Gynaecology — MCQs
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A 29-year-old woman undergoes emergency laparoscopy for suspected ruptured ectopic pregnancy. During the procedure, a ruptured left tubal ectopic pregnancy is confirmed with 800 mL of haemoperitoneum. The right fallopian tube appears normal with no evidence of adhesions. The left tube has a 2 cm rupture site with active bleeding. She has had no previous pregnancies and wishes to preserve fertility. What is the single most important factor that should guide the surgical management of the affected tube?
A 25-year-old woman with known polycystic ovary syndrome presents with irregular bleeding over the past 8 months. She has had three periods in this time, each lasting 10-14 days with moderate to heavy flow. Her body mass index is 32 kg/m². She is not currently sexually active and does not wish to conceive. Pelvic examination is normal. What is the most important initial investigation to guide management?
A 41-year-old woman with heavy menstrual bleeding is found to have a 4 cm submucous fibroid on transvaginal ultrasound. She wishes to retain her uterus and avoid hormonal treatments due to a history of hormone-sensitive breast cancer 3 years ago. Her haemoglobin is 94 g/L. What is the most appropriate management option?
A 30-year-old woman presents with 6 weeks amenorrhoea and mild left-sided pelvic discomfort. Her pregnancy test is positive. Transvaginal ultrasound shows an empty uterus with endometrial thickness of 9 mm. No adnexal masses are seen and there is no free fluid. Her serum beta-hCG is 1250 IU/L. She is haemodynamically stable. A repeat beta-hCG 48 hours later is 2780 IU/L. What is the most appropriate management?
A 35-year-old woman presents with an 18-month history of increasingly heavy menstrual bleeding. She reports using 15 super-absorbent tampons per period and experiences flooding. Her periods last 9 days and occur every 26 days. She has dysmenorrhoea requiring regular analgesia. Examination reveals a mobile tender mass arising from the pelvis. Transvaginal ultrasound shows an enlarged uterus (14 cm) with multiple fibroids, the largest being an 8 cm posterior intramural fibroid. Haemoglobin is 88 g/L. She has completed her family. What is the most appropriate definitive management?
A 33-year-old woman is being monitored following single-dose intramuscular methotrexate (50 mg/m²) for an unruptured tubal ectopic pregnancy. Her pre-treatment beta-hCG was 1850 IU/L. On day 4, her beta-hCG is 1920 IU/L, and on day 7 it is 1440 IU/L. She remains clinically stable with minimal abdominal discomfort. What is the most appropriate next step in management?
A 52-year-old woman presents with a 7-month history of intermenstrual bleeding occurring irregularly. She has had regular smear tests, the most recent being 18 months ago which was normal. Pelvic examination reveals a normal-sized uterus and no obvious cervical lesion. She is not on any medications. What is the most appropriate initial investigation?
According to the Royal College of Obstetricians and Gynaecologists guidelines, which of the following is an absolute contraindication to medical management of ectopic pregnancy with methotrexate?
A 46-year-old woman with menorrhagia has been using a levonorgestrel intrauterine system for 8 months. She reports that her bleeding has reduced from very heavy to moderate flow, but she continues to have 7-day periods with flooding on days 2-3. She is anaemic with haemoglobin of 101 g/L. Transvaginal ultrasound shows a bulky uterus (10 cm) with multiple intramural fibroids, the largest measuring 5 cm. The LNG-IUS is correctly positioned. What is the most appropriate next management step?
A 31-year-old woman undergoes laparoscopy for right-sided pelvic pain and 7 weeks amenorrhoea. A 3.5 cm unruptured ectopic pregnancy is identified in the ampullary region of the right fallopian tube. Her left fallopian tube appears healthy. She is haemodynamically stable. What is the most appropriate surgical management that balances future fertility with treatment efficacy?
Gynaecology UK Medical PG Practice Questions and MCQs
Question 11: A 29-year-old woman undergoes emergency laparoscopy for suspected ruptured ectopic pregnancy. During the procedure, a ruptured left tubal ectopic pregnancy is confirmed with 800 mL of haemoperitoneum. The right fallopian tube appears normal with no evidence of adhesions. The left tube has a 2 cm rupture site with active bleeding. She has had no previous pregnancies and wishes to preserve fertility. What is the single most important factor that should guide the surgical management of the affected tube?
- A. The presence of a healthy contralateral fallopian tube (Correct Answer)
- B. The size of the rupture site in the affected tube
- C. The volume of haemoperitoneum present
- D. The patient's desire for future fertility
- E. The location of the ectopic pregnancy within the tube
Explanation: ***The presence of a healthy contralateral fallopian tube***- In the management of **ruptured ectopic pregnancy**, **salpingectomy** (removal of the tube) is preferred over **salpingotomy** (incision to remove the pregnancy) if the **contralateral tube** is healthy.- This approach minimizes the risk of **persistent trophoblastic disease** and subsequent **recurrent ectopic pregnancy**, with comparable rates of **future intrauterine pregnancy** for nulliparous patients.*The size of the rupture site in the affected tube*- While the rupture size indicates tubal damage, the primary decision between **salpingectomy** and **salpingotomy** is based on the status of the **contralateral tube**, not solely the rupture's dimensions.- A **ruptured tube** often requires **salpingectomy** regardless of the precise rupture size due to extensive damage and difficulty in achieving hemostasis with tubal preservation.*The volume of haemoperitoneum present*- The **volume of haemoperitoneum** primarily indicates the patient's **hemodynamic stability** and the urgency of intervention, but it does not dictate the choice of tubal management (salpingectomy vs. salpingotomy).- Even with significant **haemoperitoneum**, **laparoscopic salpingectomy** remains the standard for tubal ectopic pregnancy if the patient is stable enough for the procedure.*The patient's desire for future fertility*- While **fertility preservation** is a key consideration, evidence shows that performing a **salpingectomy** on a ruptured tube when a **healthy contralateral tube** is present does not diminish future **fertility outcomes**.- Attempting **salpingotomy** in a ruptured tube, especially when the other tube is healthy, significantly increases the risk of **persistent trophoblastic disease** (15-20%) without improving subsequent pregnancy rates.*The location of the ectopic pregnancy within the tube*- The specific **tubal location** (e.g., ampullary, isthmic) can influence the technical ease of a **salpingotomy**, but it is not the primary factor guiding the choice between **salpingectomy** and **salpingotomy**.- In a **ruptured ectopic pregnancy**, particularly with a healthy contralateral tube, **salpingectomy** is generally recommended irrespective of the exact location within the affected tube.
Question 12: A 25-year-old woman with known polycystic ovary syndrome presents with irregular bleeding over the past 8 months. She has had three periods in this time, each lasting 10-14 days with moderate to heavy flow. Her body mass index is 32 kg/m². She is not currently sexually active and does not wish to conceive. Pelvic examination is normal. What is the most important initial investigation to guide management?
- A. Transvaginal ultrasound and endometrial sampling (Correct Answer)
- B. Serum follicle-stimulating hormone and luteinizing hormone
- C. Serum testosterone and sex hormone-binding globulin
- D. Oral glucose tolerance test and fasting lipids
- E. Full blood count and ferritin
Explanation: ***Transvaginal ultrasound and endometrial sampling*** - In a patient with **PCOS**, obesity, and **oligomenorrhea** (fewer than 4 periods in 6 months), there is a significant risk of **endometrial hyperplasia** or cancer due to **unopposed estrogen**. - **Endometrial sampling** is the crucial diagnostic step to rule out malignancy and guide management for abnormal uterine bleeding in high-risk patients. *Serum follicle-stimulating hormone and luteinizing hormone* - While the **LH:FSH ratio** is often elevated in PCOS, these levels do not help manage the immediate risk of **endometrial pathology**. - Measurement of these hormones is more useful for diagnosing **menopause** or primary ovarian insufficiency rather than acute bleeding management. *Serum testosterone and sex hormone-binding globulin* - These tests assess **biochemical hyperandrogenism** to confirm a PCOS diagnosis but are not indicated for investigating **prolonged irregular bleeding**. - They provide information on the cause of hirsutism or acne but do not evaluate the status of the **endometrium**. *Oral glucose tolerance test and fasting lipids* - These are important for screening **metabolic syndrome** and diabetes risk in PCOS patients but are not the priority during **acute abnormal bleeding**. - Metabolic screening is part of long-term care and does not address the risk of **endometrial carcinoma**. *Full blood count and ferritin* - These tests assess for **iron deficiency anemia** resulting from heavy flow but do not identify the **underlying cause** of the bleeding. - While supportive, they are secondary to the **histological assessment** required to exclude precancerous changes in the uterus.
Question 13: A 41-year-old woman with heavy menstrual bleeding is found to have a 4 cm submucous fibroid on transvaginal ultrasound. She wishes to retain her uterus and avoid hormonal treatments due to a history of hormone-sensitive breast cancer 3 years ago. Her haemoglobin is 94 g/L. What is the most appropriate management option?
- A. Hysteroscopic myomectomy (Correct Answer)
- B. Uterine artery embolization
- C. Levonorgestrel intrauterine system
- D. Abdominal myomectomy
- E. Combined oral contraceptive pill
Explanation: ***Hysteroscopic myomectomy***- This is the first-line surgical treatment for **submucous fibroids** (typically up to 4-5 cm) as it is minimally invasive and allows for **uterine preservation**.- It is the most appropriate choice here because it provides a **non-hormonal** definitive treatment for the specific fibroid causing her anemia and heavy bleeding, avoiding risks associated with her **breast cancer history**.*Uterine artery embolization*- While it allows for uterine preservation, it is generally reserved for **multiple intramural fibroids** rather than a single accessible submucous lesion.- There is a small risk of **premature ovarian failure**, and in this case, direct surgical removal of the submucous fibroid is more targeted.*Levonorgestrel intrauterine system*- Although effective for heavy menstrual bleeding, the use of **progestogen-releasing devices** is generally avoided or used with extreme caution in patients with a history of **hormone-sensitive breast cancer**.- It may not be as effective in the presence of a 4 cm **submucous fibroid**, which can distort the uterine cavity and lead to higher **expulsion rates**.*Abdominal myomectomy*- This procedure involves a much higher surgical morbidity, including a larger incision and a longer **recovery time**, compared to the hysteroscopic route.- It is typically reserved for **subserosal or intramural fibroids** that are too large or poorly positioned for hysteroscopic or laparoscopic approaches.*Combined oral contraceptive pill*- This is **absolutely contraindicated** in this patient due to her recent history of **hormone-sensitive breast cancer**, which carries a high risk of recurrence with exogenous estrogen.- Medical management with hormones does not address the **mechanical cause** of bleeding (the fibroid) as effectively as surgical removal in this scenario.
Question 14: A 30-year-old woman presents with 6 weeks amenorrhoea and mild left-sided pelvic discomfort. Her pregnancy test is positive. Transvaginal ultrasound shows an empty uterus with endometrial thickness of 9 mm. No adnexal masses are seen and there is no free fluid. Her serum beta-hCG is 1250 IU/L. She is haemodynamically stable. A repeat beta-hCG 48 hours later is 2780 IU/L. What is the most appropriate management?
- A. Arrange repeat transvaginal ultrasound scan in 7-10 days (Correct Answer)
- B. Administer intramuscular methotrexate
- C. Proceed to diagnostic laparoscopy
- D. Arrange suction evacuation of retained products of conception
- E. Commence expectant management with weekly beta-hCG monitoring
Explanation: ***Arrange repeat transvaginal ultrasound scan in 7-10 days***- The **beta-hCG rise** from 1250 IU/L to 2780 IU/L over 48 hours represents a 122.4% increase, which is highly suggestive of a **viable intrauterine pregnancy** as it exceeds the minimum expected rise of 63%.- At an initial hCG of 1250 IU/L, an intrauterine gestational sac is often not visible (below the **discriminatory zone** of 1500-2000 IU/L). A repeat scan in **7-10 days** allows the hCG to rise sufficiently for definitive visualization of an intrauterine pregnancy.*Administer intramuscular methotrexate*- **Methotrexate** is indicated for confirmed or highly suspected **stable ectopic pregnancies** without evidence of intrauterine viability.- Administering methotrexate in a case with **appropriately rising hCG** and no clear ectopic signs would be inappropriate, as it could harm a potentially healthy intrauterine pregnancy.*Proceed to diagnostic laparoscopy*- **Diagnostic laparoscopy** is an invasive surgical procedure typically reserved for **haemodynamically unstable** patients or those with strong ultrasound evidence of an ectopic pregnancy requiring immediate intervention.- This patient is **haemodynamically stable**, has no adnexal masses or free fluid on ultrasound, and exhibits an appropriate hCG rise, making an invasive procedure premature.*Arrange suction evacuation of retained products of conception*- **Suction evacuation** is performed for management of **miscarriage** or retained products of conception; it is not indicated for a potentially viable pregnancy.- Given the **normal rise in beta-hCG**, this procedure would result in an iatrogenic **termination** of what is likely a normal developing pregnancy.*Commence expectant management with weekly beta-hCG monitoring*- Expectant management with weekly hCG monitoring is usually reserved for **pregnancies of unknown location (PUL)** where hCG levels are plateauing or declining, suggesting a non-viable or resolving ectopic pregnancy.- In this case, the **hCG is rising appropriately**, warranting efforts to locate and confirm the viability of the pregnancy via ultrasound rather than passive monitoring for a decline.
Question 15: A 35-year-old woman presents with an 18-month history of increasingly heavy menstrual bleeding. She reports using 15 super-absorbent tampons per period and experiences flooding. Her periods last 9 days and occur every 26 days. She has dysmenorrhoea requiring regular analgesia. Examination reveals a mobile tender mass arising from the pelvis. Transvaginal ultrasound shows an enlarged uterus (14 cm) with multiple fibroids, the largest being an 8 cm posterior intramural fibroid. Haemoglobin is 88 g/L. She has completed her family. What is the most appropriate definitive management?
- A. Total hysterectomy (Correct Answer)
- B. Uterine artery embolization
- C. Myomectomy
- D. Levonorgestrel intrauterine system insertion
- E. Endometrial ablation
Explanation: ***Total hysterectomy***- A **total hysterectomy** offers a **definitive cure** for **heavy menstrual bleeding**, **dysmenorrhoea**, and fibroids, making it the most appropriate choice for a patient who has **completed her family** and seeks permanent relief.- Given the severe **anaemia (Hb 88 g/L)**, large **8 cm intramural fibroid**, and enlarged **14 cm uterus**, hysterectomy provides immediate and complete resolution of symptoms and prevents recurrence. *Uterine artery embolization*- While **uterus-preserving**, **uterine artery embolization** carries a higher **re-intervention rate** and is less definitive, especially with a large uterine and fibroid burden.- It is typically considered when fertility or uterine preservation is desired, which is not the primary goal for this patient seeking definitive management after completing her family. *Myomectomy*- **Myomectomy** is primarily indicated for women who wish to **preserve fertility** or their uterus, which is not a priority for this patient.- There is a significant risk of **fibroid recurrence** and the need for future surgeries, making it less definitive than hysterectomy for this patient's severe symptoms. *Levonorgestrel intrauterine system insertion*- The **LNG-IUS** is often less effective or prone to **expulsion** when the uterine cavity is significantly **distorted by large fibroids**, such as the 8 cm intramural fibroid in this case.- It is unlikely to adequately control the severe **heavy menstrual bleeding**, **anaemia**, and **dysmenorrhoea** associated with such a large fibroid burden and enlarged uterus. *Endometrial ablation*- **Endometrial ablation** is generally **contraindicated** or has very limited success in the presence of large **intramural or submucosal fibroids** that distort the uterine cavity.- Its efficacy is significantly reduced in uteri larger than **10-12 cm**, making it unsuitable for this patient's **14 cm uterus** and unlikely to resolve her severe symptoms.
Question 16: A 33-year-old woman is being monitored following single-dose intramuscular methotrexate (50 mg/m²) for an unruptured tubal ectopic pregnancy. Her pre-treatment beta-hCG was 1850 IU/L. On day 4, her beta-hCG is 1920 IU/L, and on day 7 it is 1440 IU/L. She remains clinically stable with minimal abdominal discomfort. What is the most appropriate next step in management?
- A. Administer second dose of methotrexate
- B. Proceed to diagnostic laparoscopy
- C. Continue weekly beta-hCG monitoring until undetectable (Correct Answer)
- D. Arrange urgent transvaginal ultrasound scan
- E. Administer multi-dose methotrexate regimen
Explanation: ***Continue weekly beta-hCG monitoring until undetectable***- In the single-dose **methotrexate** protocol for ectopic pregnancy, success is defined by a **fall in beta-hCG of ≥15%** between day 4 and day 7.- This patient showed a **25% decrease** (from 1920 to 1440 IU/L), indicating treatment is effective and requires serial monitoring until the level is below **5 IU/L**.*Administer second dose of methotrexate*- A second dose is only indicated if the **beta-hCG fall is <15%** between day 4 and day 7.- Administering unnecessary methotrexate increases the risk of **side effects** like stomatitis or liver enzyme elevation without clinical benefit here.*Proceed to diagnostic laparoscopy*- Surgical intervention is reserved for patients who are **hemodynamically unstable**, have signs of **tubal rupture**, or fail medical management.- This patient is **clinically stable** and responding well biochemically, making surgery unnecessary and riskier than continued observation.*Arrange urgent transvaginal ultrasound scan*- Routine ultrasound is not required if the patient is stable and beta-hCG levels are **adequately declining** as per protocol.- Ultrasound findings often lag behind biochemical response and may show a persistent or slightly larger mass due to **hematoma**, which does not indicate treatment failure.*Administer multi-dose methotrexate regimen*- The **multi-dose regimen** is a specific primary treatment protocol involving alternating methotrexate and **leucovorin** rescue, not a rescue therapy for successful single-dose treatment.- There is no clinical indication to switch to a more complex and potentially more **toxic regimen** when the single-dose protocol is working.
Question 17: A 52-year-old woman presents with a 7-month history of intermenstrual bleeding occurring irregularly. She has had regular smear tests, the most recent being 18 months ago which was normal. Pelvic examination reveals a normal-sized uterus and no obvious cervical lesion. She is not on any medications. What is the most appropriate initial investigation?
- A. Repeat cervical cytology
- B. Transvaginal ultrasound scan and endometrial sampling (Correct Answer)
- C. Serum follicle-stimulating hormone and luteinizing hormone levels
- D. Full blood count and thyroid function tests
- E. Diagnostic laparoscopy
Explanation: ***Transvaginal ultrasound scan and endometrial sampling*** - In a 52-year-old woman with **intermenstrual bleeding**, it is essential to exclude **endometrial hyperplasia** or **endometrial cancer** as a primary concern, given her age and symptoms. - **Transvaginal ultrasound** assesses **endometrial thickness**, while **endometrial sampling** (e.g., Pipelle biopsy) provides the necessary **histological diagnosis**. *Repeat cervical cytology* - The patient had a normal **smear test** 18 months ago and no visible **cervical lesions** on examination, making primary cervical pathology less likely as the initial cause. - Cervical cytology is primarily a **screening tool** for cervical cancer and is not the appropriate diagnostic test for investigating abnormal uterine bleeding originating from the uterine cavity. *Serum follicle-stimulating hormone and luteinizing hormone levels* - While these levels can help confirm **perimenopausal** or **menopausal status**, they do not directly explain the cause of abnormal bleeding or rule out potential **malignancy**. - Hormonal assays are secondary to structural and histological investigations when managing **abnormal uterine bleeding** in this age group, where endometrial pathology is a significant concern. *Full blood count and thyroid function tests* - **Thyroid dysfunction** can cause menstrual irregularities, but ruling out serious conditions like **endometrial cancer** is the highest priority in this age group with intermenstrual bleeding. - A **full blood count** may identify **anemia** resulting from the bleeding but will not identify the underlying anatomical or pathological cause. *Diagnostic laparoscopy* - **Laparoscopy** is an invasive surgical procedure primarily indicated for conditions like **pelvic pain**, **endometriosis**, or adnexal masses, not for the initial investigation of **intermenstrual bleeding**. - Intraluminal uterine pathologies, which are the main concern with intermenstrual bleeding, are better visualized and sampled via **hysteroscopy** or assessed with **transvaginal ultrasound** rather than external visualization through laparoscopy.
Question 18: According to the Royal College of Obstetricians and Gynaecologists guidelines, which of the following is an absolute contraindication to medical management of ectopic pregnancy with methotrexate?
- A. Serum beta-hCG level of 4500 IU/L
- B. Ectopic pregnancy measuring 38 mm on ultrasound scan
- C. Presence of fetal heartbeat on ultrasound scan (Correct Answer)
- D. Moderate free fluid visible in the pouch of Douglas on ultrasound scan
- E. Previous history of one ectopic pregnancy treated surgically
Explanation: ***Presence of fetal heartbeat on ultrasound scan***- According to **RCOG guidelines**, the presence of **visible fetal cardiac activity** is an absolute contraindication for systemic methotrexate as it signifies a high risk of **treatment failure** and tubal rupture.- Medical management is less effective in viable pregnancies with higher metabolic activity, necessitating surgical intervention to ensure patient safety.*Serum beta-hCG level of 4500 IU/L*- While a high **beta-hCG** (typically >3000 IU/L or >5000 IU/L depending on specific protocols) increases the risk of failure, it is generally considered a **relative contraindication** rather than an absolute one.- RCOG suggests that methotrexate is most successful when the initial hCG is below **1500 IU/L**.*Ectopic pregnancy measuring 38 mm on ultrasound scan*- An ectopic mass size greater than **35 mm** is a relative contraindication to medical management.- This criteria is used to select patients likely to respond to a **single-dose regimen**, but a slightly larger mass does not strictly prohibit its use if other factors are favorable.*Moderate free fluid visible in the pouch of Douglas on ultrasound scan*- Significant **intraperitoneal fluid** suggests possible rupture or hemoperitoneum, which usually warrants **laparoscopic surgery**.- However, a small or moderate amount of fluid in a hemodynamically stable patient is not always an absolute contraindication compared to a **fetal heartbeat**.*Previous history of one ectopic pregnancy treated surgically*- A history of prior surgery or ectopic pregnancy does not preclude medical management; in fact, **methotrexate** may be preferred to avoid further **pelvic adhesions**.- The eligibility for medical management focuses on the **current pregnancy characteristics** and patient stability rather than obstetric history.
Question 19: A 46-year-old woman with menorrhagia has been using a levonorgestrel intrauterine system for 8 months. She reports that her bleeding has reduced from very heavy to moderate flow, but she continues to have 7-day periods with flooding on days 2-3. She is anaemic with haemoglobin of 101 g/L. Transvaginal ultrasound shows a bulky uterus (10 cm) with multiple intramural fibroids, the largest measuring 5 cm. The LNG-IUS is correctly positioned. What is the most appropriate next management step?
- A. Continue with LNG-IUS for a further 4 months before reassessing (Correct Answer)
- B. Remove LNG-IUS and commence oral tranexamic acid and mefenamic acid
- C. Refer for uterine artery embolization
- D. Commence gonadotrophin-releasing hormone agonist therapy
- E. Refer for total hysterectomy
Explanation: ***Continue with LNG-IUS for a further 4 months before reassessing*** - The **Levonorgestrel intrauterine system (LNG-IUS)** can take up to **12 months** to reach its maximum clinical efficacy in reducing menstrual blood flow, especially in the presence of **intramural fibroids**. - Since the patient has already shown a **partial response** (reduction from very heavy to moderate flow) and the device is **correctly positioned**, it is appropriate to allow the full trial period before declaring treatment failure. *Remove LNG-IUS and commence oral tranexamic acid and mefenamic acid* - **Tranexamic acid** and **mefenamic acid** are generally less effective than the **LNG-IUS** for managing heavy menstrual bleeding associated with fibroids. - It would be counterproductive to remove a long-acting treatment that is already providing partial symptom relief for less potent **oral medical therapies**. *Refer for uterine artery embolization* - **Uterine artery embolization (UAE)** is a secondary option for women with fibroids who do not respond to medical management or wish to avoid surgery. - While the fibroids are significant (**5 cm**), more invasive procedures should typically be reserved until **medical management** has been given at least a full 12-month trial. *Commence gonadotrophin-releasing hormone agonist therapy* - **GnRH agonists** are primarily used as **preoperative treatment** to shrink fibroids or as a temporary measure for severe symptoms due to their side effect profile and risk of bone loss. - They are not considered a primary maintenance therapy for **menorrhagia** when a patient is already tolerating and responding to an **LNG-IUS**. *Refer for total hysterectomy* - **Hysterectomy** is the definitive surgical treatment but is generally considered only after **medical treatments** have failed or the patient expresses a specific preference for surgery. - This patient has not yet completed a full trial of the **LNG-IUS**, and her response suggests that continued use along with **iron supplementation** may resolve her symptoms and **anaemia**.
Question 20: A 31-year-old woman undergoes laparoscopy for right-sided pelvic pain and 7 weeks amenorrhoea. A 3.5 cm unruptured ectopic pregnancy is identified in the ampullary region of the right fallopian tube. Her left fallopian tube appears healthy. She is haemodynamically stable. What is the most appropriate surgical management that balances future fertility with treatment efficacy?
- A. Right salpingectomy (Correct Answer)
- B. Right salpingotomy
- C. Right salpingotomy with prophylactic methotrexate
- D. Segmental resection of the right fallopian tube
- E. Milking the ectopic pregnancy from the fimbrial end
Explanation: ***Right salpingectomy*** - Current **NICE/RCOG guidelines** recommend **salpingectomy** as the first-line surgical management for ectopic pregnancy if the **contralateral tube is healthy**. - Evidence shows that salpingectomy has **no disadvantage regarding future fertility** compared to salpingotomy while avoiding the risk of **persistent trophoblastic tissue**. *Right salpingotomy* - This procedure involves making an incision to remove the pregnancy while preserving the tube but carries a **15-20% risk of persistent trophoblast** requiring further treatment. - It is generally reserved for patients with **contralateral tubal damage** to maximize the chance of future natural conception. *Right salpingotomy with prophylactic methotrexate* - Adding **methotrexate** to salpingotomy does not significantly reduce the risk of persistent trophoblast compared to salpingectomy. - This approach is not recommended as it introduces **medication side effects** and requires rigorous **beta-hCG monitoring**. *Segmental resection of the right fallopian tube* - There is no clinical advantage to **segmental resection** over a total salpingectomy in the context of an ampullary ectopic pregnancy. - This technique is technically more complex and does not improve **future fertility outcomes** for the patient. *Milking the ectopic pregnancy from the fimbrial end* - This technique is associated with a **very high risk of persistent trophoblast** due to incomplete removal of the gestational tissue. - It is not a recommended surgical approach in contemporary gynaecological practice due to high **failure and complication rates**.
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