlying cause.

12. • 3- Etiology:
Fetal Causes Maternal Causes Local Causes
Commonest causes of
1st trimester
Miscarriage ( 50-60% )
1- Maternal disease 1- Cervical causes:
“ Patulous OS”
Chromosomal
Abnormality
2- Endocrinal cause:
PCO, Luteal insuff. ,
endocrinal dis. e.g.
DM, Thyroid, Prolactin
2- Uterine cause :
a. Congenital
malformation:
Septum.
Aneuploidy: Trisomy,
monosomy
Tiploidy
3- Infection.
4- others: drugs,
chemical, radiation,
truama
b. Small cavity:
submucous fibroid,
Asherman $
CFMF 5- Immunological
causes:
Auto immune: APS,
SLE
Alloimmune : Rh iso.
c. Fixed RVF uterus.
d. Aute Poly
hydraminous
Malformed fetus Macerated fetus Fresh fetus

13. Spontaneous Miscarriage
• 4- Pathogenesis:
• In 1st trimester:
• Starts as bleeding in
Decidua basalis
“choriodecidual hge”
↓
Uterine irritation →
“ Colic”
In the 2nd trimester:
ROM may occur with Pain.
Abortion
Amenorrhea
Bleeding
Pain

14. Spontaneous Miscarriage
• A. Threatened Abortion:
• 1- Def.: attempt of the uterus to expel the fetus leading to or
due to partial separation of the fertilized ova  hemorrhage in
the choriodecidual space.
• 2- Clinical Picture:
• Triad ( Am. B. P. )
• Symptoms of early preg.
• Signs:
signs of early Preg.
uterus corresponds to period
of amenorrhea
Cervix : Closed

15. Spontaneous Miscarriage
• A. Threatened Abortion:
• 3- investigations:
• For Diagnosis:
U/S ± β HCG titer
• For the cause : D.M , CL insufficiency, thyroid disease
• 4- FATE:
• 70-80% of cases  pregnancy continues but ↑ incidence of
PTL, IUGR, PPROM, APHge.
• Bleeding increased  inevitable Abortion.
• Loss of cardiac pulsations  Missed miscarriage.
• Infections occurs  septic Abortion.

16. Spontaneous Miscarriage
• A. Threatened Abortion:

17. Spontaneous Miscarriage
• A. Threatened Abortion:
• 5- Treatment: either Conservative Vs. Termination of Preg.
• a. Conservative management:
• i. REST : Physical & Sexual
• ii. Progesterone : beneficial only in CL insufficiency
Prontogest 100mg 1x2 for 5-7 days.
• iii. Antispasmodics
• iv. Anti D ( 250 IU ) > 13 wks
• b. Termination of Pregnancy:
• i. Proven CFMF ii. TURN inevitable iii. Turn Septic
• D&C will done.

18. Spontaneous Miscarriage
• B- Inevitable Abortion:
• 1- Def.: complete separation of the fertilized ova or placenta
with progressive cervical dilatation and fetal expulsion.
• 2- Clinical Picture:
• Symptoms:
• Triad + moderate to sever bleeding + sever Pain
• Signs:
• Generally : according to bleeding  Pallor & shock.
• Abdominally : uterus = period of amenorrhea
• Locally: CX is OPEN
• 3- Investigations:
• General : CBC , PT, PTT
• Specific: U/S

19. Spontaneous Miscarriage
• B- Inevitable Abortion:
• 4- Treatment:
• i. RESUSITATION:
IV Fluids ± Blood transfusion
• ii. Evacuation:
• 1st Trimester: surgical evacuation.
• 2nd Trimester: misoprostol or oxytocin then evacuation if
remnant of conception or sever bleeding.
• iii. Ecbolics and Antibiotics
• iv. Anti D in Rh –ve Patients. Especially if surgical evacuation
done or if > 12 wks.

20. Spontaneous Miscarriage
• Complete Abortion:
• 1- Def.: all products of conception have been expelled.
• 2- Clinical Picture:
• Symptoms: Triad + expulsion of the conception  ↓ bleeding
& Pain
• Signs: the same as inevitable abortion but the CX is CLOSED
• 3- Investigations:
• General investigations: CBC , PT, PTT
• U/S  Empty Uterus.
• 4- Treatment:
• Ecbolics + Antibiotic

21. Spontaneous Miscarriage
• Incomplete Abortion:
• As inevitable Abortion but part of the product of conception is
still in the uterus  confirmed by U/S
• Treatment: as inevitable Abortion.
• Cervical Abortion:
• 1- Def.: arrest of gestational sac in the cervical canal.
• 2- Clinical Picture:
• Sever, Sever Pain + Bleeding + OPENED & Swollen CX +
Part of product of conception may be felt during P.V ex.
• 3- Treatment:
• EVACUATION + Ecbolics + Antibiotics

22. Spontaneous Miscarriage
• c. Missed Abortion: “ Carneous, bloody , fleshy Mole”
• 1- Definition:
• Retention of dead or non viable product of conception within
the uterine cavity.
• 2- Clinical Picture:
• Symptoms: Triad but
• Bleeding may be mild dark brown discharge
• Milk discharge but it may occur normally in pregnancy.
• Pain is usually Absent. + Absent fetal kicks
• Signs:
• CX is CLOSED
• Uterus is < period of amenorrhea ± no sign of Preg.

23. Spontaneous Miscarriage
• c. Missed Abortion: “ Carneous, bloody , fleshy Mole”
• 3- Investigations:
• For diagnosis:
• a. U/S: i. collapsed sac
ii. –ve cardiac Puslations. CRL ≥ 6 mm
iii. Gestational sac ≥ 25mm with no fetal pole “Blighted ovum”
• b. β-HCG & repeated after 48hs : plateau or decreasing
• For complications:
• Serum fibrinogen level : decreased by 50mg/wk , repeated
weekly, if < 100mg/dl  DIC.
• 4- Complications:
Infection , DIC after 4-6 wks.

24. Spontaneous Miscarriage
• c. Missed Abortion: “ Carneous, bloody , fleshy Mole”
• 5- Treatment:
• A. Expectant Management: spontaneous expulsion within 2 wks
• B. Termination of Pregnancy according to gestational age:
• Either induction by misoprostol alone or induction followed by
D&C.
• C. in cases of ↓ fibrinogen  correct fibrinogen 1st by FFP,
Fresh blood, Fibrinogen then termination of pregnancy.
• D. Anti D in Rh -ve patient if evacuation was done .

25. Spontaneous Miscarriage

26. Spontaneous Miscarriage
• D. Septic Abortion:
• 1- Definition: superimposed infection on any type of abortion
• 2- Causative organism:
• Gram +ve  staph, strept (GBS)
• Gram –ve  E.coli, Pseudomonas
• Anareobic Bacteroids, an.strept, Clostridium.
• 3- Source of infection:
• Exogenous, Endogenous or hematogenous.
• 4- Clinical Picture:
• Symptoms: Triad of Abortion + symptoms of infection ( fever,
headache, malaise, lower Abd.Pain ) + offensive Vaginal
Discharge.

27. Spontaneous Miscarriage
• D. Septic Abortion:
• 4- Clinical Picture:
• Signs:
• Generally: Toxic, fever, Pale
• Abdominally: Tender Abdomen ± Tender uterus
• Vaginal: Bleeding + Offensive Discharge
• tender Uterus ± swelling in D.P “ Pelvic Abscess”
• 5- Investigation:
• a. for diagnosis : U/S
• b. for the cause: Blood culture, swap, CBC , CRP
• c. for complications: Renal and liver function tests, Co-
agulation Profile.

28. Spontaneous Miscarriage
• 6- Complications:
• i. local complications: spread of infection  endometritis
PID
Pelvic abscess.
• ii. General complications:
septic thrombophlebitis
generalized peritonitis
septicemia & Septic shock.
DIC
ARDS
Acute hemolysis + liver affection + renal failure 
hemolytic uremic $.

29. Spontaneous Miscarriage
• D. Septic Abortion:
• 7- Treatment:
“Aggressive Management is life saving”
• a. Stabilizing general condition:
• Strong broad spectrum antibiotic management: ( combination
between cephalosporin + gentamycin + metronidazole)
• + monitoring of vital data of the PT in ICU
• + dexamethaxone ± blood transfusion.
• b. Suction Evacuation of the uterine content “DRIANAGE”
• In few cases hysterectomy on toto may be needed.
• c. Treatment of complication.

30. Spontaneous Miscarriage
• E. Recurrent Pregnancy loss (RPL) : Habitual Abortion
• 1- Definition:
• 3 or more Successive Spontaneous Abortions.
• If not successive  repeated Abortion.
• 2- Incidence varies according to parity and increasing with it.
• 3- Etiology:
• a. Idiopathic 50% of cases.
• b. Maternal Cause:
• Local cause in the uterus or the cx: 30% of cases of 2nd
Trimester Abortion.
• General Causes .
• c. Fetal Causes 4-10% of cases “ Structural anomalies”

31. Spontaneous Miscarriage
• E. Recurrent Pregnancy loss (RPL) :
• 3- Etiology:
Maternal Local Causes Maternal General Cause
1- Patulous I.Os  Abortion in
descending manner.
1- Endocrinal : PCO, LPD, DM,
Thyroid
2- CMF in the uterus : septate,
bicornuate  Abortion in
ascending manner.
2- Immunological :
Autoimmune : APS, SLE
Alloimmune: Rh isoimm.
3- Uterine Hypo Plasia 3- Thrombophilia
4- Submucous fibroid AT3 Deficiency, Protein C,S Def.
5- Fixed RVF Uterus. Factor V Leiden Deficiency.
6- Asherman $ 4- Infections

32. Spontaneous Miscarriage
• E. Recurrent Pregnancy loss (RPL) :
• 4- Assessment:
Assessment
History Examination
General Abdominal Local
Investigations

33. Spontaneous Miscarriage
• E. Recurrent Pregnancy loss (RPL) :
• 4- Assessment:
• a. History: Personal history : Age, Residence , Occupation
Complain
History of Present Pregnancy
Past history:
Medical : for medical diseases
Surgical : for cervical trauma , Asherman $
Family history :
Menstrual History: very important
Premenstual spooting  LPD
Menorrhagia , oligomenorrhea , hypomenorrhea

34. Spontaneous Miscarriage
• E. Recurrent Pregnancy loss (RPL) :
• 4- Assessment:
• a. History : Obstetric History:
time: 1st T  Maternal general Cause / Fetal
2nd T  Maternal Local Cause
order : ascending , descending
character of the abortus:
Special character.
• b. Examination: General : signs of general dis.
Abdominal : masses
local: for Local causes.
• c. Investigations: according to the cause:
e.g. thyroid profile, Progesterone level, hormonal profile , U/S,
Thrombophilia screening , karyotyping

35. Spontaneous Miscarriage
• E. Recurrent Pregnancy loss (RPL) :
• 5- Management:
• According to the underlying cause:
• 1- Patulous Internal OS  Cerculage.
• 2- Septate Uterus  hysteroscopic resection.
• 3- Submucous fibroid  myomectomy.
• 4- Fixed RVF  Ventrosuspension.
• 5- Uterine hypoplasia  cyclical E&P.
• 6- LPD  Progesterone.
• 7- Thyroid  management of thyroid dysfunction.
• 8- APS  low dose, aspirin, clexan , steroids
• 9- genetic causes  Counseling, ICSI with PGD

36. Spontaneous Miscarriage
Antiophospholipid Syndrome (APS) :
• 1- Definition:
• 2- Antigens:
• 3- Pathophysiology:
• 4-incidence:
• 5- Types:
• 6- Morbidity:
• 7- Clinical Picture and diagnosis
• 8- Complications : Maternal & Fetal
• 9- Management.

37. Spontaneous Miscarriage
Antiophospholipid Syndrome (APS) :
• 1- Defintion:
• Auto immune disease forming antibodies against phospholipid
proteins and Plasma Proteins.
• 2- Antigens:
• β2 glycoprotein + Prothrombin + LA + Anti Cardiolipin.
• 3- Pathophysiology:
• Auto Antibodies attacks targeted antigens leading to multiple
venous and arterial thrombosis by several ways:
• As : direct cellular effect , activation of platelet , endothelial
cell activation, reduction of fibrinolysis, resistance to protein C

38. Spontaneous Miscarriage
Antiophospholipid Syndrome (APS) :
• 4- Types:
• 1ry APS
• 2ry APS : with SLE
• Catastrophic antiphospholipid syndrome  multiple organ
failure & death.
• 5- Incidence: & 6- Mobidity
• 2-12% of general population
• 30-40% of cases of SLE
• 10-15% of cases of RPL
• 30% of cases with stoke.
• 15-20% of cases with DVT.

39. Spontaneous Miscarriage
Antiophospholipid Syndrome (APS) :
• 7- Clinical Picture:
• Diagnosis is dependent on Presence of at least 1 clinical
criteria + 1 laboratory criteria
• Clinical criteria: 1- (≥3) consecutive miscarriage < 12wks.
• 2- Missed IUFD > 12wks
• 3- early SPET < 34wks - PTL.
• 4- Vascular thrombosis.
• Laboratory Criteria : Antibodies aCL , lupus anticoagulant
(LA), anti β2 glycoprotein
• 8- Management:
• Low dose aspirin (75mg/day) + LMWH

40. Spontaneous Miscarriage
Antiophospholipid Syndrome (APS) :
• 9- Complications:
• Maternal Complications: SPET
HELLP $
DVT
Stroke
PE
hemolytic anemia
thrombocytopenia
lupus nephritis and skin manifestations
• Fetal Complications: RPL, IUFD, IUGR

41. Break

42. Part 2
Ectopic Pregnancy

43. Ectopic Pregnancy
• 1- Introduction.
• 2- Definition.
• 3- Incidence.
• 4- Sites.
• 5- Etiology
• 6- Pathology
• 7- Fate.
• 8- Clinical Picture.
• 9- Investigations.
• 10- Treatment.
• 11- Deferential Diagnosis.

44. Ectopic Pregnancy
• 1- Introduction:
• Physiology of pregnancy and implantation :
• Fertilization: it is the union of a mature ovum & a mature
spermatozoon after penetration of ZP at the ampulla of the
Fallobian tube “ between the outer and middle 1/3 of the tube
 Zygot formation.
• Fertilized ova “ Zygot” rapidly divides  (Blastomere) 
(morula) and transported through the F. Tube and nourished by
the secretion of the tube “ tubal milk” helped by peristalsis of
the tube and ciliary movement to reach Uterine Cavity after
3 days of fertilization.
• Fluid accumulate in the morula (Blastocyst) and it remains
in the uetrine cavity freely for another 3 days and nourished by
secretion of the endometrium “ Endometrial Milk”

45. Ectopic Pregnancy
• 1- Introduction:
• Physiology of pregnancy and implantation :
• Implantation: blastocyst divided into 2 masses :
• inner cell mass  embryo
• outer cell mass  trophoblast
• Invasion of the trophoblast into the decidua “ modified
secretory endometrium” ( Implantation on the 6th to 7th day
after fertilization.)

46. Ectopic Pregnancy
• 1- Introduction:
• Physiology of pregnancy and implantation :

48. Ectopic Pregnancy
• 2- Definition:
• Implantation outside the endometrial cavity
• 3- Incidence: 2% and it increased in the last decades due to :
• a. STDS b. IUCD c. ART
• d. Earlier tools for diagnosis ( U/S & Laparoscopy )
• 4- Sites:
Extra Uterine Uterine
1- Tubal 98% mostly ampullary
80% then in the isthmus 12%,
1- Cervical
Fimbria 5%,and Interstitial 3% 2- Rudimentary horn
2- Ovarian 0.5% 3- Angular
3- Peritoneal ( Abdominal 1ry, 2ry) 4- Intraligamentary

49. Ectopic Pregnancy
• 5- Etiology:
• A. Causes in the tube preventing normal transport.
i. congenital : hypoplasia, diverticule
ii. Inflammatory: 50% of cases :
PID especially Chlamydial infection
iii. Traumatic: previous ectopic, Surgery due to adhesions.
iv. Neoplastic: tumors e.g. in the broad ligaments e.g. fibroid
v. Miscellaneous: Endometriosis due to adhesion
Contraception: POP, Implants  inhibit cilia mov., IUCD
Smoking
• B. Causes in the fertilized ova.
• Early disappearance of ZP & Early development of trophoblast

50. Ectopic Pregnancy
• 6- Pathology:
• A. in the tube :
• F. tube can not accommodate pregnancy due to limited tubal
distension, poor blood supply , thinner decidua  Early
disturbance < 12wks.
• B. uterus : symmetrically enlarged , Decidua with absent
chorionic villi , Arias stella Reaction 10-15%
• C. ovary: CL of pregnancy.
• 7- Fate :
• i. Undisturbed : diagnosed early.
• ii. Disturbed : repeated hge around the ova  tubal mole 
tubal abortion or rupture  acc to amount of intra peritoneal
bleeding Acute , Subacute , Chronic Disturbed.
• iii. 2ry Abdominal Pregnancy

51. Ectopic Pregnancy
• 8- Clinical Picture: according to the fate of ectopic Pregnancy
• i. Undisturbed Ectopic Pregnancy:
• Symptoms: Triad ( Amenorrhea, Pain, Bleeding ) + symptoms
of early pregnancy.
• Signs:
• Generally: signs of early pregnancy.
• Abdominally: uterus is soft and enlarged symmetrically
• Locally: Fullness in the vaginal fornix with slight
tenderness ± vaginal bleeding
Early diagnosis needs high level of suspicion “ You have to be
ectopically minded” especially with history of :
PID, Pregnant on top of IUD, and any history of any risk factor.

52. Ectopic Pregnancy
Undisturbed Ectopic Pregnancy

53. Ectopic Pregnancy
• ii. Disturbed Ectopic Pregnancy:
• a. Sub Acute Disturbed Ectopic Pregnancy: 60% of cases
• Symptoms: Triad + History of predisposing factor
Sudden sever PAIN may be: Dull aching dt. Tubal distension
Sharp stabbing dt. Tubal rupture
Colicky dt. Tubal abortion.
+ slight dark brown Discharge.
• Signs:
• Generally: various degree of shock
• Abdominally: Tenderness, Rigidity, Rebound Tenderness.
• Locally: Cervix : Tender on movement ( Jumping Sign )
“Cervical Motion Tenderness”
• Fullness in the vaginal fornix.

54. Ectopic Pregnancy
• ii. Disturbed Ectopic Pregnancy:
• b. Acute disturbed Ectopic Pregnancy

55. Ectopic Pregnancy
• Acute Disturbed Ectopic Pregnancy

56. Ectopic Pregnancy
• ii. Disturbed Ectopic Pregnancy:
• b. Acute disturbed Ectopic Pregnancy:
• Symptoms:
• Triad + Sever Abdominal Pain followed by massive
intraperitoneal hge with shock & collapse ± Shoulder Pain
• Signs:
• Generally: Shock not proportional to external Hge.
• Abdominally: Tenderness, Rigidity , R.Tend .
• Locally: difficult esp. if the pt is comatosed

57. Ectopic Pregnancy
• ii. Disturbed Ectopic Pregnancy:
• b. Chronic Disturbed Ectopic Pregnancy:
• Symptoms:
• History of Predisposing factor ± Triad
• Blood collected gradually in the DP with Pelvic hematocele
formation leading to : pressure symptoms :4Ds
Dorsal pain, Dysuria, Dyschazia, Dyspareunia
• Signs:
• Generally: pallor ± Pyrexia ± Jaundice
• Abdominally: mild tenderness.
• Locally: as before
• Diagnosis: by laparoscopy.

58. Ectopic Pregnancy
• ii. Disturbed Ectopic Pregnancy:
• c. 2ry Abdominal Pregnancy:
• Rare condition. Started as a tubal pregnancy  aborted from
the F.Tube  re-imblanted in any abdominal organ.
• Signs: Abnormal lie with easy palpation of the fetal parts.
• Diagnosed by U/S, MRI => fetus and the placenta is out side
the uterine cavity.
• Treatment: by laparotomy and if the placenta is attached to one
of the great vessels  leave the placenta and give
methotrexate for helping the absorption.

59. Ectopic Pregnancy
• 9- Investigations:
• A. General investigations: CBC, PT, PTT, Liver function tests
• B. Specific investigations:
• T.V U/S + Q.β-HCG Titer
• 1- quantitative β-HCG titer (Pregnancy test) and repeated after
48 hs  i. if increased > 66%  normal pregnancy.
• ii. If increased < 66%  ectopic Pregnancy.
• 2- T.V U/S : more sensitive than Abd. U/S:
• Gestational sac seen intrauterine at the age around 5 wks and
fetal cardiac pulsation seen at the age around 6 wks.
• Empty U/S by T.V U/S ± Adnexal mass with β-HCG titer >
1500 mIU/ml is diagnostic for Ectopic Pregnancy.
• Laparoscopy is used for diagnosis and management

60. Ectopic Pregnancy
• 10- Treatment:
• A. Expectant Management.
• B. Medical Management.
• C. Surgical Management: either Laparoscopy or Laparotomy
• D. Anti D in Rh –ve Patients specially in surgical
management.
• A. Expectant management: in case of low β-HCG < 200 & T.V
U/s is –ve  follow up with repetition of the titer after 48hs.
• B. Medical Management:
If : 1- undisturbed ectopic pregnancy
2- adnexal mass < 3cm
3- -ve Cardiac Pulsations.
4- β-HCG titer < 3000 mIU/ml.

61. Ectopic Pregnancy
• 10- Treatment:
• B. Medical Management:
• Methotrexate 50mg/m2 IM with follow up:
• Serial U/S & β-HCG titer done on Day 0: Date of injection
• Day 4
• Day 7
• There may be mild increase in β-HCG titre on day 4 but to
comment as successful medical management there is should
decrease >15% in β-HCG Titer between Day 4 and Day 7.
• Serial CBC should be done.
• If decrease is < 15 % repetition of methotrexate dose could be
used for another 2 doses  if failed  Surgical Management.

62. Ectopic Pregnancy
• 10- Treatment:
• C. Sugical Management:
• if : 1- Failed Medical Management
• 2- Disturbed Ectopic Pregnancy.
• 3- Unsuitable medical Management.
• In Disturbed Ectopic pregnancy:
• RESUSITATION + Laparoscopy if the pt is
hemodynamically stable or laparotomy if pt is
hemodynamically unstable  Peritoneal toilet +
Salpengectomy if the other tube is healthy or Salpengotomy
or Salpengostomy if the other tube is not healthy.
• In undisturbed Ectopic pregnancy : Laparoscopy is gold
standard as a diagnostic and treatment tool .

63. Ectopic Pregnancy
• 10- Treatment:
• Contra indications of methotrexate management:
• 1- Patient is hemodynamicaly unstable , sever pain
• 2- β-HCG titer > 3000 mIU/ml
• 3- Adnexal mass > 3-4 cm or free fluid in DP > 300ml
• 4- C0-Existant intrauterine living pregnancy ( heterotropic
Pregnancy).
• 5- intolerability to methotrexate therapy as in hepatic, renal or
blood disease patients.
• Contraception after ectopic pregnancy avoid IUCD & POP
 use COC unless contraindicated.
• Recurrence rate 15% and infertility or subfertility 30%

64. Ectopic Pregnancy
• 11- Differential Diagnosis:
• DD from PAIN:
• 1- Acute PID.
• 2- Complicated ovarian Cyst.
• 3- Acute appendicitis.
• 4- Acute Pyelonephritis.
• DD from Vaginal Bleeding:
• 1- Abortion.
• 2- Vesicular Mole.

65. • Abortion Vs Ectopic Pregnancy:
• Causes of post abortive bleeding:
• 1- retained product of conception “ the commonest cause”
• 2- Choriocarcinoma “ the most dangerous cause”
• 3- other: infection, perforation, general or local gyn. cause.
Abortion Etopic
Symptoms Triad Am+ Bleeding + Pain Am+ PAIN + bleeding
Amenorrhea Present Short
Pain Colicky Colic, dull, sharp stab
Bleeding Bright Red Dark
Signs: Shock Proportional to BL. Not Proportional
Abd. Mild Pain Tend, R, R.Tend
Uterus = Period of Am. < 8 wks.
Adenexa No swelling Swelling & tender
Pathology Chorionic villi No Chorionic Villi

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