Ectopic pregnancy surgical management US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Ectopic pregnancy surgical management. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Ectopic pregnancy surgical management US Medical PG Question 1: A 22-year-old primigravid woman at 12 weeks' gestation comes to the physician because of several hours of abdominal cramping and passing of large vaginal blood clots. Her temperature is 36.8°C (98.3°F), pulse is 75/min, and blood pressure is 110/65 mmHg. The uterus is consistent in size with a 12-week gestation. Speculum exam shows an open cervical os and blood clots within the vaginal vault. Transvaginal ultrasound shows an empty gestational sac. The patient is worried about undergoing invasive procedures. Which of the following is the most appropriate next step in management?
- A. Serial beta-hCG measurement
- B. Methotrexate therapy
- C. Expectant management (Correct Answer)
- D. Dilation and curettage
- E. Oxytocin therapy
Ectopic pregnancy surgical management Explanation: **Expectant management**
- The patient presents with symptoms of an **inevitable abortion** (vaginal bleeding, abdominal cramping, and an open cervical os) and an **empty gestational sac** on ultrasound, indicating a non-viable pregnancy.
- As the patient is hemodynamically stable and expresses concern about invasive procedures, **expectant management** is a reasonable and often preferred approach for early pregnancy loss, allowing the body to naturally expel the pregnancy tissue.
*Serial beta-hCG measurement*
- While useful for diagnosing pregnancy and monitoring resolution in certain cases (e.g., ectopic pregnancy or molar pregnancy), **serial beta-hCG measurement** is not the primary next step for a definitively diagnosed inevitable abortion with an empty gestational sac.
- The diagnosis of inevitable abortion is already established by clinical and ultrasound findings, so beta-hCG monitoring would primarily confirm pregnancy resolution rather than guide immediate management of the ongoing miscarriage itself.
*Methotrexate therapy*
- **Methotrexate therapy** is primarily used for the medical management of **ectopic pregnancies** or persistent gestational trophoblastic disease.
- It is not indicated for the management of an inevitable abortion in a hemodynamically stable patient, especially when a non-viable intrauterine pregnancy is confirmed.
*Dilation and curettage*
- **Dilation and curettage (D&C)** is an invasive surgical procedure to remove retained products of conception.
- While effective, the patient explicitly expressed concerns about invasive procedures, and her stable condition allows for less invasive options first.
*Oxytocin therapy*
- **Oxytocin therapy** is typically used to induce labor or augment contractions in viable pregnancies and to manage postpartum hemorrhage.
- It is not routinely used as the primary management for an inevitable abortion in the first trimester, especially when the patient is hemodynamically stable and other conservative options are available.
Ectopic pregnancy surgical management US Medical PG Question 2: 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?
- A. Complete blood count
- B. Urinalysis
- C. FAST ultrasound scan
- D. Appendectomy
- E. Urinary human chorionic gonadotropin (hCG) (Correct Answer)
Ectopic pregnancy surgical management Explanation: ***Urinary human chorionic gonadotropin (hCG)***
- Despite surgical sterilization, a **low risk of ectopic pregnancy** still exists, especially with symptoms like **severe right lower quadrant pain** and **vomiting**.
- A positive urinary hCG would necessitate further evaluation for an **ectopic pregnancy**, which is a **life-threatening condition**.
*Complete blood count*
- While a CBC assesses for **leukocytosis** (suggesting infection/inflammation) or **anemia** (suggesting blood loss), it's not the immediate priority given the potential for ectopic pregnancy symptoms.
- A CBC alone would not rule out the most critical diagnosis in this scenario.
*Urinalysis*
- A urinalysis helps rule out **urinary tract infection (UTI)** or **nephrolithiasis** (kidney stones).
- While important for differential diagnosis, the severity of pain and reproductive history make ectopic pregnancy a more immediate concern.
*FAST ultrasound scan*
- An ultrasound is useful for identifying **free fluid** in the abdomen or assessing the **uterus and adnexa** for an ectopic pregnancy.
- However, in a female of reproductive age, a **positive hCG** is generally a prerequisite for a targeted pelvic ultrasound to confirm or exclude an early ectopic pregnancy.
*Appendectomy*
- While **appendicitis** is in the differential for right lower quadrant pain, the absence of **McBurney's point tenderness** and the patient's reproductive history make other diagnoses more likely first.
- Surgery should only be considered after a thorough diagnostic workup, especially to rule out time-sensitive conditions like ectopic pregnancy.
Ectopic pregnancy surgical management US Medical PG Question 3: 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?
- A. Administration of misoprostol
- B. Administration of intramuscular methotrexate
- C. Administration of anti-D immunoglobulin and intramuscular methotrexate (Correct Answer)
- D. Repeat serum β-hCG and pelvic ultrasound in 2 days
- E. Administration of anti-D immunoglobulin and oral misoprostol
Ectopic pregnancy surgical management Explanation: ***Administration of anti-D immunoglobulin and intramuscular methotrexate***
- The diagnosis is highly suggestive of an **ectopic pregnancy** due to increasing β-hCG levels (though not doubling) with an empty uterus, and the patient has **Rh-negative blood** type.
- **Intramuscular methotrexate** is indicated for stable ectopic pregnancies with β-hCG levels below 5,000 mIU/mL, and **anti-D immunoglobulin** is crucial to prevent Rh sensitization in Rh-negative women.
*Administration of misoprostol*
- **Misoprostol** is primarily used for medical abortion of intrauterine pregnancies or managing miscarriage, not for ectopic pregnancies.
- It would be ineffective in resolving an ectopic pregnancy and does not address the need for Rh prophylaxis.
*Administration of intramuscular methotrexate*
- While **intramuscular methotrexate** is appropriate for treating the ectopic pregnancy, it omits the critical step of administering **anti-D immunoglobulin**.
- Failure to administer anti-D immunoglobulin in an Rh-negative woman with an ectopic pregnancy can lead to **Rh sensitization**, posing risks for future pregnancies.
*Repeat serum β-hCG and pelvic ultrasound in 2 days*
- The current β-hCG trend (1600 to 1900 mIU/mL in 4 days) and empty uterus already strongly indicate an ectopic pregnancy or pregnancy of unknown location with a poor prognosis.
- Delaying treatment for another 2 days for repeat tests would postpone necessary intervention and potentially increase the risk of complications from a ruptured ectopic pregnancy.
*Administration of anti-D immunoglobulin and oral misoprostol*
- **Oral misoprostol** is not an appropriate treatment for an ectopic pregnancy; it is used for intrauterine gestations or miscarriage management.
- While **anti-D immunoglobulin** is correctly included due to her Rh-negative status, the choice of misoprostol makes this option incorrect for managing an ectopic pregnancy.
Ectopic pregnancy surgical management US Medical PG Question 4: A 32-year-old primigravid woman with a history of seizures comes to the physician because she had a positive pregnancy test at home. Medications include valproic acid and a multivitamin. Physical examination shows no abnormalities. A urine pregnancy test is positive. Her baby is at increased risk for requiring which of the following interventions?
- A. Lower spinal surgery (Correct Answer)
- B. Kidney transplantation
- C. Arm surgery
- D. Cochlear implantation
- E. Respiratory support
Ectopic pregnancy surgical management Explanation: ***Lower spinal surgery***
- Maternal use of **valproic acid** during pregnancy significantly increases the risk of neural tube defects, particularly **spina bifida**, which often requires surgical correction of the lower spine in affected infants.
- **Spina bifida** results from the incomplete closure of the neural tube, leading to exposed spinal cord or meninges, and frequently necessitates surgical intervention to prevent further neurological damage and infection.
*Kidney transplantation*
- While some fetal anomalies can involve the kidneys, **valproic acid** exposure is not primarily associated with renal agenesis or severe kidney malformations requiring transplantation.
- Birth defects affecting the kidneys are more commonly linked to genetic syndromes or other teratogens, not specifically valproic acid.
*Arm surgery*
- **Valproic acid** has been associated with limb defects, but these are typically minor and do not usually directly necessitate extensive arm surgery.
- **Phocomelia** (shortened or absent limbs) is more typically associated with **thalidomide** exposure, not valproic acid.
*Cochlear implantation*
- Although **valproic acid** exposure has been occasionally linked to some congenital anomalies, it is not a primary risk factor for **severe hearing loss** requiring cochlear implantation.
- Hearing loss requiring such intervention is more often due to genetic factors, congenital infections, or other specific teratogens.
*Respiratory support*
- While a variety of congenital conditions can lead to respiratory compromise, **valproic acid** exposure does not specifically cause severe pulmonary hypoplasia or other defects that commonly necessitate prolonged or intense neonatal respiratory support.
- Respiratory distress in neonates is often related to prematurity, meconium aspiration, or other direct pulmonary issues.
Ectopic pregnancy surgical management US Medical PG Question 5: 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?
- A. Methotrexate and discharge with strict follow-up instructions.
- B. Exploratory laparotomy
- C. Dilation and curettage
- D. Transvaginal ultrasound (Correct Answer)
- E. Transabdominal ultrasound
Ectopic pregnancy surgical management Explanation: ***Transvaginal ultrasound***
- A **transvaginal ultrasound** is the most appropriate next step given the **positive pregnancy test**, significant abdominal pain, and adnexal tenderness, strongly suggesting an **ectopic pregnancy** that needs urgent confirmation and localization.
- This imaging modality provides the **highest resolution** for visualizing the uterus, adnexa, and assessing for an intrauterine pregnancy or extrauterine gestational sac or free fluid in the pelvis, which are critical for diagnosis and management.
*Methotrexate and discharge with strict follow-up instructions.*
- While methotrexate is a treatment for stable ectopic pregnancies, it is not an appropriate next step in diagnosis, and administering it without definitive diagnostic imaging is **premature and potentially harmful**.
- The patient's **acute presentation** with severe pain, vomiting, signs of peritoneal irritation (guarding, firm abdomen), and suspected vaginal bleeding indicates a potentially **ruptured or unstable ectopic pregnancy**, which mandates immediate diagnostic confirmation and likely surgical intervention, not medical management and discharge.
*Exploratory laparotomy*
- **Exploratory laparotomy** is a surgical intervention, not a diagnostic step to be performed before confirming the nature and location of the suspected ectopic pregnancy.
- While it may be necessary if the patient is **hemodynamically unstable** or if a ruptured ectopic pregnancy is strongly suspected and unable to be confirmed by less invasive means, diagnostic imaging should precede it in a relatively stable patient.
*Dilation and curettage*
- **Dilation and curettage (D&C)** is a procedure performed to remove tissue from the uterus, typically for an incomplete miscarriage or uterine pathology.
- Given the strong suspicion of an **ectopic pregnancy** (pregnancy outside the uterus), a D&C would not address the extrauterine pregnancy and could delay appropriate diagnosis and management.
*Transabdominal ultrasound*
- A **transabdominal ultrasound** can visualize pelvic structures but has **lower resolution** for early pregnancy and adnexal pathology compared to a transvaginal ultrasound.
- In a patient with suspected ectopic pregnancy and acute symptoms, the **superior detail** provided by a transvaginal ultrasound is crucial for accurate and timely diagnosis.
Ectopic pregnancy surgical management US Medical PG Question 6: 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?
- A. Serial beta-hCG measurement
- B. Bed rest and doxylamine therapy
- C. Methotrexate therapy
- D. Suction curettage (Correct Answer)
- E. Insulin therapy
Ectopic pregnancy surgical management Explanation: ***Suction curettage***
- The patient's symptoms (vaginal bleeding, pelvic pressure, nausea/vomiting), signs (hypertension, large for gestational age uterus at the umbilicus corresponding to 20 weeks gestation, proteinuria), and laboratory findings (markedly elevated beta-hCG of 110,000 mIU/mL) are highly suggestive of a **hydatidiform mole**.
- A **transvaginal ultrasound** showing a central intrauterine mass with **hypoechoic spaces** (often described as a 'snowstorm' or 'grape-like' appearance) and no fetal heart rate confirms the diagnosis of a **molar pregnancy**. The most appropriate and urgent management is **suction curettage** to remove the abnormal pregnancy tissue, which also serves a diagnostic purpose.
*Serial beta-hCG measurement*
- While **serial beta-hCG** measurements are crucial for monitoring after treatment of a molar pregnancy to detect persistent trophoblastic disease, they are not the initial management step for an active molar pregnancy with acute symptoms.
- This step would delay the necessary removal of the abnormal tissue and risk complications such as hemorrhage or progression to **gestational trophoblastic neoplasia (GTN)**.
*Bed rest and doxylamine therapy*
- **Bed rest and doxylamine** are treatments for benign conditions like **hyperemesis gravidarum** or threatened abortion, which do not align with the severe symptoms, physical findings, and ultrasound characteristics of this patient's condition.
- This approach would be completely inadequate and inappropriate for a molar pregnancy.
*Methotrexate therapy*
- **Methotrexate** is a chemotherapy agent used to treat **persistent gestational trophoblastic neoplasia (GTN)** or **choriocarcinoma** following molar pregnancy evacuation, or in cases of ectopic pregnancy.
- It is not the primary treatment for the initial removal of a molar pregnancy itself, which requires surgical evacuation.
*Insulin therapy*
- **Insulin therapy** is used to manage **gestational diabetes mellitus (GDM)** or pre-existing diabetes in pregnancy.
- There is no clinical or laboratory evidence (e.g., elevated glucose) to suggest diabetes in this patient, and it is unrelated to the primary diagnosis of molar pregnancy.
Ectopic pregnancy surgical management US Medical PG Question 7: A 27-year-old woman with a past medical history of rheumatoid arthritis and severe anemia of chronic disease presents to the emergency department for nausea, vomiting, and abdominal pain that started this morning. She has been unable to tolerate oral intake during this time. Her blood pressure is 107/58 mmHg, pulse is 127/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for left lower quadrant abdominal pain upon palpation. A urine pregnancy test is positive, and a serum beta-hCG is 1,110 mIU/mL. A transvaginal ultrasound demonstrates no free fluid and is unable to identify an intrauterine pregnancy. The patient states that she intends to have children in the future. Which of the following is the best next step in management?
- A. Repeat beta-hCG in 2 days (Correct Answer)
- B. CT scan of the abdomen
- C. Methotrexate
- D. Salpingostomy
- E. Salpingectomy
Ectopic pregnancy surgical management Explanation: ***Repeat beta-hCG in 2 days***
- With a beta-hCG level of **1,110 mIU/mL** and no intrauterine pregnancy seen on ultrasound, a **repeat beta-hCG in 48 hours** is the most appropriate next step to assess the trend and differentiate between an early, viable intrauterine pregnancy, a non-viable pregnancy (miscarriage), or an ectopic pregnancy.
- The patient is currently **hemodynamically stable**, which allows for expectant management and further diagnostic evaluation rather than immediate intervention.
*CT scan of the abdomen*
- A CT scan of the abdomen exposes the patient to **ionizing radiation**, which is generally avoided in pregnancy unless absolutely necessary.
- It would not provide the specific diagnostic information needed to evaluate for an **ectopic pregnancy** as effectively as serial beta-hCG levels and repeat ultrasound.
*Methotrexate*
- **Methotrexate** is a potential treatment for ectopic pregnancy, but it is not the first step in diagnosis and would only be considered after a definitive diagnosis.
- The patient's **hemodynamic stability** and desire for future fertility make a conservative approach involving more diagnostic steps preferable before initiating medical treatment.
*Salpingostomy*
- **Salpingostomy** is a surgical procedure to remove an ectopic pregnancy while preserving the fallopian tube, but it is a definitive treatment and not a diagnostic step.
- It would be considered for a **confirmed ectopic pregnancy** in a stable patient who desires future fertility, but only after further diagnostic evaluation.
*Salpingectomy*
- **Salpingectomy**, the surgical removal of the fallopian tube, is a treatment for ectopic pregnancy, most often reserved for cases of **rupture**, significant tubal damage, or patients who do not desire future fertility from that tube.
- This patient is **hemodynamically stable** and desires future fertility, making salpingectomy an inappropriate initial choice.
Ectopic pregnancy surgical management US Medical PG Question 8: A 32-year-old Caucasian female is admitted to the emergency department with a 48-hour history of severe and diffuse abdominal pain, nausea, vomiting, and constipation. Her personal history is unremarkable except for an ectopic pregnancy 5 years ago. Upon admission, she is found to have a blood pressure of 120/60 mm Hg, a pulse of 105/min, a respiratory rate 20/min, and a body temperature of 37°C (98.6°F). She has diffuse abdominal tenderness, hypoactive bowel sounds, and mild distention on examination of her abdomen. Rectal and pelvic examination findings are normal. What is the most likely cause of this patient's condition?
- A. Adhesions (Correct Answer)
- B. Enlarged Peyer’s plaques
- C. Gastrointestinal malignancy
- D. Malrotation
- E. Hernia
Ectopic pregnancy surgical management Explanation: ***Adhesions***
- The patient's history of **ectopic pregnancy** is a significant risk factor for **intra-abdominal adhesions**, particularly if surgical intervention was required, which can cause **small bowel obstruction**.
- Symptoms like diffuse abdominal pain, nausea, vomiting, constipation, and hypoactive bowel sounds are classic signs of **bowel obstruction**.
- **Adhesions** are the most common cause of small bowel obstruction in patients with prior abdominal or pelvic procedures.
*Enlarged Peyer's plaques*
- Enlarged Peyer's patches are typically associated with conditions like **intussusception** in children or infections, and less commonly in adults as a cause of obstruction unless severely inflamed.
- This condition does not typically present with a history linked to previous gynecological conditions or procedures that commonly induce adhesive disease.
*Gastrointestinal malignancy*
- While gastrointestinal malignancy can cause bowel obstruction, it's less likely in a 32-year-old without other risk factors for **cancer** (e.g., family history, chronic inflammatory disease, weight loss).
- The acute presentation in a young patient with a history of prior pelvic pathology makes adhesions a much more probable cause than an undiagnosed malignancy.
*Malrotation*
- **Malrotation** is a congenital anomaly usually presenting in **infancy or early childhood** with symptoms like bilious vomiting due to midgut volvulus.
- It is highly unlikely to present for the first time with this constellation of symptoms in a 32-year-old adult.
*Hernia*
- An **external hernia** would typically present with a visible or palpable lump, which was not mentioned in the physical exam findings.
- An **internal hernia** is possible but less common than adhesions as a cause of obstruction, especially in patients with a history of prior abdominal or pelvic pathology.
Ectopic pregnancy surgical management US Medical PG Question 9: 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?
- A. Laparoscopic removal of ovarian cysts
- B. Cefoxitin and azithromycin
- C. Appendectomy
- D. Cholecystectomy (Correct Answer)
- E. Intramuscular ceftriaxone followed by cephalexin
Ectopic pregnancy surgical management Explanation: ***Cholecystectomy***
- The patient's presentation (fever, RUQ pain, leukocytosis, vomiting) is classic for **acute cholecystitis** in pregnancy, which requires **cholecystectomy** as the definitive treatment.
- **Laparoscopic cholecystectomy** is safe during pregnancy and is the **preferred definitive treatment** for acute cholecystitis, ideally performed in the second trimester but can be done in the third trimester when indicated.
- While conservative management with antibiotics and supportive care can be attempted initially, cholecystectomy remains the definitive treatment and is increasingly performed during pregnancy to avoid recurrent symptoms and complications.
- The mild pyuria is likely secondary to adjacent inflammation rather than a primary UTI.
*Laparoscopic removal of ovarian cysts*
- Ovarian cysts typically present with **pelvic or lower abdominal pain**, not RUQ tenderness.
- The clinical picture with fever, leukocytosis, and RUQ pain strongly suggests biliary pathology, not ovarian pathology.
*Cefoxitin and azithromycin*
- This regimen is used for **pelvic inflammatory disease (PID)**, which presents with lower abdominal/pelvic pain, cervical motion tenderness, and vaginal discharge.
- The patient's RUQ localization and fever pattern do not support PID as the primary diagnosis.
*Intramuscular ceftriaxone followed by cephalexin*
- This regimen treats **gonorrhea/chlamydia** or uncomplicated UTIs.
- While mild pyuria is present, the dominant clinical features (fever, RUQ pain, leukocytosis) point to cholecystitis, not a primary genitourinary infection.
- Antibiotics alone would not provide definitive treatment for acute cholecystitis.
*Appendectomy*
- **Appendicitis** in pregnancy typically causes **RLQ pain** (though it can migrate superiorly in the third trimester due to uterine displacement).
- The distinct **RUQ localization** with the classic triad of fever, RUQ pain, and leukocytosis makes cholecystitis far more likely than appendicitis.
Ectopic pregnancy surgical management US Medical PG Question 10: 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?
- A. Grade 2 histology and depth of myometrial invasion
- B. Number of positive nodes and total nodes removed
- C. Lymphovascular space invasion and myometrial invasion depth
- D. Positive pelvic nodes and negative para-aortic nodes (Correct Answer)
- E. Absence of cervical involvement and patient age
Ectopic pregnancy surgical management Explanation: ***Positive pelvic nodes and negative para-aortic nodes***
- The presence of positive pelvic lymph nodes classifies this as **FIGO Stage IIIC1** disease, which is the primary driver for recommending **systemic chemotherapy**.
- The negative para-aortic nodes help delineate the **radiation field**, focusing treatment on the pelvis rather than extended-field radiation, thus making this combination critical for the management plan.
*Grade 2 histology and depth of myometrial invasion*
- While these factors contribute to the **GOG-99** or **PORTEC** risk criteria for early-stage disease, they are superseded by the presence of **nodal metastasis** (Stage IIIC).
- Myometrial invasion (>50%) and Grade 2 are baseline risk factors, but they do not dictate the switch from local to **systemic therapy** once nodes are positive.
*Number of positive nodes and total nodes removed*
- The **lymph node count** (2/15) confirms the stage but does not change the treatment algorithm as much as the **anatomical location** (pelvic vs. para-aortic) of those nodes.
- While a low total node count might suggest staging inadequacy, Stage IIIC status is already established here, making the **distribution** more clinically significant for therapy planning.
*Lymphovascular space invasion and myometrial invasion depth*
- **Lymphovascular space invasion (LVSI)** is a strong prognostic indicator for recurrence, but it is often a precursor to the nodal involvement already identified in this patient.
- These features are used to justify **adjuvant therapy** in early-stage (Stage I) patients, but nodal status is a more powerful determinant in Stage III disease.
*Absence of cervical involvement and patient age*
- The lack of **cervical stromal invasion** means the patient is not Stage II, but this is less impactful than the upgrade to **Stage IIIC** due to positive nodes.
- **Patient age** is a clinical factor used in risk-stratification models like **GOG-99**, but it does not outweigh the pathological finding of **metastasized disease** in treatment selection.
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