A 48-year-old woman presents with heavy menstrual bleeding for 11 months. Examination reveals a 12-week sized irregular uterus. Ultrasound confirms multiple intramural fibroids, the largest measuring 6cm. She has tried the levonorgestrel intrauterine system but it was expelled after 2 months. She has completed her family. Her haemoglobin is 92 g/L. She wishes to avoid major surgery if possible. What is the most appropriate next management option?
Q52
A 34-year-old woman presents to the emergency department with 6 weeks amenorrhoea, minimal vaginal spotting, and mild left-sided pelvic discomfort. Her serum beta-hCG is 800 IU/L. Transvaginal ultrasound shows an empty uterus with no adnexal masses visualised and no free fluid. She is haemodynamically stable. A repeat beta-hCG 48 hours later is 920 IU/L. What is the most likely diagnosis?
Q53
A 44-year-old woman with a BMI of 29 kg/m² presents with a 10-month history of heavy menstrual bleeding. She has tried tranexamic acid with limited improvement. She does not wish to have more children. Examination reveals a mobile anteverted uterus of normal size. Ultrasound shows endometrial thickness of 14mm on day 20 of a 30-day cycle, with normal myometrium and ovaries. Endometrial biopsy shows benign proliferative endometrium with no atypia. Thyroid function and coagulation screen are normal. What underlying diagnosis should be considered?
Q54
A 31-year-old woman with a confirmed right tubal ectopic pregnancy measuring 28mm with no fetal heartbeat is being considered for medical management. Her serum beta-hCG is 2800 IU/L. She is haemodynamically stable and asymptomatic apart from minimal lower abdominal discomfort. She has normal renal and liver function tests. Which finding would be an absolute contraindication to treatment with intramuscular methotrexate?
Q55
A 39-year-old nulliparous woman presents with heavy menstrual bleeding for 14 months that has not responded to tranexamic acid or mefenamic acid. She reports using 15-20 pads per cycle and her haemoglobin is 105 g/L. She wishes to preserve her fertility. Pelvic examination is normal. Transvaginal ultrasound shows a normal-sized uterus with endometrial thickness of 6mm on day 8 of her cycle and both ovaries appear normal. Hysteroscopy shows a normal uterine cavity with no polyps or fibroids. What is the most appropriate next management step?
Q56
A 35-year-old woman presents to the emergency department with 6 weeks amenorrhoea, right iliac fossa pain, and light vaginal bleeding. Her serum beta-hCG is 1200 IU/L. Transvaginal ultrasound shows an empty uterus with no adnexal masses visible. Free fluid is seen in the pouch of Douglas. She is haemodynamically stable with blood pressure 125/78 mmHg and heart rate 82 beats per minute. A repeat beta-hCG 48 hours later is 1450 IU/L. What is the most appropriate next step in management?
Q57
A 51-year-old woman presents with a 6-month history of irregular heavy bleeding. Her last menstrual period was 3 months ago. She reports occasional hot flushes. BMI is 27 kg/m². Pelvic examination is normal. Transvaginal ultrasound shows endometrial thickness of 6 mm with no focal abnormalities. FSH is 38 IU/L. What is the most appropriate management regarding endometrial assessment?
Q58
A 24-year-old woman presents to the emergency department with 5 weeks amenorrhoea and light vaginal bleeding. She reports mild lower abdominal discomfort. Observations: BP 125/78 mmHg, pulse 76 bpm, temperature 36.8°C. Abdominal examination reveals mild suprapubic tenderness with no guarding. Transvaginal ultrasound shows an empty uterus with 11 mm endometrium and a 2 cm right adnexal mass with a hyperechoic ring. No free fluid is visible. Serum beta-hCG is 1650 IU/L. What is the most appropriate initial management?
Q59
A 40-year-old woman with heavy menstrual bleeding is found to have a 6 cm posterior wall intramural fibroid on ultrasound. She wishes to preserve her fertility as she is planning pregnancy in the next year. Her haemoglobin is 95 g/L. She has no other significant medical history. After counselling about risks and benefits, what is the most appropriate management to address both her fertility wishes and current symptoms?
Q60
A 33-year-old woman presents with sudden onset severe right-sided pelvic pain, shoulder tip pain, and one episode of syncope. She has 6 weeks amenorrhoea. On examination, she is pale with blood pressure 95/60 mmHg, pulse 115 bpm, and has rebound tenderness in the right iliac fossa. Urine pregnancy test is positive. What is the most appropriate immediate management?
Gynaecology UK Medical PG Practice Questions and MCQs
Question 51: A 48-year-old woman presents with heavy menstrual bleeding for 11 months. Examination reveals a 12-week sized irregular uterus. Ultrasound confirms multiple intramural fibroids, the largest measuring 6cm. She has tried the levonorgestrel intrauterine system but it was expelled after 2 months. She has completed her family. Her haemoglobin is 92 g/L. She wishes to avoid major surgery if possible. What is the most appropriate next management option?
A. Uterine artery embolisation (Correct Answer)
B. Total abdominal hysterectomy
C. Repeated attempt at levonorgestrel intrauterine system insertion
D. Tranexamic acid and ferrous sulphate supplementation
E. Myomectomy via laparotomy
Explanation: ***Uterine artery embolisation***- **Uterine artery embolisation (UAE)** is a minimally invasive radiological procedure that induces **fibroid ischaemia** and shrinkage, making it ideal for patients wishing to avoid **major surgery**.- It is highly effective for women with **symptomatic fibroids** who have completed their family and where the **LNG-IUS** has already failed or been expelled.*Total abdominal hysterectomy*- While **hysterectomy** is a definitive treatment for heavy menstrual bleeding and fibroids, it is classified as **major surgery** with a long recovery period.- This option is unsuitable here because the patient specifically expressed a desire to **avoid major surgery** if possible.*Repeated attempt at levonorgestrel intrauterine system insertion*- The **LNG-IUS** was already expelled, likely due to the **distorted uterine cavity** and large **intramural fibroids**.- A repeated attempt has a high **risk of failure** and is unlikely to provide a long-term solution for symptomatic 6cm fibroids.*Tranexamic acid and ferrous sulphate supplementation*- These address the symptoms of **anaemia** and acute bleeding but do not treat the underlying **fibroid pathology** causing the 12-week sized uterus.- **Medical management** alone is typically insufficient for significant fibroid-related heavy menstrual bleeding and does not meet the patient's need for definitive management of the mass.*Myomectomy via laparotomy*- **Myomectomy** is considered a major surgical procedure involving significant blood loss risks and a long **post-operative recovery**.- This approach is generally reserved for women who wish to **preserve fertility**, whereas this patient has completed her family and wants to avoid surgery.
Question 52: A 34-year-old woman presents to the emergency department with 6 weeks amenorrhoea, minimal vaginal spotting, and mild left-sided pelvic discomfort. Her serum beta-hCG is 800 IU/L. Transvaginal ultrasound shows an empty uterus with no adnexal masses visualised and no free fluid. She is haemodynamically stable. A repeat beta-hCG 48 hours later is 920 IU/L. What is the most likely diagnosis?
A. Molar pregnancy
B. Ectopic pregnancy (Correct Answer)
C. Heterotopic pregnancy
D. Viable intrauterine pregnancy
E. Complete miscarriage
Explanation: ***Ectopic pregnancy***- A **suboptimal rise in beta-hCG** (15% in 48 hours, significantly less than the expected 53-66%) combined with an **empty uterus** on transvaginal ultrasound is highly indicative of an ectopic pregnancy.- The clinical symptoms of **amenorrhoea**, **vaginal spotting**, and **unilateral pelvic discomfort** further support this diagnosis, even without a visible adnexal mass. *Molar pregnancy*- This condition is characterized by **abnormally high beta-hCG levels** (often >100,000 IU/L) and a distinctive **"snowstorm" or vesicular appearance** of the placenta on ultrasound.- The patient's relatively low beta-hCG and empty uterus on ultrasound do not align with the typical presentation of a **hydatidiform mole**. *Heterotopic pregnancy*- A heterotopic pregnancy involves the **coexistence of both an intrauterine and an extrauterine pregnancy**.- The ultrasound report explicitly states an **empty uterus**, ruling out the presence of an intrauterine gestation, which is a prerequisite for this rare diagnosis. *Viable intrauterine pregnancy*- For a viable intrauterine pregnancy, **beta-hCG levels** are expected to increase by at least **53-66% over 48 hours**; the 15% rise seen here is significantly suboptimal.- An **empty uterus** on transvaginal ultrasound with a beta-hCG level of 800 IU/L (which is near or within the discriminatory zone for some institutions) strongly suggests an abnormal pregnancy. *Complete miscarriage*- A **complete miscarriage** is typically associated with **rapidly declining beta-hCG levels** as the pregnancy tissue has been expelled.- While the uterus is empty, the patient's **rising beta-hCG trend** (800 to 920 IU/L) indicates ongoing, albeit non-viable, trophoblastic activity, contradicting a complete miscarriage.
Question 53: A 44-year-old woman with a BMI of 29 kg/m² presents with a 10-month history of heavy menstrual bleeding. She has tried tranexamic acid with limited improvement. She does not wish to have more children. Examination reveals a mobile anteverted uterus of normal size. Ultrasound shows endometrial thickness of 14mm on day 20 of a 30-day cycle, with normal myometrium and ovaries. Endometrial biopsy shows benign proliferative endometrium with no atypia. Thyroid function and coagulation screen are normal. What underlying diagnosis should be considered?
A. Von Willebrand disease
B. Subclinical hypothyroidism
C. Endometrial hyperplasia without atypia
D. Anovulatory cycles with unopposed oestrogen (Correct Answer)
E. Occult endometrial malignancy
Explanation: ***Anovulatory cycles with unopposed oestrogen***
- The **endometrial biopsy** showing **benign proliferative endometrium** on day 20, when a **secretory phase** is expected, strongly indicates **anovulation**.
- In **anovulatory cycles**, progesterone is not produced, leading to continuous **unopposed oestrogen stimulation** of the endometrium, causing it to thicken excessively and shed irregularly, resulting in **heavy menstrual bleeding**.
*Von Willebrand disease*
- The patient's **coagulation screen** is explicitly stated as **normal**, which makes **Von Willebrand disease** highly unlikely.
- Inherited bleeding disorders typically present with **heavy menstrual bleeding** since **menarche** rather than an onset in the mid-40s.
*Subclinical hypothyroidism*
- The clinical vignette notes that the **thyroid function** tests are **normal**, explicitly ruling out thyroid-related menstrual dysfunction.
- Hypothyroidism usually presents with other systemic symptoms like **weight gain**, **lethargy**, or **cold intolerance**, which are not described.
*Endometrial hyperplasia without atypia*
- The **endometrial biopsy** specifically showed **benign proliferative endometrium**, which is a physiological state, not a hyperplastic one.
- While a thickness of 14mm is high, the histological evaluation is the **gold standard** and it ruled out **hyperplasia**.
*Occult endometrial malignancy*
- The biopsy results specifically confirmed there was **no atypia** or **malignancy**, making this diagnosis highly improbable.
- Additionally, the uterus was described as **normal size** and mobile, which is less suggestive of advanced malignant processes.
Question 54: A 31-year-old woman with a confirmed right tubal ectopic pregnancy measuring 28mm with no fetal heartbeat is being considered for medical management. Her serum beta-hCG is 2800 IU/L. She is haemodynamically stable and asymptomatic apart from minimal lower abdominal discomfort. She has normal renal and liver function tests. Which finding would be an absolute contraindication to treatment with intramuscular methotrexate?
A. Patient unwilling to attend for weekly follow-up
B. History of previous ectopic pregnancy
C. Serum beta-hCG level above 1500 IU/L
D. Ectopic mass measuring 28mm in diameter
E. Presence of fetal cardiac activity on ultrasound (Correct Answer)
Explanation: ***Presence of fetal cardiac activity on ultrasound***
- The presence of **fetal cardiac activity** indicates a more advanced and viable ectopic pregnancy, which results in a significantly **higher risk of treatment failure** with methotrexate.
- It is considered an **absolute contraindication** to medical management, necessitating surgical intervention due to the low success rates (often <10%) and risk of rupture.
*Patient unwilling to attend for weekly follow-up*
- While **inability to comply** with follow-up is a contraindication as it prevents safety monitoring of hCG levels and vital signs, being "unwilling" is a patient choice issue rather than a direct medical finding.
- It's a logistical contraindication that prevents safe management, not an **absolute medical contraindication** based on the clinical characteristics of the ectopic pregnancy itself.
*History of previous ectopic pregnancy*
- A history of a previous **ectopic pregnancy** is a risk factor for recurrence but is not a contraindication to using **methotrexate** for the current pregnancy if other criteria for medical management are met.
- Management is determined by the characteristics of the **current pregnancy** and the patient's clinical stability, not solely by past history.
*Serum beta-hCG level above 1500 IU/L*
- This is often a **relative contraindication** or a factor predicting lower success, but many protocols allow methotrexate for hCG levels up to **3000-5000 IU/L**, and even higher in some cases.
- In this scenario, 2800 IU/L is within an acceptable range for a single-dose **methotrexate** treatment protocol, provided other criteria (like absence of fetal cardiac activity) are met.
*Ectopic mass measuring 28mm in diameter*
- An ectopic mass size of **28mm** is typically below the common threshold of **35mm or 40mm** used to exclude candidates for medical management with methotrexate.
- Larger masses increase the risk of **tubal rupture** and treatment failure, but 28mm is generally considered acceptable for systemic methotrexate therapy.
Question 55: A 39-year-old nulliparous woman presents with heavy menstrual bleeding for 14 months that has not responded to tranexamic acid or mefenamic acid. She reports using 15-20 pads per cycle and her haemoglobin is 105 g/L. She wishes to preserve her fertility. Pelvic examination is normal. Transvaginal ultrasound shows a normal-sized uterus with endometrial thickness of 6mm on day 8 of her cycle and both ovaries appear normal. Hysteroscopy shows a normal uterine cavity with no polyps or fibroids. What is the most appropriate next management step?
A. Levonorgestrel intrauterine system insertion
B. Cyclical oral progestogens for 21 days per cycle
C. Endometrial ablation
D. Referral for myomectomy
E. Combined oral contraceptive pill (Correct Answer)
Explanation: ***Combined oral contraceptive pill***
- For a nulliparous woman with **heavy menstrual bleeding (HMB)**, no identifiable structural pathology after extensive investigation, and failure of non-hormonal treatments, the **Combined Oral Contraceptive Pill (COCP)** is an effective hormonal treatment.
- It significantly reduces menstrual blood loss, regulates the menstrual cycle, and allows for **rapid return to fertility** upon cessation, aligning with her desire to preserve fertility.
*Levonorgestrel intrauterine system insertion*
- While the **Levonorgestrel intrauterine system (LNG-IUS)** is highly effective for HMB and often considered first-line hormonal treatment, the patient's explicit desire to **preserve fertility** might mean she prefers a method with a quicker or more immediate return to conception plans compared to a long-acting device.
- However, it is an excellent option for HMB and does preserve fertility, but COCP is also a very appropriate medical alternative in this scenario.
*Cyclical oral progestogens for 21 days per cycle*
- High-dose cyclical oral progestogens are generally **less effective** at reducing menstrual blood loss compared to the LNG-IUS or COCP for unexplained HMB.
- They are often reserved for women with **contraindications to estrogen** or when other more effective hormonal options are not suitable.
*Endometrial ablation*
- **Endometrial ablation** is a procedure that destroys the uterine lining and is **contraindicated** in women who wish to **preserve fertility** as it can lead to severe pregnancy complications and typically results in infertility.
- It is considered a definitive surgical treatment for HMB when medical management fails and the woman has completed her family.
*Referral for myomectomy*
- This option is **inappropriate** because the patient's **transvaginal ultrasound** and **hysteroscopy** were normal, explicitly stating no polyps or fibroids were found.
- **Myomectomy** is a surgical procedure specifically indicated for the removal of **uterine fibroids** causing HMB, which are absent in this case.
Question 56: A 35-year-old woman presents to the emergency department with 6 weeks amenorrhoea, right iliac fossa pain, and light vaginal bleeding. Her serum beta-hCG is 1200 IU/L. Transvaginal ultrasound shows an empty uterus with no adnexal masses visible. Free fluid is seen in the pouch of Douglas. She is haemodynamically stable with blood pressure 125/78 mmHg and heart rate 82 beats per minute. A repeat beta-hCG 48 hours later is 1450 IU/L. What is the most appropriate next step in management?
A. Diagnostic laparoscopy (Correct Answer)
B. Repeat ultrasound scan in 1 week
C. Administer intramuscular methotrexate
D. Emergency laparotomy
E. Continue expectant management with weekly beta-hCG monitoring
Explanation: ***Diagnostic laparoscopy***
- The combination of **amenorrhoea**, **abdominal pain**, **vaginal bleeding**, a **suboptimal beta-hCG rise** (from 1200 to 1450 IU/L over 48h), and **free fluid in the pouch of Douglas** strongly suggests a **leaking or ruptured ectopic pregnancy**.
- Given the **haemodynamic stability** and these concerning findings, **diagnostic laparoscopy** is the most appropriate next step to confirm the diagnosis and provide definitive surgical treatment.
*Repeat ultrasound scan in 1 week*
- Delaying investigation for a week is unsafe due to the risk of **tubal rupture**, especially with **free fluid** in the pouch of Douglas.
- An **intrauterine pregnancy** should be detectable via transvaginal ultrasound at beta-hCG levels of 1500-2000 IU/L; an empty uterus at 1200 IU/L with rising hCG and free fluid warrants immediate action, not observation.
*Administer intramuscular methotrexate*
- **Methotrexate** is a medical management option for **unruptured ectopic pregnancies** in stable patients without signs of bleeding.
- The presence of **free fluid in the pouch of Douglas** indicates potential intra-abdominal bleeding, which is a contraindication for methotrexate and necessitates surgical intervention.
*Emergency laparotomy*
- **Emergency laparotomy** is typically reserved for patients who are **haemodynamically unstable** or have evidence of massive **haemoperitoneum**.
- As the patient is **haemodynamically stable**, **laparoscopy** is the less invasive and preferred surgical approach for diagnosis and treatment of a suspected ectopic pregnancy.
*Continue expectant management with weekly beta-hCG monitoring*
- **Expectant management** is suitable only for asymptomatic patients with **declining beta-hCG** levels and no evidence of rupture or intrauterine pregnancy.
- This patient has persistent symptoms (**right iliac fossa pain**) and a **rising beta-hCG** (even if suboptimal), making expectant management inappropriate and risky.
Question 57: A 51-year-old woman presents with a 6-month history of irregular heavy bleeding. Her last menstrual period was 3 months ago. She reports occasional hot flushes. BMI is 27 kg/m². Pelvic examination is normal. Transvaginal ultrasound shows endometrial thickness of 6 mm with no focal abnormalities. FSH is 38 IU/L. What is the most appropriate management regarding endometrial assessment?
A. Endometrial biopsy is essential due to her age and prolonged bleeding
B. No endometrial sampling required; proceed with treatment for heavy menstrual bleeding (Correct Answer)
C. Perform endometrial biopsy only if bleeding persists after 3 months of treatment
D. Hysteroscopy with directed biopsy is mandatory in this age group
E. Repeat ultrasound in 3 months to monitor endometrial thickness
Explanation: ***No endometrial sampling required; proceed with treatment for heavy menstrual bleeding***
- In a **perimenopausal** woman with vasomotor symptoms and elevated **FSH (38 IU/L)**, irregular bleeding is typically due to **anovulation** rather than malignancy.
- An **endometrial thickness (ET)** of 6 mm is considered benign in perimenopausal women (threshold for concern is typically **>10-12 mm**), making invasive sampling unnecessary.
*Endometrial biopsy is essential due to her age and prolonged bleeding*
- While age **>45 years** is a risk factor, the **reassuring ultrasound findings** (thin, regular endometrium) and clinical context of perimenopause allow for initial observation.
- Selective sampling is preferred over routine biopsy when the **ET is <10 mm** and there are no focal abnormalities or high-risk factors like **morbid obesity**.
*Perform endometrial biopsy only if bleeding persists after 3 months of treatment*
- This approach is partially correct in terms of **safety-netting**, but the immediate need is to treat the **heavy menstrual bleeding (HMB)** first.
- Biopsy is indicated if there is a **failure of medical management** or if the bleeding pattern becomes significantly more suspicious later on.
*Hysteroscopy with directed biopsy is mandatory in this age group*
- **Hysteroscopy** is the gold standard for diagnosing **focal pathology** (like polyps or fibroids), which was specifically ruled out by the normal ultrasound.
- It is not mandatory as a first-line step for a patient with a **normal pelvic exam** and a thin endometrial stripe.
*Repeat ultrasound in 3 months to monitor endometrial thickness*
- Repeating the scan is unnecessary because the **perimenopausal status** naturally causes thickness fluctuations; a single reassuring scan is sufficient to start treatment.
- Monitoring does not address the patient's primary complaint of **heavy bleeding**, which requires active management with options like **LNG-IUS** or tranexamic acid.
Question 58: A 24-year-old woman presents to the emergency department with 5 weeks amenorrhoea and light vaginal bleeding. She reports mild lower abdominal discomfort. Observations: BP 125/78 mmHg, pulse 76 bpm, temperature 36.8°C. Abdominal examination reveals mild suprapubic tenderness with no guarding. Transvaginal ultrasound shows an empty uterus with 11 mm endometrium and a 2 cm right adnexal mass with a hyperechoic ring. No free fluid is visible. Serum beta-hCG is 1650 IU/L. What is the most appropriate initial management?
A. Expectant management with repeat beta-hCG in 48 hours (Correct Answer)
B. Arrange same-day methotrexate administration
C. Emergency laparoscopy for suspected ectopic pregnancy
D. Repeat ultrasound in one week when beta-hCG will be above discriminatory zone
E. Diagnostic uterine curettage to exclude intrauterine pregnancy
Explanation: ***Expectant management with repeat beta-hCG in 48 hours*** - The patient is **hemodynamically stable** and presents with a **Pregnancy of Unknown Location (PUL)**, as the ultrasound findings are suggestive but not definitively diagnostic of an ectopic pregnancy at this beta-hCG level. - A **repeat beta-hCG in 48 hours** is essential to monitor the trend, which helps differentiate between a viable intrauterine pregnancy, a miscarriage, or an ectopic pregnancy based on its rise, fall, or plateau. *Arrange same-day methotrexate administration* - **Methotrexate** is indicated for stable patients with a **confirmed ectopic pregnancy** without a fetal heartbeat and beta-hCG below certain thresholds (e.g., <5000 IU/L), which is not the case here. - Administering methotrexate now would be premature and could **terminate a potentially viable intrauterine pregnancy** if the current ultrasound findings are simply due to very early gestation. *Emergency laparoscopy for suspected ectopic pregnancy* - **Emergency laparoscopy** is reserved for patients who are **hemodynamically unstable**, show signs of **tubal rupture**, or have significant **free fluid** on ultrasound. - This patient is stable with mild symptoms and no free fluid, making an invasive surgical procedure an inappropriate initial management step. *Repeat ultrasound in one week when beta-hCG will be above discriminatory zone* - Waiting an entire week for a repeat ultrasound is **unsafe** and carries a significant risk of **tubal rupture** if the pregnancy is indeed ectopic. - Her current beta-hCG of 1650 IU/L is already around the **discriminatory zone** (1500-2000 IU/L), where an intrauterine pregnancy should ideally be visible; thus, closer monitoring (48 hours) is warranted. *Diagnostic uterine curettage to exclude intrauterine pregnancy* - **Diagnostic uterine curettage** is an **invasive procedure** used to identify chorionic villi, but it is not a first-line diagnostic tool for a stable patient with a **PUL**. - This procedure carries the risk of **terminating a potentially viable intrauterine pregnancy** if the gestation is simply too early to be detected by ultrasound.
Question 59: A 40-year-old woman with heavy menstrual bleeding is found to have a 6 cm posterior wall intramural fibroid on ultrasound. She wishes to preserve her fertility as she is planning pregnancy in the next year. Her haemoglobin is 95 g/L. She has no other significant medical history. After counselling about risks and benefits, what is the most appropriate management to address both her fertility wishes and current symptoms?
A. Insert levonorgestrel intrauterine system to control bleeding and preserve uterus
B. Perform myomectomy after 3 months of GnRH analogue therapy (Correct Answer)
C. Arrange uterine artery embolisation to shrink fibroid
D. Commence tranexamic acid and iron therapy, then reassess after pregnancy
E. Proceed with immediate myomectomy without pretreatment
Explanation: ***Perform myomectomy after 3 months of GnRH analogue therapy*** - **Myomectomy** is the gold standard surgical treatment for symptomatic intramural fibroids in women who wish to **preserve fertility** and achieve pregnancy. - Pretreatment with **GnRH analogues** for 3 months reduces **fibroid volume** and vascularity while allowing for the correction of **anaemia (Hb 95 g/L)** before surgery. *Insert levonorgestrel intrauterine system to control bleeding and preserve uterus* - While effective for **heavy menstrual bleeding**, the **LNG-IUS** acts as a contraceptive and must be removed to allow for the patient's planned pregnancy next year. - A **6 cm fibroid** may distort the uterine cavity, increasing the risk of device **expulsion** or failed symptom control. *Arrange uterine artery embolisation to shrink fibroid* - **Uterine artery embolisation (UAE)** is generally avoided in women actively seeking pregnancy due to potential risks to **ovarian reserve** and placental blood flow. - It is associated with higher rates of **pregnancy complications** compared to surgical myomectomy. *Commence tranexamic acid and iron therapy, then reassess after pregnancy* - **Tranexamic acid** manages symptoms only and does not address the physical presence of a **6 cm fibroid**, which may hinder conception or increase miscarriage risk. - Delaying definitive treatment is inappropriate as the fibroid's size and location are likely contributing significantly to both her **anaemia** and fertility concerns. *Proceed with immediate myomectomy without pretreatment* - Operating immediately on a large fibroid with significant **anaemia (Hb 95 g/L)** increases the risk of requiring an intraoperative **blood transfusion**. - Lack of pretreatment makes the surgery technically more difficult due to higher **vascularity** and larger fibroid dimensions compared to a pre-shrunk fibroid.
Question 60: A 33-year-old woman presents with sudden onset severe right-sided pelvic pain, shoulder tip pain, and one episode of syncope. She has 6 weeks amenorrhoea. On examination, she is pale with blood pressure 95/60 mmHg, pulse 115 bpm, and has rebound tenderness in the right iliac fossa. Urine pregnancy test is positive. What is the most appropriate immediate management?
A. Arrange urgent transvaginal ultrasound to confirm diagnosis before any intervention
B. Obtain intravenous access, commence fluid resuscitation, and arrange emergency laparoscopy (Correct Answer)
C. Administer intramuscular methotrexate as she is still conscious and responding
D. Take blood for full blood count and group and save, then transfer for ultrasound
E. Request urgent serum beta-hCG level to guide management decision
Explanation: ***Obtain intravenous access, commence fluid resuscitation, and arrange emergency laparoscopy***
- The patient's presentation with sudden severe pelvic pain, shoulder tip pain, syncope, and **haemodynamic instability** (hypotension, tachycardia) in a pregnant woman strongly indicates a **ruptured ectopic pregnancy** with internal bleeding.
- Immediate management involves **aggressive fluid resuscitation** to stabilize the patient and **emergency laparoscopy** for definitive diagnosis and control of haemorrhage, as delay can be fatal.
*Arrange urgent transvaginal ultrasound to confirm diagnosis before any intervention*
- While ultrasound is crucial for diagnosing ectopic pregnancy, in a **haemodynamically unstable** patient with signs of rupture, it should not delay life-saving surgical intervention.
- The clinical picture of **shock** and **peritoneal signs** takes precedence over imaging in this emergent scenario.
*Administer intramuscular methotrexate as she is still conscious and responding*
- **Methotrexate** is a medical management option for **stable ectopic pregnancies** without rupture or significant bleeding.
- It is absolutely contraindicated in cases with **haemodynamic instability**, suspected rupture, or significant pain, as it would delay definitive surgical treatment and worsen outcomes.
*Take blood for full blood count and group and save, then transfer for ultrasound*
- Taking blood for **full blood count** and **group and save** is essential for surgical preparation, but transferring an unstable patient for ultrasound will dangerously delay definitive treatment.
- **Resuscitation** and preparation for surgery should be initiated simultaneously, with the patient heading directly to the operating theatre once stabilized for surgery.
*Request urgent serum beta-hCG level to guide management decision*
- A **positive urine pregnancy test** is sufficient to confirm pregnancy in this acute setting; quantitative serum **beta-hCG levels** are primarily used for managing stable, non-ruptured ectopics or pregnancies of unknown location.
- Waiting for laboratory results in a patient presenting with **syncope** and signs of **intra-abdominal haemorrhage** would lead to a critical delay in emergency surgical management.
