A 35-year-old woman with a 16-month history of heavy menstrual bleeding reports that her periods last 9 days and she passes large clots. She has tried tranexamic acid and mefenamic acid with minimal improvement. She has two children and does not wish for future pregnancy. Examination is normal and transvaginal ultrasound shows a normal uterus (8 cm length) with no fibroids and endometrial thickness of 6 mm on day 5 of cycle. Full blood count shows haemoglobin 101 g/L. She declines hormonal treatment. What is the most appropriate next management option?

Prescribe oral norethisterone for cycle regulation

Increase dose of tranexamic acid and mefenamic acid

Offer trial of levonorgestrel intrauterine system despite preferences

A 26-year-old woman presents to the emergency department with sudden onset severe left-sided pelvic pain, nausea, and one episode of syncope 2 hours ago. She has 7 weeks amenorrhoea. On examination, she is alert with heart rate 102 bpm, blood pressure 104/68 mmHg, and temperature 36.8°C. Abdominal examination reveals left iliac fossa tenderness with mild guarding but no rigidity. Transvaginal ultrasound shows an empty uterus, a 35 mm left adnexal mass with a hyperechoic ring, and a small amount of free fluid in the pouch of Douglas. Serum beta-hCG is 5600 IU/L. What is the most appropriate management?

Diagnostic laparoscopy with decision for salpingectomy or salpingotomy at surgery

Admit for observation with 4-hourly observations and repeat ultrasound in 24 hours

Arrange urgent MRI pelvis to better characterise the adnexal mass

A 41-year-old woman with a 10-month history of heavy menstrual bleeding undergoes hysteroscopy which reveals a 3 cm type 2 submucosal fibroid partially extending into the myometrium (>50% intramural component). She wishes to preserve her fertility. Transvaginal ultrasound confirms no other significant fibroids and normal endometrial cavity. What is the most appropriate initial management?

Trial of levonorgestrel intrauterine system

GnRH agonist therapy for 6 months

A 31-year-old woman presents to the emergency department with left-sided pelvic pain and 7 weeks amenorrhoea. Transvaginal ultrasound demonstrates an empty uterus and a 20 mm left adnexal mass. Initial serum beta-hCG is 1450 IU/L. She is clinically stable. Repeat beta-hCG 48 hours later is 1380 IU/L. What is the most appropriate management?

Expectant management with weekly beta-hCG monitoring

Repeat beta-hCG in 48 hours to confirm declining trend

Arrange MRI pelvis to confirm ectopic location

What is the primary mechanism by which endometrial ablation reduces menstrual bleeding in women with heavy menstrual bleeding?

Destruction of the endometrial basalis layer preventing regeneration

Reduction in endometrial blood vessel density through thermal injury

Decreased prostaglandin production from damaged endometrium

Hormonal suppression of endometrial proliferation

Formation of intrauterine adhesions reducing cavity volume

A 38-year-old multiparous woman with heavy menstrual bleeding has had a levonorgestrel intrauterine system in situ for 3 years. Initially, her bleeding improved significantly, but over the past 6 months, she has noticed gradually worsening menstrual bleeding returning to pre-treatment levels. She wishes to continue with hormonal management. Pelvic examination is normal. Transvaginal ultrasound shows the IUS in correct position with a normal uterine cavity and no fibroids. What is the most appropriate management?

Remove and replace the levonorgestrel intrauterine system

Add tranexamic acid during menstruation

Switch to combined oral contraceptive pill

Continue current IUS for remaining 2 years of licensed duration

A 34-year-old woman presents to the emergency department with sudden onset severe right-sided abdominal pain and syncope. She has 6 weeks amenorrhoea. On examination, she is pale with heart rate 118 bpm and blood pressure 88/54 mmHg. Abdominal examination reveals generalised tenderness with guarding. A bedside urine pregnancy test is positive. What is the most appropriate immediate management?

Insert two large-bore intravenous cannulae, cross-match 4 units blood, commence fluid resuscitation, and arrange emergency laparoscopy

Perform urgent transvaginal ultrasound to confirm diagnosis before proceeding to theatre

Administer intramuscular methotrexate and commence fluid resuscitation

Request urgent serum beta-hCG and proceed to laparoscopy only if levels are above 1500 IU/L

Arrange CT abdomen and pelvis with contrast to localise the ectopic pregnancy

A 52-year-old woman presents with a 6-month history of irregular vaginal bleeding occurring approximately every 2-3 weeks. She also reports a single episode of postcoital bleeding 2 months ago. She has never had an abnormal cervical smear and her last smear 18 months ago was normal. On speculum examination, the cervix appears healthy with no visible lesions. Bimanual examination reveals a bulky uterus. What is the single most important initial investigation?

Hysteroscopy and endometrial biopsy

A 46-year-old woman attends the gynaecology clinic with a 14-month history of increasingly heavy and irregular menstrual bleeding. Her periods occur every 18-45 days and last 7-10 days. She reports no intermenstrual or postcoital bleeding. Abdominal examination is unremarkable. Transvaginal ultrasound shows a normal-sized uterus with endometrial thickness of 18 mm. Both ovaries appear normal with multiple small follicles. What is the most appropriate next investigation?

Hysteroscopy and endometrial biopsy

Serum follicle-stimulating hormone and luteinising hormone

Repeat ultrasound in early proliferative phase

Ectopic pregnancy for UKMLA AKT: High-Yield Women’s Health Lessons

Quick Overview

Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity (97% in fallopian tubes). Affects 1-2% of pregnancies with potential for life-threatening rupture and haemorrhage. Early diagnosis via hCG trends and ultrasound is critical. NICE NG126 stratifies management into expectant, medical (methotrexate), or surgical pathways based on clinical stability, hCG levels, and ultrasound findings.

Core Facts & Concepts

Risk Factors 🚩

Previous ectopic pregnancy (10-fold increased risk)
Previous tubal surgery or pelvic inflammatory disease
Current intrauterine device (IUD) in situ
Assisted conception (IVF/ICSI)
Smoking, endometriosis, prior abdominal surgery

Diagnostic Thresholds 📊

hCG discriminatory zone: 1500 IU/L (transvaginal USS should visualize intrauterine pregnancy if present)
Suboptimal hCG rise: <63% increase over 48 hours (suggests ectopic or failing pregnancy)
Progesterone: <20 nmol/L suggests non-viable pregnancy (ectopic or miscarriage)
Progesterone: >25 nmol/L suggests viable intrauterine pregnancy (but doesn't exclude ectopic)

Ultrasound Criteria

Definite ectopic: Gestational sac with yolk sac/fetal pole outside uterus
Probable ectopic: Adnexal mass moving separately from ovary, empty uterus with hCG >1500 IU/L
Pregnancy of unknown location (PUL): No intrauterine or extrauterine pregnancy visible on USS

Figure 1: Transvaginal ultrasound showing empty uterus with adnexal mass and free fluid in pouch of Douglas

Location	Frequency
Ampullary (fallopian tube)	70%
Isthmic (fallopian tube)	12%
Fimbrial	11%
Cornual/interstitial	2-4% (highest rupture risk)
Ovarian/cervical/abdominal	<1%

Problem-Solving Approach

Clinical Presentation Red Flags 🚩

Classic triad (only 50%): Amenorrhoea + abdominal pain + vaginal bleeding
Rupture signs: Peritonism, shoulder tip pain (diaphragmatic irritation), haemodynamic instability, cervical excitation
Dizziness, syncope, or collapse suggests significant haemorrhage

NICE NG126 Management Algorithm

Resuscitate if unstable: IV access, crossmatch, emergency laparoscopy
Confirm pregnancy: Urine hCG, serum quantitative hCG
Transvaginal ultrasound: Identify intrauterine pregnancy vs ectopic vs PUL
Serial hCG monitoring (if PUL): Repeat at 48 hours
- Rising appropriately (≥63%): Likely viable IUP → repeat USS at 7-14 days
- Plateau/slow rise: Probable ectopic
- Falling: Likely failing pregnancy (may still be ectopic)

Methotrexate Eligibility Criteria 💊

Clinically stable and pain-free
Unruptured ectopic confirmed/suspected
hCG <1500 IU/L (some units <3000 IU/L)
Adnexal mass <35 mm with no fetal heartbeat
Able to return for follow-up
No contraindications (breastfeeding, immunodeficiency, blood dyscrasias, liver/renal impairment)

⚠️ Warning: 15% methotrexate failure rate requiring surgery. Monitor hCG on days 4 and 7 (expect 15% drop between days 4-7).

Analysis Framework

Management	Indications	Follow-up
Expectant	hCG <1000 IU/L, falling; minimal symptoms; no fetal heartbeat	hCG twice weekly until <15 IU/L (can take 4-6 weeks)
Medical (IM methotrexate 50 mg/m²)	Criteria above; hCG <1500 IU/L; mass <35 mm	hCG days 4, 7, then weekly. Avoid alcohol, folic acid, NSAIDs, intercourse for 3 months
Surgical (salpingectomy preferred)	Ruptured ectopic; unstable patient; hCG >5000 IU/L; pain; mass >35 mm; fetal heartbeat present	hCG at 7 days then weekly until negative
Salpingotomy	Contralateral tube damaged/absent; fertility preservation desired	Higher recurrence risk; persistent trophoblast in 5-20%

Discriminating Features: Ectopic vs Miscarriage

Ectopic: Unilateral pain, cervical os closed, adnexal mass/tenderness
Miscarriage: Central cramping pain, cervical os may be open, products in uterus on USS

Visual Aid

Key Points Summary

✓ hCG thresholds: <63% rise over 48h suggests ectopic; discriminatory zone 1500 IU/L for USS detection

✓ Methotrexate eligibility: Stable patient, hCG <1500 IU/L, mass <35 mm, no fetal heartbeat, able to follow up

✓ Rupture red flags: Shoulder tip pain, peritonism, haemodynamic instability → immediate laparoscopy

✓ Salpingectomy preferred over salpingotomy (lower recurrence, persistent trophoblast risk)

✓ PUL management: Serial hCG monitoring essential-15% are ectopics requiring intervention

✓ Progesterone levels: <20 nmol/L non-viable, >25 nmol/L likely viable IUP (not diagnostic alone)

✓ Cornual ectopic: Highest rupture risk (2-4% of ectopics); may present later (8-16 weeks) with catastrophic haemorrhage

📌 Remember: ECTOPIC - Empty uterus, Cervical excitation, Tachycardia, Orthostatic hypotension, Pain (unilateral), Irregular bleeding, Collapse risk

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