document_title: When Calls the Heart

question_text: who plays henry gowen on when calls the heart

text: When Calls the Heart

text: Plot[edit]

text: When Calls the Heart tells the story of Elizabeth Thatcher (Erin Krakow), a young teacher accustomed to her high-society life. She receives her first classroom assignment in Coal Valley, a small coal-mining town in Western Canada which is located just south of Robb, Alberta. There, life is simple—but often fraught with challenges. Elizabeth charms most everyone in Coal Valley, except Royal North West Mounted Police Constable Jack Thornton (Daniel Lissing). He believes Thatcher’s wealthy father has doomed the lawman's career by insisting he be assigned in town to protect the shipping magnate’s daughter. The town of Coal Valley was renamed Hope Valley in Episode 2, Season 2 after the coal mine was closed.

text: Living in this 1910 coal town, Elizabeth must learn the ways of the Canadian frontier movement if she wishes to thrive in the rural west on her own. Lori Loughlin portrays Abigail Stanton, whose husband, the foreman of the mine, and her only son—along with 45 other miners—have recently been killed in an explosion, which turns out to have been a tragic accident waiting to happen—a result of the mining-company site manager's irresponsible management and lack of due care in his management of the mine. The newly widowed women find their faith tested when they must go to work in the mine to keep a roof over their heads, food on the table, and compile a wage for the town's teacher.[9]

text: Episodes[edit]

text:
Season
Episodes
Originally aired

First aired
Last aired

1
12
January 11, 2014 (2014-01-11)
March 29, 2014 (2014-03-29)

2
7
April 25, 2015 (2015-04-25)
June 13, 2015 (2015-06-13)

New Year's Wish
December 26, 2015 (2015-12-26)

3
8
February 21, 2016 (2016-02-21)
April 10, 2016 (2016-04-10)

Christmas
December 25, 2016 (2016-12-25)

4
10
February 19, 2017 (2017-02-19)
April 23, 2017 (2017-04-23)

The Christmas Wishing Tree
December 25, 2017 (2017-12-25)

5
10
February 18, 2018 (2018-02-18)
April 22, 2018 (2018-04-22)

text: Cast[edit]

text: Main[edit]

text:
Erin Krakow as Elizabeth Thatcher Thornton
Daniel Lissing as Jack Thornton (Seasons 1-5)
Lori Loughlin as Abigail Stanton
Jack Wagner as Bill Avery
Martin Cummins as Henry Gowen
Pascale Hutton as Rosemary LeVeaux Coulter
Kavan Smith as Leland Coulter

text: Recurring[edit]

text:
Paul Greene as Carson Shepherd
Gracyn Shinyei as Emily Montgomery
Loretta Walsh as Florence Blakeley
Erica Carroll as Dottie Ramsey
Mark Humphrey as Frank Hogan
Johannah Newmarch as Molly Sullivan
Mitchell Kummen as Gabe Montgomery
Logan Williams as Miles Montgomery
Ben Rosenbaum as Mike Hickam
Carter Ryan Evancic as Cody Hastings
Chelah Horsdal as Cat Montgomery
Steve Bacic as Charles Spurlock
Kristina Wagner as Nora Avery
Aren Buchholz as Jesse Flynn
Charlotte Hegele as Julie Thatcher
Andrea Brooks as Faith Carter
Eva Bourne as Clara Stanton
Ava Grace Cooper as Opal
Max Lloyd-Jones as Tom Thornton
Brooke Shields as Charlotte Thornton
Devon Weigel as Viola Thatcher
Marcus Rosner as Charles Kensington
Mamie Laverock as Rosaleen Sullivan
Adrian Hough as Reverend Anderson
Lynda Boyd as Grace Thatcher
Will Verchere-Gopaulsingh as Caleb Dunbar
Ali Skovbye as Becky Hastings
Garwin Sanford as William Thatcher
Laura Bertram as Mary Dunbar
Derek Hamilton as Dewitt Graves
Niall Matter as Shane Cantrell (season 4)
Spencer Drever as Cyrus Rivera (season 4)
Josie Bissett as AJ Foster

text: Characters[edit]

text: This section may contain an excessive amount of intricate detail that may interest only a particular audience. Please help by spinning off or relocating any relevant information, and removing excessive detail that may be against Wikipedia's inclusion policy. (April 2018) (Learn how and when to remove this template message)

text:
Elizabeth Thatcher Thornton is an independent, strong-minded, passionate and dedicated young teacher from the city. The middle daughter of William and Grace Thatcher, Elizabeth has two sisters, older sister Viola and younger sister Julie. Elizabeth finds herself in Coal Valley, a small community on the Canadian frontier in need of a teacher, and quickly discovers it is not an easy place to live, lacking the creature comforts and luxuries of her privileged life with her family. She soon meets the newly appointed and charismatic Mountie Jack Thornton and develops an immediate dislike for him. However, over time they become good friends, and develop an obvious attraction to one another. In the final episode of season 1, "Prelude to a Kiss" (also titled as "Final Adieu"), after overcoming many obstacles throughout the season, Jack tells Elizabeth "You're the one, you're the only one" and they share a kiss. Throughout season 2, Elizabeth's feelings for Jack are high at times as well as low. Finally, in the season 2 finale, she admits that his job as a Mountie scares her. After being comforted both admitting that they love each other, Jack and Elizabeth kiss.
Jack Thornton is a laid back country boy. Jack is the son of Mountie Thomas Thornton and his wife Charlotte Thornton. Jack has a younger brother, Tom (named after his father). As a Mountie and a man of stout character and integrity, he often finds himself protecting and saving people. In season 1's "A Telling Silence," Jack finds a basset hound whom he names Rip (after Rip Van Winkle) and takes home with him. A source of comfort and companion in the small town, Jack often goes to Rip when times in his life are difficult. In season 2's "With All My Heart," Rip, who's afraid of thunder, hides in the mine shafts during a storm. Jack and Elizabeth search for him; in their search, their relationship grows stronger. Upon his first meeting of Elizabeth, Jack developed an instant dislike and it appeared she irritated him. However, he grew to like and then fall madly and completely in love with her over time. In "Rules of Engagement" (S.1), it is revealed that Jack was briefly engaged to Rosemary LeVeaux when she comes looking for him. However, they have both changed and realize that they cannot have a relationship as they once did ever again. In "Prelude to a Kiss" (S.1), Jack found out that Elizabeth may be leaving Coal Valley. Taking her on a walk and giving her a framed picture of them that he had sketched, he asks her not to leave Coal Valley and tells her, "You're the one, you're the only one." She replied that she was "not going anywhere", Coal Valley was where she belonged before they share a kiss. In season 2, Elizabeth and Jack share a hot-and-cold relationship until the finale, "With All My Heart." They both admit that they love each other and share another kiss. Jack's brother, Tom, is introduced season 2's "Trials of the Heart," and their rocky relationship continues until "Coming Together, Coming Apart." Jack gently reminds his younger brother how their father was so proud of him, but he wouldn't be proud of the way he was currently living. Both in tears, Jack tells his younger brother that he believes in him and that he can turn his life around. More recently, Jack has become good friends with the sawmill operator, Lee Coulter. In season 3, Jack begins the new year knowing that Elizabeth only has eyes for him and that her relationship with Charles is over for good. In "Hearts In Question," Jack's mother Charlotte shows up unexpectedly. She meets Elizabeth and is suspicious of her, but through staying her sees Elizabeth for who she really is: a trustworthy, dedicated teacher. In the season finale, "Prayers From The Heart," Jack is injured in a flood. But he miraculously recovers in time to serve as Lee's best man at his wedding.
Abigail Stanton is a Coal Valley woman who tragically lost her husband and son in the mining accident. Abigail is a very kind woman, and she stands strongly for the things she believes in. She is one of the first women to welcome Elizabeth and the two women quickly become friends. When Elizabeth accidentally burns down the little teacherage, Abigail gladly welcomes her into her home to live. After being complimented on her cooking, Abigail decides to open a cafe in Coal Valley. Together, Abigail and Elizabeth move into the rooms above the cafe. At the end of season 1, Abigail enjoys the company of Bill Avery, a Mountie, serving as a Forensic Investigator and friend of Jack Thornton's. In season 2, Abigail takes in her daughter-in-law, Clara, the wife of her late son Peter whom Abigail sees as the daughter she never had. With Bill's past being revealed, Abigail ends their friendship and spends more time with the new pastor, Frank Hogan. Also, she is a strong independent woman that is set on doing the things that are right and tries to help Elizabeth.
Bill Avery is a mysterious, quiet man. He first appears in season 1's "Rules of Engagement," in order to help Jack expose Mr. Gowen's wrongdoings. Bill is immediately attracted to widow Abigail Stanton. Things are going well until Abigail discovers a picture of Bill's family and his wedding ring. He later tells her that his son died, as well as his wife. However, his wife, Nora, comes to confront him in season 2's "Heart's Desire."
Henry Gowen is a cold, cynical man who formerly owned the coal mine. After the mine was shut down, Henry became the mayor of Hope Valley and still creates a cold, cynical presence whenever people are around him. Henry is highly disliked and feared in the town. He frequently uses bribery to get what he wants, which is never for the good of the town.
Rosemary "Rosie" LeVeaux Coulter is a flamboyant, enthusiastic actress from New York. She was briefly engaged to Jack Thornton, but they both realized that it wouldn't work out. Rosie immediately disliked Elizabeth and viewed her as "the competition," but eventually came to really care about Elizabeth, even if she has a hard time showing it. At the beginning of season 2, Rosemary began working at the cafe with Abigail and the two quickly became friends. Spending time with Abigail helped tone down some of Rosemary's enthusiasm and made her a more likable person. Rosemary even came to like Elizabeth, even if only on an acquaintance level. Truthfully, she cares about everyone in Hope Valley, especially Lee, with whom she shares an mutual attraction. When Rosie is not spending time with Lee, talking to Abigail, or dreaming about the glamorous life of an actress, she can often be found somewhere writing her weekly advice column for Hope Valley's newspaper! In season 3, Rosemary's friendship with Elizabeth deepened. Instead of viewing her as an adversary, she finds a friend in Elizabeth. Throughout season 3, Rosemary's relationship with Lee becomes more romantic. In "Heart Of A Hero," seeing that Lee needs to spend more time at the sawmill to help the new settlers find jobs, Rosemary tells Lee that the theatre doesn't have to be built. He insists, but she says how important his job is. He smiles and tells her he will one day build her theatre, telling her that she is "the best part of his life." The couple shares in their first kiss. In "A Gentle Heart," Lee is injured. Thinking he is asleep, Rosemary pours out her heart to him, telling how much she loves him. In "Heartbreak," Rosemary is offered a job in Hollywood filming. This has always been Rosemary's dream, to be an actress. Lee unselfishly tells her to do whatever she feels best, but it is obvious that the thought of her leaving Hope Valley hurts him. Rosemary considers her options and realizes that her place is in Hope Valley, with Lee. Lee then tells her that he has another "role" that he thinks would be perfect for her and proposes marriage. She happily accepts. In "Hearts In Question," Rosemary enthusiastically plans for their wedding. The couple weds in the season 3 finale "Prayers From The Heart," with Elizabeth and Abigail as her maids of honor.
Leland "Lee" Coulter is a kind, laidback, patient man who opens a sawmill in Hope Valley. When timber becomes Coal Valley's major source of natural resources, the town is renamed Hope Valley. He shares a mutual attraction to Rosemary and proves to be one of the few people who can outwit her. When she declines his romantic intentions, Lee recruits his friend, Molly Sullivan, to make Rosemary jealous; the ploy succeeds and Rosemary accepts his suit, appreciating Lee's good qualities. Despite her dramatic and occasionally prickly personality, Lee's compassion and patience never fails with her. With Rosemary's help, Lee beat Mr. Gowen at his own game in "Heart and Home." When not at work, Lee enjoys being with friends, including Jack Thornton, who shares Lee's simple and laidback outlook, allowing the men to discuss their lives and exchange romantic advice. In season 3, Lee's mill is unfortunately sabotaged by a man inside. Through Bill and Jack's investigation, they find the culprit. In season 3's "Heart Of A Hero," Rosemary unselfishly gives up the theatre that Lee promised to build her. Lee promises that one day, he will build her the theatre at a time when he isn't so involved with the sawmill and finding people jobs. In "A Gentle Heart," Lee is injured. Thinking Lee is asleep, Rosemary pours out her heart to Lee, telling him how afraid she was when she heard he had been injured. He however hears each and every word. She told him how much she loves him and to never leave her. In the episode "Heartbreak," Lee thinks Rosemary may leave Hope Valley when she is offered a movie job in Hollywood. When she gives up the movie, seeing her future in Hope Valley with him, he asks her to marry him. The couple weds in the season 3 finale, "Prayers From The Heart." Jack serves the role of Lee's best man.
Julie Thatcher is Elizabeth's hopeless romantic younger sister. She often gets herself into sticky situations by falling head over heels for men who aren't quite what they seem. In season 2 she gets involved with Jack's brother Tom, which causes trouble with her family and for Jack and Elizabeth's relationship.
Cat Montgomery is a kind, encouraging woman in Coal Valley. She is a widow and mother of three: Gabe, Miles, and Emily. Cat was one of the first mothers to show kindness to Elizabeth when she first came. She desperately wants her children to remember the good memories of their father as seen by her self-sacrificing acts in "Secrets and Lies." Possessing a great sense of teamwork and encouragement, Cat supports the women of Coal Valley while working in the mines in "Cease and Desist." She is good friends with Elizabeth and Abigail. In "These Games," she also helps Jack catch a thief.
Florence Blakeley is a feisty gossip in Hope Valley. She often has a pessimistic perspective and always seems to find the negative, even in a very positive situation. In "Heart and Home," Abigail told Florence what she really thought about her, which causes Florence to rein in her negativity somewhat, though she remains fairly outspoken. While not always likable, Florence adds spice to life in Hope Valley.
Molly Sullivan is a friend of Lee Coulter and Elizabeth Thatcher. Molly's husband was killed in the mine disaster. She has a daughter Rosaleen. In season 1's "A Telling Silence," Rosaleen has trouble in school because she misses her father so much. When she runs away, Elizabeth finds her in the mine, feeling guilty that she didn't bring her father his lunch the day of the disaster because she wanted to play with a friend instead. She fears her mother will blame her, but Elizabeth convinces her that Molly will "say that she loves her more than life itself." Molly is reunited with her daughter, to the joy of the town's people. In season 2's "With All My Heart," Lee feels it's time to "play hard to get" with Rosemary, so he enlists help from Molly. She pretends to be interested in him romantically. This ploy works and Rosemary admits that she does in fact like him. Molly is a kind woman and was among the first to welcome Elizabeth to town.
Clara Stanton is the wife of Abigail's late son Peter, and is a sweet, quiet, and sensitive young woman. Abigail never knew she had a daughter-in-law until season 2's "Trials of the Heart;" with Peter having married Clara only three days before he was killed. In "Heart's Desire," Abigail invites Clara to come live with her in Hope Valley, an offer that Clara accepts.
Charles Kensington III is an old friend of Elizabeth with whom she reconnects while in Hamilton. He is interested in her, though her feelings for Jack get in the way of their relationship.

text: Production[edit]

text: The series, originally planned to be filmed in Colorado, is filmed south of Vancouver, British Columbia, on a farm surrounded by vineyards. The fictional frontier town of Coal Valley was erected in late 2013. Some of the set trimmings and a stage coach came from the Hell on Wheels set.[10] The Thatcher home is the University Women's Club of Vancouver.[11]

text: The series was renewed for a second season,[12] which aired from April 25 to June 13, 2015. Hallmark Channel announced in July 2015 that the series had been renewed for a third season, which aired from February 21 to April 10, 2016,[13] with a sneak peek airing during the 2015 Christmas season.[14]

text: In mid-2016, it was announced that Season 4 would premiere on the Hallmark Channel Christmas Day with a two-hour special. On April 11, 2016, Lissing and Krakow announced via the series' Facebook page that Hallmark Channel had renewed the series for a fourth season, which aired from February 19 to April 23, 2017.[15][16]

text: Filming for season five began in Vancouver on August 22, 2017, and ended on December 21, 2017.[17][18]

text: Broadcast[edit]

text: The first season of the series was subsequently picked up by CBC Television for rebroadcast as a summer series in 2015.[19] The network has since aired all five seasons.[20][21] The series became available internationally on Netflix in August 2017.


document_title: List of governors of Madhya Pradesh

question_text: who became the new governor of madhya pradesh

root

text: List of governors of Madhya Pradesh

text: Governors of Madhya Pradesh[edit]

text:
#
Name
Took Office
Left Office

1
Dr. Pattabhi Sitaramayya
1 November 1956
13 June 1957

2
Hari Vinayak Pataskar
14 June 1957
10 February 1965

3
K. Chengalaraya Reddy
11 February 1965
2 February 1966

4
P. V. Dixit (Acting)
2 February 1966
9 February 1966

5
K. Chengalaraya Reddy
10 February 1966
7 March 1971

6
S. N. Sinha
8 March 1971
13 October 1977

7
N. N. Wanchu
14 October 1977
16 August 1978

8
C. M. Poonacha
17 August 1978
29 April 1980

9
B. D. Sharma
30 April 1980
25 May 1981

10
G. P. Singh (Acting)
26 May 1981
9 July 1981

11
B. D. Sharma
10 July 1981
20 September 1983

12
G. P. Singh (Acting)
21 September 1983
7 October 1983

13
B. D. Sharma
8 October 1983
14 May 1984

14
Kizhekethil Chandy
15 May 1984
30 November 1987

15
Narayan Dutta Ojha (Acting)
1 December 1987
29 December 1987

16
Kizhekethil Chandy
30 December 1987
30 March 1989

17
Sarla Grewal
31 March 1989
5 February 1990

18
M. A. Khan
6 February 1990
23 June 1993

19
Mohammad Shafi Qureshi
24 June 1993
21 April 1998

20
Bhai Mahavir
22 April 1998
6 May 2003

21
Ram Prakash Gupta
7 May 2003
1 May 2004

22
Lt. Gen. K. M. Seth (Acting)
2 May 2004
29 June 2004

23
Balram Jakhar
30 June 2004
29 June 2009

24
Rameshwar Thakur
30 June 2009
7 September 2011[1]

25
Ram Naresh Yadav
8 September 2011[1]
7 September 2016

26
Om Prakash Kohli (Additional charge)
8 September 2016 [2]
January 23, 2018

27
Anandiben Patel
January 23, 2018 [3]

tag: table


document_title: Batman: The Enemy Within

question_text: when will batman the enemy within episode 5 be released

text: Batman: The Enemy Within

text: Gameplay[edit]

text: Like most Telltale games, the game features a similar episodic format found in other titles (such as Game of Thrones, The Walking Dead, The Wolf Among Us and Tales from the Borderlands). The player controls Bruce Wayne and his alter-ego Batman, with the game evenly split for both characters. The game features a branching narrative, similar to past Telltale games, giving the player options in approaching a situation and having that choice affect later events in the game. If the player had played the previous game, choices made, such as saving certain characters or stopping a criminal, may also be imported, though the game can be played as a standalone title. The game includes action sequences that are resolved similar to Telltale's other games, using quick time events. The series also includes investigation sequences, allowing the player to use Batman's detective skills to investigate areas. Sections of the game also present situations to the player where they may choose to approach as Bruce Wayne or as Batman. Crowd Play, a feature implemented in the predecessor, also returns for The Enemy Within, allowing streamers to let their audience interact with their session with the game.

tag: p

text: Synopsis[edit]

text: Characters[edit]

text: The player once again assumes control of Bruce Wayne/Batman (Troy Baker), a billionaire who secretly fights crime in Gotham. His butler and former legal guardian Alfred Pennyworth (Enn Reitel), Police Commissioner James Gordon (Murphy Guyer), and Wayne Enterprises Chief of Technology Lucius Fox (Dave Fennoy) return to assist Batman in the field. The game introduces "The Agency", a mysterious government organization with its own agenda led by the ruthless Amanda Waller (Debra Wilson). New supporting characters are also introduced, including Special Agent Iman Avesta (Emily O'Brien), one of the Agency's operatives, and Tiffany Fox (Valarie Rae Miller), the daughter of Lucius and an employee at Wayne Enterprises.

text: "John Doe" (Anthony Ingruber) and Selina Kyle/Catwoman (Laura Bailey) also return, now members of a group of criminals called "the Pact". Other members of the group include Riddler (Robin Atkin Downes), Bane (J. B. Blanc), Dr. Victor Fries/Mr. Freeze (Matthew Mercer) and Harleen Quinzel/Harley Quinn (Laura Post).

text: Detective Renee Montoya (Sumalee Montano), Reporter Jack Ryder (Robert Clotworthy) and Wayne Enterprises Chairwoman Regina Zellerbach (Lorri Holt) return with smaller roles within the series. New minor characters introduced include Police Detective Harvey Bullock (Keith Szarabajka), Agency operative Vernon Blake (Christian Lanz), international arms dealer Rumi Mori (Keone Young), Riddler's second-in-command Eli Knable (Alex Hernandez), and Stacked Deck patrons Frank Dumfree and Willy Deever (Kirk Thornton and Dave B. Mitchell respectively).

text: Setting[edit]

text: The Enemy Within is set in the same Batman continuity introduced in Batman: The Telltale Series, which took place a number of years into Batman's career. Like the previous installment, the game is set during the mid-to-late 2010s in Gotham City, primarily the Batcave, Wayne Enterprises and Gotham City Police Headquarters. The game also follows the events of the previous game, taking place between a couple of months to a year after these events.

text: Plot[edit]

text: Approximately a year after the defeat of the Children of Arkham, Batman continues to patrol Gotham while slowly regaining his reputation as Bruce Wayne. While targeting an arms dealer, he witnesses the return of the Riddler, one of Gotham's first super-criminals. Confronting the criminal with help from Gordon and the GCPD, he fails to capture him and is assisted by the Agency and their operatives. During their clean up, Batman meets Amanda Waller, the director of the Agency, who take over the investigation and offers to assist him in tracking Riddler. After returning to the Batcave with a puzzle left by Riddler, Bruce solves it, though is fazed when discovering a signal emitter. When Lucius Fox, the chief of technology at Wayne Enterprises investigates, he is mysteriously killed in an explosion. At Lucius' funeral, Bruce reunites with former Arkham patient "John Doe", who has been discharged for good behavior. John, having made a number of "friends" after his release, asks Bruce to meet and joined his group, which he refers to as "the Pact". When finding out that Bruce is searching for Riddler, John gives him a lead to investigate in Gotham's East End.

text: With Gordon, Batman follows the lead to discover Riddler's lair, where he discovers clues to his plans and a death trap to solve. He also finds a radio wave guided homing missile and deduces that the signal was actually a homing guide and had drawn a missile to its location if allowed to play long enough, resulting Fox's death. Using evidence he finds, Batman deduces that Riddler plans to target the Agency, having hacked the agent's phones and making them send the targeting signal to call missiles to their locations. Determined to find Riddler, Bruce follows another lead and tracks him to a freight ship. After escaping a deadly game set up by Riddler, Batman manages to redirect the missiles and defeats the criminal. As he is interrogated by the vigilante, Riddler is shot with a poisoned dart and dies, revealing that he is also a member of the Pact. As the Agency and GCPD arrive, Waller takes over law enforcement in Gotham and reveals to Batman her knowledge of his true identity. Waller suggests that he infiltrates the Pact as his alter-ego and gives him an ultimatum: work with the Agency to help arrest the Pact or risk having his identity exposed.

text: Several moments later, a series of explosions go off throughout the city. Responding to an attack at the police arsenal, Batman battles another member of the Pact, Bane, who easily overpowers him with help from a steroid called Venom. Surviving thanks to help from either Gordon or Waller, Batman decides to follow the latter's advice and meets with John to accept his offer. The two meet at a bar, where he is introduced to John's former psychiatrist Harleen Quinzel, now the criminal Harley Quinn. Suspicious of Bruce, Harley gives him a chance to prove himself by stealing a prototype electrical skeleton key from Wayne Enterprises, with them joining him during the heist. Despite problems, including an unexpected encounter with Lucius' grieving daughter Tiffany, he is able to get the device to them and an EMP generator. After this show of compliance, Bruce is called to meet the other members of the Pact, Bane and Mr. Freeze, and convince them to vote him into the group. Successful, he joins them on their latest heist: a mysterious package guarded by an Agency convoy. With Waller refusing to help, Bruce is forced to assist the Pact and escapes with them. Upon returning to the group's hideout, the target is revealed to have been the Riddler's body and that his former ally Catwoman is also a member of the Pact.

text: After copying Riddler's eyes, Harley reveals one of Riddler's laptops, which he had left in their possession, and Bruce, John and Catwoman head to his hideout to find the location of their mark. After solving another death trap hidden in the lair, they discover the target to be an organization called SANCTUS, which Riddler was formerly associated with. The Pact also begin to suspect a mole, due to the time it took for the job to escalate, and suspicions fall on Bruce. After retrieving Harley's laptop through help from either Selina or John, Bruce finds that SANCTUS was one of the Agency's former divisions in charge of experimentation. The laptop contains evidence of a biological weapon called LOTUS and the lab's location, where it is being kept. After the Pact learn of the lab's location, Bruce is forced to either give himself or Selina up as the mole, leading to the Pact attempting to execute them.

text: Depending on the decision, Bruce either accompanies them during the heist and sabotages it or escapes from his fate and confronts the group as Batman, possibly with Catwoman's help. During the heist, Harley betrays the Pact and escapes with the virus, whilst Freeze and Bane are captured by the Agency. While searching for her, Bruce learns that Project LOTUS was a failed restorative agent, with Riddler being the only known survivor of the experiment. The members of the Pact have planned to use his blood to convert the virus into a healing serum to cure their own ailments. However, Waller has been aware of this plan and plotting to blackmail them into joining the Agency, with the promise of a cure. Unknown to all parties, using even the working version can cause mental problems for the user. After following another lead given by John, Bruce finds him surrounded by agents' bodies. Claiming it to be self defense, John realizes the truth about their "friendship" and reveals his knowledge of Bruce's activities as Batman. Regardless of whether he believes him, Bruce leaves to help the Agency capture a volatile Harley Quinn. During the confrontation, John arrives and attacks the Agency, escaping with LOTUS and potentially Quinn, the latter depending on the player's choices.

text: Several weeks later, John, now known as "Joker", reemerges, now either a vigilante with a twisted sense of right and wrong or a criminal collaborating with Quinn to get revenge on Bruce. The former has Batman briefly working with Joker to fights off the Agency, until he kidnaps and attempts to kill Waller. However, the latter has Joker and Harley terrorizing the city with LOTUS and forcing Bruce into a demented game, pitting him against his allies. Regardless of the path, Bruce learns that Tiffany murdered Riddler to avenge her father and he eventually defeats Joker. Following Joker's capture, Waller orders the Agency to leave Gotham and promises not to reveal Bruce's identity. As Batman, Bruce confronts Tiffany, leading to her either leaving to work for the Agency, joining him in his crusade against crime, escaping to become a fugitive, or being handed over to the authorities for murder. Returning to the manor, Bruce learns that Alfred has decided to leave Gotham to return home, having been struggling to continue since he was kidnapped by Lady Arkham. After a heated discussion, Bruce either decides to leave the life of vigilantism behind to convince Alfred to stay or allows him to leave whilst he continues to operate as Batman.

text: In a post credits scene, Joker is shown to have been returned to Arkham Asylum. If he was a vigilante, he is either visited by Bruce or decides to become the hero's archenemy. However, if he was a criminal, he is shown playing with a doll version of Bruce, which he promises to see again.

text: Episodes[edit]

text:
No.
overall
No. in
season
Title
Directed by
Written by
Original release date

1
1
"The Enigma"
Kent Mudle
James Windeler, Patrick Kevin Day & Shanon Ingles
August 8, 2017 (2017-08-08)

2
2
"The Pact"
Matthew Leach
Luke McMullen, Chris Hockabout, Shanon Ingles & Patrick Kevin Day
October 3, 2017 (2017-10-03)

3
3
"Fractured Mask"
Sean Manning
Ross Beeley, Shanon Ingles, Lauren R. Mee & Josh R. Trujillo
November 21, 2017 (2017-11-21)

4
4
"What Ails You"
Chris Rieser
Patrick Kevin Day & Lauren R. Mee
January 23, 2018 (2018-01-23)

5
5
"Same Stitch"
Kent Mudle
Meghan Thornton, Ross Beeley & Lauren R. Mee
March 27, 2018 (2018-03-27)

text: Reception[edit]

text: Critical reception[edit]

text: This section may lend undue weight to certain ideas, incidents, or controversies. Please help to create a more balanced presentation. Discuss and resolve this issue before removing this message. (April 2018)

text: Batman: The Enemy Within received generally positive reviews from critics, some of which considered it an improvement over its predecessor, earning praise for its story, choices, action sequences, and portrayal of the Batman mythos.[3][4][5] The game won the award for "Performance in a Drama, Supporting" with Debra Wilson at the 17th Annual National Academy of Video Game Trade Reviewers Awards, whereas its other nomination was for "Game, Franchise Adventure".[6][7]

text: Many reviewers praised the game's unique depiction of the Joker, with the player being given the opportunity to try to prevent him from becoming a villain. For example, Scott Maslow from GQ was happily surprised by this version of the Joker and said it managed to make "Batman's most overexposed villain" interesting again: "The Joker has always said his past is multiple-choice, but this is the first time I’ve felt like I was the one checking the boxes."[8] Bradley Shankar from MobileSyrup was especially positive with a review titled "Batman: The Enemy Within offers one of the greatest Joker stories ever told". He explained: "... while there have been numerous great interpretations of the Batman-Joker relationship over the years, there has never been one quite as complex and morally grey as what Telltale has created with The Enemy Within".[9] Tamoor Hussain from GameSpot gave the final episode a 9/10, concluding: "While Telltale's first Batman season stuck a bit too close to established mythos and delivered an underwhelming ending, the second is a memorable Joker origin story that Bat-fans should make a point of playing."[10] Stephanie Chan from VentureBeat was slightly less enthusiastic but still gave the game a score of 80/100 and said: "By the end of the series, I’ll say that Batman: The Enemy Within has tentatively won me over. That’s purely on the strength of the relationship between Batman and The Joker."[11]


document_title: Throw Momma from the Train

question_text: who played the mother in throw momma from the train

text: Throw Momma from the Train

text: Plot[edit]

text: Novelist Larry Donner (Billy Crystal) struggles with writer's block due to his resentment towards his ex-wife Margaret (Kate Mulgrew), who stole his book and garnered mainstream success and critical acclaim with it. Owen Lift (Danny DeVito) is a timid, middle-aged fellow who still lives with his overbearing, abusive and paranoid mother (Anne Ramsey). Owen fantasizes about killing his mother but can't summon the courage to bring his desires into fruition. As a student in Larry's community college writing class, Owen is given advice by Larry to view an Alfred Hitchcock film to gain some insight into plot development for his mystery stories. He sees Strangers on a Train, in which two strangers conspire to commit a murder for each other, figuring their lack of connection to the victim will, in theory, establish a perfect alibi. Having overheard Larry's public rant that he wished his ex-wife dead, Owen forms a plan to kill Margaret, believing that Larry will, in return, kill his mother.

text: He tracks Margaret down to Hawaii and eventually follows her onto a cruise ship she is taking to her book signing. He then apparently pushes her overboard while she tries to retrieve an earring that fell. Owen returns from Hawaii to tell Larry of Margaret's death and that Larry now "owes" him the murder of his mother, lest he inform the police that Larry was the killer. After having spent the night drinking alone during the hours of Margaret's disappearance, Larry panics because he lacks a sufficient alibi. That, along with a news report announcing that the police suspect foul play, convinces Larry that he's the prime suspect. He decides to stay with Owen and his mother in an attempt to hide from the police. Larry meets Mrs. Lift, but despite her harsh treatment of him he refuses to kill her. Eventually, when Mrs. Lift drives Owen to the breaking point, Larry finally relents and agrees to go through with the murder.

text: After two unsuccessful attempts, Larry flees the Lift home when Mrs. Lift recognizes him as a suspect from a news broadcast about his ex-wife's disappearance. He boards a train to Mexico and, surprisingly, Owen and Mrs. Lift come along so as to avoid having to lie for him. During the journey, Larry's patience with Mrs. Lift finally runs out when she impolitely gives him advice on writing. He follows her to the caboose with the intent of throwing her from the train, but Owen begins having second thoughts about having his mother killed and gives chase. In the ensuing fight, Mrs. Lift falls from the train but is rescued by Owen and a repentant Larry. Mrs. Lift is grateful at her son for saving her, but unappreciative of Larry's help and kicks him, resulting in him losing his balance, landing on the tracks and breaking his leg.

text: During his recovery in hospital, Larry discovers that Margaret is still alive; she simply fell overboard by accident and was rescued by a Polynesian fisherman whom she has decided to marry. Much to his annoyance, Larry learns that Margaret plans to sell the rights of her ordeal for $1.5 million. On the advice of a fellow patient, Larry chooses to free himself of his obsession with his ex-wife and instead focus on his own life, thereby freeing him of his writer's block.

text: A year later, Larry has finished a novel based on his experiences with Owen and Mrs. Lift entitled Throw Momma from the Train. Owen visits and informs him that his mother has died (of natural causes) and that he's going to New York City for the release of his own book. Unfortunately for Larry, Owen reveals that his book is also about their experiences together. Thinking that his book has been scooped once again, an enraged Larry proceeds to strangle him, but stops when Owen shows him that his book is a children's pop-up book called Momma, and Owen, and Owen's Friend, Larry with the story drastically altered to be suitable for children. Months later, Larry, Owen, and Larry's girlfriend Beth (Kim Greist) vacation together in Hawaii, reflecting on the final chapter of Larry's book. Larry and Owen's books have now become best-sellers, making them both successful writers as well as close friends.

text: Cast[edit]

text:
Danny DeVito as Owen Lift
Billy Crystal as Larry Donner
Anne Ramsey as Momma Lift
Kim Greist as Beth
Kate Mulgrew as Margaret Donner
Branford Marsalis as Lester
Rob Reiner as Larry's agent Joel
Bruce Kirby as Detective DeBenedetto
Oprah Winfrey as Herself
Farley Granger as Guy Haines (archive footage)
Robert Walker as Bruno Anthony (archive footage)

tag: ul

text: Reception[edit]

text: Review aggregation website Rotten Tomatoes gives the film a score of 63% based on reviews from 32 critics, with the consensus being that "Danny DeVito's direction is too broad to offer the kind of nastiness that would have made Throw Momma from the Train truly special, but DeVito's on-screen chemistry with co-star Billy Crystal makes this a smoothly entertaining comedy."[4]

text: Awards and nominations[edit]

text:
Award
Category
Subject
Result

Academy Award
Best Supporting Actress
Anne Ramsey
Nominated

Saturn Award
Best Supporting Actress
Won

Golden Globe Award
Best Supporting Actress – Motion Picture
Nominated

Best Actor – Motion Picture Musical or Comedy
Danny DeVito
Nominated


document_title: Bismuth subsalicylate

question_text: where does the name pepto bismol come from

text: Bismuth subsalicylate

text: Medical uses[edit]

text: As a derivative of salicylic acid, bismuth subsalicylate displays anti-inflammatory[2] and bactericidal action.[3] It also acts as an antacid.

text: Adverse effects[edit]

text: There are some adverse effects. It can cause a black tongue and black stools in some users of the drug, when it combines with trace amounts of sulfur in saliva and the colon to form bismuth sulfide.[4] Bismuth sulfide is a highly insoluble black salt, and the discoloration seen is temporary and harmless.

text: Long-term use (greater than 6 weeks) may lead to accumulation and toxicity.[5] Some of the risks of salicylism can apply to the use of bismuth subsalicylate.[6][7][8]

text: Children should not take medication with bismuth subsalicylate while recovering from influenza or chicken pox, as epidemiologic evidence points to an association between the use of salicylate-containing medications during certain viral infections and the onset of Reye's syndrome.[9] For the same reason, it is typically recommended that nursing mothers not use medication containing bismuth subsalicylate because small amounts of the medication are excreted in human breast milk, and these pose a theoretical risk of Reye's syndrome to nursing children.[10]

text: Salicylates are very toxic to cats, and thus bismuth subsalicylate should not be administered to cats.[11]

text: Mechanism of action[edit]

text: Bismuth subsalicylate is used as an antacid and antidiarrheal, and to treat some other gastrointestinal symptoms, such as nausea. The means by which this occurs is still not well documented. It is thought to be some combination of the following:[12]

text:
Retarding the expulsion of fluids into the digestive system by irritated tissues, by "coating" them.
Stimulation of absorption of fluids and electrolytes by the intestinal wall (antisecretory action)
As a salicylate, reducing inflammation/irritation of stomach and intestinal lining through inhibition of prostaglandin G/H synthase 1/2
Reduction in hypermotility of the stomach
Binding of toxins produced by Escherichia coli
Bactericidal action of a number of its subcomponents, including salicylic acid[13]
Bactericidal action via a so-called oligodynamic effect in which small amounts of heavy metals such as bismuth are toxic for a number of microbes
Weak antacid properties

text: In vitro and in vivo data have shown that bismuth subsalicylate hydrolyzes in the gut to bismuth oxychloride and salicylic acid and less commonly bismuth hydroxide. In the stomach, this is likely an acid-catalyzed hydrolysis. The salicylic acid is absorbed and therapeutical concentrations of salicylic acid can be found in blood after bismuth subsalicylate administration. Bismuth oxychloride and bismuth hydroxide are both believed to have bactericidal effects, as is salicylic acid for enterotoxigenic E. coli a common cause of "traveler's diarrhea."[13]

text: Organobismuth compounds have historically been used in growth media for selective isolation of microorganisms. Such salts have been shown to inhibit proliferation of Helicobacter pylori, other enteric bacteria, and some fungi.[14]

text: Decomposition[edit]

text: Bismuth subsalicylate is the only active ingredient in an over-the-counter drug that can leave a shiny metal oxide slag behind after being completely burnt with a blow torch.[15]

text: History[edit]

text: While bismuth salts were in use in Europe by the late 1700s, the combination of bismuth subsalicylate and zinc salts for astringency with salol (phenyl salicilate) appears to have begun in the US in the early 1900s as a remedy for life-threatening diarrhea in infants with cholera. At first sold directly to physicians, it was first marketed as Bismosal in 1918.[16]

text: Pepto-Bismol began being sold in 1900[16] or 1901[17] by a doctor in New York. It was originally sold as a remedy for infant diarrhea by Norwich Pharmacal Company under the name "Bismosal: Mixture Cholera Infantum".[16] It was renamed Pepto-Bismol in 1919. Norwich Eaton Pharmaceuticals was acquired by Procter and Gamble in 1982.[18]

text: As of 1946, Canadian advertisements placed by Norwich show the product as Pepto-Besmol both in graphic and text.[19]

text: Pepto-Bismol is an over-the-counter drug currently produced by the Procter & Gamble company in the United States, Canada and the United Kingdom. Pepto-Bismol is made in chewable tablets[20] and swallowable caplets,[21] but it is best known for its original formula, which is a thick liquid. This original formula is a medium pink in color, with a strong wintergreen or cherry[citation needed] flavor.


document_title: Ectopic pregnancy

question_text: when do the clinical manifestations of an ectopic pregnancy typically appear

text: Ectopic pregnancy

text: Signs and symptoms[edit]

text: Up to 10% of women with ectopic pregnancy have no symptoms, and one third have no medical signs.[4] In many cases the symptoms have low specificity, and can be similar to those of other genitourinary and gastrointestinal disorders, such as appendicitis, salpingitis, rupture of a corpus luteum cyst, miscarriage, ovarian torsion or urinary tract infection.[4] Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 4 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability.

text: Signs and symptoms of ectopic pregnancy include increased hCG, vaginal bleeding (in varying amounts), sudden lower abdominal pain,[4] pelvic pain, a tender cervix, an adnexal mass, or adnexal tenderness.[1] In the absence of ultrasound or hCG assessment, heavy vaginal bleeding may lead to a misdiagnosis of miscarriage.[4] Nausea, vomiting and diarrhea are more rare symptoms of ectopic pregnancy.[4]

text: Rupture of an ectopic pregnancy can lead to symptoms such as abdominal distension, tenderness, peritonism and hypovolemic shock.[4] A woman with ectopic pregnancy may be excessively mobile with upright posturing, in order to decrease intrapelvic blood flow, which can lead to swelling of the abdominal cavity and cause additional pain.[8]

text: Complications[edit]

text: The most common complication is rupture with internal bleeding which may lead to hypovolemic shock. Death from rupture is still the leading cause of death in the first trimester of the pregnancy.[citation needed]

text: Causes[edit]

text: There are a number of risk factors for ectopic pregnancies. However, in as many as one third[9] to one half[10] no risk factors can be identified. Risk factors include: pelvic inflammatory disease, infertility, use of an intrauterine device (IUD), previous exposure to DES, tubal surgery, intrauterine surgery (e.g. D&C), smoking, previous ectopic pregnancy, endometriosis, and tubal ligation.[11][12] A previous induced abortion does not appear to increase the risk.[13]

text: Tube damage[edit]

text: Tubal pregnancy is when the egg is implanted in the Fallopian tubes. Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Fallopian cilia are sometimes seen in reduced numbers subsequent to an ectopic pregnancy, leading to a hypothesis that cilia damage in the Fallopian tubes is likely to lead to an ectopic pregnancy.[14] Women who smoke have a higher chance of an ectopic pregnancy in the fallopian tubes. Smoking leads to risk factors of damaging and/or killing cilia.[14] As cilia degenerate, the amount of time it takes for the fertilized egg to reach the uterus will increase. The fertilized egg, if it doesn't reach the uterus in time, will hatch from the non-adhesive zona pellucida and implant itself inside the fallopian tube, thus causing the pregnancy.

text: Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy.[15] This results from the build-up of scar tissue in the Fallopian tubes, causing damage to cilia.[16] If however both tubes were completely blocked, so that sperm and egg were physically unable to meet, then fertilization of the egg would naturally be impossible, and neither normal pregnancy nor ectopic pregnancy could occur. Intrauterine adhesions (IUA) present in Asherman's syndrome can cause ectopic cervical pregnancy or, if adhesions partially block access to the tubes via the ostia, ectopic tubal pregnancy.[17][18][19] Asherman's syndrome usually occurs from intrauterine surgery, most commonly after D&C.[17] Endometrial/pelvic/genital tuberculosis, another cause of Asherman's syndrome, can also lead to ectopic pregnancy as infection may lead to tubal adhesions in addition to intrauterine adhesions.[20]

text: Tubal ligation can predispose to ectopic pregnancy. Reversal of tubal sterilization (Tubal reversal) carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubal clipping). A history of a tubal pregnancy increases the risk of future occurrences to about 10%.[16] This risk is not reduced by removing the affected tube, even if the other tube appears normal. The best method for diagnosing this is to do an early ultrasound.

text: Other[edit]

text: Although some investigations have shown that patients may be at higher risk for ectopic pregnancy with advancing age, it is believed that age is a variable which could act as a surrogate for other risk factors. Vaginal douching is thought by some to increase ectopic pregnancies.[16] Women exposed to diethylstilbestrol (DES) in utero (also known as "DES daughters") also have an elevated risk of ectopic pregnancy.[21] It has also been suggested that pathologic generation of nitric oxide through increased iNOS production may decrease tubal ciliary beats and smooth muscle contractions and thus affect embryo transport, which may consequently result in ectopic pregnancy.[22] The low socioeconomic status may be risk factors for ectopic pregnancy.[23]

text: Diagnosis[edit]

text: An ectopic pregnancy should be considered as the cause of abdominal pain or vaginal bleeding in every woman who has a positive pregnancy test.[1] The primary goal of diagnostic procedures in possible ectopic pregnancy is to triage according to risk rather than establishing pregnancy location.[4]

text: Transvaginal ultrasonography[edit]

text: An ultrasound showing a gestational sac with fetal heart in the fallopian tube has a very high specificity of ectopic pregnancy. Transvaginal ultrasonography has a sensitivity of at least 90% for ectopic pregnancy.[4] The diagnostic ultrasonographic finding in ectopic pregnancy is an adnexal mass that moves separately from the ovary. In around 60% of cases, it is an inhomogeneous or a noncystic adnexal mass sometimes known as the "blob sign". It is generally spherical, but a more tubular appearance may be seen in case of hematosalpinx. This sign has been estimated to have a sensitivity of 84% and specificity of 99% in diagnosing ectopic pregnancy.[4] In the study estimating these values, the blob sign had a positive predictive value of 96% and a negative predictive value of 95%.[4] The visualization of an empty extrauterine gestational sac is sometimes known as the "bagel sign", and is present in around 20% of cases.[4] In another 20% of cases, there is visualization of a gestational sac containing a yolk sac and/or an embryo.[4] Ectopic pregnancies where there is visualization of cardiac activity are sometimes termed "viable ectopic".[4]

text:
Transvaginal ultrasonography of an ectopic pregnancy, showing the field of view in the following image.

A "blob sign", which consists of the ectopic pregnancy. The ovary is distinguished from it by having follicles, whereof one is visible in the field. This patient had an intrauterine device (IUD) with progestogen, whose cross-section is visible in the field, leaving an ultrasound shadow distally to it.

Ultrasound image showing an ectopic pregnancy where a gestational sac and fetus has been formed.

text: The combination of a positive pregnancy test and the presence of what appears to be a normal intrauterine pregnancy does not exclude an ectopic pregnancy, since there may be either a heterotopic pregnancy or a "pseudosac", which is a collection of within the endometrial cavity that may be seen in up to 20% of women.[4]

text: A small amount of anechogenic-free fluid in the recto-uterine pouch is commonly found in both intrauterine and ectopic pregnancies.[4] The presence of echogenic fluid is estimated at between 28 and 56% of women with an ectopic pregnancy, and strongly indicates the presence of hemoperitoneum.[4] However, it does not necessarily result from tubal rupture, but is commonly a result from leakage from the distal tubal opening.[4] As a rule of thumb, the finding of free fluid is significant if it reaches the fundus or is present in the vesico-uterine pouch.[4] A further marker of serious intra-abdominal bleeding is the presence of fluid in the hepatorenal recess of the subhepatic space.[4]

text: Currently, Doppler ultrasonography is not considered to significantly contribute to the diagnosis of ectopic pregnancy.[4]

text: A common misdiagnosis is of a normal intrauterine pregnancy is where the pregnancy is implanted laterally in an arcuate uterus, potentially being misdiagnosed as an interstitial pregnancy.[4]

text: Ultrasonography and β-hCG[edit]

text:
Where no intrauterine pregnancy is seen on ultrasound, measuring β-human chorionic gonadotropin (β-hCG) levels may aid in the diagnosis. The rationale is that a low β-hCG level may indicate that the pregnancy is intrauterine but yet too small to be visible on ultrasonography. While some physicians consider that the threshold where an intrauterine pregnancy should be visible on transvaginal ultrasound is around 1500 IU/ml of β-hCG, a review in the JAMA Rational Clinical Examination Series showed that there is no single threshold for the β-human chorionic gonadotropin that confirms an ectopic pregnancy. Instead, the best test in a pregnant woman is a high resolution transvaginal ultrasound.[1] The presence of an adnexal mass in the absence of an intrauterine pregnancy on transvaginal sonography increases the likelihood of an ectopic pregnancy 100-fold (LR+ 111). When there are no adnexal abnormalities on transvaginal sonography, the likelihood of an ectopic pregnancy decreases (LR- 0.12). An empty uterus with levels higher than 1500 IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If the diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work. This can be done by measuring the β-hCG level approximately 48 hours later and repeating the ultrasound. The serum hCG ratios and logistic regression models appear to be better than absolute single serum hCG level.[25] If the β-hCG falls on repeat examination, this strongly suggests a spontaneous abortion or rupture. The fall in serum hCG over 48 hours may be measured as the hCG ratio, which is calculated as:[4]

h
C
G

r
a
t
i
o
=

h
C
G

a
t

48
h

h
C
G

a
t

0
h

{\displaystyle hCG~ratio={\frac {hCG~at~48h}{hCG~at~0h}}}

text: An hCG ratio of 0.87, that is, a decrease in hCG of 13% over 48 hours, has a sensitivity of 93% and specificity of 97% for predicting a failing PUL.[4] The majority of cases of ectopic pregnancy will have serial serum hCG levels that increase more slowly than would be expected with an IUP (that is, a suboptimal rise), or decrease more slowly than would be expected with a failing PUL. However, up to 20% of cases of ectopic pregnancy have serum hCG doubling times similar to that of an IUP, and around 10% of EP cases have hCG patterns similar to a failing PUL.[4]

text: Other diagnostic methods[edit]

text: A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. This is generally reserved for women presenting with signs of an acute abdomen and/or hypovolemic shock.[4] Often if a tubal abortion or tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal looking fallopian tube.

text: Culdocentesis, in which fluid is retrieved from the space separating the vagina and rectum, is a less commonly performed test that may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found may have been derived from a ruptured ectopic pregnancy.

text: Progesterone levels of less than 20 nmol/l have a high predictive value for failing pregnancies, whilst levels over 25 nmol/l are likely to predict viable pregnancies, and levels over 60 nmol/l are strongly so. This may help in identifying failing PULs that are at low risk and thereby needing less follow-up.[4] Inhibin A may also be useful for predicting spontaneous resolution of PUL, but is not as good as progesterone for this purpose.[4]

text: In addition, there are various mathematical models, such as logistic regression models and Bayesian networks, for the prediction of PUL outcome based on multiple parameters.[4] Mathematical models also aim to identify PULs that are low risk, that is, failing PULs and IUPs.[4]

text: Dilation and curettage (D&C) is sometimes used to diagnose pregnancy location with the aim of differentiating between an EP and a non-viable IUP in situations where a viable IUP can be ruled out. Specific indications for this procedure include either of the following:[4]

text:
no visible IUP on transvaginal ultrasonography with a serum hCG of more than 2000 IU/ml
an abnormal rise in hCG level. A rise of 35% over 48 hours is proposed as the minimal rise consistent with a viable intrauterine pregnancy.
an abnormal fall in hCG level, such as defined as one of less than 20% in 2 days

text: Classification[edit]

text: Tubal pregnancy[edit]

text: The vast majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can grow in the fimbrial end (5% of all ectopic pregnancies), the ampullary section (80%), the isthmus (12%), and the cornual and interstitial part of the tube (2%).[16] Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal bleeding. A review published in 2010 supports the hypothesis that tubal ectopic pregnancy is caused by a combination of retention of the embryo within the fallopian tube due to impaired embryo-tubal transport and alterations in the tubal environment allowing early implantation to occur.[26]

text: Nontubal ectopic pregnancy[edit]

text: Two percent of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria.[27]

text: While a fetus of ectopic pregnancy is typically not viable, very rarely, a live baby has been delivered from an abdominal pregnancy. In such a situation the placenta sits on the intraabdominal organs or the peritoneum and has found sufficient blood supply. This is generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Support to near viability has occasionally been described, but even in Third World countries, the diagnosis is most commonly made at 16 to 20 weeks' gestation. Such a fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy are high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data are unavailable and reliance must be made on anecdotal reports.[28][29][30] However, the vast majority of abdominal pregnancies require intervention well before fetal viability because of the risk of bleeding.

text: Heterotopic pregnancy[edit]

text: In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy.[1] Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound.

text: Although rare, heterotopic pregnancies are becoming more common, likely due to increased use of IVF. The survival rate of the uterine fetus of a heterotopic pregnancy is around 70%.[31]

text: Persistent ectopic pregnancy[edit]

text: A persistent ectopic pregnancy refers to the continuation of trophoblastic growth after a surgical intervention to remove an ectopic pregnancy. After a conservative procedure that attempts to preserve the affected fallopian tube such as a salpingotomy, in about 15–20% the major portion of the ectopic growth may have been removed, but some trophoblastic tissue, perhaps deeply embedded, has escaped removal and continues to grow, generating a new rise in hCG levels.[32] After weeks this may lead to new clinical symptoms including bleeding. For this reason hCG levels may have to be monitored after removal of an ectopic pregnancy to assure their decline, also methotrexate can be given at the time of surgery prophylactically.

text: Pregnancy of unknown location[edit]

text: Pregnancy of unknown location (PUL) is the term used for a pregnancy where there is a positive pregnancy test but no pregnancy has been visualized using transvaginal ultrasonography.[4] Specialized early pregnancy departments have estimated that between 8 and 10% of women attending for an ultrasound assessment in early pregnancy will be classified as having a PUL.[4] The true nature of the pregnancy can be an ongoing viable intrauterine pregnancy, a failed pregnancy, an ectopic pregnancy or rarely a persisting PUL.[4]

text: Because of frequent ambiguity on ultrasonography examinations, the following classification is proposed:[4]

text:
Condition
Criteria

Definite ectopic pregnancy
Extrauterine gestational sac with yolk sac and/or
embryo (with or without cardiac activity).

Pregnancy of unknown location - probable ectopic pregnancy
Inhomogeneous adnexal mass or extrauterine sac-like structure.

"True" pregnancy of unknown location
No signs of intrauterine nor extrauterine pregnancy on transvaginal ultrasonography.

Pregnancy of unknown location - probable intrauterine pregnancy
Intrauterine gestational sac-like structure.

Definite intrauterine pregnancy
Intrauterine gestational sac with yolk sac and/or embryo (with or without cardiac activity).

text: In women with a pregnancy of unknown location, between 6% and 20% have an ectopic pregnancy.[4] In cases of pregnancy of unknown location and a history of heavy bleeding, it has been estimated that approximately 6% have an underlying ectopic pregnancy.[4] Between 30 and 47% of women with pregnancy of unknown location are ultimately diagnosed with an ongoing intrauterine pregnancy, whereof the majority (50 –70%) will be found to have failing pregnancies where the location is never confirmed.[4]

text: Persisting PUL is where the hCG level does not spontaneously decline and no intrauterine or ectopic pregnancy is identified on follow-up transvaginal ultrasonography.[4] A persisting PUL is likely either a small ectopic pregnancy that has not been visualized, or a retained trophoblast in the endometrial cavity.[4] Treatment should only be considered when a potentially viable intrauterine pregnancy has been definitively excluded.[4] A treated persistent PUL is defined as one managed medically (generally with methotrexate) without confirmation of the location of the pregnancy such as by ultrasound, laparoscopy or uterine evacuation.[4] A resolved persistent PUL is defined as serum hCG reaching a non-pregnant value (generally less than 5 IU/l) after expectant management, or after uterine evacuation without evidence of chorionic villi on histopathological examination.[4] In contrast, a relatively low and unresolving level of serum hCG indicates the possibility of an hCG-secreting tumour.[4]

text: Differential diagnosis[edit]

text: Other conditions that cause similar symptoms include: miscarriage, ovarian torsion, and acute appendicitis, ruptured ovarian cyst, kidney stone, and pelvic inflammatory disease, among others.[1]

text: Treatment[edit]

text: Expectant management[edit]

text: Most women with a PUL are followed up with serum hCG measurements and repeat TVS examinations until a final diagnosis is confirmed.[4] Low-risk cases of PUL that appear to be failing pregnancies may be followed up with a urinary pregnancy test after two weeks and get subsequent telephone advice.[4] Low-risk cases of PUL that are likely intrauterine pregnancies may have another TVS in two weeks to access viability.[4] High-risk cases of PUL require further assessment, either with a TVS within 48 h or additional hCG measurement.[4]

text: Medical[edit]

text: Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment[33] which was developed in the 1980s.[34] If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; this may cause an abortion, or the developing embryo may then be either resorbed by the woman's body or pass with a menstrual period. Contraindications include liver, kidney, or blood disease, as well as an ectopic embryonic mass > 3.5 cm.

text: Also, it may lead to the inadvertent termination of an undetected intrauterine pregnancy, or severe abnormality in any surviving pregnancy.[4] Therefore, it is recommended that methotrexate should only be administered when hCG has been serially monitored with a rise less than 35% over 48 hours, which practically excludes a viable intrauterine pregnancy.[4]

text: Surgical[edit]

text: If bleeding has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound.[citation needed]

text: Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883.[35] It is estimated that an acceptable rate of PULs that eventually undergo surgery is between 0.5 and 11%.[4]

text: Autotransfusion of a woman's own blood as drained during surgery may be useful in those who have a lot of bleeding into their abdomen.[36]

text: Published reports that a re-implanted embryo survived to birth were debunked as false.[37]

text: Prognosis[edit]

text: When ectopic pregnancies are treated, the prognosis for the mother is very good in Western countries; maternal death is rare, but most fetuses die or are aborted. For instance, in the UK, between 2003 and 2005 there were 32,100 ectopic pregnancies resulting in 10 maternal deaths (meaning that 1 in 3,210 women with an ectopic pregnancy died).[38]

text: In the developing world, however, especially in Africa, the death rate is very high, and ectopic pregnancies are a major cause of death among women of childbearing age.

text: Future fertility[edit]

text: Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior history of infertility.[39] The treatment choice does not play a major role; A randomized study in 2013 concluded that the rates of intrauterine pregnancy two years after treatment of ectopic pregnancy are approximately 64% with radical surgery, 67% with medication, and 70% with conservative surgery.[40] In comparison, the cumulative pregnancy rate of women under 40 years of age in the general population over 2 years is over 90%.[41]

text: Epidemiology[edit]

text: The rate of ectopic pregnancy is about 1 and 2% of that of live births in developed countries, though it is as high as 4% in pregnancies involving assisted reproductive technology.[4] Between 93 and 97% of ectopic pregnancies are located in a Fallopian tube.[1] Of these, in turn, 13% are located in the isthmus, 75% are located in the ampulla, and 12% in the fimbriae.[4] Ectopic pregnancy is responsible for 6% of maternal deaths during the first trimester of pregnancy making it the leading cause of maternal death during this stage of pregnancy.[1]

text: Between 5% and 42% of women seen for ultrasound assessment with a positive pregnancy test have a pregnancy of unknown location (PUL), that is a positive pregnancy test but no pregnancy visualized at transvaginal ultrasonography.[4] Between 6 and 20% of PUL are subsequently diagnosed with actual ectopic pregnancy.[4]

text: Society and culture[edit]

text: Salpingectomy as a treatment for ectopic pregnancy is one of the common cases when the principle of double effect can be used to justify accelerating the death of the embryo by doctors and patients opposed to outright abortions.[43]

text: In the Catholic Church, there are moral debates on certain treatments. A significant number of Catholic moralists consider use of methotrexate and the salpingostomy procedure to be not "morally permissible" because they destroy the embryo; however, situations are considered differently in which the mother's health is endangered, and the whole fallopian tube with the developing embryo inside is removed.[44][45]

text: Live birth[edit]

text: There have been cases where ectopic pregnancy lasted many months and ended in a live baby delivered by laparotomy.

text: In July 1999, Lori Dalton gave birth by caesarean section in Ogden, Utah, United States, to a healthy baby girl who had developed outside of the uterus. Previous ultrasounds had not discovered the problem. "[Sage Dalton]'s delivery was slated as a routine Caesarean birth at Ogden Regional Medical Center in Utah. When Dr. Naisbitt performed Lori's Caesarean, he was astonished to find Sage within the amniotic membrane outside the womb ... ."[46] "But what makes this case so rare is that not only did mother and baby survive—they're both in perfect health. John Dalton [(the father)] took home video inside the delivery room. Sage came out doing extremely well because even though she had been implanted outside the womb, a rich blood supply from a uterine fibroid along the outer uterus wall had nourished her with a rich source of blood."[47]

text: On May 29, 2008 an Australian woman, Meera Thangarajah (age 34), who had an ectopic pregnancy in the ovary, gave birth to a healthy full term 6 pound 3 ounce (2.8 kg) baby girl, Durga, via caesarean section. She had no problems or complications during the 38‑week pregnancy.[48][49]

text: In September 1999 an English woman, Jane Ingram (age 32) gave birth to triplets: Olivia, Mary and Ronan, with an extrauterine fetus (Ronan) below the womb and twins in the womb. All three survived. The twins in the womb were taken out first.[50]

text: Other animals[edit]

text: Ectopic gestation exists in mammals other than humans. In sheep, it can go to term, with mammary preparation to parturition, and expulsion efforts. The fetus can be removed by caesarean section. Pictures of caesarian section of a euthanized ewe, 5 days after parturition signs.

text:
Leg of fetal lamb appearing out of the uterus during caesarian section.

External view of fetal sac, necrotic distal part.

Internal view of fetal sac, before resection of distal necrotic part.

Internal view of fetal sac, the necrotic distal part is to the left.

External side of fetal sac, proximal end, with ovary and uterine horn.

Resected distal part of fetal sac, with attached placenta.