Gynaecology — MCQs
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A 47-year-old woman with a 10-month history of heavy menstrual bleeding has been using a levonorgestrel intrauterine system for 5 months. Initially her bleeding improved, but for the last 6 weeks she has experienced persistent irregular bleeding occurring every 10-14 days. Transvaginal ultrasound confirms the LNG-IUS is correctly positioned in the uterine cavity. Endometrial thickness is 4 mm. There are no fibroids or polyps. What is the most appropriate management?
A 25-year-old woman undergoes laparoscopy for suspected ectopic pregnancy. At laparoscopy, both fallopian tubes appear normal. There is a 3 cm haemorrhagic cyst on the right ovary. The uterus appears normal-sized with no obvious pathology. Serum beta-hCG pre-operatively was 1,800 IU/L. Transvaginal ultrasound showed an empty uterus. What is the most likely diagnosis?
A 43-year-old woman presents with intermenstrual bleeding and postcoital bleeding for 4 months. Her periods are regular and normal in volume. Her last cervical screening 2 years ago was negative for high-risk HPV. On speculum examination, the cervix appears healthy with no visible lesions. What is the most appropriate initial management?
A 29-year-old woman with a confirmed tubal ectopic pregnancy receives single-dose methotrexate (50 mg/m²) on day 0. Her initial beta-hCG was 2,400 IU/L. On day 4, she complains of increased lower abdominal pain without signs of rupture. On examination, she has mild right iliac fossa tenderness but is haemodynamically stable with no peritonism. Beta-hCG on day 4 is 2,650 IU/L. What is the most appropriate management?
A 36-year-old nulliparous woman presents with heavy menstrual bleeding for 12 months. She reports using 16 pads per day for 8 days each cycle. Haemoglobin is 78 g/L. Transvaginal ultrasound shows a 4 cm subserosal fibroid on the posterior uterine wall and otherwise normal appearances. She strongly wishes to maintain her fertility. What is the most appropriate management?
A 32-year-old woman presents with 7 weeks amenorrhoea and mild abdominal discomfort. Transvaginal ultrasound shows an empty uterus and a 30mm left adnexal mass. Initial serum beta-hCG is 1,200 IU/L. She is haemodynamically stable. A repeat beta-hCG 48 hours later is 1,450 IU/L. She meets all other criteria for expectant management and wishes to avoid intervention if possible. What is the most appropriate management?
What is the primary cellular mechanism by which the levonorgestrel intrauterine system reduces menstrual blood loss in women with heavy menstrual bleeding?
A 27-year-old woman undergoes emergency laparoscopy for a ruptured left tubal ectopic pregnancy. Intraoperatively, there is approximately 800 mL of haemoperitoneum. The left fallopian tube is disrupted with active bleeding. The right fallopian tube appears normal. She has no children but wishes to preserve fertility. What is the most appropriate surgical management?
A 51-year-old woman presents with irregular heavy bleeding over 9 months. She describes cycles varying from 18 to 45 days with flooding for 7-10 days. Her last cervical smear 18 months ago was normal. BMI is 34 kg/m². Pelvic examination is normal. Transvaginal ultrasound shows an endometrial thickness of 18 mm with a normal-sized uterus and ovaries. What is the most important next investigation?
A 28-year-old woman presents with 6 weeks amenorrhoea and right-sided pelvic pain. Transvaginal ultrasound shows an empty uterus with normal endometrial thickness and a 25mm right adnexal mass with a hyperechoic ring (blob sign). There is minimal free fluid in the pouch of Douglas. Serum beta-hCG is 2,800 IU/L. She is haemodynamically stable and pain is controlled with oral analgesia. What is the most appropriate management?
Gynaecology UK Medical PG Practice Questions and MCQs
Question 91: A 47-year-old woman with a 10-month history of heavy menstrual bleeding has been using a levonorgestrel intrauterine system for 5 months. Initially her bleeding improved, but for the last 6 weeks she has experienced persistent irregular bleeding occurring every 10-14 days. Transvaginal ultrasound confirms the LNG-IUS is correctly positioned in the uterine cavity. Endometrial thickness is 4 mm. There are no fibroids or polyps. What is the most appropriate management?
- A. Remove LNG-IUS and arrange hysteroscopy
- B. Reassure and continue with LNG-IUS for 3 more months (Correct Answer)
- C. Add cyclical norethisterone for 3 months
- D. Remove LNG-IUS and start combined oral contraceptive
- E. Remove LNG-IUS and arrange endometrial ablation
Explanation: ***Reassure and continue with LNG-IUS for 3 more months*** - **Irregular bleeding or spotting** is a common side effect during the first **3 to 6 months** of LNG-IUS use, affecting a majority of patients as the endometrium adjusts. - Given the **ultrasound confirms correct positioning** and a thin **4 mm endometrium** without structural pathology, the most appropriate step is to allow more time for the bleeding pattern to stabilize. *Remove LNG-IUS and arrange hysteroscopy* - There are no **red flags** or ultrasound findings (like a thickened endometrium or polyps) to justify an invasive **hysteroscopy** at this stage. - The LNG-IUS remains the **first-line treatment** for heavy menstrual bleeding, and premature removal should be avoided unless pathology is suspected. *Add cyclical norethisterone for 3 months* - Adding **progestogens** like norethisterone is not a standard recommendation for managing initial breakthrough bleeding with an LNG-IUS. - This intervention may introduce additional side effects without addressing the underlying **endometrial thinning** caused by the IUS itself. *Remove LNG-IUS and start combined oral contraceptive* - Removing a correctly placed and effective device for a **well-known transient side effect** ignores clinical guidelines advocating for a 6-month trial period. - The patient previously had **heavy menstrual bleeding**, and the LNG-IUS typically offers better long-term management of this condition than the **COCP**. *Remove LNG-IUS and arrange endometrial ablation* - **Endometrial ablation** is an irreversible surgical procedure that should only be considered after medical management, like the **LNG-IUS**, has been given an adequate trial. - Five months is insufficient to declare **treatment failure**, especially when structural abnormalities have already been ruled out via **transvaginal ultrasound**.
Question 92: A 25-year-old woman undergoes laparoscopy for suspected ectopic pregnancy. At laparoscopy, both fallopian tubes appear normal. There is a 3 cm haemorrhagic cyst on the right ovary. The uterus appears normal-sized with no obvious pathology. Serum beta-hCG pre-operatively was 1,800 IU/L. Transvaginal ultrasound showed an empty uterus. What is the most likely diagnosis?
- A. Early intrauterine pregnancy not yet visible on ultrasound
- B. Completed spontaneous miscarriage
- C. Ovarian ectopic pregnancy
- D. Cornual ectopic pregnancy (Correct Answer)
- E. Persistent corpus luteum of failed intrauterine pregnancy
Explanation: ***Cornual ectopic pregnancy*** - A **cornual (interstitial) pregnancy** implants within the myometrium of the uterine horn, which often prevents it from being visible during a standard **laparoscopic inspection** of the fallopian tubes. - With a **serum beta-hCG of 1,800 IU/L**, an intrauterine pregnancy should be visible on ultrasound (discriminatory zone >1,500 IU/L); its absence alongside normal-looking tubes strongly suggests a hidden **interstitial implantation**. *Early intrauterine pregnancy not yet visible on ultrasound* - A visible gestational sac is typically expected on **transvaginal ultrasound** once the **beta-hCG** levels exceed **1,500 IU/L**. - Since the uterus appeared empty at this level, an early viable **intrauterine pregnancy** is highly unlikely. *Completed spontaneous miscarriage* - Following a **completed miscarriage**, the uterus should appear empty, but the **beta-hCG levels** would be rapidly declining rather than remaining at a high level like 1,800 IU/L. - Clinical presentation usually involves a history of **heavy vaginal bleeding** and passing of tissue, which is not mentioned here. *Ovarian ectopic pregnancy* - **Ovarian ectopics** typically present as a suspicious mass on the ovary during laparoscopy, following widespread **Spiegelberg criteria**. - While a 3 cm **haemorrhagic cyst** is present, this is more statistically likely to be a **corpus luteum**, which supports any pregnancy regardless of site. *Persistent corpus luteum of failed intrauterine pregnancy* - A **corpus luteum** is a normal finding in early pregnancy and not a diagnosis for the **location** of the pregnancy itself. - It does not explain the high **beta-hCG** of 1,800 IU/L in the absence of an **intrauterine sac** or visible tubal pathology.
Question 93: A 43-year-old woman presents with intermenstrual bleeding and postcoital bleeding for 4 months. Her periods are regular and normal in volume. Her last cervical screening 2 years ago was negative for high-risk HPV. On speculum examination, the cervix appears healthy with no visible lesions. What is the most appropriate initial management?
- A. Repeat cervical screening with HPV testing and cytology (Correct Answer)
- B. Transvaginal ultrasound scan
- C. Reassure and review in 3 months
- D. Hysteroscopy and endometrial biopsy
- E. Empirical treatment with norethisterone
Explanation: ***Repeat cervical screening with HPV testing and cytology*** - **Postcoital bleeding (PCB)** and **intermenstrual bleeding** are red flags for **cervical pathology**, including **cervical cancer**, even if the cervix appears healthy on speculum examination and previous screening was negative. - The most appropriate initial step is to repeat **cervical screening** with **HPV testing** and **cytology** to rule out high-risk HPV infection or early dysplastic changes that might have developed or been missed. *Transvaginal ultrasound scan* - While a **transvaginal ultrasound** is useful for assessing uterine and ovarian pathology (like fibroids or polyps), it is not the primary investigation for **postcoital bleeding** as it does not directly evaluate cervical lesions. - This scan would be more appropriate if cervical causes were ruled out and suspicion for **intracavitary uterine pathology** or ovarian issues remained. *Reassure and review in 3 months* - **Postcoital bleeding** is a concerning symptom that warrants thorough investigation to exclude **cervical malignancy** (up to 3%) or **cervical intraepithelial neoplasia (CIN)** (up to 9%). - Reassurance without investigation could lead to a **delayed diagnosis** of a potentially serious condition, which is medically inappropriate. *Hysteroscopy and endometrial biopsy* - **Hysteroscopy** and **endometrial biopsy** are indicated when there is a strong suspicion of **endometrial pathology**, such as in cases of **postmenopausal bleeding** or persistent heavy menstrual bleeding. - Given the patient's symptoms are primarily **intermenstrual** and **postcoital bleeding**, with regular normal volume periods, a cervical cause is more likely than an endometrial one as the initial focus. *Empirical treatment with norethisterone* - **Empirical hormonal treatment** like **norethisterone** can mask the symptoms of **underlying pathology**, particularly **cervical cancer**, leading to a delay in diagnosis and treatment. - Hormonal therapy is typically reserved for **dysfunctional uterine bleeding** after structural and malignant causes have been comprehensively excluded.
Question 94: A 29-year-old woman with a confirmed tubal ectopic pregnancy receives single-dose methotrexate (50 mg/m²) on day 0. Her initial beta-hCG was 2,400 IU/L. On day 4, she complains of increased lower abdominal pain without signs of rupture. On examination, she has mild right iliac fossa tenderness but is haemodynamically stable with no peritonism. Beta-hCG on day 4 is 2,650 IU/L. What is the most appropriate management?
- A. Emergency laparoscopy for presumed rupture
- B. Immediate second dose of methotrexate
- C. Reassurance and continue monitoring with day 7 beta-hCG (Correct Answer)
- D. Admit for observation and repeat ultrasound
- E. Switch to two-dose methotrexate regimen
Explanation: ***Reassurance and continue monitoring with day 7 beta-hCG***- It is expected and common for **beta-hCG levels to rise** between day 0 and day 4 of methotrexate treatment; the critical therapeutic evaluation occurs by comparing **day 4 and day 7** levels.- The patient is likely experiencing **separation pain**, a transient increase in abdominal pain typically occurring 3–7 days after methotrexate due to tubal abortion or hematoma formation in a **hemodynamically stable** patient.*Emergency laparoscopy for presumed rupture*- This patient lacks clinical signs of **hemodynamic instability**, severe peritonism, or shoulder-tip pain that would indicate an **ectopic rupture**.- Surgical intervention is reserved for patients who fail medical management or show signs of **acute hemoperitoneum**.*Immediate second dose of methotrexate*- A second dose is only considered if the **beta-hCG level** fails to drop by at least **15% between day 4 and day 7**.- Giving a second dose on day 4 is premature as the initial dose's effectiveness cannot be accurately assessed until the **day 7 measurement**.*Admit for observation and repeat ultrasound*- While monitoring is necessary, this patient is **stable** and exhibiting a physiological response to treatment that can usually be managed with **outpatient follow-up**.- An ultrasound is often unhelpful at this stage as it may show a transient increase in the size of the **ectopic mass** due to hemorrhage, which does not necessarily indicate failure.*Switch to two-dose methotrexate regimen*- The choice between single-dose and multi-dose regimens is made at **treatment initiation** based on baseline hCG levels and mass size.- Once a **single-dose protocol** has started, the standard of care is to follow the set monitoring schedule rather than switching mid-cycle due to expected day 4 hCG rises.
Question 95: A 36-year-old nulliparous woman presents with heavy menstrual bleeding for 12 months. She reports using 16 pads per day for 8 days each cycle. Haemoglobin is 78 g/L. Transvaginal ultrasound shows a 4 cm subserosal fibroid on the posterior uterine wall and otherwise normal appearances. She strongly wishes to maintain her fertility. What is the most appropriate management?
- A. Levonorgestrel intrauterine system insertion
- B. Tranexamic acid and iron supplementation (Correct Answer)
- C. Laparoscopic myomectomy
- D. GnRH analogue therapy for 6 months
- E. Combined oral contraceptive pill
Explanation: ***Tranexamic acid and iron supplementation*** - The patient has severe **anaemia (Hb 78 g/L)** due to heavy menstrual bleeding; initial management must include **iron replacement** and medical control of bleeding. - A **subserosal fibroid** does not distort the uterine cavity and is rarely the cause of heavy bleeding, making medical management more appropriate than surgery. *Levonorgestrel intrauterine system insertion* - This is a first-line treatment for heavy bleeding but provides **contraception**, which may not be ideal if she is currently trying to conceive. - While effective, the patient's immediate need is the correction of **acute severe anaemia** and stabilization of bleeding. *Laparoscopic myomectomy* - Surgical removal is generally reserved for **symptomatic fibroids** (e.g., pressure symptoms or infertility) or those distorting the cavity (submucosal). - **Subserosal fibroids** are unlikely to be causing the heavy bleeding, so removing them would not resolve her primary complaint and carries unnecessary surgical risk. *GnRH analogue therapy for 6 months* - These are typically used to **shrink fibroids** pre-operatively or as a short-term bridge to menopause, not as a long-term strategy for women wishing to retain fertility. - Symptoms recur rapidly after discontinuation, and long-term use is limited by **bone mineral density** loss. *Combined oral contraceptive pill* - While the COCP can reduce menstrual flow, it is a **contraceptive**, which conflicts with the patient's desire to maintain her fertility options. - **Tranexamic acid** is more suitable for women seeking pregnancy as it is taken only during menstruation and does not inhibit ovulation.
Question 96: A 32-year-old woman presents with 7 weeks amenorrhoea and mild abdominal discomfort. Transvaginal ultrasound shows an empty uterus and a 30mm left adnexal mass. Initial serum beta-hCG is 1,200 IU/L. She is haemodynamically stable. A repeat beta-hCG 48 hours later is 1,450 IU/L. She meets all other criteria for expectant management and wishes to avoid intervention if possible. What is the most appropriate management?
- A. Continue expectant management with weekly beta-hCG monitoring (Correct Answer)
- B. Repeat beta-hCG after another 48 hours
- C. Proceed with single-dose methotrexate therapy
- D. Arrange urgent laparoscopy
- E. Perform endometrial curettage to exclude miscarriage
Explanation: ***Continue expectant management with weekly beta-hCG monitoring*** - The patient is **haemodynamically stable** with a beta-hCG level that is low (<1500 IU/L) and an adnexal mass <35mm, meeting criteria for **expectant management** despite the slight rise in hCG, especially given her preference to avoid intervention. - Continued **weekly beta-hCG monitoring** is the standard approach for expectant management to ensure resolution or detect the need for alternative treatment if levels plateau or rise significantly. *Repeat beta-hCG after another 48 hours* - The initial 48-hour beta-hCG repeat has already provided the necessary trend information to confirm a likely ectopic pregnancy and assess suitability for expectant management. - Once expectant management is chosen, short-interval (48-hour) monitoring is generally replaced by **weekly monitoring** to track the resolution of the ectopic, rather than repeating diagnostic-phase tests. *Proceed with single-dose methotrexate therapy* - While methotrexate is an option for stable ectopic pregnancies, the patient explicitly **wishes to avoid intervention**, and expectant management is a suitable first-line approach in this scenario. - Methotrexate carries side effects and requires close follow-up; given the favorable criteria for expectant management and patient preference, it is not the most appropriate immediate next step. *Arrange urgent laparoscopy* - **Urgent laparoscopy** is indicated for haemodynamically unstable patients, those with signs of rupture (e.g., severe pain, significant bleeding), or very high hCG levels (typically >5,000 IU/L). - This patient is **haemodynamically stable** with mild discomfort and a low hCG level, thus not warranting immediate surgical intervention. *Perform endometrial curettage to exclude miscarriage* - **Endometrial curettage** is primarily used to differentiate a non-viable intrauterine pregnancy from a pregnancy of unknown location (PUL) when hCG levels are falling and no adnexal mass is clearly visualized. - In this case, a **left adnexal mass** is present, strongly suggesting an ectopic pregnancy, and curettage would not treat the ectopic or align with the patient's desire to avoid intervention.
Question 97: What is the primary cellular mechanism by which the levonorgestrel intrauterine system reduces menstrual blood loss in women with heavy menstrual bleeding?
- A. Suppression of ovulation leading to reduced progesterone production
- B. Increased endometrial stromal decidualisation with glandular atrophy (Correct Answer)
- C. Direct vasoconstriction of spiral arterioles in the endometrium
- D. Enhanced platelet aggregation at the endometrial-myometrial interface
- E. Inhibition of prostaglandin synthesis in endometrial tissue
Explanation: ***Increased endometrial stromal decidualisation with glandular atrophy*** - The **LNG-IUS** releases levonorgestrel directly into the uterine cavity, leading to high local concentrations that cause **profound endometrial suppression**. - This results in **decidualisation** of the stroma and progressive **glandular atrophy**, creating a thin, inactive endometrium that significantly reduces menstrual volume. *Suppression of ovulation leading to reduced progesterone production* - While the **LNG-IUS** may suppress **ovulation** in a small subset of users, most women continue to have regular ovulatory cycles. - The reduction in bleeding is primarily a **local endometrial effect** rather than a systemic endocrine change in progesterone levels. *Direct vasoconstriction of spiral arterioles in the endometrium* - Levonorgestrel does not act as a primary **vasoconstrictor**; its effect is mediated through cellular changes in the endometrial layers. - **Vasoconstriction** is more characteristic of pharmacological agents like ergometrine used in acute postpartum hemorrhage. *Enhanced platelet aggregation at the endometrial-myometrial interface* - The system does not primarily target **hemostatic pathways** or the coagulation cascade to control bleeding. - Mechanisms like enhanced clotting or platelet function are more relevant to therapies like **tranexamic acid**, which inhibits fibrinolysis. *Inhibition of prostaglandin synthesis in endometrial tissue* - Although progestogens can influence the local environment, the primary mechanism of **LNG-IUS** is structural atrophy rather than enzymatic inhibition. - **Prostaglandin synthesis inhibition** is the specific primary mechanism of **NSAIDs** used to treat heavy menstrual bleeding and dysmenorrhea.
Question 98: A 27-year-old woman undergoes emergency laparoscopy for a ruptured left tubal ectopic pregnancy. Intraoperatively, there is approximately 800 mL of haemoperitoneum. The left fallopian tube is disrupted with active bleeding. The right fallopian tube appears normal. She has no children but wishes to preserve fertility. What is the most appropriate surgical management?
- A. Left salpingectomy (Correct Answer)
- B. Left salpingotomy with tube preservation
- C. Bilateral salpingectomy
- D. Left salpingectomy with right prophylactic salpingectomy
- E. Segmental resection with end-to-end anastomosis
Explanation: ***Left salpingectomy***- For a **ruptured ectopic pregnancy** with significant **haemoperitoneum** and extensive tubal damage, salpingectomy is the gold-standard treatment to achieve **haemostasis** and prevent recurrence.- While fertility preservation is important, a **normal contralateral tube** means the patient still has a high chance of future spontaneous pregnancy without the risks associated with a damaged site.*Left salpingotomy with tube preservation*- This procedure is generally indicated for **unruptured ectopic pregnancies** in women who have risk factors for infertility, such as a damaged **contralateral tube**.- In the presence of **active bleeding** and a **disrupted fallopian tube**, salpingotomy is contraindicated due to the high risk of persistent trophoblastic tissue and secondary haemorrhage.*Bilateral salpingectomy*- There is no clinical indication to remove the **healthy right fallopian tube**, which is essential for preserving the patient's **future fertility** aspirations.- Removing both tubes would render the patient **permanently infertile** (barring IVF), which directly contradicts her expressed wishes.*Left salpingectomy with right prophylactic salpingectomy*- **Prophylactic removal** of a healthy fallopian tube is not standard practice in emergency management and unnecessarily compromises reproductive potential.- Surgical management should be focused on treating the **acute pathology** and the source of **haemoperitoneum** while minimizing harm to healthy pelvic structures.*Segmental resection with end-to-end anastomosis*- This technique is not performed in an **emergency setting** for a ruptured tube because it is technically difficult and carries a high risk of **tubal stricture**.- Current clinical guidelines recommend **salpingectomy** over resection because it more reliably resolves the pathology and has superior outcomes compared to acute reconstructive attempts.
Question 99: A 51-year-old woman presents with irregular heavy bleeding over 9 months. She describes cycles varying from 18 to 45 days with flooding for 7-10 days. Her last cervical smear 18 months ago was normal. BMI is 34 kg/m². Pelvic examination is normal. Transvaginal ultrasound shows an endometrial thickness of 18 mm with a normal-sized uterus and ovaries. What is the most important next investigation?
- A. MRI pelvis
- B. Hysteroscopy with endometrial biopsy (Correct Answer)
- C. Repeat transvaginal ultrasound in 3 months
- D. Saline infusion sonography
- E. CA-125 measurement
Explanation: ***Hysteroscopy with endometrial biopsy***- This 51-year-old perimenopausal woman presents with **abnormal uterine bleeding** and a significantly thickened endometrium of **18 mm**, which necessitates tissue sampling to rule out **endometrial hyperplasia** or **malignancy**.- Her **obesity (BMI 34 kg/m²)** is a strong risk factor for endometrial cancer due to unopposed estrogen, making an immediate histological diagnosis critical.*MRI pelvis*- MRI is typically used for **staging** known pelvic malignancies or for characterizing complex adnexal masses, rather than for the initial diagnosis of abnormal uterine bleeding.- It cannot provide the crucial **histological diagnosis** required to differentiate between benign endometrial changes and carcinoma in this high-risk patient.*Repeat transvaginal ultrasound in 3 months*- Delaying further investigation with a repeat ultrasound is inappropriate given the patient's age, persistent **abnormal uterine bleeding**, and a pathological **endometrial thickness** of 18 mm.- This delay could lead to a missed or later diagnosis of **endometrial cancer**, which has a better prognosis when detected early.*Saline infusion sonography*- While effective for identifying **focal intracavitary lesions** such as polyps or submucosal fibroids, saline infusion sonography (SIS) does not provide tissue for **histological analysis**.- In this context of diffuse endometrial thickening and significant risk factors for malignancy, a definitive tissue diagnosis is required.*CA-125 measurement*- **CA-125** is a tumor marker primarily used in the workup and monitoring of **ovarian cancer** and certain benign gynecological conditions.- It has no established role in the primary investigation of **abnormal uterine bleeding** or in the evaluation of endometrial pathology due to its low specificity for endometrial cancer.
Question 100: A 28-year-old woman presents with 6 weeks amenorrhoea and right-sided pelvic pain. Transvaginal ultrasound shows an empty uterus with normal endometrial thickness and a 25mm right adnexal mass with a hyperechoic ring (blob sign). There is minimal free fluid in the pouch of Douglas. Serum beta-hCG is 2,800 IU/L. She is haemodynamically stable and pain is controlled with oral analgesia. What is the most appropriate management?
- A. Expectant management with serial beta-hCG monitoring
- B. Single-dose intramuscular methotrexate 50 mg/m² (Correct Answer)
- C. Two-dose intramuscular methotrexate regimen
- D. Laparoscopic salpingectomy
- E. Laparoscopic salpingotomy
Explanation: ***Single-dose intramuscular methotrexate 50 mg/m²*** - Medical management with **methotrexate** is indicated as the patient is **haemodynamically stable**, has **minimal pain**, no fetal heartbeat, and a **beta-hCG < 3,000 IU/L** (2,800 IU/L in this case). - The adnexal mass size of **25mm** (which is < 35mm) and lack of significant abdominal fluid make her an ideal candidate for this **non-surgical** approach. *Expectant management with serial beta-hCG monitoring* - This approach is typically reserved for clinically stable patients where the initial **beta-hCG is < 1,500 IU/L** and levels are already declining. - With a beta-hCG of **2,800 IU/L**, the risk of **tubal rupture** is too high for simple observation without active intervention. *Two-dose intramuscular methotrexate regimen* - The **two-dose regimen** is generally reserved for patients with higher initial beta-hCG levels or those who do not respond adequately to the first dose. - Current guidelines recommend starting with a **single-dose regimen** for patients meeting the criteria, as it has a lower side-effect profile. *Laparoscopic salpingectomy* - **Salpingectomy** (removal of the tube) is the gold standard for **ruptured ectopic pregnancy** or when the patient is haemodynamically unstable. - Surgical intervention is less desirable here because the patient is stable and meets the criteria for **organ-preserving medical therapy**. *Laparoscopic salpingotomy* - **Salpingotomy** (incising the tube to remove the pregnancy) is considered if the patient has risk factors for **infertility**, such as damage to the contralateral tube. - It carries a risk of **persistent trophoblastic tissue** and is not the first-line choice when medical management with **methotrexate** is appropriate and available.
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