A 25-year-old woman is brought to the emergency department by her roommate with severe right lower quadrant pain for the last 8 hours. The pain is progressively getting worse and is associated with vomiting. When you ask the patient about her last menstrual period, she tells you that although she stopped keeping track of her cycle after undergoing surgical sterilization 1 year ago, she recalls bleeding yesterday. The physical examination reveals a hemodynamically stable patient with a pulse of 90/min, respiratory rate of 14/min, blood pressure of 125/70 mm Hg, and temperature of 37.0°C (98.6°F). The abdomen is tender to touch (more tender in the lower quadrants), and tenderness at McBurney's point is absent. Which of the following is the best next step in the management of this patient?

Urinary human chorionic gonadotropin (hCG)

A 25-year old woman is brought to the emergency department because of a 1-day history of lower abdominal pain and vaginal bleeding. Her last menstrual period was 6 weeks ago. She is sexually active and uses condoms inconsistently with her boyfriend. She had pelvic inflammatory disease at the age of 22 years. Her temperature is 37.2°C (99°F), pulse is 90/min, respirations are 14/min, and blood pressure is 130/70 mm Hg. The abdomen is soft, and there is tenderness to palpation in the left lower quadrant with guarding but no rebound. There is scant blood in the introitus. Her serum β-human chorionic gonadotropin (hCG) level is 1,600 mIU/mL. Her blood type is O, RhD negative. She is asked to return 4 days later. Her serum β-hCG level is now 1,900 mIU/ml. A pelvic ultrasound shows a normal appearing uterus with an empty intrauterine cavity and a minimal amount of free pelvic fluid. Which of the following is the most appropriate next step in management?

Administration of anti-D immunoglobulin and intramuscular methotrexate

Administration of intramuscular methotrexate

Repeat serum β-hCG and pelvic ultrasound in 2 days

Administration of anti-D immunoglobulin and oral misoprostol

A 23-year-old female presents to the emergency department with right lower abdominal pain that began suddenly one hour ago. She is writhing in discomfort and has vomited twice since arrival. She has no chronic medical conditions, but states she has had chlamydia two or three times in the past. Her abdomen is firm, and she is guarding. Pelvic exam reveals blood pooling in the vagina and right adnexal tenderness. Her last menstrual period was 7 weeks ago. A pregnancy test is positive. Which of the following is an appropriate next step in diagnosis?

Methotrexate and discharge with strict follow-up instructions.

A previously healthy 29-year-old Taiwanese woman comes to the emergency department with vaginal bleeding and pelvic pressure for several hours. Over the past 2 weeks, she had intermittent nausea and vomiting. A home urine pregnancy test was positive 10 weeks ago. She has had no prenatal care. Her pulse is 80/min and blood pressure is 150/98 mm Hg. Physical examination shows warm and moist skin. Lungs are clear to auscultation bilaterally. Her abdomen is soft and non-distended. Bimanual examination shows a uterus palpated at the level of the umbilicus. Her serum beta human chorionic gonadotropin concentration is 110,000 mIU/mL. Urine dipstick is positive for protein and ketones. Transvaginal ultrasound shows a central intrauterine mass with hypoechoic spaces; there is no detectable fetal heart rate. An x-ray of the chest shows no abnormalities. Which of the following is the most appropriate next step in management?

Bed rest and doxylamine therapy

A 30-year-old woman, gravida 1, para 0, at 30 weeks' gestation is brought to the emergency department because of progressive upper abdominal pain for the past hour. The patient vomited once on her way to the hospital. She said she initially had dull, generalized stomach pain about 6 hours prior, but now the pain is located in the upper abdomen and is more severe. There is no personal or family history of any serious illnesses. She is sexually active with her husband. She does not smoke or drink alcohol. Medications include folic acid and a multivitamin. Her temperature is 38.5°C (101.3°F), pulse is 100/min, and blood pressure is 130/80 mm Hg. Physical examination shows right upper quadrant tenderness. The remainder of the examination shows no abnormalities. Laboratory studies show a leukocyte count of 12,000/mm3. Urinalysis shows mild pyuria. Which of the following is the most appropriate definitive treatment in the management of this patient?

Laparoscopic removal of ovarian cysts

Intramuscular ceftriaxone followed by cephalexin

A 67-year-old woman with endometrial cancer undergoes robotic-assisted staging surgery. Final pathology reveals grade 2 endometrioid adenocarcinoma with 60% myometrial invasion, positive pelvic lymph nodes (2/15), negative para-aortic nodes (0/8), and lymphovascular space invasion. No cervical or adnexal involvement. The tumor care team debates adjuvant treatment. Evaluate which combination of pathologic features most significantly impacts treatment recommendations?

Positive pelvic nodes and negative para-aortic nodes

Grade 2 histology and depth of myometrial invasion

Number of positive nodes and total nodes removed

Lymphovascular space invasion and myometrial invasion depth

Absence of cervical involvement and patient age

Ectopic pregnancy surgical management for USMLE Step 2 CK: High-Yield Surgery Lessons

🕵️‍♀️ Diagnosis - Spotting the Stowaway

Initial Workup: Quantitative $\beta$-hCG, CBC (for Hct), blood type & screen.
Imaging (TVUS): Transvaginal ultrasound is the primary diagnostic tool.
- Definitive Finding: Gestational sac with a yolk sac or embryo located outside the uterine cavity.
- Presumptive Findings: An adnexal mass (often complex and separate from the ovary) with an empty uterus.
- 💡 "Ring of Fire": A hypervascular ring on color Doppler around the adnexal mass. This is suggestive but not specific (can also be a corpus luteum).
- ⚠️ Rupture Sign: Echogenic free fluid (hemoperitoneum) in the cul-de-sac or Morison's pouch (FAST exam).

⭐ The $\beta$-hCG "discriminatory zone" (typically 1,500-2,000 mIU/mL) is the level where an intrauterine pregnancy (IUP) should be visible on TVUS. An empty uterus above this threshold is highly suspicious for an ectopic pregnancy.

Transvaginal US: Ectopic pregnancy with "ring of fire"

🔪 Management - The Decisive Incision

Surgical intervention is required when medical management is contraindicated or has failed. The approach is typically laparoscopic unless the patient is hemodynamically unstable.

Indications for Surgery:
- Absolute: Hemodynamic instability, signs of rupture (hemoperitoneum), heterotopic pregnancy with a viable intrauterine pregnancy.
- Relative: Contraindications to methotrexate (MTX), failed MTX therapy (stagnant/rising $hCG$), ectopic mass >3.5 cm, fetal cardiac activity, patient preference/unreliable for follow-up.

Feature	Salpingectomy (Excision)	Salpingostomy (Incision)
Best For	Ruptured/damaged tube, large ectopic (>5 cm), completed childbearing, recurrent ectopic.	Stable patient, unruptured tube, small ectopic (<5 cm), strong desire for future fertility.
Procedure	Complete removal of the affected fallopian tube.	Linear incision over ectopic, removal of products of conception (POC), tube left to heal.
Pros	Definitive treatment (100% cure), no risk of persistent ectopic.	Preserves tube, potentially ↑ future fertility if contralateral tube is damaged.
Cons	Removes tube, may ↓ overall fertility.	5-15% risk of persistent trophoblastic tissue; requires strict $hCG$ follow-up.

Laparoscopic view of ruptured tubal ectopic pregnancy

⚠️ Complications - Post-Op Perils

Immediate Complications
- Hemorrhage: Significant blood loss from the implantation site or mesosalpinx; may necessitate conversion from salpingostomy to salpingectomy or laparotomy.
- Iatrogenic Injury: Damage to adjacent organs (bowel, bladder, ureters), especially with dense adhesions or distorted anatomy.
Long-Term Sequelae
- Persistent Trophoblastic Tissue (PTT): Occurs in 5-15% of salpingostomies due to incomplete removal of chorionic villi.
- Future Fertility Impact:
  - Reduced intrauterine pregnancy rates.
  - Increased risk of recurrent ectopic pregnancy (~10-15%).

⭐ After salpingostomy, serial $β-hCG$ monitoring is crucial. A plateau or rise suggests persistent trophoblastic tissue. Failure of $β-hCG$ to decline appropriately (e.g., <15% drop from day 4 to 7) warrants treatment, typically with methotrexate.

⚡ High-Yield Points - Biggest Takeaways

Surgical management is first-line for hemodynamic instability, ruptured ectopic, or failed/contraindicated methotrexate therapy.

Laparoscopy is the standard approach unless a patient is severely unstable, warranting a laparotomy.

Salpingostomy (tube-sparing) is for stable, unruptured ectopics (<5 cm) in patients desiring future fertility.

Post-salpingostomy, monitor for persistent trophoblastic tissue with serial β-hCG levels.

Salpingectomy (tube removal) is definitive; indicated for rupture, severe tubal damage, or completed childbearing.

Always administer anti-D immune globulin to Rh(D)-negative patients.

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